Meeting of the Board of Directors
10.00am to 12.20 on Thursday 26th April 2018
Boardroom, Washington Suite, Worthing Hospital, Lyndhurst Road, Worthing BN11 2DH
AGENDA – MEETING IN PUBLIC
1 10.00 Welcome and Apologies for Absence Chair
2 10.00 Declarations of Interests All
3 10.00 Minutes of Board Meeting held on 01st February 2018 Enclosure Chair To approve
4 10.05 Matters Arising from the Minutes Enclosure Chair To note
5 10.10 Chief Executive’s Report Enclosure MG To receive and agree any necessary actions
PATIENT SAFETY/EXPERIENCE ITEMS
6 10.20 Patient First Metrics Enclosure All To note
6.1 Quality Report Enclosure GF/NR 6.2 Performance Report Enclosure JF 6.3 Organisational Development and Workforce Enclosure DF 6.4 Financial Performance Enclosure KG To receive and agree any necessary actions
7 11.00 Nursing Staffing Capacity Report Enclosure NR To receive and agree any necessary action
8 11.15 Annual Report on Organ Donation Presentation GF/RA To receive and agree any necessary actions & Enclosure
STRATEGIC ITEMS
9 11.30 Quality Report 2017/18 Draft Version 3.0 Enclosure GF To receive and agree any necessary action
GOVERNANCE ITEMS
10 11.40 Provider Self-Certification Enclosure BC To receive and agree any necessary actions
11 11.45 Use of Trust Seal Enclosure MG To note
OTHER ITEMS
12 11.50 Proposed Amendments to the Trust Constitution Enclosure Chair To receive and agree any necessary actions
13 12.00 Other Business Chair
14 12.05 Resolution into Board Committee Verbal Chair To pass the following resolution:
“That the Board now meets in private due to the confidential nature of the business to be transacted.”
15 12.05 Date of Next Meeting Chair
The next meeting in public of the Board of Directors is scheduled to take place at 10.00am on 26th July 2018 in the Boardroom, Washington Suite, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH.
16 12.05 Close of Meeting Chair
17 12.05 Questions from the Public Chair – 12.20 Following the close of the meeting there will be an opportunity for members of the public to ask questions about the business considered by the Board.
Corporate Governance Director Tel: 01903 285288
Minutes of the Board of Directors meeting held in Public at 10.00am on Thursday 01 February 2018, The Bateman Room, Chichester Medical Education Centre, St Richard’s Hospital, Spitalfield Lane, Chichester, PO19 6SE.
Present: Mike Viggers Non-Executive Director (Chairman) Joanna Crane Non-Executive Director Mike Rymer Non-Executive Director Patrick Boyle Non-Executive Director Lizzie Peers Non-Executive Director Jon Furmston Non-Executive Director Marianne Griffiths Chief Executive George Findlay Chief Medical Officer and Deputy Chief Executive Karen Geoghegan Chief Financial Officer Denise Farmer Chief Workforce and OD Officer
In Maggie Davies Nurse Director Attendance: Tim Taylor Medical Director Kirstin Baker Non-Executive Director Adviser Martin Sinclair Non-Executive Director Adviser Anil Mathew Director of Continuous Improvement (For Item 8)
Ann Maloney Senior Acute Oncology Nurse (For Item 8) Nikki Turner Macmillan Nurse (For Item 8) Rachel Edmonds Assistant Care Group Manager – Theatres (For Item 8) Andy Gray Corporate Governance Director Tanya Humphrys Board Administrator
TB/01/18/01 Welcome and Apologies
1.1 The Chair welcomed all those present to the meeting.
1.2 Apologies were received from Pete Landstrom, Nicola Ranger and Jane Farrell.
TB/01/18/02 Declarations of Interests
2.1 There were no declarations of interest.
TB/01/18/03 Minutes of Board Meeting held on 26th October 2017
3.1 The Board received the minutes of the meeting held on 26th October 2017.
3.2 The Board resolved that the minutes of the Board meeting held on 26th October 2017, would be approved as an accurate record of the meeting and signed by the Chairman.
TB/01/18/04 Matters arising from Minutes
4.1 The Matters Arising from previous meetings were received.
4.2 All Matters Arising related to items on the agenda or were on a forward agenda plan.
TB/01/18/05 Chief Executive’s Report
George Findlay presented the Chief Executive’s Report on behalf of
Marianne Griffiths.
5.1 George advised the Board that the Chief Executive and Chairman would be in attendance momentarily, explaining that the Secretary of State for Health and Social Care, Mr Jeremy Hunt had visited the Trust and had acknowledged how busy the NHS has been over the last few months, highlighting that demand for services has been unprecedented.
5.2 George explained that during the festive fortnight, the Trusts emergency teams saw more than 5,600 patients and our ward teams admitted and cared for 2,200 new people.
5.3 The Board was advised that the Chief Executive has publicly thanked our staff and acknowledged how hard our teams are working, in very challenging circumstances, and how they do it with exemplary skill, kindness and compassion.
5.4 It was noted that patients on our wards can now enjoy seeing relatives and other visitors at any time of the day between 10am and 10pm which replaces the old split visiting times of 3-5pm and 6.30-8pm. The decision, which applies to all adult inpatient areas, was informed by feedback from pilots on six wards where open visiting 24 hours a day was trialled for three months.
5.5 More than 1,100 new electric profiling beds will be replacing all the trust’s current bed stock on the wards this year with the first having arrived just before Christmas. The news has been enthusiastically welcomed by ward teams and especially nursing colleagues who on a daily basis deal with difficult manual controls, foot pumps and manipulating heavy metal frames.
5.6 Lizzie Peers enquired whether there were any downsides to the extended visiting hours. In response George explained that it was a considerable culture change for staff but the overall feeling is that it has been hugely beneficial.
5.7 Maggie Davies highlighted that the ‘upsides’ were particularly significant in dementia patients, in addition to it helping reduce falls on the wards.
5.8 Marianne Griffiths and Mike Viggers joined the meeting. Marianne concluded the Chief Executives Report by sharing her gratitude for the thanks and support expressed by our patients who have acknowledged the quality of care and friendly service experienced during this particularly busy period.
TB/01/18/06 Quality Report – Month 9
George Findlay and Maggie Davies introduced the Quality Report and highlighted the key points.
6.1 The Board was advised that Crude non-elective mortality increased from 3.06% in November to 3.26% in December. This is marginally below the equivalent month in 2016 and is well within the normal limits associated with the seasonal variation in crude mortality.
6.2 It was noted that it is reassuring that the site difference is minimal, in addition that the Trust has remained in the top 20% of Trusts on the 15th centile.
Minutes page 2
6.3 Tim Taylor advised the Board that in October the Trust took part in its third self-assessment (NHSE) for 7 Day Services.
6.4 This round of self-assessment focused purely on Clinical Standard 2 ‘Patient to be seen by a consultant within 14 hours of admission’ across the country.
6.5 It was noted that the Results have remained static from the last self- assessment in the spring 2017. Tim explained that there will be more comprehensive feedback at Board in April. GF/TT
6.6 Maggie Davies highlighted that there were no outstanding Central Alert System (CAS) safety alerts in the Trust up to December 2017.
6.7 There were ten reported incidents categorised as Serious Incidents Requiring Investigation in December. It was noted that there was a reduction in January from ten to six.
6.8 On a monthly basis there is triangulation of information arising out of complaints, claims, incidents and inquests to identify any areas of learning or for focus.
6.9 The newly revised Triangulation Committee (From January 2018) will focus on how we share learning across the organisation, with a detailed ‘Deep Dive’ focus on an incident(s) (where the learning for the organisation is significant) being discussed at each meeting.
6.10 There was one case of MRSA during December where there was a noted lapse in care attributable to the Trust. The Post Infection Review (PIR) is due in January 2018.
6.11 Maggie advised the Board that Safer Care Live has been rolled out across the organisation. Staff are asked to input data on how many nurses they have requested and how many are actually on duty. Maggie explained that it is hoped this will provide much more ‘live’ visibility about how the Trusts deploys workforce.
6.12 Joanna Crane commented that Emergency Floor moves continue to increase, and enquired whether this is due to staff waiting to move the patient. Maggie confirmed this was often the case.
6.13 George explained that there is accelerated focus on discharge times and flows with the intention to bring discharge time back to 12 noon rather than 5pm.
6.14 Joanna commended the staff on the extraordinarily small number of nursing complaints during such adverse conditions.
TB/01/18/07 Performance Report – Month 9
The Performance Report was introduced by Marianne Griffiths.
7.1 The Board was advised that operationally December saw an increased level of A&E demand, and an increase in emergency admissions relative to the same period in 2016.
7.2 Marianne explained that the increase in activity and unprecedented demand was unfortunately due to high levels of demand which has been exacerbated by the significant impact of flu. This reflects the national
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picture.
7.3 It was noted that The Trust was not compliant against the National target in December, with 85.4% of patients waiting less than four hours from arrival at A&E to admission, transfer, or discharge. Cumulative year to date performance for the Trust in December was 93.52%.
7.4 Marianne advised the Board that performance was below 90% at both Worthing and St Richard’s, noting that a reduction of Community beds had also affected this.
7.5 The Trust was compliant against all 7 cancer metrics applicable to the Trust in December. The board is reminded that there is approximately a six week lag from the end of the reporting period, to publication of final performance for cancer metrics.
7.6 It was noted that as Winter Plans have deteriorated both NHS England and NHS Improvement sent joint letters advising Trusts that they were to pace all elective treatment and cancel non urgent operations in order to provide safe emergency treatment.
7.7 The Trust was non-compliant against the Referral to Treatment target (RTT) of 92% in November with 87.1% of pathways waiting less than 18 weeks.
7.8 This is 1.95% deterioration in performance since November (89.02%). Numbers of patients waiting over 18 weeks increased by 689 patients between months.
7.9 Marianne explained that the Trust has tried to reduce the number of cancellations that are made on the day, as this only leads to an increase in the backlog.
7.10 Patrick Boyle enquired in relation to the Trust working with the Ambulance Service during particularly busy periods. In response Marianne advised that there were two days when the Trust had to hold ambulances.
7.11 George Findlay commented that when they do queue the relationship between paramedics and staff is very good, does not deteriorate and staff work flexibly together.
7.12 Mike Viggers advised that the Board needs to remain sighted on RTT JF returning to a manageable position.
7.13 The Chairman requested a Trust overview on the Winter period and the JF pressures experienced.
TB/01/18/08 Organisational Development and Workforce Transformation Report – Month 9
Denise Farmer presented the Workforce Report for Month 9.
8.1 Denise explained that whilst the volume of supply of temporary staff through the staff bank decreased in month, the proportion used was higher.
8.2 It was noted that supply through employment agencies between Christmas and New Year fell significantly for both medical and nursing staff.
Minutes page 4
8.3 The Board was advised that the Trusts retention of staff is high in comparison to other organisations noting staff turnover fell during December to 7.8%, with further improvement within the Core Division. This is a seasonal fall and reflects the month 9 position of previous years.
8.4 Denise highlighted that the Trust has been successful in recruiting a Chief Operating Officer, Jayne Black, who will be joining the Trust from the 23rd April 2018.
8.5 It was noted that the Trust is providing a new initiative to support to Healthcare workers who would like to go onto further higher education.
8.6 The Bridging Programme is a 12 week course which gives individuals the requirements to get into a degree level course. This is being offered to all Clinical Support staff in the Trust. The Bridging programme is currently being advertised in the Trust.
8.7 Jon Furmston commented that to sustain above 90% attendance on statutory training while under such pressure is impressive and reassuring that there is management discipline in the way in which attendance is managed.
TB/01/18/09 Financial Performance – Month 9
Karen Geoghegan presented the Financial Performance Report.
9.1 The Trust reported a surplus of £0.706m in December bringing the total surplus to £2.266m.
9.2 The Trust has achieved its control total for Quarter 3 and will therefore earn a minimum of £2.4m of STF income. A further £1m is available subject to delivery of GP streaming and A&E waiting time targets.
9.3 The Trust delivered its cumulative A&E waiting time trajectory to 24th December but was marginally below the cumulative trajectory at the end of December. The Trust is appealing this element of the STF on the basis of increase in acuity and a reduction in community capacity.
9.4 The forecast for Quarter 4 is being reviewed in light of the significant pressures experienced by the Trust in Quarter 3 and continuing into Quarter 4.
9.5 Karen advised the Board that despite winter pressures agency expenditure continues to fall and is £3m below the target. Highlighting that in spite of the pressure the Trust has delivered savings.
TB/01/18/10 Learning from Deaths
Tim Taylor presented the Learning from Deaths paper, copies of which had previously been circulated.
10.1 Tim advised the Board that the Trust is required to publicly report on all deaths within the organisation, highlighting that since April 2017 the Trust has been consultants to review every death.
10.2 It was noted that there is a national programme in place and Trusts finding are very much in keeping with information provided by other Trusts.
Minutes page 5
10.3 A Structured Judgement Case not Review (SJR) will be mandatory in the following cases: . Any death where independent review has been requested as a result of screening . All deaths where bereaved families and carers, or staff, have raised a significant concern about the quality of care provision that has not been addressed . All deaths of those with significant mental illness. A modified SJR is being developed nationally which the Trust will adopt for appropriate cases once available . All deaths in a speciality, particular diagnosis or treatment group where an ‘alarm’ has been raised either internally or via Dr Foster, Imperial College, CQC or any other external source . Any death within 24 hours of surgery . Any death where death would be unexpected e.g. following elective surgery or in low risk diagnostic groups . Serious Incident Requiring Investigation (SIRI) involving a patient death
10.4 Tim explained that there is a requirement that the Trust will audit a random sample of 5% of deaths that do not fall into the aforementioned categories. The Board was advised that already the SJRs have highlighted good or excellent care as a result of the good communication between staff and patient families.
10.5 Mike Rymer asked about a move from five to seven day service for Clinical Nurse Specialists in palliative care. In response Tim explained that there is ongoing work to strengthen palliative care cover seven days a week.
10.6 Maggie Davies advised that in addition the Trusts lead cancer nurse is looking to Macmillan for what level of support they may be able to provide.
10.7 Patrick Boyle enquired where this process will sit with the Trusts other pathways, SIRIs, Never Events etc. Tim explained that the process was presented to the Triangulation Committee in relation to links with other governance structures within the Trust.
10.8 Lizzie Peers highlighted that the report references staff skills and commented how important the management of death and dying is, asking where the Trust should support staff in relation to trauma and the impact on staff.
10.9 In response Tim agreed that there are clear areas for development and this will be shared with the End of Life Board to ensure it is sighted on the issue.
10.10 Mike Viggers concluded that the report was in a format and structure that the Board was comfortable with and requested that the next report provides some oversight on links to other areas of learning across the GF/TT Trust.
10.11 In addition that the report provides detail on training and support for the GF/TT SJR reviewers.
Minutes page 6
TB/01/18/11 Patient First Improvement – “Our People Practicing Patient First”
Anil Mathew introduced the Patient First Improvement Presentation, “Our People Practicing Patient First”. Anil explained that both presentations that the Board was going to see were good examples of where improvement was the key theme.
Suspected Neutropenic Sepsis Kaizen Project – Ann Maloney & Nikki Turner: 11.1 The Board heard that as part of their role within the Acute Oncology Team (AOT) both Ann and Nikki review cancer patients that are admitted via the emergency department with: . Symptoms related to their cancer; . Patient diagnosed with a new malignancy; . Toxicities following chemotherapy treatment (e.g. neutropenic sepsis).
11.2 Ann explained that they had completed their Yellow Belt training eighteen months previously and immediately identified a pathway that they felt they could improve for the patients.
11.3 . Worthing and St Richard’s hospitals had different pathways for patients attending hospital for suspected neutropenic sepsis; . Data was collected by different teams and numbers were inaccurate; . NICE recommendation is that patients should receive antibiotics for suspected neutropenic sepsis within 1 hour of attending hospital.
11.4 The Board heard that using a structured process they started to map the problems identified and set about gathering evidence and data.
11.5 Ann explained that they took over the data collection so there was one datasheet Trust Wide, they mapped pathways as Worthing patients were accessing hospital via various departments.
11.6 The project had the support of a Trust Sponsor, in Medical Director Tim Taylor and a patient representative.
11.7 As a result of the project and a meeting that involved all key stakeholders, the process is now: . All patients go via Ambulatory Care Area Trust Wide – previously patients at Worthing could be admitted via a number of different departments; . Point of care testing is being piloted Trust wide to establish white/neutrophil count to enable early decision for the patient; . IV antibiotics are given to patients that are neutropenic; . Data collected by AOT and presented weekly; . Door to needle time is 100%.
TCI Card Rapid Improvement Event – Rachel Edmonds: 11.8 Rachel explained to the Board that Theatres held a utilisation workshop with all staff Trust wide and the most common theme was issues with TCI cards.
11.9 A rapid improvement event was held over three days to look at the process. An audit of over 400 TCI cards took place with the findings as follows: . 25% of the cards were difficult to read; . The current card is difficult to complete fully; . There were 6 different methods of delivery; . The average time to complete a TCI card took between 1-2 minutes.
Minutes page 7
11.10 The Board was advised that with Executive sponsorship from Pete Landstrom the team mapped a different process, with a team of staff from each department along the pathway.
11.11 Rachel explained that within the first day the team had designed a new card and created a process as ‘fool proof’ as possible, highlighting that as part of the process if the card arrives at a department with missing information it is returned.
11.12 Rachel finished by advising the Board that the intention is to audit the process, following go-live with the card on 29 January, to ensure that it has been designed correctly and is fit for purpose.
11.13 The teams felt that they had a voice and everyone wants it to work. In both instances the patient was at the center of the project with the intention to improve the patient pathway.
11.14 Jon Furmston asked how crucial was the Patient First approach to being able to achieve these projects. In response Rachel explained that gave them the structure to approach it in the right way.
11.15 Ann commented that they had tried many times before with no resolution. Having a structured approach and focusing on what the issue is was greatly beneficial adding that using the process maps as a visual representation was hugely beneficial.
11.16 Mike Viggers commented that the teams should be incredibly proud of what had been achieved and thanked Anil and his team.
TB/01/18/12 Annual Equality Report
Denise Farmer presented the Annual Equality Report for 2017 and highlighted the key points.
12.1 It was noted that the Trust has not been as focussed on patient areas of equality as staff areas. Going forward this will be a priority and WHST will work, with support from colleagues in Brighton Sussex University Hospitals (BSUH), to improve this.
12.2 The Board was advised that in relation to the Gender Pay Gap the Trust is required to report this by the end of March 2017, noting that a paper will be brought to Trust Board in February.
12.3 Denise explained that throughout the year there has been much good work which demonstrates the Trust’s commitment to driving the equality agenda forward.
12.4 It was noted that the Trust is utilising experience and evidence to deliver service improvements for staff and patients as detailed in a number of case studies set out in the report.
12.5 In addition there are a number of areas where the Trust is doing particularly well: . From the demographic data (that is known) - there is a fair representation of most protected characteristics across the board. . Accessibility to training is on the whole equal across the board. . On the whole patient satisfaction for the Trust’s services is good.
Minutes page 8
12.6 Joanna Crane commented that last year the Trust was concerned about the drop off of certain races and ethnic minorities after application and interview, and asked if the Trust has tried to change that trend.
12.7 In response Denise explained that some work was done on the issue, however there is further work to do and a discussion is taking place with colleagues in BSUH who may be able to provide a fresh approach.
12.8 Mike Viggers highlighted that there are some historic themes running through the report and requested that there is some focus on a number of the areas for improvements detailed in the Equality Report and how the Trust intend to address them, with an update being brought back for the DF Board to review.
12.9 The Board NOTED the 2017 Equality Report and APPROVED it for publication.
TB/01/18/13 Proposed Amendments To The Trust Constitution
The Chairman presented the Proposed amendments to the Trust Constitution Paper, copies of which had been previously circulated.
13.1 Mike Viggers advised the Board that the changes set out in the paper had been approved by the Trusts Governing Council.
13.2 It was noted that the changes are as follows: . There should be one Patient (Out of area) Governor. Currently there are three Patient Governors representing a constituency of 264.
. That the representation of the Public Elected Constituencies should be: Current number of Governors: Adur 2 Arun 4 Chichester 3 Horsham 1 Worthing 3 Patient (Out of area) 3 Proposed number of Governors: Adur 2 Arun 5 Chichester 3 Horsham 1 Worthing 3 Patient (Out of area) 1
. Arun District has the largest population within the area covered by the Trust. To reflect this it is proposed that there is one additional elected Governor for this constituency.
. Arun District Council should also be asked to nominate an appointed Governor to represent them on the WSHFT Council of Governors. Currently both Chichester District Council and Worthing Borough Council are represented on the Council of Governors.
. The Trust’s volunteers should be represented on the WSHFT Council of Governors.
. The possible tenure of Governors should remain at two periods of
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three years in line with the terms of office on the Trust’s Non-Executive Directors.
. There should be reference in the Trust’s Constitution to the Pre- Council of Governors meeting.
. There should be reference in the Trust’s Constitution to the Role of Lead and Deputy Lead Governors.
13.3 The Board recognised that the Lead and Deputy Lead roles in the Council have been invaluable and thanked the members for their input.
13.4 The Board NOTED the changes to the constitution and APPROVED the changes as set out in the paper.
TB/01/18/14 Other Business
14.1 The Chairman formally thanked the staff of Western Sussex Hospitals for their hard work and dedication during the difficult winter period. Commenting that their commitment to the patients and safe care has been outstanding.
TB/01/18/15 Resolution into Board Committee
15.1 The Board resolved to meet in private due to the confidential nature of the business to be transacted.
TB/01/18/16 Date of Next Meeting
16.1 It was noted that the next Board Meeting would take place on Thursday 26th April in the Boardroom, Washington Suite, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH.
TB/01/18/17 The Chair formally closed the meeting
TB/01/18/18 Questions from Members of the Public
18.1 John Thompson commended the performance of the staff during the busy winter period and advised the Board that the feedback from the public had been positive. Noting that the article in the paper made a real difference and was very helpful.
18.2 John went on to comment how positive the extended visiting hours are and enquired when there are rare cases of visitors behaving badly and staff need assistance with such behaviours security should be available.
18.3 In response Maggie Davies advised that there has only been one instance since visiting has been extended and that families are reminded that the Trust has a zero tolerance for bad behaviours. In addition families are reminded that they need to allow staff to care for their relative.
18.4 John Bull asked whether the Trust has sufficient air beds. In response Maggie Davies advised that WSHT has its own stock of air beds, however when there is high occupancy the Trust hires additional beds into the organisation.
18.5 Anita Mackenzie asked about the failure to review regular opioid treatment mentioned in the Learning from Deaths paper, and what controls are in place for how opioids are delivered. Tim Taylor explained that any frail
Minutes page 10
patient could be effected by opioids and the expectation is that the consultant will review the patient during their round.
18.6 Anita also asked whether there is a separation between TIAs and majors on the stroke wards. Denise responded by explaining that this is currently not the case and the key is that the patient is in the right place receiving the right care.
Tanya Humphrys Board Administrator February 2018 Signed as an accurate record of the meeting
…………………………………………………. Chair ………………………………………………… Date
Minutes page 11
MATTERS ARISING Board in Public Agenda Item: 4
Meeting Minute Ref Action Responsible Deadline Status Person Include the Population of New 26th October Performance (medicines optimisation) 2017 PB/10/17/5.1 metrics in the Quality Report for st 31 May On the forward agenda plan for May & November Board. GF th 2018 2018 29 November PB/11/17/4.2 ------2017 Review of Quality Dashboard
st st An in depth presentation on Winter 01 February Trust overview of Winter Pressures at the 31 May TB/01/18/7.13 JF Pressures on the forward agenda plan 2018 appropriate juncture. 2018 for May.
st Stroke Services - Further information in Completed – An update was included as 01 February TB/01/18/6.1 relation to Staffing levels and GF/TT - part of the Quality Report at Board on 2018 st performance 01 March 2018. Seven Day Service Audit - Update 01st February specifically in relation to the mandated 31st May This will now come back to the Board in TB/01/18/6.5 GF/TT 2018 standard/s that the Trust needs to 2018 May – on the forward agenda plan. improve on. Learning from Deaths report to have 01st February oversight on how it links in to governance 26th July On the forward agenda plan for July TB/01/18/10.10 GF/TT 2018 structures and other areas of learning 2018 Public Board. within the Organisation.
st Learning from Deaths report to include th 01 February 26 July On the forward agenda plan for July TB/01/18/10.11 some detail on training and support for GF/TT 2018 2018 Public Board. the in-depth reviewers.
st Some focus on a number of the areas for Completed – An update was included as 01 February TB/01/18/9.5 improvements in the Equality Report and DF - part of the Workforce Report at Board on 2018 th how the Trust intend to address them. 28 March 2018. 01st February Completed – The Board received a TB/01/18/9.6 Update on the gender pay gap DF - st 2018 paper at the meeting on 01 March 2018.
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28th March Additional detail on MRSA numbers 26th April PB/03/18/5.6 NR/GF Included as part of the Quality Report. 2018 included in the next Quality Report 2018
th Additional information on the night time th 28 March 26 April PB/03/18/5.4 moves from the Emergency Floor to be NR/GF Included as part of the Quality Report. 2018 2018 included in the Quality Report
th Report to be brought back to Board th 28 March 28 June On the forward agenda plan for June PB/03/18/5.7 following the Infection Control cross-site NR/GF 2018 2018 2018. Review. 28th March Update on the Apprentice Strategy to be 26th April PB/03/18/7.7 DF Included as part of the Workforce Report. 2018 included in the Workforce Report. 2018
th Information in relation to the Trusts th 28 March 26 April PB/03/18/13.6 compliance to NICE Guidance to be NR/GF Included as part of the Quality Report. 2018 2018 included in the Quality Report.
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To: Trust Board Date: 26th April 2018
From: Marianne Griffiths, Chief Executive Agenda Item: 5
FOR INFORMATION
CHIEF EXECUTIVE’S BOARD PAPER
1. Highlights and headlines
Extended winter with unprecedented demand Yet again, staff and volunteers at Western Sussex Hospitals have gone above and beyond to care for very high numbers of sick people this winter. The last quarter of 2017/18 has been particularly challenging, characterised by unprecedented demand for urgent care and exceptionally cold weather, compounded by high incidence of flu and seasonal infections. Every year, our staff care for more people and go to even greater lengths to ensure their safety and quality of care while in our hospitals. Each year, our services are in greater demand than the year before and our staff have to work harder to rise to the challenge. I would like to take this opportunity to once again pay tribute to all our people, both on the front line and all those who support the delivery of outstanding care at Western Sussex Hospital. When you look at statistics from the last quarter of 2017/18, the achievements are truly humbling. In January, February and March this year, our A&E teams saw on average 11 more patients every day, compared to the same period last year. Many of those presenting at A&E are also older than in previous years and have more complex care needs. For example, A&E attendances by over-65s was up 6.5% this winter, and by 5.4% for over- 85s, compared to last year. Many of these patients require admission to a ward and consequently our emergency admission rate increased by more than 7% this year (over-65s 7.1% and over-85s 6.8%). As a result, our hospitals were running at, and often over their capacity for protracted periods this winter. Our staff and volunteers have worked harder than ever before in recent months and I wish to commend and thank them all for their outstanding commitment to our patients amidst these extraordinary challenges.
Staff Survey – 5-star review Staff gave the trust a 5-star review in this year’s NHS Staff Survey results, published in March. Western Sussex was in the top five trusts in England where employees are most likely to recommend their hospital as a place to work or be treated. More than 300 organisations were surveyed, with 485,000 members of NHS staff completing the confidential questionnaire, including 4,000 from St Richard’s, Worthing and Southlands hospitals. We were all absolutely thrilled that our hospitals have been ranked fifth best in the country against these key questions in the annual survey and delighted to be ranked in the top 20% of all NHS England trusts in terms of overall staff engagement levels. We are now using this excellent endorsement to aid recruitment. The survey also helps to highlight areas of concern for staff and action plans are being put in place to address too.
Let’s Get You Home campaign The Let’s Get You Home policy, launched in December, is beginning to show some promising results and helping our patients to be discharged in a more timely way. The new policy encourages earlier conversations with patients and their relatives about discharge planning and standardises the approach of all local health and social care partners involved in the discharge of hospital patients across Sussex. The latest figures show that the average time it takes for patients who have been declared fit to be discharged to actually leave hospital was lower in March than at any time since the trust started recording this data in 2016. Last month, Medically Fit for Discharge (MFFD) patients waited an average of 8.16 days before going home or to a more appropriate care setting. This new low is in stark contrast to the average in November last year, before various improvement initiatives were started, when the MFFD delay was 11.23 days. A three day reduction in average MFFD delay is the equivalent to having an additional 20 beds available for patients last month, compared with four months ago in November.
New ward A new ward has been opened in Worthing Hospital following the move of Ophthalmology Outpatients to our new purpose built facility a Western Sussex eye Care | Southlands. Balcombe ward is the new home for the haematology, oncology and general medicine team who have moved from Burlington ward. The newly refurbished 20-bed ward is bright and spacious and importantly provides better facilities for our patients, such as more side rooms all with en-suite shower room facilities.
£1.5m A&E investment £1.5m has been invested to improve the environment and facilities for patients and staff in the A&E departments. At St Richard’s, the works have included creating six new patient cubicles, a new three-bay observation area and an additional GP triage room. The resuscitation area has also had a complete makeover.
Trust chairman announces retirement Mike Viggers has announced that he will retire as Chairman of the Board and Council of Governors at the end of May, aged 65. We often talk about our staff going the extra mile for patients, but that absolutely applies to Mike’s own commitment to them too. We could not have wished for a better and more dedicated chairman than Mike, and we will all miss him as a colleague, a supporter and a friend. He will be a hard act to follow. We managed to persuade him to stay on beyond his original term once and I’m only sorry that we haven’t been able to do so again! We all wish Mike a very happy retirement and thank him again for his service to our hospitals, patients and community. We hope to appoint his successor very soon.
2. Events and visits
Secretary of State for Health, Jeremy Hunt MP On Thursday 1 February, the Secretary of State for Health Jeremy Hunt MP paid his third visit to the trust and reiterated his support for our Patient First approach while speaking to staff about the Department of Health’s ambition to make the NHS the safest health service in the world. Mr Hunt championed Western Sussex Hospitals as a leading trust contributing to this ambition and he reaffirmed his belief that we are the best example of a learning culture that he has seen anywhere in the NHS.
CEO Forum lean network Chief executives from leading healthcare organisations in Europe and North America visited Worthing Hospital on Friday 16 March to learn more about the trust’s Patient First lean approach to continuous improvement. The Lean Healthcare Transformation CEO Forum members are interested in lean working and learning from each other to improve patient care. The delegates were impressed with all the teams they met as well as the way in which corporate objectives are shared through strategy deployment at every level of the organisation, from board to ward.
Diary dates The next Council of Governors Meeting is Monday 11 June, 9.30-12.30pm, Mickerson Hall, Chichester Medical Education Centre, St Richard’s Hospital. The next Trust Board takes place on 26 July, 10am-12.30pm, in the Boardroom, Washington Suite, Worthing Hospital. I would urge anyone wishing to keep in touch with Trust news and dates of future events to become a member of the Foundation Trust. Please follow the link on our website. Members automatically receive our monthly e-newsletter called @westernsussex.
3. Our People
Employees of the Month Employees of the Month can be nominated by patients, visitors or staff. Winners receive £50, a letter of commendation on their HR file and an invitation to the trust’s annual staff recognition awards. • Nicole Jones - Congratulations to staff nurse Nicole Jones on Fishbourne ward at St Richard’s who was nominated by ward manager Sophie Wright for being a fantastic new addition to their team and always being enthusiastic, caring and flexible to help others. • Julie Emery - Congratulations to head and neck clinical nurse specialist Julie Emery who was nominated by Macmillan dietitian Carolyn Stapely who commended Julie’s compassion and empathy for patients and their loved ones and how this was particularly demonstrated in the support she gave to a family whose relative had passed away unexpectedly following their operation. • Lisa Simmons – Congratulations to housekeeper Lisa Simmons who was nominated by housekeeping manager Gill Sorrell for her excellent commitment to patient care and going above and beyond for mums-to-be and their families in the maternity department in Worthing Hospital.
Apprentices Our apprenticeship programme continues to grow with more than 50 trust apprentices invited to our awards events at St Richard’s and Worthing in April. Six higher level apprentices were also invited to a special graduation ceremony held in Chichester Cathedral during National Apprenticeship Week (5-9 March 2018). Congratulations to: • Steph Berry (Occupational Therapy assistant apprentice) Level 3 Allied Healthcare • Joanne Hauffe (Widening Participation Lead) Level 5 Management • Chloe Lambourne (Apprentice Administrator) Level 3 Business and Administration • Gina Waldron (Finance apprentice) Level 3 AAT • Jessica Smethurst (Finance Apprentice) Level 3 AAT • Scott Newman (Apprentice Administrator) Level 3 Procurement
Welcome to new colleagues Dr Samy Sadek, Consultant in Emergency Medicine (Worthing) – Start date: 1 May 2018 Dr Andrew Ghabbour, Fixed Term Consultant in Diabetes and Endocrinology (Worthing) – Start date 26 March 2018 Dr Deirdre O’Callaghan, Fixed Term Consultant in Dermatology (Cross-site) – Start date 7 February 2018 Dr George Jacob, Consultant in Radiology (Chichester) – start date 1 April 2018 Dr Sheetal Gagrani, Consultant in Radiology (Worthing) – start date 1 May 2018 Dr Konstantina Boulougouri, Consultant in Radiology (Worthing) – start date 14 August 2018 Dr Osman Taha Nemeri, Consultant in Stroke Medicine (Chichester) – start date 1 September 2018
New chief operating officer Jayne Black, our new chief operating officer started on Monday 16 April and has been getting to know colleagues and the organisation before taking on full responsibility for the COO role at the beginning of May. A nurse by background, Jayne joins us from Croydon Health Services, a joint provider of acute and community services where she has been Deputy Chief Executive and Chief Operating Officer. We offer a warm welcome to Jayne and sincerely thank Jane Farrell for her invaluable support over these past few months as interim chief operating officer. We wish her all the very best for the future.
Patient First Board Report – April 2018
True North
Family and Friends Budget HSMR Patient Safety Referral to A&E 4 Hours Staff Score Management Thermometer Treatment Time Engagement
Breakthrough Arrows indicate: Objectives Reduce the Reduce MFFD Reduce the Staff are able to Metrics improving numbers of Falls Delays amount of make Premium rate Improvements Metrics stable spend Metrics worsening
Strategic Achieving target/project on track Initiatives
Patient First Sustainability & Outpatient Workforce Not achieving target/not on track Improvement Transformation Transformation Transformation Programme Plan
Corporate Projects
WS Eye Care @ CWS MSK Junior Doctor Clinical Document Acute Surgical Pathology LIMS Southlands Integrated Contract Management Review Services Portal True North
Owner : Nicola Ranger Status is AMBER and IMPROVING Friends What are we trying to achieve? What is it important to know? and Family Friends and Family Test - Positive Recommendation rate % • High Recommendation rates have been • Aim to achieve rates >97% positive 100% Target, Score sustained across the following areas: recommendation 97% 95% Inpatients =97% • Not to exceed 0.7% of not outpatients = 97% recommended 90% Maternity birth = 98%. • Achieve response rate of >40% for • Recommendation rate for A&E remains 85% inpatients Apr-15 Aug-15 Dec-15 Apr-16 Aug-16 Dec-16 Apr-17 Aug-17 Dec-17 consistent at 87% source: Dr Foster
What’s gone well? What are the current challenges? What are we doing about them? • Maternity (birth) FFT performance • A&E response rate has increased by • Implementing PDSA cycles to achieved true north in March 2% since February. address themes of poor patient experience
Patient
A&E What are the Organisational Risks? How are we managing them? Board Assurance Risk Score • As a result of patients having a • Monthly meetings will commence in 7 4 Hours Target M1 M2 M3 M4 poor experience we incur adverse clinical areas in May to support the 6 9 7 7 8 feedback which impacts on our teams to deliver improvements in Friends and Family Test scores patient experience. M5 M6 M7 M8 M9 7 7 6 6 7 M10 M11 M12 6 6 6
True North
Owner : Karen Geoghegan Status is RED and STABLE
Budget What are we trying to achieve? What is it important to know? Management • The Trust is required to deliver its Financial Variance From Budget (£000s) • In January, the Trust revised its financial plan of £3.4m surplus in 3,000 forecast out-turn to £0.6m surplus, order to fund service excluding STF and any impact from developments and ensure the 2016/17 income dispute. The sustainability (2,000) Trust is reporting an out-turn of • Delivery of the financial plan £0.6m surplus in line with the enables the Trust to access the STF revised forecast. income. A total of £11.6m is (7,000) • Including the resolution of the available to the Trust. Apr-15 Aug-15 Dec-15 Apr-16 Aug-16 Dec-16 Apr-17 Aug-17 Dec-17 16/17 income dispute and STF • Metric is variance to financial plan. income the Trust has achieved a control total surplus of £4.2m for 2017/18.
What’s gone well? What are the current challenges? What are we doing about them? • The Trust delivered its revised • Impact of heightened seasonal demand • De-escalation plans to be agreed forecast. and operational pressures on capacity and • 2018/19 budgets have been set to • £6.5m of STF income has been staffing. deliver expected activity levels in secured as a result of financial and 2018/19. operational performance in Q1- Sustainability Q3.
What are the Organisational Risks? How are we managing them? Board Assurance Risk Score • Local health economy • Close working with commissioners sustainability and ability of through aligned incentives Target M1 M2 M3 M4 commissioners to afford activity approach. 12 20 20 20 20 levels. • Delivery of efficiency and M5 M6 M7 M8 M9 • Achievement of the financial transformation schemes., overseen 20 20 20 20 20 control total in order to be eligible by Efficiency and Workforce to receive STF income Steering Group. M10 M11 M12 20 20 20 True North
Owner : Denise Farmer Status is GREEN and STABLE Staff What are we trying to achieve? What is it important to know? Engagement This image cannot currently be displayed. Ensure that all staff are fully engaged • Overall Staff engagement increased to Score in the work of the Trust. Three key Highest (best) 20% of Acute Trusts elements: • Ranked in the highest (best) 20% of 1. Able to make improvements Acute Trusts in 7 key findings 2. Healthy culture • Staff Survey overall engagement score 3. Motivation at work remains the same from 2016 at 3.88 • Best Trust scores to date - positive results overall inc. recommend place to work/receive treatment, H&WB, team working
What are we doing about them? What’s gone well? What are the current challenges? • Promoting results across the Trust • Response to staff survey 2017 increased • Medical engagement remains low • Compare National results People by 7% to 66% • Violence, Harassment & Bullying • A3 refresh on breakthrough objective • Communications strategy for staff survey remains a concern • Leadership Academy within facilities and estates – 3 sessions now completed
Board Assurance Risk Score
What are the Organisational Risks? How are we managing them? Target M1 M2 M3 M4 • Operational pressures and • Divisional SDR focus on improving 12 9 9 9 9 available capacity impact on staff engagement M5 M6 M7 M8 M9 availability to engage • Analyse bespoke questions obtained 9 9 9 9 9 • Dissonance in organisational on Violence & Aggression and values and staff experience complete A3 by end April M12 M10 M11 9 9 9
True North
Owner : George Findlay Status is GREEN and STABLE
What is it important to know? What are we trying to achieve? • HSMR is 88.1 (12mths to December HSMR • Reduce the mortality rate for non- Hospital Standardised Mortality Ratio 100 2017) with 1842 observed vs 2091 elective patients, we want to 95 Most expected deaths reduce the number of potentially recent • WSHFT HMSR is on the 16th avoidable deaths. 90 Nat. 20th percentile percentile • To be in top 20% of trusts as 85 *, 90 • HSMR by site SRH 84.2/ WH 91.5 measured by Dr Foster 80 • March’s crude mortality rate was • To learn from all deaths occurring 3.52%, slightly higher than last year at WSHFT and improve end of life source: Dr Foster 3.46% and ytd 3.10% (limit set at care 3.13%) What are the current challenges? • Continuing to achieve the sepsis
What’s gone well? bundle & antibiotic administration • First report to public board took < 1 h over the winter place in January 17 • Full implementation of the the What are we doing about them?
• Consultant screening reviews have Structured Judgement Mortality • Increasing the workload of SJR’s Quality reviewed 85% of deaths since and starting panel reviews Case Note review (SMR) tool for Improvement inception targeted cases. • Including End of Life Business case • Five mortality reviewers have • Responding to the learning points in core division service priorities been trained and started work in emerging from the reviews e.g. for 2018/19 January 2018. earlier recognition of end of life care needs.
What are the Organisational Risks? Board Assurance Risk Score • Mortality reviews highlight How are we managing them? patients with delays in Target M1 M2 M3 M4 • Detailed Dr Foster monthly reports recognition and issues meeting 9 9 9 9 9 shared with divisions and oversight end of life care needs. via Quality Board M5 M6 M7 M8 M9 • Achieving the required volume of 9 9 9 9 9 • Mortality Steering Group SJ reviews implementing process for review of M10 M11 M12
all deaths and additional oversight 9 9 9
True North March 2018
Owner : Nicola Ranger Status is RED and STABLE What are we trying to achieve? Patient Safety • Reduce the number of patients What is it important to know? Patient Safety Thermometer - % Patients with no new Thermometer coming to harm during their stay 100% harms
in WSHFT, this can impact on • 97.51% no new harms this month, a Target, 99% wellbeing, length of stay and decrease on February 2018. and 95% below our goal of 99% harm free care. recommendation. .
Harm is measured monthly using % Patients audited • the National Safety Thermometer. 90% Apr-15 Sep-15 Feb-16 Jul-16 Dec-16 May-17 Oct-17 Mar-18 d li d What are we doing about them? What’s gone well? • Pressure Ulcer Improvement workshops has What are the current challenges? • Zero CAUTI’s reported on safety taken place , supported by the Kaizen Team to revise the Trust and local A3 plans, to
thermometer day • Hospital acquired Pressure Injury revisit the data and challenge current • 5 out of 9 reported pressure injuries were
continues to be the biggest contributor approaches. Work streams are being found to have no lapses in care. to harms on the safety thermometer. undertaken by the Divisions and the Harm • 4 out of 6 reported VTE’s were deemed • Validation of falls, highlights the lack of Free Care team to address identified areas unavoidable. for improvement. postural blood pressure recording. Quality • The recording of postural blood pressure monitoring will become a mandatory Improvement assessment on Patientrack. What are the Organisational Risks? • Prompt cards have been redistributed t the • Safety Thermometer is a once a Divisions and training is provided. month prevalence measure and only measures 4 harms on that day. Board Assurance Risk Score • Falls • Pressure Damage Target M1 M2 M3 M4 • Catheter associated urinary tract How are we managing them? 8 12 12 12 12 infections (CA-UTI’s) • All harms reported via Datix system. • Venous Thromboembolism . (VTE’s) M5 M6 M7 M8 • Oversight of all harms via M9 12 12 12 12 Triangulation Committee. 12
M10 M11 M12 12 12 12 True North
Owner : Pete Landstrom Status is RED and STABLE Referral to Treatment What are we trying to achieve? What is it important to know? Times • Reduce the number of patients • Achieved 85% <18 wks for March. waiting an unacceptable time for • The Trust was non-compliant with elective treatments and National target and below the 17/18 appointments which leads to a STF trajectory. poor patient experience. • 12 specialties were non compliant • Metric is percentage of patient pathways completed in less than
18 weeks.
What are the current challenges? What’s gone well? What are we doing about them? • Emergency demand requiring planned • Continued compliance for women • Alongside the surgical plan for reduction of elective inpatient activity, ophthalmology the Trust has a & children and core services maintaining cancer and urgent elective sustainability plan for all specialties. divisions. throughput • Increase in patients waiting over 18 weeks • Focus is on recovery but within funded March (+747 patients) capacity, and avoiding high cost premium solutions. • Specific ophthalmology and Systems Partnerships and Systems What are the Organisational Risks? How are we managing them? orthopaedic review/ actions with • Activity and pathway management A&E • Increased volumes, reduced flow, executive and clinical leads programme in place tracking 4 Hours and non-delivery of activity volumes lead to a poor patient speciality level delivery . Board Assurance Risk Score • Weekly specialty level improvement experience and waiting times. and recovery review with DDOs and Target M1 M2 M3 M4 • Failure to achieve National RTT Divisions. 9 12 12 12 12 18wk constitutional target. • Executive led ophthalmology M5 M6 M7 M8 recovery plans 12 12 12 12 • Orthopaedic productivity focus. M9 M10 M11 M12 12 12 12 12 True North
Owner : Pete Landstrom Status is RED and STABLE A&E 4 Hour What are we trying to achieve? What is it important to know? Waiting • Demands in the urgent care • A&E attendances 3.5% higher than Times system lead to patient flow being same period Feb-17 compromised and poor patient • Over 65 emergency admissions experience. increased by 12.8% compared to • Metric is percentage of patients March 2017, whilst over 85s attending A&E seen within 4 hours increased by 19.2% in comparison to - aiming to achieve 95% within 4
the preceding year. hours.
What’s gone well? What are the current challenges? • 90.0% compliance despite significant • Bed Occupancy remained high in What are we doing about them? operational demand pressures March 97% Worthing, 94.1% SRH. • Focus has been on improving flow • Medically Fit for Discharge patients The Trust flexes beds according to • A revised bed plan for 17/18 has on average 159 patients per day need where possible. March (-9 per day compared to Feb) been developed by Medicine and • Formally Delayed Discharges 2.99% Surgery Divisions. March compared to 3.14% Feb-17
Systems Partnerships and Systems A&E What are the Organisational Risks? How are we managing them? 4 Hours • Changes to system wide capacity • A&E 4hr position discussed through increases demand on hospital services Strategy Deployment Room and A&E Board Assurance Risk Score and impacts on A&E delivery and Delivery Board. Target M1 M2 M3 M4 potential failure to meet STF metrics. • System wide Resilience Plan and 8 9 8 9 9 • Highly reliant on temporary staffing performance to be monitored with possible shortfalls impacting through A&E Delivery Board. M5 M6 M7 M8 9 8 9 12 pressures on existing staff. • Daily escalation and monitoring. • Ward discharge by midday project M9 M10 M11 M12 focus 12 12 12 12
Breakthrough Objectives
Owner : George Findlay March 2018 Status is RED and STABLE Reduce the What is it important to know? Number of What are we trying to achieve? Number of Falls 230 Falls • Reduce the number of • There were 159 falls this month, 120 patients that fall in our Trust. 180 resulted in no harm. This causes harm and has an Target (30% impact on length of stay and 130 reduction), • Actual falls have decreased year on our reputation. 130 year . 2017 saw 1707, compared to 80 2148 in 2016 • Falls are measured Apr-16 Jul-16 Oct-16 Jan-17 Apr-17 Jul-17 Oct-17 Jan-18
continuously via Datix. source: Dr Foster
What are the current challenges?
What’s gone well? • Bay watch and bay working How are we managing them? • The surgical division has seen two requires further embedding • All harms reported via Datix system. consecutive months of lower falls. across all wards. Oversight of all harms via Weekly intensive ‘SWARM’ deep dive • Due to existing co-morbidities and Triangulation Committee. frailty the deconditioning of our meetings continue to be undertaken. The Quality matrons and ward sisters promote team patients remains a risk. Improvement discussion, wider learning and obtain a What are we doing about them? full understanding of the patient fell. • To replicate the deep dive meetings within Overall since the programme began we the Medical Division. have seen a 32% reduction in falls and • Weekly meeting to identify areas that require Board Assurance Risk Score 24% reduction in falls causing significant extra support, and discuss themes. harm • During April 2018 a meeting will be held to reintroduce and embed the concept of Target M1 M2 M3 M4 Baywatch/Bayworking and SWARM within 9 9 12 12 12 clinical areas. M5 M6 • The National campaign to raise awareness M8 12 9 M7 M9 What are the Organisational Risks? about the deconditioning of our patients is 12 12 12 • Focus on falls prevention could being reflected throughout the Trust with all result in other types of harm members of the multidisciplinary teams.
increasing. M12 M10 M11 12 12 9
Breakthrough Objectives
Owner : Pete Landstrom Status is RED and STABLE Reduce MFFD What are we trying to achieve? What is it important to know? Delays • Reduce the number of patients in • MFFD average patient days our hospitals that are medically fit reduced to 1,304 in March for discharge. (compared with 1495 February) • MFFD patients in hospital beds can • Numbers of delayed pts varied compromise patient flow, and between 116 on 25th March to impact on A&E wait and LOS. 198 on 6th March. • Metric is to reduce average
patient days delayed by 50% .
What’s gone well? What are the current challenges? What are we doing about them? • Average A&E demand greater than • Agreed National Funding to support same period 2017 (+3.5%) • Trust occupancy 95.7% on average increased resilience schemes for • DTOC patients reduced to 2.99% midnight Mar-17 (97% Worthing, 94.2% CWS including 25 additional from 3.14% Feb and 3.16% March SRH) community beds 2017 • Average A&E demand greater than • Senior Management ward buddies • Reduction in average MFFD per same period 2017 (+3.5%) implemented to support Board day to 159 average Trust wide Rounds and discharge flow including Mar-18 compared with 158 launch of ‘Early Bird’ patient Partnerships and Systems discharges to lounge before 9am A&E preceding month 4 Hours What are the Organisational Risks? How are we managing them? • Failure to reduce MFFD patients • Weekly MFFD multi agency Board Assurance Risk Score occupying acute hospital beds meetings on both acute sites as per Target M1 M2 M3 M4 adversely impacts delivery of A&E national recommendations. 9 9 9 9 9 and elective targets. • Daily Board Round collection of • Patients own health and wellbeing delays and next step information by M5 M6 M7 M8 9 9 9 12 can be compromised by staying in Discharge Team Daily SITREP hospital longer than required. reporting of formal DTOC patient M9 M10 M11 M12 numbers and reasons. 12 12 12 12
Breakthrough Objectives
Reduce the Owner : Karen Geoghegan Status is GREEN and STABLE amount of What are we trying to achieve? What is it important to know? premium Agency Spend (£000s) rate pay • Reduce the amount spent on 5,000 • Premium pay expenditure is £3.9m premium rate workforce solutions 3,000 below target at the end of financial spend • Remain within the agency ceiling year. 1,000 set by NHS Improvement. • Total agency expenditure for • Reduce medical agency (1,000) 2017/18 was £12.9m,£4.4m lower expenditure by £1.0m compared (3,000) than the agency ceiling. to 2016/17 in line with target set (5,000) • The agency ceiling will reduce to by NHSI. Apr-17 Jun-17 Aug-17 Oct-17 Dec-17 Feb-18 £14.9m in 2018/19.
What are the current challenges? What are we doing about them? What’s gone well? • No reduction in medical agency • Bilateral meetings to review key • Sustained reduction in nursing expenditure compared to 2016/17 areas of spend and exit plans for agency, spend in 2017/18 has • Improving cap compliance medical agency. reduced by more than 50% particularly within medical • Regular reporting and review,
compared to 2016/17. placements. including Chief Executive approval, Sustainability • Reduction in total agency spend of • Delivery of elective waiting times of high cost and long-term over 30% compared to 2016/17. without increasing reliance on WLI placements. payments. • Establishment of Medical Workforce Action Group.
What are the Organisational Risks? How are we managing them? Board Assurance Risk Score • Premium rate pay expenditure is • Weekly reporting of agency spend unsustainable and Trust is unable at Executive Agency Review Target M1 M2 M3 M4 to deliver I&E control total and Meeting. 9 12 12 12 12 therefore not able to access • Targeted divisional focus through M5 M6 M7 M8 M9 Sustainability and Transformation strategy deployment. 12 12 8 8 8 fund. • Weekly scrutiny of agency spend M10 M11 M12 against overall ceiling trajectory 8 8 8 plan.
Breakthrough Objectives
Owner : Denise Farmer Status is GREEN and IMPROVING Staff are able to make What are we trying to achieve? What is it important to know? improvements • Enable staff to have the • Staff survey 2017 results show opportunities, tools and support improvement in Q4d up by 2% to 57%. to identify and make Average for acute trusts 56% improvements in their area of • Results by Key Finding 1, 4 & 7 now work available at divisional. Department, team and cost centre level
What’s gone well? What are the current challenges? What are we doing about them? • SDR process in divisions with • Understanding what’s • Communicating staff survey results engagement as a driver metric underpinning variation in monthly through posters of top 5, bottom 5 • Roll out of improvement huddles in results findings non-clinical areas • Analysing Q4d by cost centre People • Refresh A3 supporting staff able to make improvements
What are the Organisational Risks? How are we managing them? A&E Board Assurance Risk Score • Roll out of PFIS to clinical areas • Continuing roll out of PFIS inc. women and 4 Hours risks disengaging some groups of children’s division staff • Extending improvement huddles in non-clinical Target M1 M2 M3 M4 areas – estates and facilities at St Richards 12 9 9 9 9 M9 M5 M6 M7 M8 9 9 9 9 9
M10 M11 M12 9 9 9
Strategic Initiatives
What are we trying to achieve? How are we doing? What is important to know?
Owner: Anil Mathew • Patient First presentation shared at “Lean Process Excellence • Development of continuous Conference” with global Patient improvement (Kaizen) Strategy that organisations including BP, LEGO, First supports True North and Patient UBS Bank, BBC, Siemens – First objectives within the Trust to impressed with our approach, Patient empower staff to solve problems lean methodology and successes and make improvements. to date
• To ensure all staff have knowledge, • This months Yellow Belt training at SRH (day 2) has finished - with positive skills to participate in Lean based 426 improvement activities in helping feedback from our staff. Capacity • Some YB trainees have identified “early and to build a culture of continuous improvement in supporting True discharge of Patients”, and “improving
Capability People North and objectives of Patient 29 accuracy of EDD” as projects to work on First as part of YB.
• Kaizen Team currently providing coaching
• The Lean Improvement Projects and support for the new “Putting Patients are assigned to the Kaizen Team First for earlier discharges home” – with who provide coaching and Lean full Exec support and buy-in to the mentoring, A3 approach and Insert project approach. Projects Problem Solving working within a New Project Huddle Board created as Quality collaborative team environment •
part of the weekly team review with Exec Improvement & Project Leads in attendance
• PFIS Wave 8 at SRH has started for GDU, • Lean management systems (PFIS) 37 W5 (4) implemented across the whole PreOp, Delivery, Tangmere, Ashling, Ford, Day
organisation with full support and Surgery, Goodwood Lounge PFIS engagement from all teams, • Coaching and Mentoring continues in line with operationalised to the required implementation plan & schedules with agreed Quality standard to enable staff to make Driver & Watch Metrics in place to align with improvements SDR / Divisions Improvement Strategic Initiatives
Owner: Andy Gray Sustainability What are we trying to achieve? How are we doing? What is important to know? and • Deliver a system wide plan to deliver • The Trust continues to engage with • New STP Chair appointed. Initial
Transformation the 5 year forward view and close gaps range of STP forum meeting held with Chief Executive. Plan in health and wellbeing, care and quality • Trust continues to support CCG in and finance across Sussex and East
developing Local Community Patient Surrey. Networks as outlined within ‘Inspiring Healthier Communities’
What are we trying to achieve? How are we doing? What is important to know? • A population based approach for Coastal • Development of Local Community • CCG Considering future options and West Sussex delivered through increasing Networks being led by CCG and models. Commitment to Place Based Coastal Care integration in order to improve standards, receiving good engagement. Plan remains. manage demand and make the system financially sustainable. • Strategy includes Health and Social Care. Sustainability
What are we trying to achieve? How are we doing? What is important to know? • Ensure the provision of high quality stroke • CWS CCG and WSHFT have • CCG & WSHFT are in process of
Stroke services meeting the National Stroke collaborated to implement the agreeing a joint Reconfiguration Strategy 2007 clinical standards activity, bed capacity and financial recommendation which will to • Sussex-wide review of Stroke Services analysis re-work recommended by take into account the STP
supported by the Sussex Collaborative Clinical Senate planning process Quality
Delivery Team and funded by the seven Improvement Sussex Clinical Commissioning Groups Strategic Initiatives
Owner: George Findlay What is important to know? What are we trying to achieve? • Programme priorities being delivered predominantly to plan. Text reminder pilot • To improve every outpatient demonstrated to be successful, implementation Outpatient appointment interaction Transformation pending business case to demonstrate cost • To improve patient experience neutral. Patient and simultaneously make the • Docman well received by specialties and best use of Trust resources implementation in final stage
What are we trying to achieve? What is important to know?
• Once a referral is received, • 86.4% of referrals registered within 2 working manual processes are needed. days year to date – target 80%. Time taken to Achieving best practice could • Docman referral management system process reduce the time taken to implementation in final stage – anticipated completion April 2018 referrals manage and grade referrals by • Development work with NHS Digital ongoing to Sustainability an average of 8 days prepare for ‘Paper Switch Off’ by 1.10.18
What are we trying to achieve? What is important to know
• This transformational programme • March 2018 DNA rate plateaued to 6.30% from will support specialties to review 5.59% low in November 2017 Demand and clinic capacity . We anticipate this • DNA target 5.4% by 31.03.2018 – to achieve top Capacity will reduce on-day delays and 10% nationally. • SMS pilot demonstrated effectiveness to support improve overall capacity to see business case development. Systems and Systems more patients with the same • Expected SMS go-live Q1 2018/19 subject to Partnerships resource. approval
What are we trying to achieve? What is important to know?
• When patients come to our • March 2018 recommend rate compliant at Outpatients, they are waiting 97.1%. 7/12 months above 97% target. Patient on- too long to be seen. Our • March 2018 response rate compliant at 7%. 9/12 site waiting objective is to reduce these months above 6.5% target. times • Analysis of patient feedback continuous to inform Quality waiting times - prioritising future actions specialties with longer waits Improvement Strategic Initiatives
Owner: Denise Farmer
Workforce What are we trying to achieve? How are we doing? What is important to know? Transformation • To develop and maintain a robust • Nursing spend continues to decrease, • Staff vacancies remain around 9%, medical workforce, including creation with agency reliance now at lowest with a slightly improved turnover as of new and/or alternate roles to levels for the past year. Cap we move into Q4 mitigate recruitment challenges and compliance fluctuates around 50% as • Challenges from higher rates offered reduce reliance on agency we balance fill of escalation shifts by neighbouring Trusts continues to • Market manage agencies to ensure during winter pressure with notice impact on our ability to fill temporary consistency and quality of supply at offered to above-cap agencies
shifts People cost-effective rates, and to work • Medical workforce spend remains • Continued roll-out of HR IT systems towards full cap compliance against run-rate in 2017, with will provide increased visibility on job • To maximise opportunities from continued difficulties in recruitment planning, junior doctor rostering and substantive workforce, including into medical workforce vacancies; part annual leave, improved recruitment, retention and mitigation achieved through • Full Safe Care compliance is now staff management development of alternate roles forecast for 1st April 2018 West Sussex Southlands Eye @ Care
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M9 M4 6 2
Patient Corporate Projects
Owner: Marianne Griffiths MSK Programme High level Milestones - Updated Sept 2017 Target Date Action Completeness CWS MSK What are we trying to achieve? What is important to know? Jul-16 Develop detailed plans for triage and treatment service 100% Improved patient outcomes, shorten Discussions relating to integrated Integrated Jul-16 Present work to date to CCG 100% • waiting times & control health economy Service Aug-16 Develop Early Implementation and Change Control process 100% models of care, collaboration and costs by: Aug-16 Develop Locality Plan and Iitemise Service Changes 100% progressing MSK are ongoing. • Redesigning MSK Pathways for Aug-16 Response from CCG to contract negotiation Still awaiting These will continue in the context elective and outpatient care Dec-16 Partnership MOU and NDA in place 100% of the Aligned Incentive Contract. • Lead on delivering an integrated Feb-17 Introduce GP Pilot and Triage and Treatment Service 100% • The upgrade of the Physiotherapy service collaboratively with SCFT & Feb-17 Clinical Information System implementation commenced Investment TBD Department in Worthing Hospital rd
3 parties. Apr-17 Colocated MDT hubs in place at Worthing and Pulborough Investment TBD to support the MSK redesign plan May-17 Develop detailed plans for specialist MDT pathways not started is complete. Jun-17 Self management service commences (subject to contract) not started Oct-17 Bognor and Southlands Hubs and all MDTs fully operational not started Systems and Systems Partnerships Key Risks: Mitigations: • Significant loss of staff engagement • Dialogue between SCFT and WSHT at Target M1 M2 M3 M4 and momentum due to ongoing delays operational and executive level to 8 20 20 20 20 in start of the full MSK redesign Integrate care on several programme programmes of work and ensure M5 M6 M7 M8 M9 20 20 20 20 20 • The central MSK programme team priorities are aligned.
within WSHFT has no staff in post following the promotion of the Project M10 M11 M12 Manager within SCFT. 20 20 20 Junior Doctor Junior Doctor Contract Contract Corporate Projects
Roll-Out Owner: Ian Arbuthnot Action Progress Timeframes
Clinical Document What are we trying to achieve? What is important to know? Management • All patient records to be Apr 18 Roll-out to Upper GI In progress 1. The successful upgrade to Evolve 3.7 Portal paperlight at WSHFT by 2020 / General Surgery took place over the weekend of Patient 23/24 March. This will enable the team to enhance functionality for End Apr / beginning Roll-out to Paediatric On track clinical staff. May 18 IP Wards, both sites 2. Statistics since go live to end March 2018:
• 3,927 staff trained to date • 2,047 active system users May 18 Roll-out to On track • 49,412 completed e-Forms to Patient Colorectal OP date.
Mitigations: Key Risks: • Work is prioritised and completed • Project is under resourced across all teams, Target M1 M2 M3 M4 within the team’s capacity. In addition, with a lack of the necessary skill mix to 9 9 9 9 9 BAU teams are being upskilled to meet achieve results in a timely manner to meet requirements. project timescales. • Investigate areas with less operational M5 M6 M7 M8 M9 • Operational Pressures and in some areas a pressures. Liaison with services to 9 9 9 9 9 resistance to change, may mean that minimise the resistance. Where agreed project timescales will not be met. M10 M11 reluctance persists, to be escalated to 9 the Project Board. 9
Clinical Portal Corporate Projects
Owner: George Findlay
How are we doing? What is important to know? Acute Surgical • Review is complete – 16 recommendations • No major reconfiguration required at this Review What are we trying to achieve? • Report presented to Trust Board, TEC, joint time – not evidenced via the review. • Service review to ensure we are surgical governance meetings and physicians • Very clear view articulated via the listening operating emergency and urgent meeting. exercise – all of these viewed represented surgery across the St Richard’s and • Colorectal team now meeting weekly. in the recommendations. Worthing sites in the most • Joint polyp MDT commenced January 2018. • Some recommendations already effective way. • RMOs started in August to help under pin implemented and others merging to junior doctor shortages at WG. Full review of reduce recommendations and manage jnr dr workforce to take place Q4 17/18. project more effectively. • 2 emergency consultant surgeons now • 2 outstanding recommendations relating to appointed at WG. centralisation agenda for Breast and • Improved data quality and project level KPI Urology part of the 1819 Surgery
dashboards progressing as part of the 1819 Improvement Strategy Corporate Project Surgery Improvement Strategy • Project Resource Plan progressing to
resource a the increase in scope for surgery Patient delivery in 1819
Key Risks: Mitigations: • Risk of lack of engagement by staff. • Communication and engagement • Data analysis must be robust – tight plans in place to communicate Target M1 M2 M3 M4 timeframe to complete this work. outcome – complete. 6 6 6 6 6 • Risk outcome may not be accepted by • Project governance further M5 M6 M7 M8 M9 surgeons who feel the review has take supported by PMO. 8 8 6 6 6 too long and not addressed key issues. • Key recommendations to try and • Some concerns around overnight address concerns of clinicians – M10 workload for RMOs and Jnr Drs. some like cross site working may 6 Subject to full review by DDO/CoS. not be popular but deemed necessary for cross collegiate working to improve .
Corporate Projects
Owner: Pete Landstrom
What are we trying to achieve? What is important to know? Pathology How are we doing? • Install a new laboratory information • To ensure clinical safety, go-live date • Additional staff will be required to facilitate LIMS management system (Winpath) and has been moved to 14th May 2018. the dual running and double data entry order comms system (Cyberlab) as part • Project Board satisfied with progress. period of the cutover. The majority of whom of the Abbott pathology managed Risks reduced due to closure of P1 will be existing Trust staff working additional equipment service which will support issues, so downgrading risk rating to hours. full service integration and delivery of Amber. the process and workforce efficiencies • A discrete training system has been provided • User Acceptance Testing (UAT) 100% associated with the planned automated complete for WinPath (LIMS). to allow training to continue at pace and hot and cold site lab configuration for • GP testing of CyberLab (Order Comms) during periods of main system unavailability. WSHFT. 100% complete. • Data Take On complete with Blood • Weekly communications are going out to Transfusion & Cellpath data merged, GPs. tested and accepted. • Training progressing to plan and will be completed prior to go-live. Patient
Key Risks: Mitigations: • There is a risk that transition period • Recruitment has begun and people activities may be hampered by have already stepped forward, offering delays in recruiting appropriately their support. qualified staff. • Business case is being prepared to • There is a risk that transition period secure funding. activities may be hampered by delays in securing funding.
To: Quality Board Date of Meeting: April 2018 Agenda Item: 6.1
Title Month 12 (March), 2017/18 Monthly Quality Report
Responsible Executive Director Dr George Findlay (Chief Medical Officer) and Nicola Ranger (Chief Nurse)
Prepared by Jo Habben (Head of Clinical Governance and Patient Safety)
Status Disclosable
Summary of Proposal Not applicable
Implications for Quality of Care Describes performance against quality outcome KPIs, including safety, infection control, experience, effectiveness and mortality.
Link to Strategic Objectives/Board Assurance Framework This report pulls together key national, regional and local quality indicators relating to quality and safety providing assurance for the Board and (if necessary) highlighting issues.
Financial Implications Describes KPIs that have potential financial impact (e.g. CQUIN.)
Human Resource Implications Describes KPIs linked to workforce.
Recommendation The Board is asked to: Note the contents of this report.
Communication and Consultation Not applicable
Appendices Appendix 1: Quality Scorecard Appendix 2: Ward Staffing Scorecard Appendix 3: Night moves summary report Appendix 4: NICE Update
1 INTRODUCTION 1.1 This report brings together key national, regional and local indicators relating to quality, performance and safety. The purpose of the report is to bring to the attention of the Trust Board quality performance within Western Sussex Hospitals Foundation Trust (WSHFT).
1.2 The paper describes performance on an exceptional basis determined by RAG (red/amber/green) ratings based on national, regional or local targets.
2 2017/18 REFRESH 2.1 There will be a refresh of the Monthly Quality Report for 2017/18 to reflect the key quality objectives for the next year aligned to Patient First and our True North objective1, the Trust is currently working on an updated scorecard for 2018/19 which will include the streamlining of a number of metrics and all metrics being available at site level. For now however, the report follows the same format as previously using the same suite of metrics, with revised targets using similar logic in the interim to that applied for 2016/17:-
• If 2016/17 performance exceeded target, then 2016/17 actuals used as 2017/18 target • If 2016/17 performance did not meet target then 2016/17 target remains the same for 2017/18 • If there is a national or set target then that will continue as the measure • Any metrics with no target set continue as before
2.2 The new scorecard is in development and will incorporate a more extensive range of metrics and targets.
3 KEY QUALITY OBJECTIVES 3.1 Scorecard Definitions
3.1.1 The full Clinical Quality Scorecard is presented as Appendix 1. Figures are in-month figures (e.g. the number of falls reported in March) unless otherwise stated. The scorecard shows 13 months to allow trends to be identified, although some data items are reported retrospectively. Year to date actuals/targets are based on financial years unless otherwise stated (standardised mortality ratios are recorded as 12 month positions for example). A subset of the key measures from the report is presented at 3.3. These remain the same sub-set as last year and will be refreshed when the new scorecard is established.
3.1.2 Exception reports are included under the relevant section of this report (Effectiveness, Safety and Patient Experience).
1 Patient First is our long term approach to transforming services. ‘True North’ is the one constant towards which the four strategic themes for the organisation – sustainability, people, quality improvement and Systems & partnerships – should lead. 1 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety 3.1.3 Although the scorecard reflects 13 months of data, only the current financial year and year to date values are RAG rated - with the exception of those metrics reported in arrears where the most recent data-point of last year is RAG rated.
3.2 Domain scores 3.2.1 The score is an overall indication of the performance in relation to each of the domains - Effectiveness, Safety and Patient Experience. The score is calculated as follows: Each RAG rated indicator for a month is scored: red scores 1, amber scores 2, green scores 3. These scores are then totalled and divided by the total number of indicators with RAG ratings to give a score for the domain as a whole between 1 and 3. This final score can then itself be RAG rated with >2.5 giving an overall green, 1.5 to 2.5 amber and <1.5 an overall red score for the domain as a whole. For example if a domain had two greens and a red the calculation would be as follows: 3 (green) + 3 (green) + 1 (red) = 7 7 / 3 (i.e. the total number of metrics) = 2.33 i.e. amber overall.
3.2.2 Domain scores are calculated based on the year to date RAG ratings for each metric. Previous months are retrospectively updated to take account of any measures reported in arrears, and should additional metrics be added within the domain. As with any aggregate indicator, it remains essential that the Board retains sight of the individual elements as well as the domain score as a whole.
3.3 Overview of Key Quality Objectives 3.3.1 The following table shows performance against key quality objectives. Indicator Jan Feb March 2017/18 2017/18 2018 2018 2018 to date Target / limit Effectiveness Domain Score 2.22 2.30 2.47 2.52 2.5 Safety Domain Score 2.19 2.31 2.07 1.97 2.5 Experience Domain Score 2.52 2.48 2.32 2.39 2.5 E01 Trust crude mortality rate (non-elective) 4.25% 3.86% 3.52% 3.10% 3.13% E03 Hospital Standardised Mortality Ratio for 88.1 <92 top 56 diagnoses (Dr Foster, based on rolling 12 months) S06 Number of Serious Incidents Requiring 6 3 2 53 60 Investigation (number reported in month) S14 Numbers of hospital attributable MRSA 1 1 0 3 0 S28 Numbers of hospital C. diff where a 4 2 2 20 16 lapse in the quality of care was noted X38 The Friends and Family Test: 97.0% 97.0% 96.3% 96.7% 97% Percentage Recommending Inpatients X39 The Friends and Family Test: 88.0% 85.5% 87.4% 85.8% 93% Percentage Recommending A&E X13 Mixed Sex Accommodation breaches 0 0 0 0 0 (number of breaches) X18 Number of complaints 34 28 38 438 570
2 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety 4 EFFECTIVENESS
4. 1 Crude Trust Mortality
4.1.1 Due to the low level of mortality experienced in elective care, the Trust measures mortality in relation to non-elective activity using the previous year as a benchmark.
4.1.2 Crude non-elective mortality decreased from 3.86% in February to 3.52% in March, this is marginally higher than the equivalent month in 2017 (3.46%). Whilst this remains slightly higher than the normal limits associated with the seasonal variation in crude mortality the Trust continues on a positive downward trajectory from January’s reported peak at 4.25%. Screening data from the ‘Learning from Deaths’ process will also be examined carefully to check there has been no increase in reported problems.
4.1.3 The number of non-elective patients (Crude) who died in March was 219 (3.52%) from 6227 discharges. Worthing and Southlands reported 123 deaths of 3198 discharges (3.85%) and St Richards Hospital reported 96 deaths of 3029 discharges (3.17%). The year to date mortality rate is 3.10% and the rolling 12 month mortality rate is 3.11%. The limit for both measures is 3.13%.
4.2 Hospital Standardised Mortality Ratio (HSMR)
4.2.1 There is a delay in data being available in Dr Foster tools to allow for coding and processing by the Health and Social Care Information Centre and Dr Foster. The most recent data available is December 2017.
4.2.2 The Trust’s HSMR for the twelve months to December 2017 is 88.1 (1842 deaths against expected 2091) 100 is the level predicted by the Dr Foster model using the September 2017 benchmark.
4.2.3 The twelve month HSMR to December 2017 split by site continues to be lower for St Richard’s 84.2 (833 deaths against expected 899) than for Worthing and Southlands 91.5 (1010 deaths against expected 1104). The difference is marginally lower than the previous month and remains well within acceptable variation limits, with both sites remaining below 100.
4.2.4 E10. 30 day mortality rate following hip fracture – remains relatively static and in December 2017 was reported at 6.8% against target of 5.70%
4.2.6 A further report is available to clinical leaders in the Trust showing the clinical diagnostic areas with high actual versus expected mortality and any mortality CuSum alerts.
4.2.7 The Trust has set the goal of achieving a position within the top 20% of Trusts as measured by HSMR. For the twelve months to November 2017 performance using this measure continues to place us well within the top 20% of Trusts on the 16th centile.
3 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety 4.3 Summary Hospital-Level Mortality Indicator (SHMI)
4.3.1 The latest data made available by the Health and Social Care Information Centre is for the period to September 2017. The Trust value remains at 0.95 (where 1.00 is the national average), with the Trust banded as “as expected”.
4.4 Exception Reports Relating to Effectiveness
4.4.1 E13. C-Section rate- the Trust Caesarean Section rate from January to February remains static at 31.3% (28.5% YTD) against a target of 26.5%. Each case where a woman has a caesarean delivery undergoes a review process to look for learning opportunities. No systemic causes or trends have been identified and practice is very much in line with national recommendations for safe practice and NICE guidance. Increasing normal birth continues to be an area of focus for the division and rates are closely monitored via monthly divisional performance reviews.
4.4.3 E42. Night time moves in patients with a diagnosis of dementia. In March, 59 patients with a diagnosis of dementia were moved at night (between 23:00-07:00hrs), this is a rise from January when a total of 44 patients were moved at night. A detailed summary report is contained in Appendix 3.
4.4.4 The dementia team continues to monitor and record/audit the moves and the Kaizen work stream is not only focused on patients with a diagnosis of dementia but also any patient that is moved at night. Ongoing improvement work continues with representation from the Kaizen team, matrons, dementia matron, the site team and the clinical lead for the emergency floors.
4.4.5 E27. Stroke thrombolysis within 60 minutes of arrival (reported February) demonstrates a decrease in performance from January (66.7%) to 40.0% against a target of 95% (YTD actual 71.9%).
4.4.6 E30. The percentage of patients at high risk Transient Ischemic Attack (TIA) seen within 24 hours demonstrates a significant decrease from January (14.3%) to a 0% return in February. (YTD actual 15.1% against an annual target of 60%).
4.4.8 E28. Swallow screen for patients within 4 hours of admission- performance has increased in February to 85.4% (From January’s data 66.2%) against an annual target of 95% (YTD actual 85.7.%)
4.4.9 Trust performance for stroke continues with Worthing achieving a Sentinel Stroke National Audit Programme (SNAP) score of B, and Chichester a C (A being the highest score and E being the lowest). A recent Kaizen event was held to review the scores and the primary issue appeared to be the service provision out of hours. In Worthing there is an additional resource of a nurse who is responsible for assessing and transferring patients to the stroke unit, this post does not exist at present in Chichester (this is the main part of the business case for supporting 24/7 thrombolysis).
4 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety
4.4.10 Other main themes being looked at with the support from the Kaizen team include- transfer time to CT scan, time to transfer to the stroke unit and the provision of therapies.
4.4.11 In response to system pressures and at the request of the CCG, the Trust have devised a business case to support 24/7 thrombolysis on both sites. Subject to successful recruitment of the necessary nursing staff the Trust plans to implement this in Q1 2018.
4.5 Implementation of NICE guidance
4.5.1 Despite having a clear policy and process the Trust is currently experiencing difficulties in meeting its responsibilities related to the implementation of national guidance with a significant number not having been assessed or where the process, as outlined in the policy, has not been completed. This does not necessarily mean that clinicians are not discussing and using national guidance but that the Trust does not have the completed evidence that gives us assurance or an assessment of risk. This is particularly the case in medicine where the volume of guidance issued is significant. The attached report (Appendix 4) provides the detail.
4.6.2 Divisional progress against NICE is monitored through the quarterly divisional governance meetings and the divisions have been asked to prioritise the work related to NICE implementation in line with with the CQC Key Lines of Enquiry. Divisions have also been asked to assess the risk of the current backlog and add to the divisional risk registers accordingly.
5 SAFETY
5.1 Central Alert System (CAS) Safety Alerts
5.1.1 There are no outstanding alerts for the Trust up to March 2018.
5.2 Serious Incidents Requiring Investigation (SIRIs)
5.2.1 There were 2 reported incidents categorised as a Serious Incident (SI) requiring investigation in March. One patient fell and sustained a fractured neck of femur requiring further surgery; and one visitor fell on the stairwell at Worthing Hospital and sustained a fracture to his patella (knee) requiring admission and orthopedic surgery. A detailed serious incident report is provided to the committee section of the Trust board. The board should note there can be slight variation in the month-by-month numbers between the SIRI report and the number of significant incidents – this is because incidents are attributed to the month in which they occur whereas the SIRI data is based on the month in which the SIRI was reported externally.
5 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety 5.2.2 Any incidents that are reported as causing significant harm (moderate, severe or resulting in the death of a patient) are notified immediately to the senior team in the Trust including the chief nurse and the chief medical officer with at least weekly updates on progress. In March 21 incidents were reported, YTD 176 incidents have been reported against a target of 153.
5.2.3 S09. Moderate/severe incidents involving drug/prescribing errors- March’s data has noted a continued increase in reporting, making a YTD total of 9 reported incidents against an annual target of 5.
5.2.4 On a monthly basis there is triangulation of information arising out of complaints, claims, incidents and inquests to identify any areas of learning or for focus. The newly revised Triangulation Committee will focus on how we share learning across the organisation, with a detailed ‘Deep Dive’ focus on an incident(s) (where the learning for the organisation is significant) being discussed at each meeting.
5.3 Infection control
5.3.1 There were 2 cases of Clostridium difficile reported in March where there was a noted lapse in care attributable to the Trust (both cases reported at Worthing). YTD there have been 20 reported cases against an annual target of 16. A detailed action plan is being implemented and each case is reviewed in detail, with the sharing of lessons learned at a weekly Root Cause Analysis (RCA) panel chaired by the nurse director.
5.3.2 The allocated Trust target limit for 2017/18 (C/Diff) is set at 39 2 (unchanged from last year). Incidence in March was 16.9 (5) cases per 100,000 bed days against the national average for 2015/16 of 14.9 cases per 100,000 bed days 3, YTD 35 cases have been reported against an annual target of 39.
5.4 Falls
5.4.1 In February, inpatient falls increased from a total of 119 reported in February, to 159 reported in March, and of these 40 resulted in harm exceeding the monthly target threshold of 38. From the overall monthly total of 159, 79 falls were noted at Worthing Hospital and 83 were recorded at St Richards Hospital.
5.4.2 There were 4 falls resulting in a moderate degree of harm to patients. Two of these incidents resulted in a patient injury of a neck of femur fracture, and a patient sustaining a knee injury both requiring surgery and were reported as Serious Incidents as outlined in 5.2.1.
5.4.3 The number of falls in February equates to 5.3 per 1,000 bed days against a national figure of 6.63.4 Of the 40 falls reported as resulting in harm in February, those causing significant harm (moderate, severe harm/death) equate to 0 per 1000 bed days against the national figure of 0.19.
2 NHSI (2017) Clostridium difficile infection objectives for NHS organisations in 2017/18 and guidance on sanction implementation. Page 5 3 https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data.
6 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety 5.4.4 A number of patients that fell during March were unwitnessed falls, therefore a planning meeting will be held during April to reintroduce and embed the concept of baywatch/bayworking and SWARM within the clinical areas. Twice weekly teaching on harm free care continues on the annual clinical update. A proposal for a workshop and stall at the Trusts staff conference has been submitted.
5.4.5 Activities Volunteers are now working with therapy teams in 4 ward areas on the St Richards site, and will also be supporting the wards at Worthing within the next few weeks. A second meeting of the Deconditioning focus group has met to discuss the Trust strategy to progress the deconditioning work throughout the organisation, and focus on the reconditioning and independence of our patients promoting a safe and effective discharge.
5.5 Tissue Viability
5.5.1 Changes to the way the Trust is required to report pressure ulcers meant that more grade 2 and grade 3 ulcers were reported in 2015/16 than in previous years. This method of reporting changed from October 2016 and grade 3 or greater damage will not be routinely reported as a Serious Incident unless it meets the national threshold for Serious Incident (NHSE SI Framework 2015) reporting. Internal scrutiny of cases continues exactly as before with robust follow through of actions.
5.5.2 During March the Trust reported at total of 37 incidents of pressure damage both equal to and greater than European Pressure Ulcer Advisory Group (EPUAP) category 2- a marked increase in reporting from Februarys data of 19. Of these reported cases- there were 27 category 2 hospital acquired pressure ulcers, 9 suspected deep tissue injuries (SDTI) and 1 category 3 hospital acquired pressure ulcer. Of the overall total of 37, 22 of these incidents occurred at the Worthing Site. YTD the Trust has reported 356 pressure ulcer >Cat 2 against an annual YTD target of 220.
5.5.3 The incidence of pressure ulcers, category 2 and above including those developing within 72 hours after admission per 1000 bed days in March was 1.25, against a national rate of 0.9 (as per the Safety Thermometer data).
5.5.4 There were 195 patients admitted to the Trust from the community with existing pressure damage, the majority being from the patient’s own home.
5.5.5 Continued work with the divisions and the Kaizen team is being implemented; ensuring that patients who no longer require pressure redistribution mattress are identified within the safety huddles and the de-escalation process discussed. Embedding this in the safety huddles, will ensure that pressure redistribution systems no longer required will be returned to the equipment library and utilised for other patients requiring pressure redistribution surfaces in a timely manner. During March there was
4 Royal College of Physicians. National Audit of Inpatient Falls: audit report 2015. London: RCP, 2015.
7 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety an increase in suspected deep tissue injuries (SDTI's), which indicates repositioning and patient handling techniques need to be reviewed.
5.5.6 Following the successful Pressure Ulcer Improvement Event which was delivered in January 2018, where wards identified actions to reduce pressure injuries, a further follow up workshop has been organised for April 2018 where the wards will present and share their success and identified learning to reduce the incidences of hospital acquired pressure injuries. An algorithm has been designed for the ward areas outlining the de-escalation process to support the safe step down of patients identified as no longer requiring a pressure redistribution system to support their skin integrity. All SDTI's will be now be initially graded as 'moderate' harm and a tracker developed by the TVN team will enable prompt fortnightly review will be undertaken to determine the evolution of the injury (either will have reabsorbed or evolved into deeper tissue injury, 3/4 or unstageable).
5.6 NHS Patient Safety Thermometer
5.6.1 The NHS Patient Safety Thermometer is used across all relevant acute wards. This tool looks at point prevalence of four key harms - falls, pressure ulcers, urinary tract infections and deep vein thrombosis (DVT) and pulmonary embolism (PE) in all patients on a specific day in the month. A dashboard is available to each ward showing Trust-wide and ward-level data for each individual harm as well as the harm-free care score. These numbers are also shared via the new ward screens.
5.6.2 S02. The harm-free care score for the Trust in March was 93.5%- against the annual target of 95.7%.
5.6.3 The Safety Thermometer includes harms suffered by the patient in healthcare settings prior to admission. The actual number of patients who suffered no new harm during their inpatient stay at WSHFT (indicator S03) in March was 97.9% against a national average of 97.8% and close to achieving the challenging internal target of 99% set by the organisation.
5.6.4 S11. Compliance with VTE assessment of patients was 93.2% against a target of 95%.
5.6.5 National data relating to the NHS safety thermometer is available here: http://www.safetythermometer.nhs.uk/
6 PATIENT EXPERIENCE
6.3 PALS and Complaints
6.3.1 During March the Trust received 38 complaints, the top six themes (in order) being noted as clinical treatment, admissions/transfer/discharge, staff attitude/behaviour, date for appointment, end of life care, patient privacy and dignity.
8 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety
6.3.2 The top five themes for PALS concerns trust wide during March 2018 (in order) are noted as date for appointment, communication (oral),clinical treatment, communication (written) and date of admission.
6.3.3 Divisions continue to embed a more proactive response to new complaints to try to facilitate resolution quickly for patients and families. The Executive team set a target of working towards achieving 60% of complaints to be closed within 25 days each month, this has been achieved in March 2018 by women & children (75%) and core (100%) followed by medicine (57%) and surgery (44%) as detailed in Figure 1. This is equal to average percentage of 69% achieved across the trust.
6.3.4 Figure 1.
Division % in 25 days % in 26-60 days
Q2 17-18 Q3 17-18 Q4 17-18 Q2 17-18 Q3 17-18 Q4 17-18
Women & Children 14% 63% 62% 60% 28% 25% Medicine 20% 50% 52% 55% 33% 41% Surgery 34% 70% 38% 61% 25% 46% Core 86% 50% 100% 14% 57% 0%
6.3.5 The Quarterly Complaints Report provides an in-depth analysis of trends and lessons learned. This is reviewed by the Patient Experience and Feedback Committee and is presented to the Trust Board.
6.4 Friends and Family Test (FFT)
6.4.1 Patients who access hospital services are asked whether they would recommend WSHFT to their friends or family if they needed similar treatment. Patients who access inpatient, outpatient, day-case, A&E and maternity are all offered the opportunity to respond to the question.
6.4.2 Immediate feedback is provided to wards and departments on a continuous basis to ensure staff can address problems or get positive feedback as quickly as possible. In addition to this, a dashboard is available giving wards access to their individual scores and a poster printed with ward performance to display to the public. Ward ‘recommend’ rates are shown on the screens installed on wards.
6.4.3 Friends and Family Test Response Rates:
6.4.4 Work continues to improve response rates towards a target this year of 40% (with an interim target for A&E of 23% YTD actual 10%). The average response rate in 2015/16 for NHS acute trusts was 24.7%. Currently, response rates for Inpatients and A&E for March are below the Trust target.
9 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety 6.4.5 While acknowledging work still to be done in achieving better response rates particularly in A&E, the proportion of patients who would have recommended our services to friends and family in March compares favourably with national median benchmark and with the exception of A&E also against our internal target as per the table below: 6.4.6 Percentage recommending Target WSHFT in March (plus YTD) Inpatient care 96.3% (96.7%) 97% A&E 87.4% (85.8%) 93% Maternity: Delivery care 98.0% (97.9%) 97% Outpatient care 97.1% (97.0%) 97% Maternity: Antenatal care 100% (97.6%) 97% Maternity: Postnatal ward 98.0% (97.9%) 97%
Maternity: Postnatal 100% (98.7%) 97% community care
7 RECOMMENDATION
7.3.1 The Board is asked to note the contents of this report.
Jo Habben Head of Clinical Governance and Patient Safety 17th April 2018.
10 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board Jo Habben Head of Clinical Governance and Patient Safety Operational Planning and Performance: Quality
MARCH 2018 QUALITY SCORECARD YTD YTD APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Target Trend Actual Target EFFECTIVENESS Effectiveness domain score 2.59 2.41 2.52 2.52 2.52 2.48 2.46 2.36 2.29 2.22 2.30 2.47 2.52 Trust-wide mortality E01 Trust crude mortality rate (non-elective) 2.80% 2.82% 2.56% 2.64% 2.60% 2.65% 3.15% 3.06% 3.26% 4.25% 3.86% 3.52% 3.10% 3.13% 3.13%
E02 Crude mortality rate (non-elective): 12 month rolling 3.16% 3.11% 3.11% 3.09% 3.09% 3.09% 3.07% 3.06% 3.05% 3.07% 3.10% 3.11% 3.11% 3.13% 3.13%
E03 Trust Hospital Standardised Mortality Ratio (HSMR) (rollin 12M) 89.4 87.4 89.0 88.8 88.4 88.7 88.2 88.5 88.1 88.1 92 92
E04 Summary Hospital-level Mortality Indicator (SHMI) (rolling 12M) 0.95 0.95 0.95 1 1
E45 % of Part 1 inpatient deaths reviewed *NEW* Improve mortality in specific conditions E07 Crude non-elective mortality for Renal failure 11.4% 17.4% 12.5% 16.2% 17.4% 11.5% 17.1% 20.0% 8.0% 27.8% 14.3% 14.0% 16.3% 15.50% 15.50%
E46 % Compliance with Sepsis care bundle *NEW* 62.8% 57.9% 62.2% 57.8% 45.8% 57.4% 80% 80%
E47 % patients with sepsis receiving antibiotic therapy within one hour *NEW* 94.9% 100.0% 97.4% 97.2% 90% 90%
E48 Timely identification of sepsis in emergency department and inpatient setting *NEW* 97.0% 100.0% 96.0% 97.7% 90% 90%
E49 % patients with 72 hour antibiotic review for sepsis *NEW* 57.9% 76.5% 81.0% 71.8%
E50 Hospital acquired AKI mortality within 28 days of AKI diagnosis *NEW* 15.8% 16.2% 14.4% 14.7% 14.6% 15.2% Reduce mortality following hip fracture E09 SMR for hip fracture (all diagnoses/procedures) (rolling 12M) 88.1 87.0 97.2 101.3 95.7 92.2 89.4 93.8 88.5 88.5 100 100
E09a Worthing SMR for hip fracture (all diagnoses/procedures) (rolling 12M) 95.0 94.2 105.0 112.9 104.1 101.5 100.1 109.5 96.1 96.1 100 100
E09b St Richard's SMR for hip fracture (all diagnoses/procedures) (rolling 12M) 80.0 78.1 88.1 89.1 87.4 83.3 79.1 78.7 80.4 80.4 100 100
E10 30 day mortality rate following hip fracture (rolling 12M) 6.5% 6.5% 6.8% 7.2% 7.3% 7.1% 7.0% 7.2% 6.8% 6.8% 5.70% 5.70% Seven Day Servies *NEW* E51 % consultant review within 14 hours of admission: Weekday *NEW*
E52 % consultant review within 14 hours of admission: Weekend *NEW*
E53 Access to diagnostics: MRI (split weekday Vs weekend access): *NEW* Reduce the rate of readmission following discharge from the Trust E11 Emergency readmissions within 30 days % 14.4% 14.7% 13.5% 14.7% 13.4% 13.8% 14.4% 14.0% 13.6% 13.2% 14.4% 13.8% 14.3% 13% 13% To improve maternity care by encouraging natural chilbirth E13 C-Section Rate 24.3% 27.0% 30.1% 22.8% 27.0% 29.4% 27.1% 28.8% 33.0% 29.4% 32.1% 31.3% 28.5% 26.50% 26.50%
E14 % Mothers requiring forceps for delivery 14.8% 11.4% 12.1% 12.4% 10.1% 10.5% 11.0% 11.7% 9.4% 10.9% 9.7% 9.5% 11.2% <15% <15%
E15 % Deliveries complicated by post-partum haemorrhage 0.5% 0.9% 0.2% 0.2% 0.2% 0.2% 0.7% 0.2% 0.3% 0.5% 1.1% 0.2% 0.4% 1% 1%
E16 Maternal deaths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
E17 Admission of term babies to neonatal care 2.4% 3.7% 4.0% 3.4% 3.7% 2.5% 3.5% 2.6% 3.8% 2.1% 3.8% 3.1% 3.2% < 10% < 10%
6.1(a) Quality scorecard 1718_M12.Quality Scorecard Page 1 of 5 Printed 20/04/2018 11:50 Operational Planning and Performance: Quality
MARCH 2018 QUALITY SCORECARD YTD YTD APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Target Trend Actual Target Caring for the elderly patient E18 % Emergency admissions staying over 72h screened for dementia 90.0% 93.4% 91.0% 90.6% 91.8% 82.9% 94.2% 96.9% 87.0% 94.0% 93.0% 88.9% 91.2% 90% 90%
E19 % Patients identified as at risk of dementia for whom further investigations are carried out 92.4% 96.9% 91.0% 95.3% 91.6% 85.4% 100.0% 94.0% 96.0% 98.0% 93.2% 83.8% 93.3% 90% 90%
E20 % Patients with identified dementia referred to specialist services 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% 90% 90%
E25 Number of admissions for patients with dementia flag 221 237 203 216 228 192 185 228 237 277 198 223 2645 NA NA
E39 Ward moves for patients flagged with dementia 184 235 180 203 180 110 174 163 217 236 193 182 2257 2376 2376
E42 Night-time ward moves for patients flagged with dementia (23:00 - 07:00) : Total 34 43 46 38 22 23 44 44 66 42 44 59 505 500 500
E42a Night-time ward moves for patients flagged with dementia (23:00 - 07:00) : From Emergency Floor 76.9% 73.3% 79.2% 81.3% 90.5% 75.0% 69.2% 75.0% 80.0% 74.0% 57.3% 76.3% 75.7% NA NA
E42b Night-time ward moves for patients flagged with dementia (23:00 - 07:00) : From all other wards 23.1% 26.7% 20.8% 18.8% 9.5% 25.0% 30.8% 25.0% 20.0% 26.0% 42.7% 23.7% 24.3% NA NA
E43 Documentation Audit: % patients with dementia with Knowing Me document 65.8% 71.2% 90.5% 90.1% 97.5% 94.9% 97.8% 92.4% 93.3% 88.8% 89.0% 89.7% 87.2% 75% 75%
E53 % reduction in admission of frail older patients *NEW* Stroke care E26 % CT scans undertaken within 12 hours 97.7% 94.4% 95.5% 97.7% 96.9% 95.1% 90.2% 97.6% 93.6% 91.9% 97.9% 95.3% 95% 95%
E27 % Stroke thrombolysis within 60 minutes of hospital arrival 52.9% 71.4% 71.4% 69.2% 100.0% 77.8% 81.8% 77.8% 88.9% 66.7% 40.0% 71.9% 95% 95%
E28 % Swallow screen for stroke patients within 4 hours of admission 79.2% 93.9% 92.2% 87.3% 94.9% 87.9% 83.3% 87.8% 71.8% 66.2% 85.4% 85.7% 95% 95%
E29 % of stroke patients admitted to stroke unit within 4 hours of admission 70.9% 77.5% 78.8% 70.1% 70.3% 76.8% 74.4% 75.0% 72.3% 50.0% 79.2% 70.8% 90% 90%
E30 % high risk TIA patients seen within 24 hours 37.5% 20.0% 50.0% 33.3% 5.0% 8.3% 15.4% 7.7% 0.0% 14.3% 0.0% 15.1% 60% 60% Ensure active engagement with research E21 Patients recruited to interventional studies within CRN portfolio 17 23 62 22 7 25 34 21 31 28 20 146 436 tbc tbc
E22 Patients recruited to observational studies within CRN portfolio 109 119 34 252 47 91 44 24 43 96 63 125 1047 tbc tbc
E23 Local Clinical Research Network (LCRN) Score 569 670 801 1124 242 594 528 312 492 622 440 2043 8436 6268 6268 Data Quality E24 NHS IC Data validity summary (YTD) 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9
E37 % inpatients with electronic discharge summaries produced 94.3% 93.9% 93.3% 94.6% 93.2% 92.7% 93.4% 92.6% 91.5% 92.2% 92.7% 92.0% 93.0% 94.2% 94.2% Mental Health Care *NEW* E54 Improving services for people with mental health needs who present in A&E *NEW* 42 37 46 27 36 34 222 244 488
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MARCH 2018 QUALITY SCORECARD YTD YTD APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Target Trend Actual Target SAFETY Safety domain score (Patient Aggregate Safety Score - PASS) 2.42 2.35 2.39 2.39 2.06 2.19 2.06 2.22 2.14 2.19 2.31 2.07 1.97 Safer staffing S36 Safer Staffing: Average fill rate - registered nurses/ midwives (day shifts) 97.3% 97.1% 97.6% 96.2% 94.2% 94.0% 91.7% 94.3% 94.1% 95.6% 92.2% 93.0% 94.8% 95% 95%
S37 Safer Staffing: Average fill rate - registered nurses/ midwives (night shifts) 97.7% 98.1% 98.4% 97.0% 94.0% 94.9% 91.2% 95.1% 93.7% 97.1% 90.6% 90.1% 94.8% 95% 95%
S38 Safer Staffing: Average fill rate - care staff (day shifts) 95.4% 92.9% 95.3% 94.8% 93.4% 94.3% 90.5% 92.7% 93.6% 93.8% 90.3% 90.5% 93.1% 95% 95%
S39 Safer Staffing: Average fill rate - care staff (night shifts) 96.2% 94.6% 95.2% 96.4% 92.4% 93.8% 91.2% 94.4% 93.3% 95.8% 92.4% 92.7% 94.1% 95% 95%
S41 Care Hours Per Patient Day (CHPPD) 6.80 6.60 6.80 6.80 6.90 7.07 6.43 6.50 6.40 6.40 6.30 6.30 6.60 tbc tbc NHS safety thermometer S02 Safety Thermometer: % of patients harm-free 94.5% 95.8% 98.2% 96.9% 95.5% 95.5% 94.4% 92.9% 92.8% 94.4% 95.4% 93.5% 94.9% 95.70% 95.70%
S03 Safety Thermometer: % of patients with no new harms 98.7% 98.7% 98.7% 98.9% 98.7% 98.8% 98.4% 97.1% 97.5% 97.9% 98.6% 97.9% 98.4% 99% 99%
S29 % of patients with catheters and UTIs where best practice protocol was not followed. 0.23% 0.0% 0.0% 0.0% 0.0% 0.0% 0.11% 0.23% 0.0% 0.0% 0.0% 0.0% 0.05% 0.06% 0.06% Monitoring of clinical incidents 8122- 8122 - S04 Total incidents 727 844 774 721 741 685 800 767 762 846 719 764 9150 10988 10988 S05 Total moderate, severe or death incidents 8 12 14 9 18 13 15 21 15 11 19 21 176 153 153
S06 Total serious incidents (SIRIs) 3 5 8 1 5 6 2 4 10 6 3 2 53 60 60
S07 Number of outstanding CAS alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Improve safety of prescribing 1056- 1056 - S08 Total incidents involving drug/prescribing errors 71 104 83 85 88 73 93 85 83 99 75 77 1016 1428 1428 S09 Moderate/severe incidents involving drug/prescribing errors 1 1 0 1 2 0 0 0 0 0 1 3 9 5 5 Reduce incidence of healthcare acquired infections S14 Number of hospital attributable MRSA cases 0 0 0 0 0 0 0 0 1 1 1 0 3 0 0
S15 Number of hospital C.diff cases 0 3 3 4 4 1 2 3 1 6 3 5 35 39 39
S28 Number of C. diff cases where a lapse in the quality of care was noted 0 2 1 1 4 1 0 2 1 4 2 2 20 16 16
S16 Number of reportable MSSA bacteraemia cases 9 6 7 5 12 9 9 9 8 6 7 7 94 102 102
S16a Number of hosptial attributable MSSA bacteraemia cases 3 2 1 1 3 2 3 2 2 1 3 1 24 tbc tbc
S17 Number of reportable E.coli cases 30 28 27 39 49 31 38 36 25 35 29 33 400 375 375
S17a Number of hospital attributable E.coli cases 8 5 3 5 7 3 6 6 6 8 7 3 67 tbc tbc
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MARCH 2018 QUALITY SCORECARD YTD YTD APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Target Trend Actual Target Improve theatre safety for patients S18 Full compliance with WHO Surgical Safety Checklist 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% 100%
S19 NEVER events 1 0 0 0 0 1 0 0 0 0 0 0 2 0 0
S30 SSIs: Total hip replacement (YTD is rolling 12 months) 0.6% 2.5% 1.6% 1.5% 1.1% 1.1%
S33 SSIs: Total knee replacement (YTD is rolling 12 months) 2.0% 4.1% 2.2% 2.8% 1.5% 1.5%
S34 SSIs: Large bowel surgery (YTD is rolling 12 months) 9.8% 15.0% 9.9% 11.5% 12% 12%
S35 SSIs: Breast surgery (YTD is rolling 12 months) 6.3% 5.2% 5.5% 5.7% 3.80% 3.80% Reduce number of falls in hospital S49 All falls 137 141 152 136 129 105 133 134 160 179 119 159 1684 1452 1452
S21 Falls resulting in harm 34 37 44 36 39 31 43 38 46 47 38 40 473 451 451
S22 Falls resulting in severe harm or death 0 0 1 0 0 1 0 0 0 0 1 0 3 1 1
S40 Repeat falls 8 9 9 7 12 3 12 10 7 9 8 12 106 97 97
S23 Falls assessment within 24hrs of admission (Surgery only) 88% 83% 95% 83% 91% 91% 89% 88% 95% 93% 93% 88% 90% 80% 80%
S24 Avoidable falls identified on the Safety Thermometer 0.69% 0.34% 0.34% 0.33% 0.32% 0.34% 0.87% 0.47% 0.65% 0.87% 0.33% 1.21% 0.56% 0.65% 0.65% Pressure ulcers S49 Grade 2+ pressure ulcers 19 24 25 16 17 25 33 52 46 43 19 37 356 240 240 Other safety metrics S11 VTE Assessment Compliance 95.0% 93.3% 94.7% 94.2% 94.9% 94.1% 94.9% 93.8% 93.0% 93.9% 94.1% 93.2% 94.1% 95.30% 95.30% Medicines Optimisation *NEW* S44 Antimicrobial stewardship and consumption: 2% Reduction in overall antibiotic consumption *NEW* 11.5% 4.2% 10.6% 9.8% 3.3% 3.5% 8.4% 0.5% 7.6% 6.0% 4.7% 6.4% -2.0% -2.0%
S45 Antimicrobial stewardship and consumption: 1% reduction in the use of carbapenems *NEW* -13.0% -1.0% -1.0% 20.0% 34.0% 2.0% 8.0% -24.0% 2.0% -1.0% 13.5% 3.6% -1.0% -1.0%
S46 Antimicrobial stewardship and consumption: 1% reduction in the use of Tazocin *NEW* -23.0% -69.7% -67.7% -36.1% -23.3% -1.0% -43.0% -37.0% -38.0% -23.0% -34.0% -36.0% -1.0% -1.0%
S47 Focus on anticoagulants: Patients on Direct Oral Anticoagulants (NOACs) receiving counselling *NEW* 35.0% 36.0% 49.0% 52.0% 50.0% 49.0% 56.0% 52.0% 46.0% 50.0% 46.0% 47.4% 50.0% 50.0%
S48 Focus on anticoagulants: Patients with correct prophylaxis prescribed *NEW* 94.0% 94.0% 100.0% 100.0%
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MARCH 2018 QUALITY SCORECARD YTD YTD APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Target Trend Actual Target EXPERIENCE Experience domain score 2.39 2.35 2.39 2.13 2.26 2.48 2.39 2.52 2.52 2.52 2.48 2.32 2.39 Friends and Family Test X38 Trust Friends and Family Recommend %: Inpatient 96.9% 96.9% 96.8% 96.7% 96.9% 96.7% 96.7% 97.0% 95.7% 97.0% 97.0% 96.3% 96.7% 97% 97%
X39 Trust Friends and Family Recommend %: A&E 84.6% 84.1% 85.6% 84.8% 84.8% 84.0% 85.5% 88.1% 84.5% 88.0% 88.5% 87.4% 85.8% 93% 93%
X40 Maternity Friends and Family Recommend %: Antenatal care (36 weeks) 100.0% 95.2% 96.3% 95.5% 100.0% 100.0% 96.6% 100.0% 89.5% 100.0% 100.0% 100.0% 97.6% 97% 97%
X41 Maternity Friends and Family Recommend %: Delivery care 98.8% 98.2% 96.3% 97.9% 97.2% 96.1% 97.5% 98.5% 97.9% 98.9% 98.4% 98.0% 97.9% 97% 97%
X42 Maternity Friends and Family Recommend %: Postnatal ward 98.8% 98.2% 96.3% 97.9% 97.2% 96.1% 100.0% 98.5% 97.9% 98.9% 98.4% 98.0% 97.9% 97% 97%
X43 Maternity Friends and Family Recommend %: Postnatal community care 100.0% 100.0% 100.0% 97.3% 96.2% 100.0% 97.5% 100.0% 100.0% 100.0% 100.0% 100.0% 98.7% 97% 97%
X44 Trust Friends and Family Recommend %: Outpatient 96.8% 96.1% 97.5% 96.4% 96.8% 97.4% 97.1% 97.2% 97.2% 97.7% 96.5% 97.1% 97.0% 97% 97% Friends and Family Test response rates X24 Trust Friends and Family Response Rate: Inpatient 31.8% 35.6% 36.9% 32.0% 41.9% 35.4% 42.2% 41.8% 35.2% 34.5% 39.0% 33.1% 37.0% 40% 40%
X25 Trust Friends and Family Response Rate: A&E 9.0% 9.3% 8.2% 9.9% 11.3% 8.1% 11.6% 13.6% 11.0% 9.1% 8.0% 10.1% 10.0% 23% 23%
X33 Maternity Friends and Family Response Rate: Delivery care 42.8% 45.4% 34.2% 33.6% 33.9% 58.5% 80.5% 65.2% 39.9% 87.9% 51.2% 48.1% 52.0% 40% 40% Reduction in patients suffering a bad experience dealing with the Trust X08 Percentage of re-booked outpatient appointments 12.7% 11.8% 12.5% 13.0% 12.1% 12.4% 12.6% 11.9% 13.0% 12.4% 13.6% 14.2% 12.5% 7.80% 7.80%
X09 Clinics cancelled with less than 6 weeks notice for annual/study leave 17 12 15 71 70 40 26 23 20 44 41 18 397 278 278
X11 PALS contacts relating to appointment problems (pior % of total appts) 0.14% 0.09% 0.09% 0.09% 0.08% 0.09% 0.09% 0.09% 0.10% 0.10% 0.12% 0.13% 0.10% 0.08% 0.08%
X12 Reduce patients cancelled on the day of surgery for non-clinical reasons 14 39 18 23 35 9 56 41 18 29 30 42 354 337 337
X13 Breaches of mixed sex accommodation arrangements 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Nutritional Assessment X14 Compliance with MUST tool after 24 hours 81.5% 83.5% 85.6% 86.8% 87.0% 88.3% 88.3% 87.4% 83.4% 83.0% 85.6% 78.4% 85.2% 80% 80%
X15 Compliance with MUST tool after 7 days 98.1% 98.9% 98.9% 99.1% 99.5% 99.4% 99.2% 99.3% 98.8% 98.1% 98.7% 100.0% 98.9% 95% 95% Cleanliness / PLACE Survey X16 Internal PLACE compliance : St Richard's Hospital 91% 93% 96% 90% 98% 96% 98% 95% 95% 96% 96% 96% 95% 95% 95%
X17 Internal PLACE compliance : Worthing Hospital 97% 96% 95% 96% 97% 96% 95% 94% 96% 98% 98% 98% 96% 95% 95% Improve our customer service and become a more caring organisation X18 Number of complaints 35 47 30 44 40 38 32 42 30 34 28 38 438 570 570
X19 Complaints where staff attitude or behaviour is an issue 4 8 4 5 2 4 6 2 3 1 0 3 42 54 54
X20 Complaints where staff communication is an issue 2 0 2 6 7 1 1 2 0 2 2 0 25 49 49
X21 Complaints about nursing 5 3 4 4 5 0 5 9 2 2 2 5 46 39 39 Staff engagement (indicators/targets not yet agreed) *NEW* X47 Local staff engagement score: % of staff agree they can make an improvement *NEW* 91.0% 91.0% 91.0% 91.0% 91.0% 68% 68%
X48 PFIS Health Check *NEW*
X49 Staff wellbeing programme: % uptake in flu vaccinations for front-line staff *starts Oct-17* EMERGING PROGRAMMES (indicators/targets not yet agreed) *NEW* X52 Workforce Transformation Plan *NEW*
6.1(a) Quality scorecard 1718_M12.Quality Scorecard Page 5 of 5 Printed 20/04/2018 11:50 Operational Planning and Performance: Quality
SAFER STAFFING SCORECARD - Registered Nurses March 2018 YTD Shift Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Trend Actual Day 94.0% 97.3% 97.1% 97.6% 96.2% 94.2% 94.0% 91.7% 94.3% 94.1% 95.6% 92.2% 93.0% 94.8% WSHFT Night 96.5% 97.7% 98.1% 98.4% 97.0% 94.0% 94.9% 91.2% 95.1% 93.7% 97.1% 90.6% 90.1% 94.8% Day 93.5% 98.3% 97.4% 100.0% 98.7% 97.4% 95.3% 95.2% 95.7% 91.3% 98.7% 94.3% 94.5% 96.4% Acute Cardiac Unit Night 92.7% 99.2% 99.2% 100.0% 100.0% 97.6% 97.5% 96.0% 95.0% 92.7% 98.4% 93.8% 91.9% 96.8% Day 92.1% 94.8% 99.3% 97.0% 97.8% 91.8% 95.2% 86.7% 95.2% 95.3% 96.8% 90.9% 93.9% 94.6% Ashling Night 80.6% 91.7% 100.0% 95.0% 91.9% 82.3% 91.7% 75.8% 91.7% 91.9% 91.9% 80.4% 80.6% 88.8% Day 95.7% 96.9% 96.5% 98.6% 97.3% 93.8% 96.1% 95.2% 90.8% 96.8% 93.5% 92.9% 96.0% 95.4% Barrow Night 100.0% 100.0% 97.6% 99.2% 99.2% 97.6% 98.3% 97.6% 98.3% 95.2% 96.8% 92.0% 92.7% 97.1% Day 97.1% 98.0% 97.7% 95.3% 95.2% 94.5% 96.0% 93.2% 97.3% 100.0% 98.1% 97.9% 97.4% 96.7% Becket Night 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 96.8% 98.3% 100.0% 100.0% 100.0% 90.3% 98.6% Day 97.7% 100.0% 92.1% 88.0% 87.7% 100.0% 97.4% 100.0% 97.3% 93.3% 94.9% 97.1% 90.4% 94.7% Beeding Night 98.7% 95.1% 83.9% 89.9% 86.8% 100.0% 95.8% 100.0% 94.7% 93.8% 97.3% 94.2% 89.3% 93.1% Day 99.2% 100.0% 99.1% 91.4% 96.6% 97.2% 99.0% 100.0% 98.4% 100.0% 100.0% 97.4% 100.0% 98.4% Bluefin Night 100.0% 100.0% 97.3% 99.0% 99.1% 100.0% 100.0% 96.7% 95.9% 98.4% 97.6% 97.3% 98.3% 98.2% Day 91.1% 97.9% 100.0% 98.8% 97.6% 97.2% 95.8% 91.1% 99.6% 97.6% 98.4% 96.9% 92.7% 97.0% Bosham Night 88.7% 96.7% 100.0% 96.7% 95.2% 95.2% 91.7% 83.9% 100.0% 96.8% 96.8% 96.4% 87.1% 94.7% Day 91.9% 95.4% 94.5% 93.5% 94.1% 93.4% 95.4% 93.0% 96.6% 94.8% 95.2% 89.8% 91.1% 93.9% Botolphs Night 100.0% 100.0% 100.0% 95.6% 95.7% 94.6% 100.0% 92.5% 96.7% 92.5% 94.6% 89.3% 91.4% 95.3% Day 97.2% 99.6% 98.4% 99.6% 97.6% 95.2% 96.7% 87.9% 91.3% 89.9% 98.0% 88.8% 90.7% 94.5% Boxgrove Night 95.2% 100.0% 100.0% 100.0% 95.2% 90.3% 95.0% 83.9% 80.0% 80.6% 95.2% 78.6% 80.6% 90.0%
6.1(b) SaferStaffingScorecard_1718_M12 SaferStaffingWardNurseScorecard 1 of 3 20/04/2018 11:51 Operational Planning and Performance: Quality
SAFER STAFFING SCORECARD - Registered Nurses March 2018 YTD Shift Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Trend Actual Day 94.0% 97.3% 97.1% 97.6% 96.2% 94.2% 94.0% 91.7% 94.3% 94.1% 95.6% 92.2% 93.0% 94.8% WSHFT Night 96.5% 97.7% 98.1% 98.4% 97.0% 94.0% 94.9% 91.2% 95.1% 93.7% 97.1% 90.6% 90.1% 94.8% Day 87.1% 96.0% 93.8% 98.5% 95.7% 98.1% 98.5% 82.7% 90.6% 87.0% 80.4% 83.0% 81.7% 90.5% BuckinghamAcute Cardiac Unit Night 98.4% 100.0% 100.0% 100.0% 96.8% 100.0% 100.0% 100.0% 100.0% 98.4% 96.8% 94.6% 85.5% 97.7% Day 88.2% 95.6% 95.3% 99.4% 98.2% 89.4% 95.1% 86.7% 87.2% 94.0% 91.2% 94.1% 88.8% 92.9% Burlington Night 98.4% 96.7% 98.4% 100.0% 98.4% 96.8% 100.0% 96.8% 93.3% 98.4% 100.0% 98.2% 90.3% 97.3% Day 96.4% 99.3% 97.8% 100.0% 93.5% 96.1% 96.7% 97.1% 96.3% 96.8% 94.3% 92.9% 94.3% 96.3% Castle Night 98.9% 98.9% 96.8% 98.9% 98.9% 91.4% 93.3% 86.0% 92.2% 95.7% 93.5% 84.5% 80.6% 92.6% Day 92.5% 95.8% 98.3% 97.1% 94.7% 90.8% 87.5% 86.2% 93.0% 91.0% 98.1% 90.7% 94.2% 93.1% Chichester Emergency Floor Night 93.0% 96.8% 98.7% 96.4% 95.6% 87.3% 85.9% 84.6% 93.2% 92.5% 97.8% 86.9% 92.1% 92.4% Day 98.1% 99.0% 100.0% 98.5% 98.1% 96.7% 96.1% 94.8% 99.0% 98.1% 100.0% 93.8% 87.8% 96.8% Chilgrove Night 96.8% 96.7% 100.0% 96.7% 96.8% 88.7% 90.0% 87.1% 98.3% 98.4% 100.0% 87.5% 77.4% 93.2% Day 96.8% 98.8% 98.8% 97.9% 94.0% 91.1% 94.2% 91.1% 93.3% 93.1% 95.2% 95.1% 94.4% 94.7% Chiltington Night 98.4% 100.0% 100.0% 98.3% 96.8% 98.4% 98.3% 95.2% 98.3% 96.8% 98.4% 98.2% 91.9% 97.5% Day 93.1% 97.9% 99.2% 97.5% 92.3% 92.7% 91.7% 88.7% 95.8% 95.6% 93.5% 99.6% 98.4% 95.2% Clapham Night 100.0% 96.7% 98.4% 96.7% 96.8% 93.5% 96.7% 87.1% 93.3% 95.2% 98.4% 96.4% 93.5% 95.2% Day 94.4% 98.8% 97.2% 95.4% 91.1% 90.7% 90.8% 93.5% 93.3% 96.0% 89.5% 93.3% 94.4% 93.7% Coombes Night 100.0% 100.0% 100.0% 100.0% 91.9% 91.9% 95.0% 96.8% 98.3% 96.8% 96.8% 96.4% 82.3% 95.5% Day 91.9% 97.7% 96.5% 97.3% 94.5% 92.6% 92.7% 92.6% 95.0% 95.2% 95.2% 92.9% 94.8% 94.7% Courtlands Night 97.4% 99.3% 96.1% 100.0% 98.1% 96.1% 94.7% 92.9% 96.0% 94.2% 95.5% 94.3% 92.9% 95.8% Day 95.9% 99.0% 96.3% 98.1% 98.6% 94.9% 91.9% 91.7% 90.5% 94.5% 92.2% 88.8% 88.5% 93.8% Ditchling Night 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 98.3% 95.2% 98.3% 100.0% 100.0% 96.4% 93.5% 98.4% Day 94.9% 98.1% 96.3% 97.1% 96.8% 93.5% 95.7% 91.7% 94.3% 96.8% 93.5% 96.9% 98.6% 95.8% Durrington Night 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 98.3% 98.4% 95.0% 98.4% 100.0% 100.0% 98.4% 98.9% Day 95.6% 97.5% 93.1% 98.8% 96.8% 96.0% 93.8% 91.5% 92.1% 94.8% 96.8% 93.8% 91.1% 94.7% Eartham Night 100.0% 100.0% 98.9% 100.0% 98.9% 98.9% 100.0% 97.8% 96.7% 98.9% 100.0% 95.2% 93.5% 98.3% Day 92.2% 97.3% 94.0% 100.0% 97.4% 97.0% 93.7% 91.7% 89.7% 91.2% 92.2% 95.2% 91.3% 94.2% Eastbrook Night 100.0% 100.0% 98.4% 100.0% 98.4% 96.8% 100.0% 96.8% 100.0% 98.4% 98.4% 96.4% 95.2% 98.2%
6.1(b) SaferStaffingScorecard_1718_M12 SaferStaffingWardNurseScorecard 2 of 3 20/04/2018 11:51 Operational Planning and Performance: Quality
SAFER STAFFING SCORECARD - Registered Nurses March 2018 YTD Shift Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Trend Actual Day 94.0% 97.3% 97.1% 97.6% 96.2% 94.2% 94.0% 91.7% 94.3% 94.1% 95.6% 92.2% 93.0% 94.8% WSHFT Night 96.5% 97.7% 98.1% 98.4% 97.0% 94.0% 94.9% 91.2% 95.1% 93.7% 97.1% 90.6% 90.1% 94.8% Day 93.5% 95.8% 95.2% 96.1% 95.7% 92.7% 91.0% 90.9% 89.9% 93.4% 91.1% 87.6% 87.0% 92.2% EmergencyAcute Cardiac Floor Unit Worthing Night 98.4% 98.9% 98.4% 99.7% 96.8% 93.5% 94.7% 86.6% 95.0% 91.1% 95.2% 89.3% 86.0% 93.8% Day 100.0% 99.2% 98.4% 99.2% 100.0% 100.0% 99.2% 100.0% 100.0% 99.2% 100.0% 100.0% 99.2% 99.5% Enhanced Surgical Care Unit Night 100.0% 100.0% 100.0% 100.0% 96.8% 100.0% 93.3% 96.8% 100.0% 96.8% 100.0% 96.4% 100.0% 98.4% Day 90.8% 97.6% 94.0% 96.2% 91.7% 94.0% 94.3% 94.5% 94.8% 97.7% 95.4% 95.4% 97.7% 95.3% Erringham Night 100.0% 100.0% 100.0% 100.0% 96.8% 100.0% 100.0% 93.5% 98.3% 98.4% 100.0% 91.1% 91.9% 97.5% Day 92.7% 97.1% 91.5% 97.5% 99.6% 98.8% 93.3% 97.2% 96.7% 88.7% 98.8% 87.9% 92.7% 95.0% Fishbourne Night 91.9% 95.0% 85.5% 100.0% 100.0% 100.0% 86.7% 100.0% 93.3% 79.0% 100.0% 75.0% 80.6% 91.4% Day 93.5% 94.3% 98.7% 99.3% 98.1% 95.2% 95.0% 92.9% 97.7% 95.5% 99.4% 95.0% 97.1% 96.5% Ford Night 90.3% 90.0% 98.9% 98.9% 96.8% 91.4% 92.2% 88.2% 94.4% 92.5% 97.8% 92.9% 92.5% 93.9% Day 96.7% 100.0% 100.0% 97.4% 100.0% 99.0% 99.0% 100.0% 97.5% 99.2% 100.0% 94.6% 98.3% 98.8% Howard Children's Unit Night 99.2% 90.5% 100.0% 93.4% 99.0% 96.9% 98.9% 99.2% 100.0% 99.2% 100.0% 95.5% 100.0% 97.8% Day 91.4% 94.1% 99.3% 98.5% 97.1% 92.5% 93.7% 90.0% 95.9% 90.3% 96.1% 85.7% 90.7% 93.7% Lavant Night 83.9% 91.7% 98.4% 96.7% 96.8% 83.9% 88.3% 83.9% 90.0% 82.3% 88.7% 66.1% 85.5% 87.8% Day 95.2% 96.7% 97.6% 98.8% 96.0% 88.3% 92.5% 84.3% 92.5% 87.5% 97.6% 84.4% 86.7% 91.9% Middleton Night 91.9% 95.0% 95.2% 100.0% 95.2% 64.5% 85.0% 66.1% 86.7% 77.4% 93.5% 60.7% 71.0% 82.6% Day 96.3% 100.0% 100.0% 95.2% 100.0% 98.9% 98.6% 100.0% 100.0% 100.0% 97.6% 98.6% 98.8% 99.0% Neonatal Unit Night 100.0% 100.0% 100.0% 100.0% 98.8% 98.9% 100.0% 100.0% 94.7% 100.0% 97.6% 98.6% 100.0% 99.0% Day 96.8% 99.4% 97.8% 100.0% 96.8% 91.4% 90.0% 90.3% 92.2% 94.1% 99.5% 92.3% 95.7% 95.0% Petworth Night 100.0% 100.0% 100.0% 100.0% 96.8% 91.9% 88.3% 90.3% 90.0% 96.8% 98.4% 94.6% 95.2% 95.2% Day 92.5% 96.5% 100.0% 99.6% 97.9% 95.4% 93.1% 85.4% 95.7% 90.8% 99.2% 93.5% 93.3% 95.0% Selsey Night 92.5% 96.7% 100.0% 100.0% 97.8% 93.5% 92.2% 81.7% 94.4% 89.2% 97.8% 92.9% 93.5% 94.2% Day 96.0% 99.6% 100.0% 98.8% 96.8% 96.4% 95.0% 94.8% 96.3% 97.6% 98.8% 90.2% 90.7% 96.3% Wittering Night 95.2% 100.0% 100.0% 96.7% 93.5% 93.5% 96.7% 91.9% 93.3% 95.2% 98.4% 83.9% 88.7% 94.4%
6.1(b) SaferStaffingScorecard_1718_M12 SaferStaffingWardNurseScorecard 3 of 3 20/04/2018 11:51 NIGHT MOVES SUMMARY
MARCH 2018
The dementia team continue to monitor the night moves on a monthly basis for those patients with a known diagnosis of dementia. There is a Kaizen workstream as part of the larger non-elective flow project to look at this which is not only focussed on patients with a dementia but also any patient that is moved at night.
The first project meeting was held on the 30th November but unfortunately, due to levels of activity and acuity, there was very poor representation and the site team were unavailable. This resulted in being restrictive in what we could achieve which the Kaizen team fed back on. However, the Emergency Floor at Worthing are going to trial keeping a log of moves and reasons for night moves which they will feed back on. The Kaizen team are currently undertaking some further data analysis and members for the workstream have been identified. As this workstream is so interlinked with a larger scale project, it was deemed appropriate to combine it with the whole non- elective work. Dr Duckitt and Lisa Ekinsmyth have now also asked to be included in this workstream which will be helpful.
With the unprecedented activity levels in December and January, there was unfortunately an increase in these moves. However, having analysed the data for February 2018, this did reflect a decrease.
Aattached the last 3 months data of ward moves for patients with a dementia diagnosis.
SRH:
Month 23.00 – EF to Ward to 19.00 – EF to Ward to 06.00 Ward Ward 23.00 Ward Ward Dec 4 4 0 14 11 3 Jan 7 6 1 21 15 6 Feb 6 6 0 6 6 0
Worthing:
Month 23.00 – EF to Ward to 19.00 – EF to Ward to 06.00 Ward Ward 23.00 Ward Ward Dec 17 16 1 23 14 9 Jan 15 15 0 19 16 3 Feb 13 12 1 12 10 2
The moves will continue to be monitored and it is anticipated that the project will assist in reducing these figures across both sites. The site team are currently advertising bank positions for staff between 16.00 and 22.00hours to assist in transferring patients earlier in the day to improve the patient experience and the flow. It is worth highlighting that the vast majority of moves are those from the EF to the wards rather than ward to ward. Patients with a dementia diagnosis continue to be highlighted.
F Usher-Smth.
To: Trust Board
Date of Meeting: 16/04/2018
Title NICE Performance Report Responsible Executive Director
George Findlay Prepared by
Simon Higgs (Clinical Effectiveness Manager) & Patience Mugawazi (NICE Manager & Clinical Effectiveness Facilitator) Status
Disclosable Summary of Proposal
There is some engagement and consistency issues in the implementation of NICE guidance within the Trust. Implications for Quality of Care • Patients may not get access to best practice treatments and interventions may not be delivered safely if NICE recommendations are not followed. • Failure to benefit from cost savings which may arise from not implementing guidance related to cost effectiveness • Failure to meet the standards set by the CQC which significantly increases the risk of a negative regulatory status and rating. Link to Strategic Objectives/Board Assurance Framework
Implementing NICE guidance is one of the strategic objectives towards high quality care, patient safety and quality improvement. Financial Implications
• Failing to capitalise on opportunities of joint working in delivering care and quality improvements
Human Resource Implications
Recommendation
Divisions with high levels of outstanding guidance to report risks on their Risk Register and monitor.
Communication and Consultation
Appendices
1 Update on NICE National Guidance December 2017 Report on Clinical Effectiveness – national guidance with outstanding issues in review / implementation Full participation by the Trust in the implementation of guidance published the by the National Institute for Health and Care Excellence (NICE), the National Confidential Enquiries (NCE) and the National Audits is mandated by the Department of Health. All medical practitioners are expected to contribute to the relevant national guidance, enquiry or audit that is relevant to their practice and speciality this is also supported by the General Medical Council (DH, 2013). The Trust has the following policies: Implementation of National Guidance; National Institute for Health and Care Excellence (NICE) the National Confidential Enquiries (NCEs) and the National Audits in WSHT This policy define the Trust process that is supported by the organisation’s quality improvement and clinical governance framework in order to provide robust assurance regarding the level of compliance to the Trust board on adherence to national guidance. The Trust approach ensures a coordinated approach to dissemination, implementation and outcome across the whole organisation, through the clearly defined process, which offers a standardised system to the Clinical division’s approach to responding to the above National guidance. Participation in the implementation of national guidance also helps the Trust to meet the regulatory standards set by the Care Quality Commission (CQC). Communication, reporting and dissemination of guidance to the Clinical Divisions is facilitated via the monthly Clinical Effectiveness and Clinical Audit bulletins. NICE As per agreed process, the divisions have up to three months to provide a documented response to the published guidance and feedback to the Clinical Effectiveness Team for reporting and record keeping. Below is a status report on the adherence to the agreed process and the implementation of NICE guidance and NCE and National Audits as per Trust policy by Clinical Divisions. The following report, updated on a monthly basis, will be part of the Clinical Divisions’ monthly bulletins and their quarterly reviews, to help with monitoring and review of progress. The reporting will provide details of the outstanding issues over a rolling three year period. *outstanding refers to the following • there has been no lead nominated / formal assessment of guidance regarding the relevance to the Trust • guidance that has been assessed as relevant to the trust and current treatment or intervention is non-compliant with recommendations • guidance with a completed gap analysis but action plan is outstanding • (excludes New guidance – within three months of publication) The percentage of guidance with outstanding issues (in three year rolling period) is calculated by dividing the number of guidance with outstanding issues (within the three year rolling period) by the number of guidance published (within the three year rolling period) but minus new guidance within three months of publication and guidance assessed as non-relevant.
Outstanding issues are reported as non-compliance with guidance until action is initiated.
There still need to improve engagement with the NICE implementation process from all divisions.
2 Update on NICE National Guidance December 2017 Medicine Division
3 Update on NICE National Guidance December 2017
Surgery Division
4 Update on NICE National Guidance December 2017
Core Division
5 Update on NICE National Guidance December 2017
Women & Children Division: Obstetrics, Maternity, Gynaecology & Sexual Health
6 Update on NICE National Guidance December 2017
Women & Children Division: Paediatrics
7 Update on NICE National Guidance December 2017
Trust wide Guidance
8 Update on NICE National Guidance December 2017
Actions:
On a monthly basis, the Divisions will receive the Clinical Effectiveness Bulletins with newly published NICE guidance and and a Tracker to help monitor responses and the implementation process. Progress will be reviewed at Divisional Clinical Governance monthly and quarterly review meetings. Significant risks relating to NICE compliance should be recorded on Divisional Risk Registers.
At Trust level, the following groups / committees will review progress in relation to the implementation of NICE:
Quality Assurance Group
Quality Board
Quality and Risk Committee
Escalation should be as per NICE implementation policy unless there is other process to consider which states the following:
The Divisional Management Boards will review and action the Division’s Clinical Effectiveness bulletin and at the Divisional Monthly meetings. Divisional Governance Quality Reviews as part of their regular agenda, will also review progress with implementation of NICE guidance.
9 Update on NICE National Guidance December 2017
To: Trust Board Date of Meeting: 26th April 2018 Agenda Item: 6.2
Title Month 12, 2017-18 Performance Report Responsible Executive Director Jane Farrell, Chief Operating Officer Prepared by Giles Frost, Interim Director – Performance & Information Status Disclosable Summary of Proposal The paper sets out organisational compliance against national and local key performance metrics. The report summarises both in year and projected year end performance for Western Sussex Hospitals NHS Foundation Trust, as detailed in dedicated performance scorecards relating to Quality Board indicators aligned to the Quality Strategy, the NHSI Single Oversight Framework and, when relevant, other indicators. This paper describes performance on an exceptional basis determined by RAG rating, key national/regulatory significance, or in year trend analysis.
Implications for Quality of Care Describes Quality Outcome KPIs Link to Strategic Objectives/Board Assurance Framework Trust Strategic Theme B - Provide the highest possible quality of care to our patients. This we will do through focusing on a range of measures to improve clinical effectiveness. Trust Strategic Theme G - Ensure the sustainability of our organisation by exceeding our national targets and financial performance and investing in appropriate infrastructure and capacity. Trust Strategic Theme F - Improve our performance against a range of quality, access and productivity measures through the introduction and spread of best practice throughout the organisation. Financial Implications Describes KPIs linked to financial performance Human Resource Implications Describes KPIs linked to workforce Recommendation The Board is asked to: NOTE the Trust position against the NHS Single Oversight Framework and STF Performance Monitoring targets. Communication and Consultation Not applicable Appendices Appendix 1: Key Performance Deliverables, Operational Performance Scorecard, Single Oversight Framework Scorecard, STF Performance Monitoring.
1
To: Trust Board Date: 26 April 2018
From: Jane Farrell, Chief Operating Officer Agenda Item: 6.2
FOR INFORMATION
WSHFT PERFORMANCE REPORT: MONTH 12, 2017/18
1. INTRODUCTION
1.1 This report summarises both current in year and projected performance for Western Sussex Hospitals NHS Foundation Trust, with further detail provided in the appendices relating to: • The NHSI Single Oversight Framework • Key Performance Deliverables Report • Operational Performance Scorecard • Sustainability and Transformation Fund Performance Monitoring
1.2 This paper provides the Board with an update on performance on a specific basis determined by RAG rating, national significance, or in year trend analysis.
1.3 Introduced as a condition of the National Sustainability and Transformation Programme and Funding, all Trusts have again submitted joint performance trajectories on the key areas of A&E, RTT, and Cancer. The detailed tracking of the Trust’s performance against this trajectory is included in an Appendix of this report, and performance against the requirements is summarised for each relevant performance area. The trajectory has changed for 2017/18 based on specific criteria for all indicators, and diagnostic waiters are no longer included. The Sustainability and Transformation Fund payments in 2017/18 are indicatively based on A&E performance against trajectory only as per NHS Improvement guidance.
2. SUMMARY PERFORMANCE
2.1 Under the Single Oversight Framework, the Trust was compliant for Cancer against STF trajectory in March. RTT 18 week compliance and A&E 4 hour performance were below the national constitutional targets and STF trajectories for March. Diagnostics was compliant against national target in March.
2
2.2 Operationally March saw an increased level of A&E demand, and an increase in emergency admissions relative to the same period in 2017.
• 11,808 A&E attendances compared to 11,409 in March 2017 (representing a 3.5% increase on this time last year). For patients aged 65 and over there was an increase in attendances of 10.3%. For patients aged 85 and over, the increase was 11.4%. • 5,221 emergency admissions in March 2018 comparison to 4,732 in March 2017, an increase of 10.3%. • Over 65 emergency admissions increased in March 2018 with a 12.8% increase compared to March 2017. For patients 85 and over, the increase was 19.2%. • Formally reportable Delayed Transfers of Care totalled 2.99% for March 2018. This is a decrease from the February figure of 3.14%. • Average Inpatient Bed Occupancy was 95.7% in March, including escalation, with peaks of 99.6%. On average, 34 escalation beds per day were open across the trust during March, ranging from between 23 to 47 beds. This position is unchanged from the February position. The Trust flexes the number of open beds to respond to fluctuations in demand.
3. KEY AREAS OF PERFORMANCE
3.1 A&E Compliance
3.1.1 The Trust was not compliant against the National target in March, with 90.0% of patients waiting less than four hours from arrival at A&E to admission, transfer, or discharge, a 2.8% decline against February performance. Cumulative year to date performance for the Trust for 2017/18 was 92.9%.
3.1.2 By site, St Richard’s Hospital (SRH) performance in March was 89.4%, with Worthing (WSH) achieving 89.1%. Emergency admissions at SRH increased by 11.5% from March 2017. Worthing saw a slightly smaller increase in emergency admissions of 9.3% over the same period, but on both sites acuity high; and both volume and complexity a particular issue in the first two weeks of the month. For the 85+ age group, SRH saw an increase of 35.1%, an additional 129 admissions from this time last year, compared to Worthing with 7%.
3.1.3 Worthing saw an average of 490 beds occupied in March, and an average occupancy of 97.0%, with the highest occupancy of 99.8% on 7th March. Emergency medical length of stay at Worthing increased marginally to 7.2 days in March from 7.1 days February. SRH saw an average of 387 beds occupied in March. Occupancy at SRH averaged 94.1% in March 2018, reaching 99.3% also on 7th March. For SRH, emergency medical length of stay increased marginally from 5.6 days on average in February to 5.7 days March.
3
3.1.4 In March, delayed transfers of care (DTOC) decreased to 2.99% compared to 3.14% in February. March DTOCs peaked at 6.16% on 4th March. In real terms, this reflects an impact in ‘lost’ beds that fluctuated between a minimum of c10 beds and a high of c58 beds during the month. Patients who were medically fit for discharge (MFFD) decreased to 159 patients on average per day in March
3.1.5 The number of adult patients (medical and surgical patients) with a LOS greater than 7 days at the trust reduced by 35 patients on average per day (-6.8%) February 2018 compared to January 2017. This is 27 patients on average fewer than observed February 2017 (-5.3%)
3.1.6 The Trust was affected by an outbreak of vomiting and diarrhoea towards the end of March. At its peak on the 21st March there were 98 beds affected, of which 25 were unoccupied (lost beds). The number of beds affected reduced to 30 by the end of March, with 8 beds lost. At time of writing, there are 44 beds affected with 9 unoccupied (as of 19th April). SRH has also had an outbreak of the virus, although the impact on lost beds has been less than at Worthing. 33 beds were affected with 2 beds lost at the end of March at SRH, but has been clear since 9th April.
3.1.7 Nationally and regionally A&E delivery has continued to be challenging. National performance reduced to 84.6% in March 2018 from 85.0% in February 2018 for all attendances. Board members should note these figures also include type 3 A&E attendances (such as minor injuries units) for non-acute providers. Regionally, compliance for the South of England remained at 86.4%, with NHS England South Surrey & Sussex Trusts (excluding WSHFT) generating aggregate compliance of 89.4%.
3.1.8 The publication of national data confirms that WSHFT with 90.0% was the 32nd highest performing trust nationally in March 2018, and the 12th best performing trust in NHS South. Note that these figures include type 3 attendances for other non-acute providers in the Coastal West Sussex Acute Trust Footprint.
3.1.9 For type 1 attendances only (major A&E Unit activity, including the Trust’s Emergency Floor activity), the Trust’s performance for March 2018 was 89.2% and was ranked 22nd best performing trust and 14th best performing for the year to date.
3.1.10 April has shown improved performance at the Trust, with A&E performance to the 16th April of 93.6%. This is despite an increase in demand in April 2018 relative to numbers of patients for the corresponding time period April 2017 (8 more emergency admissions on average per day, a 5.3% increase between years, and an 8.9% increase in over 65 patients)
3.2 Cancer
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3.2.1 The Trust was provisionally compliant against the 62 day metrics relating to the Single Oversight Framework in March, and against all 7 wider cancer metrics (including metrics outside of the Single Oversight Framework) to the Trust in March.
3.2.2 The trust was compliant against the 62 day GP target with 91.12% against a target of 85%, and compliant against 62 day urgent and screening pathways (as monitored as part of the STF and Single Oversight Framework) with 92.36% against 85.08% target. The board is reminded that there is approximately a six week lag from the end of the reporting period, to publication of final performance for cancer metrics.
3.2.3 2 week referrals received in March 2018 were 11.4% higher than the level observed in March 2017. For the year April 2017 to March 2018, 2 week referrals registered on the Cancer database (Somerset) have increased by 4.5%
3.2.4 For context, latest comparative nationally published data relating to February 2018 shows national aggregate compliance for cancer attendance to be:
• 81.0% for treatment within 62 days from GP referral (target 85.0%) compared to WSHFT performance of 86.3%. WSHFT is the 44th best performing trust against this standard nationally in the year to date and the 7th best in the South of England. In February 2018, 57% of Trusts receiving GP referrals in England were non-compliant against this standard.
3.3 Referral to Treatment (RTT/18 Weeks)
3.3.1 The Trust was non-compliant against the National Constitutional Target of 92% in March with 85.0% of pathways waiting less than 18 weeks. This is a 1.4% deterioration in performance since February (86.4%). Numbers of patients waiting over 18 weeks increased by 747 patients between months.
3.3.2 There were zero patients waiting over 52 weeks at the end March 2018.
3.3.3 When stratified by division there was 2.1% deterioration in surgical performance, with a 610 increase in surgical backlog. Medical specialties saw a marginal deterioration, with an impact impact of 0.1% against Q4 plan.
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3.3.4 The Trust Quarter 4 recovery plan as described in last month’s paper has been significantly affected by non-elective pressures (as described in more detail in section 3.1) which adversely impacted on the Trust’s ability to deliver the intended elective recovery actions in January and February, and ongoing in March. The board should therefore note that the Quarter 4 action plan that sought to stabilise the first 9 month trend of decline, and recover the position to within the range of 86% - 87% by year end has not been delivered. April remains highly challenging with elective bed capacity significantly constrained, hence performance improvement is not anticipated but stabilisation is forecast.
3.3.5 RTT 2018/19 Delivery Plans are under development, recognising the ambition to improve performance throughout the year but balance this against the risk of on-going urgent and emergency demand pressures. This work is being undertaken alongside the completion of the 2018/19 Operational Plan refresh, as required under national planning guidance. Improvement proposals will be subject to executive scrutiny in May and an update provided next month.
3.3.6 Latest published national data relates to February 2018 and shows national compliance reduced to 87.9% from 88.2%. This figure is exclusive of independent sector providers and does not reflect a number of large acute NHS providers that currently are not reporting RTT positions as part of agreed ‘special measure’ arrangements. Trust performance dipped below the national compliance figure in July and remained below in February with 86.4% for the Trust compared to 87.9% nationally. Just over half (52%) of Trusts were non-compliant in February.
3.4 Diagnostic Test Waiting Times
3.4.1 The Trust compliance for March was 0.97% over 6 week waiters across all diagnostic modes, which is compliant against the 1% national target. This represents 46 over 6 week waiters of a total list of 4751 patients.
3.4.2 WSHFT performance compared favourably against regional peers in February (the latest comparable national data); with South of England Region aggregate compliance of 1.8% and National compliance at 1.6%, compared to WSHFT February performance of 0.7%. Just under 30% of Trusts were non-compliant in February 2018.
4 RECOMMENDATION
4.1 The Board is asked to receive the Month 12 position.
4.2 The Board is also asked to note the year to date compliance against the delivery requirements of the Sustainability and Transformation Fund (STF) for Cancer, and non-compliant position for RTT and A&E.
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Jane Farrell, Chief Operating Officer
17th April 2018
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Mark Dennis, Head of Information Services t: 01903 285273 (ext 5273)
NHS Improvement MARCH 2018 Single Oversight Framework Year to Threshold Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Date Trend Operational Performance Metrics A&E: maximum waiting time of four hours from arrival to OP1 95% 94.9% 95.2% 94.1% 94.2% 95.1% 95.4% 94.1% 92.7% 85.4% 89.5% 92.8% 90.0% 92.9% admission/transfer/discharge Maximum time of 18 weeks from point of referral to treatment in aggregate OP2 92% 90.7% 91.3% 90.6% 89.4% 89.0% 88.7% 88.4% 89.0% 87.1% 86.6% 86.4% 85.0% 88.5% – patients on an incomplete pathway
OP3A All cancers : 62-day wait for first treatment following urgent GP Referral 85% 94.1% 90.3% 89.3% 86.2% 86.6% 87.7% 88.9% 91.9% 86.3% 88.1% 86.0% 90.9% 88.7% All cancers : 62-day wait for first treatment following consultant screening OP3B 90% 100.0% 93.5% 90.9% 98.1% 94.2% 98.2% 94.2% 94.2% 96.0% 85.2% 96.6% 100.0% 94.9% service referral
OP4 Maximum 6-week wait for diagnostic procedures 1% 0.9% 1.0% 0.9% 1.0% 1.3% 1.0% 0.6% 0.7% 1.3% 0.8% 0.7% 1.0% 0.9%
Notes
Single Oversight Framework M12.1.SCORECARD Page 1 of 1 Printed 20/04/2018 12:27 Mark Dennis, Head of Information Services t: 01903 285273 (ext 5273)
Key Performance Deliverables Report MARCH 2018
A&E 4-hour waiting time target Description / Comments / Actions Target Month YTD Projected O/T Patients can expect to be admitted, transferred or discharged in 4 hours from arrival in A&E 95% 90.0% 92.9% 92.9%
100% Sustained increases in underlying demand and acuity. Increased demand challenging ability to maintain hospital/system flow essential to delivery of A&E waiting time. 95% 90% 85% 80% Actions: 75% 1. Enhanced discharge planning arrangements 70% 2. Augmented patient flow arrangements in conjunction with external partners 65% 3. Dedicated operational delivery review cycle under the leadership of the Chief Operating Officer 60% 55%
50%
Jul
Jan
Jun
Oct
Apr
Sep Feb Feb
Dec
Aug
Nov
Mar May
Cancer - Two weeks from urgent GP referral to first appointment Description / Comments / Actions Target Month YTD Projected O/T Patients can expect to be seen within 2 weeks following an urgent GP referral for suspected cancer. 93.0% 95.6% 96.2% 96.2% Significant and sustained increases in demand level. 100% 95% 90% 85% 80% Actions: 75% 1. Management/tracking oversight through DDO led Cancer Delivery Group 70% 2. Dedicated weekly review led by Chief Operating Officer 65% 60% 55%
50%
Jul
Jan
Jun
Oct
Apr
Sep Feb Feb
Dec
Aug
Nov
Mar May
Cancer - Two weeks from urgent GP referral to first appt - Breast symptoms Description / Comments / Actions Target Month YTD Projected O/T Patients with breast symptoms can expect to be seen within 2 weeks following an urgent GP referral. 93% 95.5% 96.1% 96.1%
100% Significant and sustained increases in demand level. 95% 90% 85% 80% Actions: 75% 1. Management/tracking oversight through DDO led Cancer Delivery Group 70% 2. Dedicated weekly review led by Chief Operating Officer 65% 60% 55%
50%
Jul
Jan
Jun
Oct
Apr
Feb Sep Feb
Dec
Aug
Nov
Mar May
Cancer - 62 days from referral to treatment following screening contact Description / Comments / Actions Target Month YTD Projected O/T Patients with cancer can expect to commence treatment within 62 days following referral after a positive screening test. 90% 100.0% 94.9% >90%
100% Delays in receipt of onward referral from screening which reduces the time to secure capacity to treat patients. 95% 90% 85% 80% Actions: 75% 1. Management/tracking oversight through DDO led Cancer Delivery Group 70% 2. Dedicated weekly review led by Chief Operating Officer 65% 60% 55%
50%
Jul
Jan
Jun
Oct
Apr
Sep Feb Feb
Dec
Aug
Nov
Mar May
Key deliverables report M12.1.Exception Report Page 1 of 2 Printed 20/04/2018 12:28 Mark Dennis, Head of Information Services t: 01903 285273 (ext 5273)
Key Performance Deliverables Report MARCH 2018
Cancer - 62 days from referral to treatment following urgent referral by a GP. Description / Comments / Actions Target Month YTD Projected O/T Patients with cancer can expect to commence treatment within 62 days following urgent referral by a GP. 85% 90.9% 88.7% 88.69%
100% Demand pressure exposing pathway efficiencies. Reduces the time to secure capacity 95% to treat patients. 90% 85% 80% Actions: 75% 1. Management/tracking oversight through DDO led Cancer Delivery Group 70% 2. Dedicated weekly review led by Chief Operating Officer 65% 60% 55%
50%
Jul
Jan
Jun
Oct
Apr
Feb Sep Feb
Dec
Aug
Nov
Mar May
Referral to treatment - Incomplete Pathways Description / Comments / Actions Target Month YTD Projected O/T All patients can expect to commence treatment within 18 weeks of a referral to consultant. 92.0% 85.1% 88.5% 88.5%
100% Non-compliance an expected outcome of planned RTT recovery programme. 98% 96% 94% 92% Actions: 90% 1. Increase in internal capacity as per Monitor/NHSE agreed Joint Recovery Plan 88% developed with support from IMAS 86% 2. CCWSCCG commitment to reduced demand levels as supporting component of Joint Recovery Plan. 84% 3. Dedicated weekly Divisional review meeting, with overarching assurance review by 82% Chief Operating Officer (also weekly)
80% 4. System Summit meetings with Monitor/NHSE to ensure partner deliver of agree Joint
Jul
Jan
Jun
Oct
Apr
Feb Sep Feb
Dec
Aug Nov
Mar Recovery Plan actions. May
% Medically fit hip fracture patients going to theatre within 36 hours Description / Comments / Actions Target Month YTD Projected O/T To ensure the best possible outcomes, hip fracture patients who are medically fit should be operated on within 36 hours of admission. This standard is part of the 'Best 90% 88.1% 89.1% 89% Practice Tariff' payment process under PbR. 100% Increased volume of demand and variation of demand have impacted sustained 90% compliance. 80% 70% 60% Actions: 50% 1. Improved tracking and escalation processes in place to manage fluctuations in 40% demand on a daily basis 30% 2. Revised protocol introduced based on four key demand based triggers to ensure 20% early escalation/intervention in periods of abnormal demand. 10%
0%
Jul
Jan
Jun
Oct
Apr
Feb Sep Feb
Dec
Aug
Nov
Mar May
Key deliverables report M12.1.Exception Report Page 2 of 2 Printed 20/04/2018 12:28 Mark Dennis, Head of Information Services t: 01903 285273 (ext 85273)
OPERATIONAL PERFORMANCE MARCH 2018 SCORECARD 2017/18 2017/18 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MAR YTD Target Trend NATIONAL AND OPERATIONAL PERFORMANCE TARGETS A&E : Four-hour maximum wait from arrival to admission, transfer O01 95.8% 94.9% 95.2% 94.1% 94.2% 95.1% 95.4% 94.1% 92.7% 85.4% 89.5% 92.8% 90.0% 92.86% 95% or discharge
O02 Cancer: 2 week GP referral to 1st outpatient 96.9% 94.4% 96.6% 95.7% 95.9% 96.9% 95.8% 96.7% 96.7% 97.0% 95.9% 96.8% 95.6% 96.15% 93%
O03 Cancer: 2 week GP referral to 1st outpatient - breast symptoms 97.4% 91.7% 99.4% 98.3% 92.7% 98.7% 99.2% 97.2% 94.9% 96.9% 91.6% 99.3% 95.5% 96.05% 93%
O04 Cancer: 31 day second or subsequent treatment - surgery 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% 100.00% 94%
O05 Cancer: 31 day second or subsequent treatment - drug 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% 98%
O06 Cancer: 31 day diagnosis to treatment for all cancers 99.0% 100.0% 100.0% 99.6% 99.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.9% 96%
O07 Cancer: 62 day referral to treatment from screening 100.0% 100.0% 93.5% 90.9% 98.1% 94.2% 98.2% 94.2% 94.2% 96.0% 85.2% 96.6% 100.0% 94.9% 90%
O08 Cancer: 62 day referral to treatment from hospital specialist 88.1% 90.9% 93.3% 94.4% 84.6% 68.8% 67.9% 96.2% 92.9% 89.7% 84.0% 96.8% 72.0% 86.7% N/A
O09 Cancer: 62 days urgent GP referral to treatment of all cancers 87.9% 94.1% 90.3% 89.3% 86.2% 86.6% 87.7% 88.9% 91.9% 86.3% 88.1% 86.0% 90.9% 88.7% 85%
O14 RTT - Incomplete - 92% in 18 weeks 92.0% 90.7% 91.3% 90.6% 89.4% 89.0% 88.7% 88.4% 89.0% 87.1% 86.6% 86.4% 85.0% 88.50% 92%
RTT delivery in all specialties O15 6 8 6 8 9 11 10 11 11 12 13 11 12 13 0 (Incomplete pathways)
O16 Diagnostic Test Waiting Times 0.84% 0.92% 0.97% 0.92% 1.00% 1.28% 0.99% 0.61% 0.69% 1.31% 0.83% 0.68% 0.97% 0.93% <1%
O17 Cancelled operations not re-booked within 28 days 0 2 0 0 1 1 0 1 2 0 3 3 3 13 -
O18 Urgent operations cancelled for the second time 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -
Clinics cancelled with less than 6 weeks notice for annual/study O19 28 17 11 15 71 71 40 26 23 20 44 41 18 379 - leave
O20 Mixed Sex Accommodation breaches 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
O33 Delayed transfers of care 3.16% 3.12% 3.15% 3.15% 3.34% 4.32% 4.15% 3.34% 3.47% 2.73% 3.07% 3.14% 2.99% 3.3% 3.0%
IMPROVING CLINICAL PROCESSES
O23 % hip fracture repair within 36 hours 89.2% 88.9% 90.5% 95.3% 89.3% 84.2% 88.2% 88.0% 90.5% 83.3% 96.2% 83.3% 88.1% 89.1% 90% Patients that have spent more than 90% of their stay in hospital on O24 87.6% 90.9% 92.7% 92.3% 86.4% 82.3% #N/A 89.2% 80% a stroke unit+
Operational performance scorecard M12.2.SCORECARD Page 1 of 2 Printed 20/04/2018 12:28 Mark Dennis, Head of Information Services t: 01903 285273 (ext 85273)
OPERATIONAL PERFORMANCE MARCH 2018 SCORECARD 2017/18 2017/18 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MAR YTD Target Trend OPERATIONAL EFFICIENCY
O36 Average length of stay - Elective 3.19 3.19 2.94 3.04 3.07 3.09 2.99 3.35 3.22 3.63 2.95 3.13 3.41 3.16 3.72
O37 Average length of stay - Non-elective Surgery 5.51 5.16 5.61 5.87 5.34 5.76 5.66 5.29 5.93 5.38 5.80 5.89 5.51 5.59 6.07
O38 Average length of stay - Non-elective Medicine 8.50 7.60 8.07 7.68 7.88 7.61 7.31 7.82 7.79 7.37 8.03 7.88 7.94 7.75 7.80
Day case rate (CQC day case basket of procedures) O39 86.88% 90.08% 89.01% 88.38% 86.03% 90.80% 89.70% 90.10% 90.00% 91.85% #N/A #N/A #N/A 89.60% 75.0% source: Dr Foster (reported 2-3 months in arrears)
O40 Elective day of surgery rate (DOSR) 97.9% 97.2% 98.8% 98.5% 98.1% 98.2% 98.4% 98.5% 99.1% 98.2% 98.9% 98.9% 96.5% 98.3% 90.0%
O41 Did not attend rate (outpatients) 6.73% 6.85% 6.57% 6.80% 6.36% 6.36% 6.09% 5.80% 5.72% 6.38% 6.11% 6.32% 6.26% 6.10% 7.65%
SUSTAINABILITY
O43 Bank staff - % of all staff pay 9.43% 7.60% 6.97% 6.92% 7.07% 8.40% 8.99% 7.85% 8.29% 8.12% 7.49% 8.62% 8.46% 7.29% 7%
O44 Agency staff - % of all staff pay 6.03% 5.09% 5.33% 5.58% 5.03% 4.30% 4.51% 3.84% 5.06% 4.28% 4.30% 3.67% 3.96% 5.78% 2%
O45 Nurse : occupied bed ratio 1.821 1.843 1.767 1.793 1.785 1.850 1.861 1.805 1.774 1.741 1.690 1.760 1.729 1.820 -
O46 % nurses who are registered 68.75% 68.44% 68.23% 67.99% 67.78% 67.71% 67.67% 68.40% 68.30% 68.34% 68.49% 68.58% 68.35% 68.19% -
O47 % Staff appraised 83.95% 83.83% 89.33% 89.50% 86.80% 89.11% 88.05% 88.37% 88.20% 87.60% 87.70% 87.00% 86.20% 86.20% 90%
Sickness Absence: % Sickness O48 3.22% 3.19% 3.17% 3.27% 3.31% 3.20% 3.77% 3.80% 3.60% 3.80% 4.30% 3.58% #N/A 3.52% 3.3% (reported one month in arrears)
O49 Staff Turnover: Turnover rate (YTD position) 8.03% 8.46% 8.46% 8.30% 8.10% 8.14% 8.00% 8.24% 8.20% 7.80% 7.70% 7.40% 7.50% 7.50% 11%
ACTIVITY
A01 Day Cases 5,855 4,395 4,945 4,990 4,707 4,784 4,767 4,900 5,359 4,248 5,056 4,471 4,613 57,235 61,086
A02 Elective Inpatients 683 538 624 660 633 580 614 548 589 456 362 484 410 6,498 7,376
A03 Non-elective inpatients 5,767 5,537 5,887 5,779 5,765 5,544 5,622 5,814 5,827 5,842 6,076 5,387 6,229 69,309 69,238
A04 Outpatient First attendances 14,843 11,898 13,894 13,731 12,832 12,817 12,859 13,808 13,992 10,732 13,444 11,509 12,483 153,999 168,736
A05 Outpatient Follow-up attendances 23,593 18,524 21,852 21,719 19,668 20,904 20,796 22,271 23,697 18,067 23,174 19,733 20,969 251,374 256,721
A06 Outpatients with procedure 4,779 5,150 6,282 6,111 5,333 6,217 6,521 7,287 7,131 5,196 6,612 6,407 5,948 74,195 73,106
A07 A&E Attendances 11,410 11,569 12,093 11,985 12,531 11,960 11,598 11,734 11,566 11,865 12,418 12,418 12,418 144,155 143,983 Notes 1 National reporting for these performance measures is on a quarterly basis. Data are subject to change up to the final submission deadline due to ongoing data validation and verification. 2 Data are provisional best estimates and will be amended to reflect the position signed-off in the relevant statutory returns in due course. 3 Staff sickness is reported one month in arrears. 4 A&E counting kept consistent with 2017/18 LHE reporting January 2018, following NHSE revised guidance to remove non co-terminous MIU activity and EF type 3 attendances from monthly Trust reporting from January (which is then subsequently reallocated back to the LHE)
Operational performance scorecard M12.2.SCORECARD Page 2 of 2 Printed 20/04/2018 12:28 Giles Frost, AD Operational Planning Performance TEL: 01903 205111 (85545)
STF PERFORMANCE TRAJECTORY MONITORING March 2018 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
A&E : FOUR-HOUR MAXIMUM WAIT FROM ARRIVAL TO ADMISSION, TRANSFER OR DISCHARGE
Trust Patients Seen 12,405 13,761 13,093 14,153 13,592 12,998 13,027 12,313 12,746 11,819 10,931 12,597 Trajectory >4 Hours 794 881 838 760 730 698 911 861 892 1,054 682 629 Performance 93.6% 93.6% 93.6% 94.6% 94.6% 94.6% 93.0% 93.0% 93.0% 91.1% 93.8% 95.0% Cumulative Performance 93.6% 93.6% 93.6% 93.9% 94.0% 94.1% 94.0% 93.9% 93.8% 93.5% 93.5% 93.7% Trust Patients Seen 13,272 13,994 14,012 14,501 13,910 13,562 13,610 13,267 13,563 12,418 11,730 13,814 >4 Hours 652 630 826 848 688 626 802 968 1,974 1,297 849 1,387 Actual Performance 95.1% 95.5% 94.1% 94.2% 95.1% 95.4% 94.1% 92.7% 85.4% 89.6% 92.8% 90.0% Cumulative Performance 95.1% 95.3% 94.9% 94.7% 94.8% 94.9% 94.8% 94.5% 93.5% 93.2% 93.1% 92.9%
CANCER 62 DAY PATHWAYS > 62 DAYS
Trust Patients Seen 149.0 170.0 190.0 148.0 152.0 148.0 175.0 195.0 161.0 188.0 198.0 181.0 Trajectory >62 days wait 22.0 25.5 28.5 22.0 22.5 22.0 26.0 29.0 24.0 28.0 29.5 27.0 Performance 85.2% 85.0% 85.0% 85.1% 85.2% 85.1% 85.1% 85.1% 85.1% 85.1% 85.1% 85.1% Trust Patients Seen 146.5 157 185.5 177 173 167 195.5 189 171 164.5 148 150.5 Actual >62 days wait 7 14.5 19 21 21.5 19 21.5 14.5 22.5 23 21.5 11.5 Performance 95.2% 90.8% 89.8% 88.1% 87.6% 88.6% 89.0% 92.3% 86.8% 86.0% 85.5% 92.4%
REFERRAL TO TREATMENT INCOMPLETE PATHWAYS > 18 WEEKS
52 Week Trajectory 0 0 0 0 0 0 0 0 0 0 0 0 Total Patients Waiting 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949 33,949 Trajectory Patients waiting >18 weeks 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715 2,715 Compliance 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 52 Week Trajectory 0 1 0 0 0 0 1 2 0 0 0 0 Total Patients Waiting 33,985 32,955 32,639 32,838 33,222 33,027 33,097 33,129 33,440 32,932 34722 36643 Actual Patients waiting >18 weeks 3,147 2,875 3,074 3,479 3,671 3,760 3,834 3,636 4,325 4,400 4739 5480 Cumulatively Ahead(behind trajectory) -432 -592 -951 -1,715 -2,671 -3,716 -4,835 -5,756 -7,366 -9,051 -11,075 -13,840 Compliance 90.7% 91.3% 90.6% 89.4% 89.0% 88.6% 88.4% 89.0% 87.1% 86.6% 86.4% 85.0%
Performance meets Constitutional Standard and STF Trajectory Performance meets STF Trajectory but not Constitutional Standard Performance doesn't meet STF Trajectory
DRAFT Performance Monitoring STF to Mar-18 Printed 20/04/2018 12:29
To: Board Date of Meeting: 26th April 2018 Agenda Item: 6.3
Title: Report on Organisational Development and Workforce performance Responsible Executive Director Denise Farmer, Director of OD and Leadership Prepared by: Jennie Shore, Human Resources Director Status: Disclosable Summary of Proposal: This report details the Trust’s performance in relation to the supply, development and engagement of its workforce and the organisations culture. Implications for Quality of Care: Provision of high quality, engaged staff has a direct impact on the quality of care. Financial Implications: Supports good financial performance Human Resource Implications: As described Recommendation The Board is asked to NOTE the report Consultation: n/a Appendices: None
This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.
To: Trust Board Date: April 2018
From: Denise Farmer, Chief Workforce and OD Officer Agenda Item: 6.3
FOR INFORMATION
WORKFORCE AND ORGANISATIONAL DEVELOPMENT REPORT
1.00 Introduction 1.01 This sets out the key headlines relating to the Trust’s workforce at 31 March 2018.
2.00 Workforce Capacity
2.01 Operational pressures continued during March with additional capacity open across both bed- holding hospitals. This resulted in workforce capacity exceeding the budgeted establishment by 31 wte, Within the Medicine Division the funded position was exceeded by 133.30 wte in month. Despite an increase in the number of substantive staff contracted in the division of 53.70 wte, the division has continued to exceed its funded position throughout 2017/18.
2.02 Substantive staff accounted for 91% of total capacity used in the Trust during month 12. This is an improvement on the previous month of 89%.
2.03 At month 12, there was an adverse pay spend of £357k. Whilst this is not an acceptable or sustainable position, the level of overspend in month 12 was at its lowest all year. It compares to £786k in February £931k in January bringing the end of year position of £9.3m adverse.
2.04 The amount of temporary staff used in month remained at a broadly similar level to last month at 10.5%. The proportion of bank staff used fell to 8.8% with agency used rising marginally to 1.7%.
2.05 Total spend on agency staff in 2017/18 was £12.86m, compared to £18.90m in 2016/17 Medical agency accounted for 54% of total use with nursing agency accounting for 33%.
3.00 Workforce Efficiency
3.01 Sickness absence fell during February across all divisions to 3.6%. The number of sickness episodes reduced by over 500 in month resulting in a drop in the number of staff experiencing short term absence.
3.02 Within the Estates and Facilities division, there has been focused attention to address the number of staff with a muscular skeletal disorder. Interventions include the development of a MSK/back care support pack by the physiotherapy service that includes appropriate exercises for staff to practice; tailored back care training; train the trainer in housekeeping This has resulted in improvements in the number of staff absent by this category. For example, at Worthing Hospital between December 2017 and February 2018 the number of staff with an MSK related absence within housekeeping improved from 56% to 11% with portering rates impoving from 71% to 41%. These successful interventions are now being rolled out to the respective teams at St Richards Hospital including the Laundry.
3.03 Staff turnover remains static at 7.5% and in the last year, the rolling 12 month rate has reduced again by 0.4%. Retention of registered nurses and HCA’s has improved to 7.10% and 7.30% respectively. This compares very favorably to other NHS trusts in the south east coast and south central regions where nurse turnover averages at 12%, and ranges from 7% to 24%.
4.00 Organisational Change
There are currently a number of service changes impacting on staff. These include:
4.01 Mental Health Pharmacy Services
A TUPE transfer of 32 staff delivering pharmacy services to Sussex Partnership NHS Foundation Trust is proposed, effective from 1 June 2018. Consultation with staff affected is currently underway.
4.02 Theatres Recovery
Consultation with 22 staff to standardise the shift length and align the number of staff rostered with theatre activity has closed and is proceeding to implementation.
4.03 Patient Experience and Customer Relations
Consultation to integrate and co-locate the two teams has commenced. It is anticipated that this will improve resolution of complaints in a timelier manner and facilitate the distribution of workload more appropriately.
4.04 Housekeeping
Phase 1 consultation to strengthen the management structure and standardise the job descriptions of team and zone leaders has been completed and now proceeds to implementation.
Phase 2 consultation which will standardise the job descriptions of housekeepers and transfer elements of work from night to day time commenced on 16 April This affects 120 staff and implementation will be phased over 12 months to mitigate the impact on individuals. This includes the exploration of alternative roles including HCA’s.
5.00 Equality and Diversity
5.01 Gender Pay Gap Reporting
As noted last month, the Trust published the gender pay gap report on 26 March ahead of the 30 March deadline.
The mean gender pay gap for the whole of the public sector economy is 17.7%1
An analysis of the gender pay gap for South East Coast, South Central and South West NHS Trusts is set out below, noting that the percentage figure is how much men are paid more on average than women.
1 October 2017 – Office for National Statistics (ONS) Annual Survey of Hours and Earnings (ASHE) Page 2 of 7
WSHFT South East South Central South West Coast Mean (%) 19.62 20.2 21.1 21.1 Median (%) (0.89) 8.7 7.0 7.5 Range in mean (%) 35.7 30.4 41.5
Changes to the ESR reporting suite will facilitate easier collation of future gender pay gap data enabling improved analysis by staff group and protected characteristic. This will be managed through the Diversity Matters Group.
5.02 Workforce Disability Equality Standard (WDES)
The NHS Standard Contract for 2017-19 sets out that NHS trusts and foundation trusts will have to implement the WDES in the first year. The proposed standard will use data from the NHS annual staff survey to understand workforce representation, reasonable adjustments, employment experience and opportunities.
As part of the development of the standard, NHS Employers are seeking views about the metrics and the wording of the disability questions in the NHS staff survey.
It is anticipated that comprehensive guidance will be available to NHS employers in due course to ensure that the reporting deadline of August 2019 is met.
5.03 Equality, Diversity and Human Rights Week
Preparations to celebrate the Equality, Diversity and Human Rights Week between 14-18 May 2018 are underway. This will be led jointly with Brighton and Sussex University Hospitals colleagues.
The new equality and diversity training materials, delivered on the Trust’s Your Health and Safety days will also be launched on 14 May. This refreshed material includes voice overs, a video clip and will also inform staff on the progress of the violence, aggression, harassment and bullying workstream.
6.00 Employment Related Legal Changes
6.01 Trade Union Act 2016
Whilst the main provisions to the Trade Union Act 2016 became effective from 1 March 2017, there were a number of changes with a delayed implementation that impact on the Trust.
These are:
• Deductions from Contributions at Source (DOCAS) - effective from 10 March 2018, employers are required to levy a reasonable fee for the cost of deductions of trade union subscriptions from staff salaries. Agreements are in place with Unison and the GMB to deduct 0.5% of the total value of the subscriptions collected. The financial value is very small with the majority of trade unions now collecting subscriptions through direct debit.
• Facility time – the Regulations require employers to publish facility time which covers duties carried out for the trade union or as a union learning representative. This will include the number of employees who were union officials during the relevant period, the percentage of time spent on facilities time for each relevant union official, the percentage of pay bill
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spent and the number of hours spent on paid trade union activities as a percentage of paid facility time hours.
The reporting deadline is 31 July 2018 for the financial year 2017/18.
6.02 Taxation of termination payments
Effective from 1 April 2018, changes to the taxation of termination payments have been made. This includes the removal of the distinction between contractual and non-contractual payments in lieu of notice (PILONs) so that all PILONs are taxable and subject to Class 1 National Insurance contributions (NICs). In cases of redundancy the first £30,000 will continue to be exempt from taxation but will be subject to NICs.
A review of the contract of employment templates has been completed. A contractual term that allows for a PILON already exists in all contracts and is therefore not impacted by this change. Any future settlement agreements will reflect the taxation changes.
7.00 NHS Terms and Conditions of Service: Contract Refresh 2018
7.01 Further details of the proposals to the Agenda for Change terms and conditions, including a 3 year pay deal, are emerging. This follows the government announcement on 21 March.
7.02 If accepted by trade unions, the proposed framework agreement will see widespread reform of the current terms and conditions for the majority of staff in the Trust, including the removal of automatic pay progression. There has been a change of language to reflect the new agreement including pay step points and pay step dates rather than increments.
7.03 Whilst it is understood that the proposals, if accepted, will be fully funded, the mechanism to implement this remains unclear (eg. how vacancies at 1 April will be treated, whether employers will receive funds directly).
7.04 It is anticipated that if agreement cannot be reached with trade unions, the Pay Review Body will make their recommendation on NHS pay to the government and central funding will be capped at 1%. NHS employers are therefore encouraged to recommend the proposed deal to staff and trade unions.
7.05 In the meantime the NHS Pension Scheme Advisory Board has been asked by the Department of Health to consider the design of membership contributions from April 2019. This may include staff being able to choose their own pension contribution levels in the future.
It is noted that under contract refresh proposals, staff at the top end of the Band 5 payscale will trigger a threshold increase in their pension contributions from 7.1% to 9.3%.
7.06 In readiness for implementation of the framework agreement, a project plan has been established and will be overseen by a steering group with appropriate representation across the organisation, including trade unions.
8.00 Statutory and Mandatory Training
8.01 Attendance on all mandatory training modules continues to remain above the Trust target of 90% for the consecutive month.
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8.02 The DNA rate has slightly increased and is currently 7.27%. This is due to operational pressures which result in some nursing staff being withdrawn from training at the last minute. This has also impacted on our overall capacity and led to an increase in demand for training places.
8.03 The number of staff who have never completed any training is 11, an increase of 8 since last month. The majority of those on the list (9) are medical staff who have joined the Trust in the last 6 months and have not completed their mandatory on-line Induction training. This has been escalated to Chiefs/ DDOs and we will continue to work with Divisions to ensure that these individuals completed their training as soon as possible.
9.00 Widening Participation
9.01 Apprenticeship Levy
For the financial year 2017/18 the total committed Levy spend on apprentices was £265.5k.
Of this £139k was for new apprentices starting in the Trust.
£126.5k was spent on supporting existing staff.
The Levy contribution for April 2018 was circa £96k, with an additional 10% government contribution the total amount entering the Apprentice Service (TAS) Account in April was £105k
Payments for apprenticeship qualifications are deducted monthly from the Apprentice Account.
The total spends out of the Levy account for March 2018 was £11.5k.
9.02 Apprentice starts
Since the 1 April there are seven new apprentices waiting to start in post in the Trust with a further 16 apprentice vacancies either at advert or waiting for interview stages.
12 existing staff have been entered onto the Apprentice Service (TAS) to complete a variety of IT qualifications including cyber security and IT infrastructure.
The committed Levy spend entered onto TAS for these apprentices is £192,000.
9.03 Procurement
This month procurement has commenced for health care support workers (level 2) and senior health care worker (level 3) qualifications.
9.04 Awards Ceremony
On 16 and 19 April the Widening Participation Team held their annual Awards Ceremony for all apprentice completers in the last year. The Chairman and HR Director attended on behalf of the Trust and awarded each apprentice with a certificate.
9.05 Work experience
There are four level 3 Health and Social Care students on placement at St Richards and one student at Worthing Hospital. Their mid-point review took place in mid March and the students fed back that they were settling in well and enjoying the tasks.
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There has been a adhoc placement in the Dietitians, ICT, Cancer Services, and Chichester Suite teams.
10.00 Communications, Engagement and Fundraising
10.01 Campaigns
The communications team has continued to work with colleagues from across the trust to provide support for a number of strategic campaigns and initiatives. This includes plans for the 70th anniversary of the NHS this year; launch of Affinity IT suite; infection control guidance; support for recruitment campaigns; preparatory work for this year’s Patient First STAR Awards launching next month; and support of staff engagement initiatives, including staff health and wellbeing and the Wellbeing Wednesdays campaign, which was again very successful in April with colleagues engaging with activities as diverse as Yoga, Nordic Walking, Zumba and Kickboxing.
10.02 News and social media
The Trust’s social media audiences continue to grow as the communications teams shares more trust news, staff achievements and team successes directly with the public via Facebook, Twitter, Instagram and YouTube. Highlights from the previous month include a Facebook LIVE interview with LEGO’s director of continuous improvement Peter Evans in Worthing Hospital (2,700 views); housekeeper Lisa Simmons wins Employee of the Month pictured on the trust’s Facebook page (4,000 views + 400 reactions, comments and shares); and again on Facebook a welcome to new student nurses (3,500 views + 300 reactions, comments and shares). Additionally, in the last month the trust’s @westernsussex Twitter account has reached more than 3,000 followers and our recently launched Instagram account has nearly 600 followers to date.
10.03 Fundraising
Love Your Hospital is the charity for Western Sussex Hospitals NHS Foundation Trust, raising funds to support the three hospitals and help ensure patients have access to the best and most modern facilities and equipment as well as support staff to provide outstanding care.
The following describes the headline activities of the past month:
Corporate and Community
Kardinal Healthcare has chosen Love Your Hospital as their Charity of the Year.
NJS Group are supporting Love Your Hospital as part of their competition for a Chichester family to win a holiday to Lapland.
Easter egg donations were received by our children’s and elderly care wards from many local businesses and organisations including Anytime Fitness, Wickham Arms Bikers, Tesco Durrington, Mercer, Nature’s Way, Worthing Rugby Club and many others.
Love our Hospital Events A Quiz ‘n’ Curry night at Worthing Rugby Club on 9 March raised more than £1,000 and attracted an audience of more than 100 people.
Lottery The development of lottery collateral and promotional strategy has continued during March and April to enable the introduction of a new recruitment programme in 2018/19. Lottery plays at Page 6 of 7
the end of 2017/18 currently stand at 648 and a retention programme has commenced. During 2018/19, sales will be used to benchmark the lottery strategy moving forward.
11.00 RECOMMENDATION
The Board is asked to NOTE the report.
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WSHFT WORKFORCE SCORECARD March 2018
2017/18 Target/ Key performance Indicators Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Ceiling Amber Limit Trend 1) WORKFORCE CAPACITY NB Budgeted FTE 6734.6 6584.8 6586.6 6591.3 6609.3 6610.5 6614.8 6619.1 6619.1 6634.6 6634.6 6634.6 6638.1 6614.8 N/A N/A
Total FTE Used 6692.3 6529.6 6545.0 6632.5 6564.5 6596.5 6560.6 6602.6 6666.4 6597.7 6570.7 6652.4 6669.1 6599.0 N/A N/A
Total FTE Used Variance from Budget -42.3 -55.2 -41.6 41.2 -44.8 -14.0 -54.2 -16.5 47.3 -36.9 -63.9 17.8 31.0 N/A N/A N/A
Total FTE Used Vacancy Factor 0.6% 0.8% 0.6% -0.6% 0.7% 0.2% 0.8% 0.2% -0.7% 0.6% 1.0% -0.3% -0.5% 0.2% N/A N/A
Substantive Contracted FTE 6064.6 6033.4 6011.0 6029.2 6011.6 6188.9 6046.9 6062.1 6036.5 6040.4 6037.2 6034.8 6049.1 6048.4 N/A N/A
Substantive FTE Worked 5909.4 5881.5 5870.8 5883.5 5868.5 5888.7 5877.4 5917.9 5922.9 5932.9 5923.9 5939.3 5971.5 5906.6 N/A N/A
Substantive FTE Used Vacancy Factor 9.9% 8.4% 8.7% 8.5% 9.0% 6.4% 8.6% 8.4% 8.8% 9.0% 9.0% 9.0% 8.9% 8.6% N/A N/A
Bank Usage As % Of Total FTE Used 8.8% 7.3% 7.5% 8.6% 8.1% 8.6% 8.4% 8.5% 8.9% 8.4% 7.9% 9.1% 8.8% 8.3% N/A N/A
Agency Usage As % Of Total FTE Used 2.9% 2.6% 2.8% 2.7% 2.5% 2.1% 2.1% 1.9% 2.3% 1.7% 1.9% 1.6% 1.7% 2.1% N/A N/A 2) WORKFORCE EFFICIENCY NB Rolling 12 Month Sickness Absence 1 3.7% 3.7% 3.6% 3.6% 3.6% 3.5% 3.6% 3.6% 3.5% 3.5% 3.5% 3.5% N/A 3.3% 3.3%
In Month Sickness Absence % 3.2% 3.2% 3.2% 3.3% 3.3% 3.2% 3.8% 3.8% 3.6% 3.8% 4.3% 3.6% 3.5% 3.3% 3.3%
In Month Maternity Leave % 2.4% 2.4% 2.3% 2.3% 2.4% 2.3% 2.3% 2.4% 2.4% 2.4% 2.4% 2.3% 2.4% N/A N/A
In Month Other Absence % 1.8% 1.5% 1.8% 1.7% 1.5% 1.2% 1.8% 1.9% 2.2% 1.5% 1.4% 1.8% 1.7% N/A N/A
In Month Total Absence % 7.4% 7.1% 7.3% 7.2% 7.2% 6.7% 7.9% 8.1% 8.2% 7.7% 8.1% 7.8% 7.6% N/A N/A
Sickness Episodes 1285 1114 1149 1128 1157 1145 1317 1435 1535 1753 1887 1381 N/A
Maternity Heads 196 189 187 187 199 195 188 196 194 199 198 190 N/A N/A N/A
In Month Long Term Sickness Absence % (28 Days Or More) 1.4% 1.6% 1.5% 1.5% 1.5% 1.6% 1.7% 1.7% 1.5% 1.4% 1.3% 1.3% 1.5% N/A N/A
In Month Short Term Sickness Absence % (<28 days) 1.8% 1.6% 1.6% 1.8% 1.8% 1.6% 2.1% 2.0% 2.2% 2.5% 3.0% 2.3% 2.0% N/A N/A
In Month Stress Related Sickness Absence % 0.6% 0.5% 0.6% 0.7% 0.6% 0.6% 0.8% 0.8% 0.7% 0.7% 0.6% 0.7% 0.7% N/A N/A
In Month Musculo Skeletal Sickness Absence % 0.6% 0.8% 0.8% 0.7% 0.7% 0.7% 0.7% 0.7% 0.6% 0.7% 0.7% 0.7% 0.7% N/A N/A
Number of Staff breaching Management Triggers for sickness absence 1051 1036 1032 1037 1020 998 995 1009 1016 1026 1047 1028 N/A
% of Staff (headcount) 15.0% 14.7% 14.7% 14.7% 14.5% 14.2% 14.1% 14.3% 14.4% 14.5% 14.8% 14.6% N/A
Rolling 12 Month Turnover 7.9% 8.2% 8.2% 8.3% 8.1% 8.1% 8.0% 8.2% 8.2% 7.8% 7.7% 7.4% 7.5% N/A 8.5% 8.5% 3) TRAINING & PERSONAL DEVELOPMENT NB % Appraisals Up To Date 83.9% 83.8% 89.3% 89.5% 86.8% 89.1% 88.1% 88.4% 88.2% 87.6% 87.7% 87.0% 86.2% N/A 90.0% 80.0%
% In Date - All Mandatory Training 2 82.5% 81.7% 82.3% 83.2% 81.9% 83.4% 83.6% 83.7% 86.1% 85.2% 86.6% 86.5% 86.3% N/A 90.0% 80.0%
% In Date - Fire 92.2% 91.2% 92.1% 92.6% 89.9% 92.2% 92.2% 92.4% 93.0% 92.3% 93.0% 93.4% 93.7% N/A 90.0% 80.0%
% In Date - Infection Control (Role Specific) 89.9% 89.6% 90.6% 90.6% 88.2% 90.9% 90.8% 90.8% 91.9% 91.4% 92.2% 92.3% 92.0% N/A 90.0% 80.0%
% In Date - Back Training (Role Specific) 92.9% 92.8% 92.9% 93.1% 91.6% 92.3% 92.0% 92.4% 93.8% 93.7% 94.1% 94.1% 94.2% N/A 90.0% 80.0%
% In Date - Child Protection (Role Specific) 96.6% 96.5% 96.9% 97.4% 96.0% 96.5% 96.7% 96.9% 97.7% 97.7% 98.0% 98.0% 98.2% N/A 90.0% 80.0%
% In Date - Information Governance 90.3% 89.7% 90.3% 90.6% 89.0% 91.1% 91.3% 91.1% 91.9% 91.2% 92.2% 92.1% 91.8% N/A 90.0% 80.0%
% In Date - Adult Protection 95.9% 95.9% 96.1% 96.5% 94.7% 95.3% 95.3% 95.4% 96.9% 96.9% 96.7% 96.4% 96.1% N/A 90.0% 80.0%
Number of Staff with no mandatory training 8 6 6 6 8 5 4 5 5 3 3 3 11 N/A
Number of Staff > 12 months since any mandatory training 0 0 0 0 0 0 0 0 0 0 0 0 0 N/A 4) REAL-TIME STAFF FEEDBACK NB Total Respondents To Survey 266 246 274 386 258 212 300 257 276 239 170 204 288 3110 N/A N/A
% Respondents who would recommend this trust as a place to work 83.4% 84.7% 84.3% 84.9% 83.1% 82.5% 84.3% 86.4% 89.8% 85.3% 84.0% 87.7% 85.9% 85.3% N/A N/A
% Respondents happy with standard of care if a friend/relative needed treatment 89.2% 92.9% 90.8% 91.5% 91.6% 92.7% 91.2% 90.8% 94.7% 91.5% 91.1% 93.1% 95.4% 92.3% N/A N/A
Overall Staff Engagement Composite Score 3 3.76 3.92 3.98 3.98 3.89 3.93 3.88 3.94 3.91 3.91 3.87 3.85 3.93 N/A 4.02 3.78
Notes: 1 Absence data is available one month in arrears. 2 An employee is counted as being up to date with all their mandatory training if their Fire, Infection Control, Back, Child Protection and Information Governance training is up to date. 3 Overall indicator for staff engagement is a composite score using 3 key finding questions, friend and family recommendation, motivation and making improvements. 3 WSHT Total Respondents To Survey is greater than the sum of the divisional Total Respondents To Survey as some staff did not select a division when completing the survey. 3 Baseline Data from 2016 Staff Survey, Overall Staff Engagement Score - 3.88
To: Trust Board Date of Meeting: 26th April 2018 Agenda Item: 6.4
Title Financial Performance - March 2018 Presented by Karen Geoghegan, Chief Financial Officer Prepared by Alison Ingoe, Finance Director; David Lowe, Assistant Director of Finance Status Confidential Summary of Proposal The Trust reported a deficit of £2.3m at the end of March, excluding STF. This included a £0.6m surplus on 2017/18 operational activities, in line with the revised forecast agreed with the Finance and Investment Committee in January, and a £2.9m adverse movement following completion of expert determination for the outstanding dispute of £8.6m in relation to 2016/17. The Trust has earned £9.9m STF in 2017/18. £6.5m for performance in Q1-Q3 and £3.47m as part of an incentive distribution from NHSI at year end which brings the out-turn position to a surplus of £7.7m. The Trust is reporting an FSRR rating of '2'. The Financial Performance paper provides further detail on the Trust’s financial position. Implications for Quality of Care Financial planning principles have been established to ensure that expenditure budgets reflect anticipated activity levels and that agreed staffing levels are maintained. Support for/integration with Corporate Objectives and Strategies G1. Maintain an acceptable financial risk rating Financial Implications These are noted within the Financial Performance Report Human Resource Implications N/A Recommendation The Board is asked to NOTE the Financial Performance Report for March 2018. Consultation N/A Appendices Financial Performance Report
This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288. Finance Report M12 2017/18
Summary The Trust reported a deficit of £2.3m at the end of March, excluding STF. This included a £0.6m surplus on 2017/18 operational activities, in line with the revised forecast agreed with the Finance and Investment Committee in January, and a £2.9m adverse movement following completion of expert determination for the outstanding dispute of £8.6m in relation to 2016/17. The Trust has earned £6.5m STF for performance in Q1-Q3 and an incentive distribution at year end of a further £3.4m bringing the total to £9.9m for 2017/18. The out-turn position, including STF is a surplus of £7.7m.The Trust is reporting an FSRR rating of '2'.
SOF Finance Rating G Control Total (exc STF) Surplus £k A Premium Pay Spend £k G
Plan Actual / Forecast Plan Actual / Forecast Plan Actual Year to Date 1 2 Year to Date £k 3,363 (2,279) Agency Ceiling (YTD) £k 17,249 12,873 Year End Forecast 1 2 Year End Forecast £k 3,363 (2,279) WLI Payments (YTD) £k 2,187 2,682 Total Premium Pay (YTD) £k 19,436 15,555 At the end of March, the Trust is reporting a FSRR of '2'. At the end of March, the Trust is reporting a surplus of £0.59m excluding STF and the At the end of March premium pay expenditure is £3.9m below the target level, primarily outcome of expert determination. Operational pressures continued resulting in higher due to agency spend reporting a £4.4m favorable variance to the ceiling level. pay and non pay expenditure in comparison with February. Emergency activity Expenditure on Waiting List Initiative payments remained above plan by £0.5m. increased significantly and elective activity remained below plan .
Income £k G Operating Costs £k R Agency Ceiling £k G
Plan Actual / Forecast Plan Actual / Forecast Plan Actual/Forecast Year to Date £k 424,857 427,354 Year to Date £k (397,698) (406,918) Year to Date £k 17,249 12,873 Year End Forecast 424,856 427,354 Year End Forecast £k (397,698) (406,918) Year End Forecast £k 17,249 12,873
Cumulatively income is £2.5m above plan. Non-elective admissions have increased in Pay expenditure increased by £0.6m in March, with the majority of the increase being Agency expenditure was cumulatively £4.4m below the ceiling target at the end of the March alongside a decrease in elective activity. The resolution of a 2016/17 dispute within substantive medical staff. Non pay also increased by £0.5m, £0.2m of which financial year. Agency expenditure was £0.1m higher in March than the previous month has resulted in a net reduction in income of £2.9m. Private patient income remains related to PbR exclusions which are matched with income. Clinical supplies and with increased agency usage across all staff types, stemming largely from the covered behind plan year to date. services reduced as a result of reduced elective activity levels and the impact from the required to support additional non-elective capacity. year end stock take, but remains above plan overall.
Cash £k A Capital £k G Efficiency and Transformation Programme £k G
Plan Actual Plan Actual / Forecast Plan Actual / Forecast Year to Date £k 7,306 6,538 Year to Date £k 19,003 20,301 Year to Date £k 19,949 19,973 Year End Forecast £k 7,306 6,538 Year End Forecast £k 19,003 20,301 Year End Forecast £k 19,949 19,973
The cash position is behind plan by £0.8m. The Trust's financial position has March capital expenditure totalled £4.9m. Out-turn expenditure is £1.2m higher than Full year efficiency savings of £20.0m (100% of plan) have been achieved. Under- contributed to an adverse cash variance of £10.3m, which includes a £2.9m reduction the original plan, but this includes the GP A&E streaming of £1.3m which is fully funded performance in workforce and transformation schemes was mitigated by over- relating to the outcome of the expert determination for 2016/17. This has been offset by PDC dividend and was authorised in addition to the original planned schemes via the performance in Medicines Management, Commercial and Procurement work-streams. by restricting payment runs to suppliers as well as additional PDC capital funding. DoH central programme Finance Report M12 2017/18 SOF Finance Rating G
At the end of March, the finance rating has remained as a '2'. All of the ratings have remained the same as in February, apart from a reduction in the liquidity ratio from a '2' to a '3'.
Plan Plan Actual Actual YTD Metric Rating Metric Rating
Capital Service Capacity 3.4 1 2.7 1
Liquidity (0.7) 2 (8.2) 3
I&E Margin 3.4% 1 1.8% 1
Distance from Financial Plan 0.0% 1 (1.6)% 3
Agency Spend (11.3)% 1 (25.4)% 1
2017/18 Finance Rating 1 2
Area Metric Construction Rating Weighting 1 2 3 4 (best) (worst)
Capital Service Capacity Revenue available for capital service 2.5x 1.75x 1.25x <1.25x 20% Annual debt service Financial Sustainability Working capital balance x 360 Liquidity Days 0.0 (7.0) (14.0) <(14.0) 20% Annual operating expenses
I&E Surplus or deficit Financial I&E Margin 1% 0% (1)% ≤(1)% 20% Total Operating and Non Op Income Efficiency
Distance from Financial Plan YTD Actual I&E Surplus/Deficit - YTD Planned I&E Surplus/Deficit 0% (1)% (2)% ≤(2)% 20% Financial YTD Planned I&E Surplus/Deficit Controls YTD Actual Agency Ceiling - YTD Planned Agency Ceiling Agency Ceiling 0% 25% 50% ≥50% 20% YTD Planned Agency Ceiling Finance Report M12 2017/18 Surplus A
The Trust reported a deficit of £2.3m at the end of March, excluding STF. This included a £0.6m surplus on 2017/18 operational activities, in line with the revised forecast agreed with the Finance and Investment Committee in January, and a £2.9m adverse movement following completion of expert determination for the outstanding dispute of £8.6m in relation to 2016/17. The Trust has earned £6.5m STF for performance in Q1-Q3 and an incentive distribution at year end of a further £3.4m bringing the total to £9.9m for 2017/18. The out-turn position, including STF is a surplus of £7.7m.
Year To Date Year Forecast Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k Surplus (Deficit) including STF 3,363 (2,279) (5,642) Surplus (Deficit) 3,363 (2,279) (5,642) less Sustainability and Transformation Fund 11,557 9,943 (1,614) less Sustainability and Transformation Fund 11,557 9,943 (1,614) Underlying Performance against Control Total excluding STF 14,920 7,664 (7,256) Underlying Performance against Control Total excluding STF 14,919 7,664 (7,255)
Following periods of high activity, non-elective discharges increased in March, although elective activity remained low.
Medical pay increased by £0.3m. Increased recruitment of substantive staff was not mitigated by any reductions within premium rate staff; as there was a requirement for additional temporary workforce to support additional capacity and emergency department activity . Substantive nursing agency costs remained at a similar level to February, however, there was a small increase in bank spend. Savings from vacancies in corporate areas helped mitigate pressures experienced in clinical divisions.
Non Pay expenditure increased by £0.5m, of which £0.2m related to PbR exclusions which are matched with income. Clinical supplies and services also reduced as a result of reduced activity levels in orthopaedics and a favourable stock stake movement, but cumulatively remain the largest cost driver within non pay.
Year to Date Full Year Prev Yr Actual Plan Actual Variance Plan Actual Variance £k £k £k £k £k £k £k Income 424,726 424,857 427,354 2,497 Income 424,857 427,354 2,497 Pay (282,810) (277,980) (285,507) (7,527) Pay (277,980) (285,507) (7,527) Non-Pay (tariff) (89,671) (87,531) (90,551) (3,020) Non-Pay (tariff) (87,531) (90,551) (3,020) Non-Pay (PbR exc) (31,191) (32,187) (30,861) 1,327 Non-Pay (PbR exc) (32,187) (30,861) 1,327 EBITDA * 21,054 27,159 20,436 (6,723) EBITDA * 27,159 20,436 (6,723)
Profit / Loss on Disposal of Fixed Assets 5 - 7 7 Profit / Loss on Disposal of Fixed Assets - 7 7 Interest Payable (896) (888) (727) 161 Interest Payable (888) (727) 162 Interest Receivable 25 33 25 (7) Interest Receivable 33 25 (7) Depreciation (13,643) (14,536) (14,071) 466 Depreciation (14,536) (14,071) 465 Impairments (5,875) - (1,648) (1,648) Impairments - (1,648) (1,648) Public Dividend Capital Dividend (7,604) (7,996) (7,930) 66 Public Dividend Capital Dividend (7,989) (7,930) 58 Net Surplus / (Deficit) (6,934) 3,771 (3,908) (7,679) Net Surplus / (Deficit) 3,778 (3,908) (7,686) less: Impairment 5,875 - 1,648 1,648 less: Impairment - 1,648 1,648 Retained Surplus/(Deficit) (1,059) 3,771 (2,260) (6,031) Retained Surplus/(Deficit) 3,778 (2,260) (6,038) Donated Assets (1,847) (1,481) (832) 649 Donated Assets (1,481) (832) 649 Donated Asset Depreciation and Amortisation 1,060 1,073 819 (253) Donated Asset Depreciation and Amortisation 1,065 819 (246) less Profit/Loss on Disposal of Fixed Assets (5) - (7) (7) less Profit/Loss on Disposal of Fixed Assets - (7) (7) Control Total excluding STF (1,850) 3,363 (2,279) (5,642) Control Total excluding STF 3,363 (2,279) (5,642) add Sustainability and Transformation Fund 9,900 11,557 9,943 (1,614) add Sustainability and Transformation Fund 11,557 9,943 (1,614) Control Total including STF 8,050 14,920 7,664 (7,256) Control Total including STF 14,919 7,664 (7,255) * EBITDA Earnings before Interest Taxation Depreciation and Amortisation
Control Total by Month Cumulative Control Total by Month 4,000 16,000
3,000 14,000
2,000 12,000
1,000 10,000
0 8,000
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Budget Budget
(1,000) 6,000 £000s Actual £000s Actual (2,000) 4,000
(3,000) 2,000
(4,000) 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar (5,000) (2,000)
(6,000) (4,000) Finance Report M12 2017/18 Sustainability and Transformation Fund A
The Trust was notified, by NHS Improvement on the 20th April, that they were eligible for £3.47m of incentive STF as part of a general distribution. Therefore the total of STF earned in 2017/18 was £9.9m. performance.
Q1 Q2 Q3 Q4 2017/18
Plan £000s 737 803 2,228 3,363 3,363 Financial Control Total (exc STF) Actual £000s 741 897 2,265 (2,272) (2,272)
Eligible for STF Funding Yes Yes No
STF Income Available £000s 1,734 2,311 3,468 4,044 11,557
Delivery of Financial Control Total Achieved? Yes Yes No Income 70.0% 1,213 1,618 2,428 0 5,259
A&E Waiting Times Achieved? Yes No No Income 30.0% 520 693 1,213
RTT Achieved? No No No Income 0.0% 0 0
Cancer Achieved? Yes Yes Yes Income 0.0% 0 0
Incentive STF 3,470
Total STF Income Achieved (£000s) 1,734 2,311 2,428 3,470 9,942 Finance Report M12 2017/18 Income G
Total income is £2.5m favourable to plan. Contract income is £1.7m favourable to plan. Lower non-contract income and private patient activity has been offset by increased by increased education and training income and central support for seasonal resilience.
Year To Date Year End Forecast Prev Yr. Actual Plan Actual Variance Plan Actual Variance £k £k £k £k £k £k £k Total Income 424,726 424,857 427,354 2,497 Total Income 424,856 427,354 2,498
Cumulatively income is 1.7m above plan. Non-elective admissions have increased again in March and elective activity has decreased further. Expert determination on a series of disputes with CWS-CCG from 2016/17 has ruled that a £4.9m credit note is due for last year, this was partially provided for and the impact in 2017/18 is £2.9m, this is the main driver of the change in income this month.
Private patient income remains behind plan year to date. Planned increases in income from overseas visitors are continuing. Donated asset income is behind plan and is forecast to remain so, however, this is excluded from calculation of the control total.
Year to Date Full Year Prev Yr Actual Plan Actual Variance Plan Actual Variance Income £k £k £k £k Income £k £k £k Coastal West Sussex 298,386 298,443 302,238 3,795 Coastal West Sussex 298,443 302,238 3,795 Other Clinical Commissioning Groups 17,996 19,938 18,980 (958) Other Clinical Commissioning Groups 19,938 18,980 (958) Specialist LAT 52,153 49,762 48,890 (872) Specialist LAT 49,762 48,890 (872) WSCC - Sexual Health 4,707 5,200 5,099 (101) WSCC - Sexual Health 5,200 5,099 (101) NCA 6,831 6,294 5,130 (1,164) NCA 6,294 5,130 (1,164) Other Trust Income 1,465 2,339 3,298 959 Other Trust Income 2,339 3,298 959 Income From Activities 381,538 381,976 383,635 1,659 Income From Activities 381,976 383,635 1,659 Private Patients 6,824 6,995 5,915 (1,080) Private Patients 6,995 5,915 (1,080) Education, Training and Research 14,647 14,299 15,684 1,385 Education, Training and Research 14,299 15,684 1,385 Donated Asset / Grant Income 1,847 1,481 832 (649) Donated Asset Income 1,481 832 (649) Other Income 19,869 20,105 21,288 1,183 Other Income 20,105 21,288 1,183 Other Operating Income 43,187 42,880 43,719 839 Other Operating Income 42,880 43,719 839 Total Income 424,726 424,857 427,354 2,497 Total Income 424,856 427,354 2,498 Sustainability and Transformation Funding Sustainability and Transformation Funding (STF) 9,900 11,557 9,943 (1,614) (STF) 11,557 9,943 (1,614) Total Income including STF 434,626 436,413 437,297 884 Total Income including STF 436,413 437,297 884 of which : PbR Drugs/Devices 31,191 32,187 30,861 (1,327)
Monthly Income Monthly Income Yearly Comparison 39,000 39,000 38,000 37,000 37,000 35,000
36,000
33,000
35,000 £000 £000 31,000 34,000
33,000 29,000
32,000 27,000
31,000 25,000
Jul
Jan
Jun Oct
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr
Feb Sep
Dec
Aug
Nov
Mar May
Budget Actual 2016-17 2017-18 Finance Report M12 2017/18 Contract Performance A
The Trust reports income based on the contract monitoring position for prior months and an estimate of income for the current month based on priced and coded activity in the month as available. An estimate is made for the value of uncoded spells and missing days and included within the reported income position.
1) Context
The Trust has signed contracts with all of its major commissioners. The Trust signed an Aligned Incentives contract variation with Coastal West Sussex Clinical Commissioning Group for 2017/18 in October.
2) YTD Report
Trust internal monitoring information shows overperformance against the Trust's main CCG contract. It is important to note that the performance indicated is compared to the Trust's plan and does not necessarily reflect the over-performance against commissioner contracts.
Table 1. Total Financial Values by Contract Table 2. Activity and Income by Point of Delivery
Activity Volumes £'000 Estimated Values YTD (inc CQUIN) £'000 Point of Delivery YTD Plan YTD Actual YTD Var YTD Plan YTD Actual YTD Var FYE Plan YTD Plan YTD Actual YTD Var Daycases 61,086 57,212 (3,874) 38,850 36,728 (2,122) Coastal West Sussex 298,443 298,443 302,238 3,795 Elective Spells 7,376 6,492 (884) 23,062 21,737 (1,325) Other CCG Acute contracts 19,938 19,938 18,980 (958) Elective Excess Bed days 1,405 921 (484) 349 230 (119) NHS England 49,762 49,762 48,890 (872) Non Elective Spells 55,870 56,180 310 120,845 126,404 5,558 Integrated Sexual Health Services 5,200 5,200 5,099 (101) Non Elective short-stay 13,368 13,108 (260) 9,813 10,049 235 Non Contract Activity 6,294 6,294 5,130 (1,164) Non Elective Excess Bed days 6,351 15,799 9,448 1,613 4,001 2,388 Outpatients 606,613 585,389 (21,224) 62,638 60,862 (1,777) Total 379,637 379,637 380,337 700 A&E 143,983 139,430 (4,553) 18,246 18,186 (60) PbR exclusions 32,187 30,861 (1,327) NB: Variances are reported against Western Sussex Hospitals Planned Income Levels Critical Care 16,135 14,364 (1,771) Maternity Pathway 10,923 10,802 (121) OP Diagnostic Imaging 7,583 7,424 (158) Sexual Health 5,075 4,974 (101) Direct Access Pathology 9,595 9,192 (403) Other Direct Access (Imaging and Dietetics) 2,581 2,332 (249) Breast Screening 3,367 3,367 - Other 9,933 11,956 2,023 CQUIN 6,841 6,868 28 Total 379,637 380,337 701
Table 3. - Reconciliation to Income Reporting Table 4. Contract Income by CCG and NHS England £000s FYE Plan YTD Plan YTD Actual SUSSEX CCGs and NHS ENGLAND £'000 This table represents the Trusts Contract Monitoring Performance 372,796 372,796 373,469 YTD Plan YTD Actual YTD Var assessment of the performance CQUIN 2.0% 6,841 6,841 6,868 NHS COASTAL WEST SUSSEX CCG 298,247 302,238 3,991 against commissioners only with Total Contracted Income 379,637 379,637 380,337 NHS HORSHAM AND MID SUSSEX CCG 4,811 4,710 (101) whom a Contract SLA has been NHS BRIGHTON AND HOVE CCG 5,744 5,309 (434) agreed. Income Recharged non-contract NHS HIGH WEALD LEWES HAVENS CCG 504 515 11 Seasonal Resilience funding 2,208 2,209 2,209 NHS CRAWLEY CCG 314 402 88 There are some differences between Horsham Older People's service 370 370 370 NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 486 450 (36) the Trust's income plan and the Maternity pathway payment (156) (156) (23) NHS HASTINGS AND ROTHER CCG 259 285 26 agreed contract values due to QIPP Cystic Fibrosis 346 346 163 NHS SOUTH EASTERN HAMPSHIRE CCG 6,365 5,944 (422) assumptions Other invoicing (429) (429) 338 NHS PORTSMOUTH CCG 661 568 (92) Work-in-progress adjustment 0 0 242 NHS FAREHAM AND GOSPORT CCG 277 342 66 NHS GUILDFORD AND WAVERLEY CCG 517 455 (62) Total Income from Activities 381,976 381,976 383,635 Subtotal CCG Acute Contracts 318,185 321,218 3,033
Strategic Transformation Fund 11,557 11,557 9,943 NHS England 49,628 48,890 (738) Total 367,813 370,108 2,295 Total Income from Activities plus STF 393,533 393,533 393,578
Page 6 Finance Report M12 2017/18 Operating Costs R
Expenditure increased in March in comparison to February with significant movements in both pay and non pay. The most significant area of expenditure is within medical staffing where additional premium rate costs were incurred to manage the high levels of emergency activity. Cumulatively, total expenditure exceeds plan by £9.2m.
Year To Date Year Forecast Prev Yr Actual Plan Actual Variance Plan Actual Variance £k £k £k £k £k £k Pay (282,810) (277,980) (285,507) (7,527) Pay (277,980) (285,507) (7,527) Non Pay (120,862) (119,718) (121,411) (1,693) Non Pay (119,718) (121,411) (1,693) Operational Costs (403,672) (397,698) (406,918) (9,220) Operational Costs (397,698) (406,918) (9,220)
Pay: In totality the underlying pay expenditure increased by £0.6m in comparison with February. The most significant increase was within medical staffing, where increased recruitment of substantive staff was not mitigated by any reductions within premium rate staff. In March there was a requirement for additional temporary workforce, both medical and nursing to manage the high emergency activity numbers which necessitated the Trust entering periods of business continuity. Substantive nursing agency costs remained at a similar level to February, whilst bank costs increased by £0.1m. Non pay: Non pay increased by £0.5m, of which £0.2m related to PbR exclusions which are matched with income. Clinical supplies and services also reduced as a result of reduced activity levels in orthopaedics and a favourable stock stake movement. A further stock movement was recognised within drugs, which mitigated some of the activity related pressures experienced in the clinical areas.
Year to Date Full Year Prep Yr. Actual Plan Actual Variance Plan Actual Variance £k £k £k £k £k £k £k Pay Pay Management & Admin (38,747) (41,129) (39,675) 1,454 Management & Admin (41,129) (39,675) 1,454 Medical and Dental Staff (79,893) (77,981) (82,742) (4,761) Medical and Dental Staff (77,981) (82,742) (4,761) Nursing & Midwifery (107,747) (105,425) (108,101) (2,675) Nursing & Midwifery (105,425) (108,101) (2,675) Other Healthcare (40,456) (39,514) (39,977) (463) Other Healthcare (39,514) (39,977) (463) Estates (15,965) (15,399) (15,011) 388 Estates (15,399) (15,011) 388 Other Staff (1) 1,468 (2) (1,470) Other Staff 1,468 (2) (1,470) Total Pay (282,810) (277,980) (285,507) (7,527) Total Pay (277,980) (285,507) (7,527) Non-Pay Non-Pay Services from Other NHS Bodies (3,480) (2,291) (3,221) (930) Services from Other NHS Bodies (2,291) (3,221) (930) Purchase of Healthcare from Non NHS Bodies (2,489) (2,350) (2,166) 184 Purchase of Healthcare from Non NHS Bodies (2,350) (2,166) 184 Drugs & Medical Gases - tariff (12,327) (12,437) (12,486) (50) Drugs & Medical Gases (12,437) (12,486) (50) Drugs & Medical Gases - PbR excluded (25,191) (25,775) (25,651) 124 Drugs & Medical Gases - PbR excluded (22,884) (25,651) (2,767) Drugs & Medical Gases - Cancer Drug Fund (2,929) (2,901) (1,628) 1,274 Drugs & Medical Gases - Cancer Drug Fund (5,792) (1,628) 4,165 Supplies and Services - Clinical (34,584) (32,543) (34,484) (1,941) Supplies and Services - Clinical (32,543) (34,484) (1,941) Supplies and Services - Clinical PbR Excluded (3,071) (3,511) (3,582) (71) Supplies and Services - Clinical PbR Excluded (3,511) (3,582) (71) Supplies and Services - General (4,502) (3,561) (3,974) (412) Supplies and Services - General (3,561) (3,974) (412) Establishment Expenses (5,830) (5,206) (5,829) (623) Establishment Expenses (5,206) (5,829) (623) Premises (15,683) (15,786) (15,862) (76) Premises (15,786) (15,862) (76) Education and Training (1,009) (1,235) (987) 247 Education and Training (1,235) (987) 247 Clinical Negligence Premium (7,261) (10,342) (10,166) 177 Clinical Negligence Premium (10,342) (10,166) 177 Other Non-Pay (2,506) (1,780) (1,375) 405 Other Non-Pay (1,780) (1,375) 405 Total Non-Pay (120,862) (119,718) (121,411) (1,693) Total Non-Pay (119,718) (121,411) (1,693) Total Expenditure (403,672) (397,698) (406,918) (9,220) Total Expenditure (397,698) (406,918) (9,220)
Monthly Pay Monthly Non Pay
26,000 15,000
24,000 10,000 £000s £000s 22,000 5,000
20,000 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Budget Actual Budget Actual
Monthly Operating Costs Monthly Pay Yearly Comparison 36,000 26,000
35,000 25,000
34,000 24,000
33,000 23,000 £000s 32,000 £000s 22,000 31,000 21,000 30,000 20,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Budget Actual 2016-17 2017-18 Finance Report M12 2017/18 Payroll & Premium Pay Costs R
Agency Year To Date Waiting List Initiative Payments 1) Context 2015/16 2016/17 Ceiling Actual Variance Year to Date £k £k £k £k £k Budget Actual Variance Medical and Dental Staff (10,172) (7,031) (6,635) (6,936) (301) Division Nursing & Midwifery (9,170) (9,283) (8,672) (4,412) 4,260 Surgery (1,220) (1,335) (115) Other Healthcare (2,892) (2,197) (1,921) (1,405) 516 Medicine (148) (419) (272) Management & Admin (520) (195) - (113) (113) Core (921) (876) 46 Estates (509) (182) (21) (8) 13 Women & Children (12) (51) (39) - Corporate 115 (0) (115) (23,263) (18,887) (17,249) (12,873) 4,376 (2,187) (2,682) (495)
Medical Locum Agency Expenditure Comparison Year to Date 2,000 Budget Actual Variance Division 1,500 Surgery (657) (686) (29)
£000s 1,000 Medicine (1,498) (4,970) (3,472) Core (446) (376) 70 500
Women & Children (104) (875) (772)
Jul
Jan
Jun
Oct
Apr
Sep Feb
Dec
Aug
Nov Mar May Corporate 6 (22) (28) 2017-18 Ceiling (2,699) (6,930) (4,231)
Payroll Year To Date Staff in post incl Bank Year To Date Prev Yr Actual Plan Actual Variance Prev Yr Actual Plan Actual Variance £k £k £k £k WTE WTE WTE WTE Medical and Dental Staff (66,895) (70,025) (66,867) 3,157 780 792 816 (24) Nursing & Midwifery (89,184) (101,502) (103,284) (1,781) 2,712 2,810 2,806 5 Other Healthcare (34,756) (38,510) (38,355) 155 1,014 1,047 1,004 43 Management & Admin (34,942) (41,066) (39,510) 1,556 1,311 1,328 1,306 22 Estates (14,406) (15,369) (15,000) 368 684 660 624 36 Other Staff (1) 1,468 (2) (1,470) - - - -
(240,184) (265,003) (263,018) 1,985 6,501 6,638 6,556 82 Finance Report M12 2017/18 Divisional Performance R
Surgery: Activity was on plan in M12 across all specialities with the exception of orthopaedics. Medicine: Outpatient, Day Case and Elective activity reduced as business continuity Core: Contract income continues to be behind plan levels with direct access activity low in Operational pressures arising from business continuity led to the cancellation of all elective pressures resulted in increased A&E and Non Elective activity during March. Contract income March due to staffing constraints. Other income is below plan driven by lower private patient arthroplasty activity. Expenditure remained at a similar level to February, with medical staffing remains above plan, but not sufficiently to mitigate all operational challenges within pay. activity and reduced education income earlier in the year. Pay expenditure continues above and administration vacancies resulting in a favourable pay position. Increases relating to Expenditure on premium rate staff has been caused by both the need to cover gaps in plan predominantly within Medical Imaging, as vacancies remain covered by temporary staff at substantive recruitment were offset by reductions in premium rate expenditure. Non pay establishments due to recruitment difficulties and also to respond to increased non-elective premium rates. Cancer growth has resulted in nursing expenditure above plan during the reflected reductions in clinical supplies in relation to the reduced orthopaedic activity. demand. Actions taken in year to increase internal capacity and reduce agency rates have second half of the year. Non pay expenditure remains above plan predominantly in Pathology partially mitigated the pressure on pay within nursing . Premium medical pay remain the largest where consumable expenditure remains a key driver. contributor to the overspend in Q4 and remain a focus going into 18/19.
Year To Date Year To Date Year To Date PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG £k £k £k £k £k £k £k £k £k £k £k £k Contract Income 110,694 106,713 101,812 (4,902) R Contract Income 159,073 164,924 167,689 2,765 G Contract Income 41,254 44,668 43,691 (977) R Other Income 2,315 2,153 2,300 147 G Other Income 2,988 2,811 2,851 40 G Other Income 11,985 12,001 11,660 (342) R Total Income 113,009 108,866 104,112 (4,754) R Total Income 162,061 167,735 170,540 2,805 G Total Income 53,239 56,670 55,351 (1,318) R Pay (64,244) (63,569) (63,290) 279 G Pay (89,419) (85,874) (91,183) (5,309) R Pay (55,825) (55,984) (56,845) (861) R Non Pay (22,488) (22,088) (22,065) 23 G Non Pay (34,455) (34,399) (34,422) (22) R Non Pay (25,033) (23,580) (25,260) (1,680) R Total Expenditure (86,732) (85,656) (85,355) 302 G Total Expenditure (123,873) (120,274) (125,605) (5,331) R Total Expenditure (80,859) (79,564) (82,105) (2,541) R
EBITDA Surplus/(Deficit) 26,277 23,210 18,757 (4,452) R EBITDA Surplus/(Deficit) 38,188 47,461 44,935 (2,526) R EBITDA Surplus/(Deficit) (27,620) (22,895) (26,754) (3,859) R
Contribution 23% 21% 18% Contribution 24% 28% 26% Contribution (52%) (40%) (48%)
Women & Children: Contract income within maternity has increased in M12 and continues to Facilities & Estates: The division delivered a favourable performance to plan, an improvement Corporate: Despite continued high NHS occupancy, private patient activity increased be above plan. The higher birth numbers seen at the start of Q4 have continued. Medical compared to February’s position. Income was in line with expectations due to improved car marginally in March but remains behind plan. Income for Education and Research continues to Staffing has been impacted by the premium cost of using agency doctors to cover vacancies parking income and accommodation occupancy rate. Pay remains favourable to plan as a perform above plan partially offset by increased expenditure costs. Corporate departments in both Paediatrics and Obstetrics & Gynaecology. Pressures within pay have been incurred result of roster improvements being implemented which has reduced premium rate. Non pay were cumulatively underspent due to the impact of vacancy control and discretionary spend all year and longer term substantive solutions continue to be sought. Non Pay expenditure remains adverse, driven by increased reactive maintenance works, utilities charges and repair controls. remains above plan with high cost consumables continuing in maternity linked the volume of costs relating to the fire earlier in the year. deliveries.
Year To Date Year To Date Year To Date PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG £k £k £k £k £k £k £k £k £k £k £k £k Contract Income 58,346 60,579 61,145 567 G Contract Income 0 - - - Contract Income 4 (0) 0 0 G Other Income 886 842 984 142 G Other Income 5,159 4,334 4,139 (195) R Other Income 15,220 15,416 16,996 1,580 G Total Income 59,231 61,421 62,129 709 G Total Income 5,159 4,334 4,139 (195) R Total Income 15,224 15,416 16,996 1,580 G Pay (31,170) (30,968) (32,011) (1,043) R Pay (16,117) (15,467) (14,977) 490 G Pay (26,380) (27,798) (27,595) 203 G Non Pay (10,752) (11,498) (11,676) (178) R Non Pay (14,462) (14,306) (14,598) (292) R Non Pay (13,882) (14,459) (14,729) (270) R Total Expenditure (41,921) (42,466) (43,687) (1,220) R Total Expenditure (30,579) (29,773) (29,575) 198 G Total Expenditure (40,262) (42,257) (42,324) (67) R
EBITDA Surplus/(Deficit) 17,310 18,954 18,443 (511) R EBITDA Surplus/(Deficit) (25,420) (25,439) (25,435) 3 G EBITDA Surplus/(Deficit) (25,038) (26,842) (25,328) 1,513 G
Contribution 29% 31% 30% Finance Report M12 2017/18 Statement of Financial Position
The Trust Balance Sheet is produced on a monthly basis, and reflects changes in the asset values, as well as movement in liabilities.
Year to Date Full Year Plan Actual Variance Notes Plan Actual Variance Notes £k £k £k £k £k £k Property, Plant and Equipment 277,373 279,862 2,489 1 Property, Plant and Equipment 277,373 279,862 2,489 1 Intangible Assets 390 6,616 6,226 Intangible Assets 390 6,616 6,226 Other Assets - - - Other Assets - - - Non Current Assets 277,763 286,478 8,715 Non Current Assets 277,763 286,478 8,715 Inventories 6,450 6,993 543 Inventories 6,450 6,993 543 Trade and Other Receivables 43,268 33,411 (9,857) 2 Trade and Other Receivables 43,268 33,411 (9,857) Cash and Cash Equivalents 7,306 6,538 (768) Cash and Cash Equivalents 7,306 6,538 (768) Non Current Assets Held for Sale - - - Non Current Assets Held for Sale - - -
Current Assets 57,024 46,942 (10,082) Current Assets 57,024 46,942 (10,082) Trade and Other Payables (48,292) (46,722) 1,571 3 Trade and Other Payables (48,292) (46,722) 1,571 Borrowings (2,224) (549) 1,675 Borrowings (2,224) (549) 1,675 Other Financial Liabilities - - - Other Financial Liabilities - - - Provisions (811) (228) 583 Provisions (811) (228) 583 Other Liabilities - - - Other Liabilities - - - Current Liabilities (51,327) (47,499) 3,829 Current Liabilities (51,327) (47,499) 3,829 Borrowings (20,564) (22,185) (1,621) Borrowings (20,564) (22,185) (1,621) Trade and Other Payables - - - Trade and Other Payables - - - Provisions (2,530) (2,958) (428) Provisions (2,530) (2,958) (428) TOTAL ASSETS EMPLOYED TOTAL ASSETS EMPLOYED 260,366 260,778 412 260,366 260,778 412 Financed by: Financed by: Public Dividend Capital 239,210 240,844 1,634 Public Dividend Capital 239,210 240,844 1,634 Retained Earnings (19,833) (37,311) (17,478) Retained Earnings (19,833) (37,311) (17,478) Surplus/(Deficit) for Year - - - (Surplus)/Deficit for Year - - - Revaluation Reserve 40,989 57,245 16,256 Revaluation Reserve 40,989 57,245 16,256 TOTAL TAXPAYERS EQUITY TOTAL TAXPAYERS EQUITY 260,366 260,778 412 260,366 260,778 412
1. The out-turn position includes the full delivery of the capital programme. The variance to plan is due to the impact of year-end valuations in 2016/17. 2. The trade and other receivables balance continues to be higher than plan due to higher trade receivables due to 2016/17 invoices raised to the Trust's main commissioner that remain outstanding. 3. Trade payables are lower than plan due to the Trust being able to reduce the outturn creditor numbers in 2016/17 by £4.2m, however the restriction of supplier payments continued in Q4 2017/18. Finance Report M12 2017/18 Cash A
The cash position is behind plan by £0.8m. The Trust's financial position has contributed to an adverse cash variance of £10.3m, which includes a £2.9m provision relating to the outcome of the expert determination relating to the 2016/17 dispute with the Trust's main commissioner. These items have been offset by the movement in working capital by restricting payment runs and the receipt of capital monies via the drawdown of PDC dividend, predominantly for A&E GP Streaming (£1.4m)
Year To Date Full Year Plan Actual Variance Plan Actual Variance £k £k £k £k £k £k Cash Balance 7,306 6,538 (768) 7,306 6,538 (768)
Year to Date Full Year Plan Actual Variance Plan Actual Variance £k £k £k £k £k £k EBITDA 37,233 30,404 (6,830) EBITDA 37,233 30,404 (6,830) Movement in Working Capital (4,635) (447) 4,188 Movement in Working Capital (4,635) (447) 4,188 Provisions - (170) (170) Provisions - (170) (170) Cashflow from Operations 32,598 29,786 (2,812) Cashflow from Operations 32,598 29,786 (2,812) Capital Expenditure (19,003) (20,246) (1,243) Capital Expenditure (19,003) (20,246) (1,243) Cash receipt from asset sales - - - Cash receipt from asset sales - - - Cashflow before financing 13,595 9,540 (4,054) Cashflow before financing 13,595 9,540 (4,054) PDC Received - 1,634 1,634 PDC Received - 1,634 1,634 PDC Repaid - - - PDC Repaid - - - Dividends Paid (7,987) (7,930) 57 Dividends Paid (7,987) (7,930) 57 Interest on Loans and leases (888) (584) 304 Interest on Loans and leases (888) (584) 304 Interest received 33 25 (8) Interest received 33 25 (8) Donations received in cash - - - Donations received in cash - - - Drawdown on debt - - - Drawdown on debt - - - Repayment of debt (2,158) (2,187) (29) Repayment of debt (2,158) (2,187) (29) Cashflow from financing (11,000) (9,042) 1,958 Cashflow from financing (11,000) (9,042) 1,958 Net Cash Inflow / (Outflow) 2,595 498 (2,096) Net Cash Inflow / (Outflow) 2,595 498 (2,096) Opening Cash Balance 4,712 6,040 1,328 Opening Cash Balance 4,712 6,040 1,328 Closing Cash Balance 7,306 6,538 (768) Closing Cash Balance 7,306 6,538 (768) Finance Report M12 2017/18 Aged Debtors
The Trust debtors are a mixture of invoiced debtors, accrued income and prepayments as set out in the table below. The Trust has outstanding debtors of 31 days or more of £17.7m, which is a decrease of £2.3m since February, £1.2m of this reduction is due to the payment of invoices by Brighton and Sussex Hospitals. The most significant debtors greater than 90 days relate to invoices for 2016/17 over- performance with the Trust's lead CCG and outstanding balances with three foundation trusts for provider to provider agreements and specialist drugs/services.
Overdue Within Total Debtors Terms 31-60 61-90 1-30 days > 90 days days days £k £k £k £k £k £k 3,933k CCG's 1,571 268 130 277 10,137 12,382 NHS England (in Health 78 902 401 514 208 2,104 Education England) NHS Trusts - 1,304 236 228 1,692 3,460 955k Foundation Trusts - 554 95 125 2,239 3,013 1-30 days Other NHS (8) 3 18 3 114 130 1,257k 31-60 days Non-NHS 38 902 75 110 1,168 2,292 61-90 days Total 1,679 3,933 955 1,257 15,558 23,382 7% 17% 4% 5% 67% > 90 days 15,558k Provision for Bad Debts (including RTA Provision) (776) Accrued Income (including Work in Progress) 5,080 Prepayments 1,065 Other Debtors 4,661 Total Trade & Other Receivables 33,411
Other debtors includes £2.3m of RTA debtors, £1.2m of Private Patients, £0.6m relates to Charity funding (of which £0.4m relates to the League of Friends and £0.2m relates to LYH) and £0.6m relating to VAT and other debtors. Accrued income consists of £3.4m of STF distributed by NHSI at year end, £1.0m of commissioned income, £1.4m of provider to provider income, non-contracted activity £0.6m, drugs/pharmacy £0.2m, private patients £0.3m, work-in-progress £2.9m and £0.1m of other income recharges including radiology, catering and clinical excellence award. This reduced by a credit note provision against Coastal West Sussex of £4.9m relation to the outcome of the 2016/17 expert determination with Coastal West Sussex CCG. This is an increase of £2.9m compared to the balance held at the end of 2016/17. Finance Report M12 2017/18 Capital G
February capital expenditure totalled £4.9m. The largest areas of expenditure are £1.1m Patient First, £0.7m medical imaging equipment, £0.3m hot and cold water replacement, £0.3m standby electrical generator, £0.2m for GP A&E streaming, £0.2m for defibrillators, £0.2m of expenditure on the Southlands masterplan and £0.2m on office space in Worthing. Out-turn expenditure is £1.2m higher than plan, but this includes the GP A&E streaming of £1.3m which is fully funded by PDC dividend and was authorised in addition to the original planned schemes via the DoH central programme
Year To Date Year End Forecast Plan Actual Variance Plan Actual Variance £k £k £k £k £k £k Total Capital 19,003 20,301 (1,298) Total Capital 19,003 20,301 (1,298)
Capital Year to Date Full Year Budget Actual Variance Plan Actual Variance Source of Funds £k £k £k Source of Funds £k £k £k Depreciation (net of IFRIC 12) 15,180 14,071 (1,109) Depreciation (net of IFRIC 12) 15,180 14,071 (1,109) Loan Repayments (1,158) (1,158) - Loan Repayments (1,158) (1,158) - Charitable Funds 1,000 414 (586) Charitable Funds 1,000 414 (586) Donation/Grants 481 417 (64) Donation/Grants 481 417 (64) GP A&E Streaming PDC Funding 1,634 1,634 GP A&E Streaming PDC Funding - 1,634 1,634 Cash Reserves/Other 3,500 4,852 1,352 Cash Reserves 3,500 4,852 1,352
19,003 20,230 1,227 19,003 20,230 1,227 Application of Funds Application of Funds Southlands Ophthalmology 498 768 (270) Southlands Ophthalmology 498 768 (270) MSK 500 151 349 MSK 500 151 349 Equipment Replacement - Imaging 1,050 1,108 (58) Equipment Replacement - Imaging 1,050 1,108 (58) Other Service Developments 11,376 7,616 3,760 Other Service Developments 11,376 7,616 3,760 Medical Equipment 2,096 1,670 426 Medical Equipment 2,096 1,670 426 Facilities & Estates 4,894 3,116 1,778 Facilities & Estates 4,894 3,116 1,778 Information Technology 3,581 3,290 291 Information Technology 3,581 3,290 291 A&E GP Streaming - 1,342 (1,342) A&E GP Streaming - 1,342 (1,342) Patient First - 1,112 (1,112) Patient First - 1,112 (1,112) Misc - 128 (128) Misc - 128 (128) Overprogramming (4,992) - (4,992) Overprogramming (4,992) - (4,992) Total Expenditure 19,003 20,301 (1,298) Total Expenditure 19,003 20,301 (1,298) Finance Report M12 2017/18 G
Full year efficiency savings of £20.0m (100% of plan) have been achieved. Under-performance in workforce and transformation schemes was mitigated by over-performance in Medicines Management, Commercial and Procurement work-streams.
Full Year Workstream Plan Actual Variance £k £k £k
FYE 16/17 1,348 1,293 (56) Back Office & Corporate Support 847 958 112 Commercial Opportunities 2,174 3,197 1,023 Core 1,418 1,298 (120) Estates & Facilities 583 589 6 Growth 2,000 2,000 - IM&T 53 34 (19) Medical Workforce 3,246 3,132 (114) Medicine 100 100 0 Medicines Management 200 390 189 Nursing Workforce 2,866 3,309 443 Procurement 2,150 2,351 201 Salary Sacrifice 10 21 10 Surgery 94 94 - Women and children 16 18 3 Workforce 1,230 1,188 (42) Transformation 1,614 - (1,614) Efficiency Plan Total 19,949 19,973 24 100.1%
Month 12 Plan vs Actual 3,500
3,000
2,500
2,000
£000s 1,500
1,000 Plan Actual 500
0
To: Trust Board Date of Meeting: 26th April 2018 Agenda Item: 7
Title Nursing Staffing and Capacity Levels Report Responsible Executive Director Nicola Ranger, Executive Chief Nurse Prepared by Maggie Davies, Nursing Director Status Disclosable Summary of Proposal The purpose of this report is to provide the Trust Board a 6 monthly report of the staffing and capability levels for adult inpatient wards, midwifery and children’s wards across the Trust, as required by the National Quality Board directive. Implications for Quality of Care To consider areas of concern and provide assurance of safe nursing staff levels. Link to Strategic Objectives/Board Assurance Framework Patient Safety agenda – improving the patient experience/learning lessons. Financial Implications 1. Financial penalties may be incurred. 2. Subsequent patient litigation claims may occur. 3. Loss of Commissioner confidence may result in loss of Trust business. Human Resource Implications 1. Professional performance management issues for individuals. 2. Learning and development requirements. 3. Organisational, behavioural and cultural issues. Recommendation The Board is asked to NOTE the report. Communication and Consultation This paper will be provided to divisions for review at their relevant meetings. Appendices A: red flags B: Bed to registered Nurse Ratios by site and ward C. Children’s staffing report
Report to the Board of Directors
Nurse Staffing and Capacity Levels Report for Adult Inpatient wards,
Midwifery and Children’s Wards across Western Sussex Hospitals Foundation Trust
1 Introduction
1.1 The purpose of this report is to present to the board a review of ward nurse staffing level as directed by the National Quality Board (NQB). The NQB has stipulated that; ‘Boards must take full responsibility for the quality of care provided to patients, and as a key determinant of quality, take full and collective responsibility for nursing, midwifery and care staffing capacity and capability’. Within their recommendations it states that every six months as required by the NHS England Hard Truths report, that the board of directors should receive and discuss at a public board meeting a report on staffing capacity and capability. This was requirement came following a number of national reports.
• The Francis report on Mid Staffordshire (2013) resulted in the publication of a number of documents focussing on the importance of safe nurse staffing levels.
• Keogh review into the quality of care and treatment provided in 14 hospital trusts in England (2013)
• Cavendish review (2013), an independent enquiry into healthcare assistants and support workers in the NHS and social care setting.
• Berwick report on improving the safety of patients in England (2013)
• ‘How to ensure the right people, with the right skills, are in the place at the right time. A guide to nursing, midwifery and care staffing capacity and capability’ (National Quality Board 2013).
• ‘Hard truths. The journey to putting patients first’ (DH, 2013)
1.2 As a result of the recommendations ‘Safe staffing for Nursing in adult inpatient wards in acute hospitals’ (NICE 2014) was developed, this provides detail on the methodology for undertaking a staffing review and, processes requirements for escalation including the introduction of ‘red flags’ which were a series of incidents that NICE identified should be reported by ward staff. (Appendix 1). These are reported through Datix and reviewed each month at the triangulation committee.
1.3 The board currently receives monthly information on the percentage of staff shifts filled (RN & HCA) and since May 2016 on the number of care hours per patient per day by ward as a part of the board quality report. Currently wards display publicly, daily information shift by shift of the 1
staff available versus those that were planned for the shift.
1.4 The board is reminded that registered nurse workforce capacity across the local region and nationally remains a challenge to all health providers. WSHT has a recruitment campaign that is focussed on national and international recruitment to reduce the current RN nurse shortfall. Bank and agency staff are utilised to maintain safe staffing of wards where ever possible. Currently the trust has a registered Nurse vacancy 217 WTE and 17 WTE HCAs under establishment (02/18). There remains focussed activity on nursing recruitment, retention, sickness management and in increasing our bank pool while aiming to reduce our use of agency staff. The Trust are currently using a variety of recruitment methods including return to practice, flexible working and rotation programmes to our recruitment adverts. We have a rolling programme of recruitment dates on both sites including weekend dates. We are also planning 1,2, and 3 year development plans for our RNs.
2 Adult Inpatient wards
2.1.1 This report will now summarise the position on the adult inpatient wards at WSHT, children’s wards and maternity department staffing, including Registered Nurse ratios to patient by ward and by site.
2.1.2 Current staffing data on establishments and current staff in post is provided by the Heads of Nursing with information also taken from the rostering system. Calculating staffing requirements is multi-faceted and is dependent upon a number of factors including the use of professional judgement. This includes the dependency (acuity) of patients on nursing care and factors such as skill mix of staff available and others including the culture and leadership of the team. The next acuity and dependency review will be presented to the board in July 2018. This year the ‘Safer care live module’1 is enabled to allow capture of acuity & dependency across all areas, triangulated with planned vs actual RN staffing. In the near future the Safer care data will become the national reporting on staffing level to Unify.
2.1.3 Currently there is an annual process whereby ward templates are reviewed annually within the divisions, ward sister/charge nurse and presented to the Chief Nurse for approval. This methodology will be reviewed in the forthcoming year. As part of the assurance process the triangulation committee will review staff vacancies, retention trends, safety flags and ward establishments to triangulate any possible impact of staffing and safety.
1 Safe Care Live an IT system facilitates patient acuity and dependency can be recorded up electronically and for staffing information accessed can than be accessed from the roster system. This enables a picture of the site to be available and supports the reallocation of staff across the site to the areas of most need. The system also provides the information for the monthly national staffing submission that is a national requirement.
2
2.1.4 The Safer Staffing Alliance states there is evidence that care is compromised where there are more than 8 patients (beds) to 1 nurse. The staffing ratios on adult wards within the Trust in the trust are presented in Appendix 2. The table in Appendix 2 details by ward, the RN staffing established and planned ratios over a 24 hour period during -the day and night shifts on all adult wards in the trust). This data excludes the ward coordinator from the ratios in the day time but the nurse in charge is included at night. Within the trust have a ratio of 1:8 on the majority of the wards during the day. The variance on the wards is between 1:6.8 to1:10.0 (excluding the ward coordinator). On the night shifts across the wards on both sites the ratios vary between 1:7 and 1:13. There is currently no evidence that the higher patient to nurse ratio at night is affecting safety but where there are only 2 trained nurses at night it can have an impact on RNs due to work demand and resilience at night. On the higher acuity areas such as emergency floor and critical care, the establishment is adjusted for RN staffing ratios of 1:5.6 and 1:1.2 respectively. If the acuity and dependency requirements on any particular shift on any ward necessitates additional RN, RMN or HCA support, there is a well established system of requesting additional support via temporary or bank staffing, authorised by the Head of Nursing.
2.1.5 Currently the Trust produces an acute site operation plan for each site, and which is reported 4 times daily the site team. This is cascaded to the Chief Executive, Chief Operating Officer, Chief Nurse and Executive Director on call together with key operational staff across the Trust. Within the body of the report staffing levels and shortfalls are reported and mitigation plans are updated. In line with previous winters, during the winter months the trust has opened additional bed capacity on both Worthing and St Richards sites to meet the demand of high numbers of admissions particularly in our over 85 year old population.
2.2 Care Hours Per Patient Day (CHPPD)
2.2.1 Model Hospital provides details on the average number of actual nurse care hours spend with each patient per day. The data indictes that WSHFT is in the lower quartile of RN distribution CHPPD in January 2018. CHPPD is calculated by the total care hours (sum of actual hours worked) by nursing and midwifery staff, divided by total patient bed days (daily patient count snapshot by ward at 23.59). Day care, CDU, clinical assessment areas, additional capacity wards and A&E are excluded. In January 2018 the CHPPD data by national median was 7.6 vs WSHFT 6.4 overall. RN national median 4.6 Vs 3.8 WSHFT. HCA national median 3.0 Vs Trust 2.7.
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Table 1 – Run Rate comparison of total nursing and midwifery staff (RN/RM and HCA/MCA). Peer group selected ‘My STP footprint’
Table 2 – RN distribution of CHPPD (the bold line to the left represents the WSFT position nationally)
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Table 3 – HCA distribution of CHPPD
2.3 Vacancy Rates and Recruitment
2.3.1 The vacancy factor for all areas is managed by the use of bank and agency staff and the board receive a monthly dashboard summarising the percentage of filled shifts by ward and role (registered / non registered staff) every month within the quality report. The monthly quality report also includes safety metrics including falls and pressure ulcers. Registered nursing staff continue to be recruited through a domestic campaign led by the divisions interviewing staff every two weeks.
2.4 Overseas recruitment
2.4.1 The project to recruit from Philippines has been in place since 2015, with the first RNs arrived in January 2016, a total 40 nurses arrived during 2016 with 37 nurses obtaining their registration with support from the project team.
2.4.2 Following a further successful recruitment campaign the in 2016, we achieved the target of 30 RNs commencing with the Trust during 2017 which led to a further recruitment campaign in October 2017. A total of 110 candidates were interviewed with 86 posts offered with the target of 60 nurses to commence in 2018, of which 11 have already arrived in the trust.
2.4.3 Each wards publicly displays the daily nurse staffing information (RNs & HCAs) per shift. This information is the actual vs planned staffing on each ward. An escalation process (see above) is available for staff to follow when staffing does not meet the planned numbers and a process for recording red flag incidents is in place.
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3 Maternity
3.1.1 WSHFT midwifery staffing extends across the acute and community settings. The professionally endorsed model for assessing whether midwifery staffing is at a safe level is based on the crude numbers of women who give birth together with the acuity of the cohort. The last assessment of the midwifery workforce numbers using the Birthrate Plus tool was in 2012 when a ratio of 1:29 was recommended. The Trust has maintained at this budgeted establishment since that time however it is recognised nationally that the case mix of women has changed together with guidance around managing complications in pregnancy resulting in a higher proportion of women presenting with clinical risk factors requiring additional intervention (age, obesity, diabetes, reduced fetal movements and growth for example) or social risk factors (safeguarding concerns, mental health problems, alcohol/drug use and migrant populations). It is likely therefore that the current midwifery establishment may be insufficient to safely meet the changing acuity profile in the future.
3.1.2 Currently the template for staffing maternity for each shift is: a midwifery coordinator to oversee the shift2, 8 midwives and 4 maternity assistants allocated to days and nights (on nights one of the 8 midwives is twilight only). The coordinator allocates and moves staff throughout the shift depending on the needs and acuity of the women. The maternity wards on each site have 27 beds where midwives are caring for women in the antenatal period together with new mothers and babies. The labour wards on each site have 8 birthing rooms with an additional two birthing rooms on the Birth Centre at SRH.
3.1.3 Maternity is an ‘ebb and flow’ service that requires flexible use of midwives and support staff across the labour ward and maternity ward settings. Although a small amount of elective work is undertaken (elective caesarean and induction for example), childbirth is unpredictable both in terms of demand and the potentially rapid change in the acuity profile. At times there is need for escalation. Labour wards are prioritised and midwives will move from the maternity ward to labour ward when this is required for safety. This can at times impact on the numbers of midwives on the maternity ward who are available to support women. For example, if there are 6 women on labour ward requiring one-to-one care (either because they are in established labour, having an elective caesarean or are high risk), only 2 midwives will be left to care for the women on the maternity ward. The service has an escalation procedure and there is a dedicated Midwifery Manager on call 24/7 to support staffing and decision making at times of increased activity. As a last resort the community midwives on call can be called in to support, this will mean that they are then
2 This midwife is based on labour ward and should be supernumerary as the role extends to coordinating the whole of the inpatient setting and to community out of hours. 6
unavailable for homebirths and may in fact have worked much of the previous day prior to the on- call.
3.1.4 In October 2017 there were some concerns raised by staff on the Worthing site about staffing numbers of shift. On review of rosters it was apparent that a number of factors were contributing:
• Due to the specialist nature of midwifery and the national requirements for fitness to practice, mandatory training requirements are over and above the Trust allocation for other nursing groups • High headcount due to an almost 70% part time workforce compounds this issue by having to release more staff for training • Consistently high level of maternity leave • Short and long term sickness absence • Staff with specific rostering requirements due to ill health and supported by the Occupational Health Service • Lack of parity in the bank payment enhancement leading to lack of willingness to do bank
3.1.5 Representatives of maternity at Worthing met with the Chief Nurse to discuss concerns and an action has been taken to resolve most of the issues. Staffing levels have improved and are being closely monitored by the matrons and escalated where there are identified shortfalls. There is only a small level of vacancy in maternity and active recruitment is a priority.
3.2 Re-assessment: Although the birth rate has remained broadly static since the last independent midwifery workforce assessment, the Trust has commissioned a further assessment across both sites in order to establish whether the funded establishment for midwives and support staff continues to meet the acuity needs of women. This is likely to take place in June 2018. Based on the findings of the assessment, the Board will be notified of any identified need to make changes to midwifery staffing.
3.3 Caseloading: A significant development in terms of the models of care and likely staffing needs for the future is the move to a case-loading model of care. The maternity component of the Five Year Forward View is called ‘Better Births’3 and requires services to develop care to provided safer care with increased personalisation and choice for women and their families.
3 National Maternity Review - Better Births: Improving outcomes of maternity services in England. A five Year Forward View for maternity care. (February 2016) www.england,nhs.uk/ourwork/futurenhs/mat-review
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A key part of the programme is the requirement to move to a case-loading model of midwifery care for ‘most’ women by 2021. An interim target of 20% of women being booked to this model of care by March 2019 has been set in the NHS Planning Guidance 2018/19. Currently around 4% of women (usually women in the most vulnerable groups) receive this model of care at WSHFT. The model provides women with continuity of midwife/small team of midwives throughout the antenatal, birth and postnatal period. Midwives providing case-load care to women need to be able to work very flexibly to enable them to continuously met the needs of their group of women and there is generally a significant on-call component to the roles.
3.4 Principles of case-loading:
3.4.1 There are four main principles that will need to underpin the provision of continuity of carer models across the country:
1. Provide for consistency of the midwife who cares for a woman throughout the antenatal, intrapartum and postnatal periods
2. Include a named midwife who takes on responsibility for co-ordinating a woman’s care throughout the antenatal, intrapartum and postnatal periods
3. Enable the woman to develop an ongoing relationship of trust with her midwife
4. Where possible be implemented in both the hospital and community settings.
The Birthrate Plus workforce assessment will include case-loading requirements in assessing the numbers of midwives required to deliver this model of care – workforce and financial modelling will then follow.
4 Paediatrics
4.1 The workforce requirements for the children’s units, Howard ward/Bluefin Ward are audited and monitored against the RCN 2013 guidance, defining staffing levels for children’s and young people’s services. (Appendix 3)
The ratio’s recommended are:
1:3 for under 2’s
1: 4 for over 2’s
1:2 for HDU care
1:1 for specialling CAMHs
1: 3 for ‘Intensification of treatment i.e. Oncology/CF’
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4.2 Professional judgement is key and on a shift by shift basis the matrons use this to monitor staffing levels and may rotate staff members as the need arises. Staffing compliance on both sites this year has improved mainly due to the introduction of the paediatric nursery nurse. In December there was a peak in children requiring High Dependency care on the St Richards site.
4.3 Since November 2017 there has been an increase in admissions of children with mental health needs and children under the Feeding and Eating Disorder Service (FEDS) across both sites. These children often require intensive nursing support to facilitate their care. This has been supplemented through the use of Registered Mental Health Nurses. The discussion has taken place with the Head of Nursing for Women’s and Children and the Chief Nurse to expire the opportunities for courses and extra training on adolescent mental health issues.
5 Neonatal Nursing
5.1 The standards aligned to the neonatal nursing workforce are the DH Neonatal toolkit standards 2009 and the British Association of Perinatal Medicine 2010. WSHT provides compliance data through the neonatal networks and measures progress through monthly workforce audits using a nationally validated tool (Badgernet). This tool provides objective data based on the acuity of each baby, and is calculated twice a day. In recognition of the need to respond to sudden the changes in patient acuity, we provide flexibility within the workforce to respond to need.
5.2 The compliance on the neonatal units is largely good with appropriate escalation of staffing to meet the sudden increase in acuity whilst stabilising a critically sick baby. Neonatal activity saw a peak in October on the Worthing site. February has seen a peak in activity on the St Richards site. Both periods have required close management of safe staffing levels to maintain safety.
6 Summary
6.1 This report provides information on all adult inpatient wards at WSHT, maternity and children’s wards. The Chief Nurse is satisfied that children, maternity and adult staffing is managed on a day to day basis in relation to patient safety. However, there remains a need for further review on adult wards with current provision at 2 trained RNs at night, and this is being reviewed further.
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APPENDIX A
Nursing Red Flags Nursing Red Flag Events – October 17-March 18 (Quarter 3 and 4 2017/18)
Unplanned Delay of Vital signs Delay or Shortfall Less than Delayed Missed or Missed Delay of Delay of 2 Delayed Total omission in more than not omission of 2 or delayed medicatio 30 mins or hours or recognition providing 30 assessed/r of registered registered cancelled care (i.e. n during more more of & action patient needs minutes in ecorded intentiona nurse nurses on time delay of 60 an between between on providing as per l rounding establish the ward cancelled mins or admission presentati admission abnormal pain relief care plan ment critical more in to on & for vital signs (>8hrs or activity washing & hospital triage induction 25%) suturing or and midwifery beginning -led unit of process Accident & Emergency 0 1 0 0 1 0 0 0 0 0 0 0 2 (SRH) Accident & Emergency 0 1 0 0 0 0 0 1 0 1 0 0 3 (WH) Acute 2 0 0 0 1 0 0 0 0 0 0 0 3 Cardiac Unit Acute Stroke Assessment 0 0 0 0 1 0 0 0 0 0 0 0 1 Unit Any Other 1 0 0 1 0 0 0 0 0 0 0 0 1 Location Barrow Ward 12 1 4 8 9 1 1 2 0 0 1 0 39 Becket Ward 1 0 0 0 0 0 0 0 0 0 0 0 1 Bosham 0 0 0 0 3 0 0 0 0 0 0 0 3 Ward Botolphs 6 0 2 3 14 2 1 1 1 0 0 0 30 Ward Boxgrove 0 0 0 0 3 0 0 0 0 0 0 0 3 Ward Bramber 0 2 1 0 2 2 0 0 0 0 0 0 7 Ward Broadwater 0 0 0 0 1 0 0 0 0 0 0 0 1 Ward Buckingham 1 0 0 0 1 1 0 0 0 0 0 0 3 Ward Burlington 1 0 0 0 0 0 0 0 0 0 0 0 1 Ward Castle Ward 0 2 1 1 0 0 0 0 0 0 0 0 4 CCU/Courtla 0 0 0 1 1 0 0 0 0 0 0 0 2 nds CDU (SRH) 1 0 0 0 0 0 0 0 1 0 0 0 2 Chichester Emergency 0 0 0 1 3 0 0 0 1 0 0 0 5 Floor Chichester 0 0 0 0 1 0 0 0 0 0 0 0 1 Suite Chilgrove 1 1 1 1 3 2 0 0 0 0 0 0 9 Ward Chiltington 0 0 1 0 0 0 0 1 0 0 0 0 2 Ward
Delivery 0 1 0 0 0 0 3 2 1 4 0 1 12 Suite Ditchling 0 0 0 0 1 0 0 1 0 0 0 0 2 Ward Donald Wilson 0 0 0 0 0 1 0 1 0 0 0 0 2 House Downlands 1 0 0 0 0 14 0 0 0 0 0 0 15 Suite Durrington 1 0 1 1 0 1 0 0 0 0 0 0 4 Ward
Eartham 0 0 0 0 1 0 0 0 0 0 0 0 1 Ward Eastbrook 1 2 3 2 0 0 0 0 1 0 0 0 9 Ward Emergency 0 1 0 1 3 1 0 0 1 0 0 0 7 Floor (WH) Eye Clinic 0 0 0 0 1 0 0 0 0 0 0 0 1 Fishbourne 2 0 1 1 5 3 0 0 1 0 0 0 13 Ward Ford Ward 0 0 0 0 15 0 0 0 0 0 0 0 15 Lavant Ward 0 0 0 1 6 1 0 0 0 0 0 0 8 Medical Day 0 0 0 0 0 0 1 0 0 0 0 0 1 Case Unit Middleton 0 0 0 0 0 0 0 0 1 0 0 0 1 Ward Selsey Ward 0 0 0 0 0 0 0 0 1 0 0 0 1 Theatres 0 0 1 0 0 0 0 0 0 0 0 0 1 Total 31 12 16 22 76 29 6 9 9 5 1 1 217
Patient to Registered Nurse Ratios by Site and Ward Patients per RN - Excluding Co-ordinators in day Sum of #OccBedDays Including co-ordinators at nig
Site WardName2 Beds Early Late Night Worthing Hospital BARROW 38 7.6 9.5 9.5 BECKET 22 7.3 11.0 11.0 BOTOLPHS 28 7.0 9.3 9.3 BROADWATER 22 7.3 7.3 11.0 BUCKINGHAM 22 7.3 11.0 11.0 BURLINGTON 18 6.0 6.0 9.0 CASTLE 26 6.5 8.6 8.6 CHILTINGTON 21 7.0 7.0 10.5 CLAPHAM 27 6.8 6.8 10.8 COOMBES 27 6.8 6.8 13.5 COURTLANDS 17 5.7 5.7 4.3 CRITICAL CARE (WOR) 12 1.3 1.3 1.2 DITCHLING 24 8.0 12.0 12.0 DURRINGTON 23 7.7 11.5 11.5 EARTHAM 21 7.0 10.5 10.5 EASTBROOK 23 7.7 7.7 11.5 Emergency Floor 67 5.6 5.6 5.6 ERRINGHAM 22 7.3 11.0 11.0 Worthing Hospital Total St Richards Hospital ACUTE CARDIAC UNIT 27 6.8 6.8 6.8 APULDRAM 16 8.0 8.0 8.0 ASHLING 26 8.7 8.7 8.7 BIRDHAM 19 9.5 9.5 9.5 BOSHAM 26 8.7 8.7 10.4 BOXGROVE 27 9.0 9.0 13.5 CHILGROVE 22 7.3 7.3 11.0 ef c 55 6.9 6.9 6.1 FISHBOURNE 26 8.7 8.7 8.7 FORD 26 6.5 8.6 8.6 ITCHENOR 10 1.3 1.3 1.3 LAVANT 26 6.5 8.7 13.0 MIDDLETON 27 6.8 9.0 9.0 PETWORTH 20 10.0 10.0 10.0 SELSEY 26 8.7 8.7 13.0 WITTERING 26 8.7 8.7 13.0
Workforce Review (April 2018)
Child Health and Neonatal Nursing
Sue Nicholls
1. Introduction and background
1.1 This report describes the findings of a Paediatric audit undertaken in April and December 2107. This audit has been benchmarked against the RCN 2013 guidance, defining staffing levels for children’s and young people’s services
1.2 The neonatal audits have been benchmarked against the standards aligned to the neonatal nursing workforce are the DH Neonatal toolkit standards 2009 and the British Association of Perinatal Medicine 2010. WSHT provides compliance data through the neonatal networks and measures progress through monthly workforce audits using a nationally validated tool (Badgernet). For the purposes of this report information on compliance to the standards is included for the months of October 2017 and February 2018.
2. Progress - Paediatrics
2.1 There is now sufficient senior cover at band 6 for each 24 hour period. A 3RD cohort of staff are currently undertaking the band 6 nurse development programme which standardises the clinical and leadership skills required for our band 6 staff . This development course is over a 12 – 18 month period and includes the Edward Jenner NHS leadership modules, EPLS and a recognised High Dependency course delivered at Brighton.
2.2 The ward sisters currently undertake 1 – 2 supernumerary (management shifts) per week, not unlike their colleagues on general wards. This has remained a challenge across both sites with the ward managers unable to maintain their management shifts due to clinical pressures. It is acknowledged that this can leave the role of the ward sister with significant competing demands in terms of the day to day running of the ward and importantly providing the required support for their team.
1
3. Current models and audit - Paediatrics
3.1 The current model has a seasonal variation recognising the changes in both activity and acuity. The seasonal model has changed to an even split for winter and summer from an 8 month winter / 4 month summer model. From 2017 onwards summer model is from the 1st April to the 30th September and the winter model is from 1st October to the 31st March. This was implemented in the summer of 2017
3.2 The introduction of the paediatric nursery nurse is now complete which provides the staffing model with a member of staff who can take a pre-determined caseload of patients. The paediatric nursery nurses provide cover 24/7 and this has had a positive impact on providing safe staffing levels for the paediatric unit during the audit.
3.3 The audits look to see compliance by measuring our ability to provide a nurse to patient ratio of:
1:3 for under 2’s
1: 4 for over 2’s
1:2 for HDU care
1:1 for specialling CAMHs
1: 3 for ‘Intensification of treatment i.e. Oncology/CF’
3.4 Graph 1 and 2 illustrate our compliance with staffing in April and December to meet the required standards: Green = compliant/Amber = compliant, with staff moved from other areas/Red= non-compliant (i.e. escalation failed)
Worthing
Graph 1- Bluefin April 17
Occupancy Bluefin 7.14% 9.52% April/May 2017 Total Entries 42
Green 83.34% Amber Red
2
Graph 2 - Bluefin December 2017
Bluefin 3.22% Occupancy for December 2017 Fully staffed
Understaffed
96.77% Total Entries 62
St Richards
Graph 3 - Howard – April17
Occupancy 7% Howard April/May 2017
Green
93% Amber
Graph 4 - Howard – December 2017
Howard Occupancy for December 2017 3.33% 15.00% Fully staffed
Staff relocated from elsewhere
81.66% Understaffed
Total Entries 60
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3.5. Paediatric staffing is monitored closely by the paediatric matrons during the week with a robust plan for out of hours. The paediatric bleep holders (band 6) on each site liaise with each other to appropriately manage the staff across both sites to maintain safe staffing levels. Last year saw an unusual rise in acuity on the Worthing site (Bluefin) during the summer months which necessitated escalation through our usual processes to maintain safe staffing levels. The unusual acuity was a combination of complex needs children and children requiring high dependency care and retrievals. The winter months have seen similar activity across both sites with a rise in children requiring care for anorexia and children with complex mental health issues. Both wards have seen an increase in the number of children who are medically fit for discharge but who have remained inpatients waiting for specialist inpatient care or community packages. On the SRH site there has been a rise in the number of new oncology diagnosis which has contributed to the rise in acuity of our patients. The increase of red shifts for the children unit on the St Richards site in December reflects a period of increased activity of children requiring high dependency care, which was managed through cohorting these children and escalation.
Professional judgement remains the most valuable tool we have to assess safe staffing levels in relation to the dependency / acuity of our patients rather than patient numbers.
Neonates
Worthing
Graph 5 Beeding – October 2017
Beeding Occupancy for October 2017 17.74% Fully staffed
6.45%
Staff relocated from elsewhere 75.80%
Understaffed Total Entries 62
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Graph 6 - Beeding - February 2018
3.70% Beeding Occupancy for February 2018 12.96% Fully staffed
Staff relocated from elsewhere 83.33% Understaffed Total Entries 54
St Richards
Graph 7 - NNU – October 17
1.61% NNU Occupancy for October 2017 Fully staffed 4.83%
Staff relocated from elsewhere Understaffed 93.54%
Total Entries 62
Graph 8 -NNU – February 2018
NNU Occupancy for February 2018 14.28% Fully staffed
17.86% Staff relocated from elsewhere 67.86% Understaffed
Total Entries 56
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3.6. Neonatal activity saw a peak in October on the Worthing site. February has seen a peak in activity on the St Richards site. Both periods have required close management of staffing to maintain safety.
As our audits demonstrate staffing is well managed. The red shifts largely relate to difficult stabilisations of sick infants as they are prepared for transfer to a tertiary service, or require ongoing intensive care on the St Richards site whilst staffing is escalated to meet the increase needs.
Conclusions
4.1.1.1 The compliance on both sites this year has improved and the implementation of the paediatric nursery nurse has contributed to this. The activity across both sites has been comparable over the year and we are reviewing how we collate out data and this will be presented in the following report . Since November 2017 there has been a noticeable increase in admissions of children with mental health needs and children under the Feeding and Eating Disorder Service (FEDS). These children often require intensive nursing support to facilitate their care. This has been supplemented through the use of Registered Mental Health Nurses.
4.2 The compliance on the neonatal units is largely good with appropriate escalation of staffing to meet the sudden increase in acuity whilst stabilising a critically sick baby.
REF: Defining staffing levels for Children and young people’s Services – 2013
Neonatal Toolkit Standards DH 2009
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To: Trust Board Date of Meeting: 26th April 2018 Agenda Item:8
Title Organ Donation Annual Report 2016-17 Responsible Executive Director N/A Prepared by Dr Ryck Albertyn Status Disclosable Summary of Proposal N/A Implications for Quality of Care Board information on performance of the Trust and Organ Donation Committee Financial Implications Nil Human Resource Implications Nil Recommendation Commendation of the Report to Board
Communication and Consultation
Appendices
This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.
Western Sussex Hospitals Trust Organ Donation Annual Report 2016 – 2017 Business Plan 2017 - 2018
Dr R D Albertyn (Trust Clinical Lead Organ Donation) Dr D Melville (Deputy Clinical Lead) Mrs T Thomas (Trust Specialist Nurse Organ Donation) Mrs A H Fisher (Trust Non – clinical Lead Organ Donation)
1
Contents
Glossary & Definitions 3
1. Executive Summary 7
2. Report from the Organ Donation Committee (ODC) 11
3. Policy Frame work 14
4. Hospital Organ Donation Team Structure 16
5. Organ Donation Rates / PDA Benchmarking 2015/16 18
6. Performance against 2015/16 Objectives 31
7. Strategic Responses to Issues from 2015/16 33
8. Objectives for 2016/17 and Monitoring Arrangements 34
9. Risks to Delivery of Objectives and Mitigating Actions 35
10. Appendices
A. NHSBT Trust DBD/DCD Data 37
B. FINANCE 38
2
Glossary
• CLOD – Clinical Lead Organ Donation
• SNOD – Specialist Nurse Organ Donation
• NCLOD – Non-clinical Lead Organ Donation
• NHSBT – NHS Blood and Transplant
• DBD – Donation after Brain Death
• DCD – Donation after Circulatory Death
• ODC – Organ Donation Committee
• PDA – Potential Donor Audit (national audit of activity by NHSBT)
• ICU/ITU – Intensive Care Unit
• ED/A&E – emergency department
• SRH – St Richards Hospital
• WH – Worthing Hospital
3
Definitions
4
1. Executive Summary
What the Organ Donation Committee does: • is about dignity • saves and improves lives • is about the donor and their family
This Report is about the facts behind donation
2016/17 was another highly active year for organ donation across the Western Sussex Hospitals NHS Trust supported by a strong, progressive organ donation committee. There was 100% attendance by the SNOD, CLOD and Non – CLOD.
Organ donation activity It is important to note that numbers are small so even a loss of 1 potential donor results in a large percentage change.
DBD & DCD Donors, patients transplanted and organs per donor, 1 April 2016 - 31 March 2017 (1 April 2015 - 31 March 2016 for comparison)
Δ% Average number of organs Number Number of from donated per donor Donor type of Patients donors 2015/16 transplanted Trust UK
DBD 8 (8) 0 23 (18) 3.8 (2.8) 3.8 (3.9) DCD 4 (5) -20% 6 (9) 2.8 (2.0) 2.8 (2.8) Totals 12 (13) -8% 29 (27) 3.4 (2.5) 3.4 (3.4)
Comments:
• DBD Numbers of donors maintained but significantly increased organs per donor 2016/17 BSD testing rates have improved from 75% to 91%
• DCD Drop in number of donors by 1 (20%) Referral rate up again from 82% to 93% The consent rate has risen to 77% from 50%. A 27% improvement! There was only 1 true ‘missed’ (unrecognized potential) DCD donor across the trust over the past year.
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Organs transplanted by type, 1 April 2016 - 31 March 2017 (1 April 2015 - 31 March 2016 for comparison)
Donor type Number of organs transplanted by type Kidney Pancreas Liver Heart Lung DBD 15 (12) 0 (1) 5 (6) 1 (0) 4 (0) DCD 4 (8) 0 (0) 1 (2) 0 (0) 2 (0) Totals 19 (20) 0 (1) 6 (8) 1 (0) 6 (0)
Comment:
We have seen a record number of patients transplanted this year.
Numbers of organs donated this year (32) is again up on the previous year (29). This reflects the increased referral rates and general improved awareness. A formal SNOD presence has had a very positive impact over the year.
The most notable improvement in our activity is the number of organs per donor has significantly improved, placing us bang on the national averages .
The data continues to illustrate that the number of organs available from DBD donors is significantly greater than that from DCD donors. Additionally the condition of the organs (and thus ‘transplantability’) is far superior in all organs with the exception of kidneys where organ survival is similar.
The 19 kidneys donated from WSHT patients alone will save the NHS £/ year or £ over the next 10 yrs (assuming an average transplanted kidney lifespan of 10 yrs).
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• Finances 2016/17 – (appx 2)
Income: £ 34 468
Expenditure: £ 20 665
Balance: £ 13 802
• Additional activities
Relocation of “The Gift” commemorative artwork on both sites.
Promotional Film project – Donors/Recipients and waiting list stories – to be used for training and motivation –well under way.
• Looking forward The Organ Donation Committee is dedicated to improving organ donation rates with an ongoing trust wide education and awareness strategy aimed at key stakeholders.
Significant work remains to maintain and improve several key performance indicators esp. DCD referral and Donor Management.
Integration and utilization of volunteers in organ donation to work within the Trust and community promoting organ donation in line with NHSBT’s national 2020 strategy.
Refurbishment of the Worthing Site Critical Care Relatives Room - funding & planning STILL in progress
Commissioning of a 3rd ‘The Gift’ statue for Southlands Hospital – planning in progress.
Funding of ITU nursing staff course & meeting fees
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2. Report from the Organ Donation Committee (ODC)
Organ Donation Committee quarterly meetings are conducted within the lines of the Terms of Reference and the Annual Planning cycle.
In addition to usual committee business and in support of the advancement of organ donation activity within the trust the committee has, more specifically, undertaken:
ODT quarterly meetings are conducted within the guidelines also Terms of Reference and the Annual Planning Cycle.
High levels of attendance by SNOD, CLOD and NON-CLOD
In addition to usual committee business and in support of the advancement of Organ Donation activity within the Trust the committee has more specifically, undertaken a wide range of activities: -
OUTSIDE TRUST:
Presentations to various groups within the local community including
• U3A – University of the 3rd age • Women’s Institute – WI’s • GP’s surgery’s • Libraries and various Educational campuses • Local and National Companies, Superdrug and Asda etc.
WITHIN TRUST:
Taken part in NHSBT Regional and National Collaboration events.
Volunteers – Annual Training & awareness
Maintained and increased numbers of volunteers
Increased local awareness and organised “AWARENESS CAMPAIGN”
Organised display units and Lift covers during campaign
Responsible for display units throughout trust both SRH & Worthing
SNOD - increased training within both ITU’s and A&E’s departments
- Achieved 100% referral
Supported ITU Nurses financial to attend various outside training courses
Financially supported “Relatives room – Worthing” refurbishment
Supported SRH Consultants to attend Intensive Care meeting
Supported ODT film completion and procurement of equipment to use for training within trust and local community.
Joint promotion with “Storm Knitters” & “Worthing Hockey Club (The Penguins) “during National Transplant week: photo shoot with all members used in local and national press.
Due to refurbishment and installation of Costa Coffee in the Main Entrance in both SRH & Worthing, The Gift statue required a new area to be displayed and raise awareness. With
8 support from our Estates Department we have successfully found new homes for both these iconic statues on both sites
We have continued to give moral support to a local kidney recipient patient after sadly experiencing ongoing complications.
Our ODT volunteers have been outstanding in their support to the trust on a monthly basis and also during ODT (Organ donation & Transplant) awareness week last September. They set up all the presentation boards in the main entrance, and in the Restaurants along with the A&E departments. They manned the stands each day during the awareness campaign then dismantled them at the end. They have undertaken to raise awareness within the local community - at schools, football clubs, and GP surgeries and we are indeed indebted to them for their kindness and support.
I wish to recognise specifically the work of our SNOD, Tracey Thomas who has successfully continued her much focussed delivery of support for the trust despite being under severe pressure regionally to cover a significant shortage of SNODS.
I also strongly believe that the results of this year would not have been attainable without the work ethic of the members of our Organ Donation & Transplant Committee
Angela Fisher
Chair & Non-Clinical Lead
WSHT Organ Donation & Transplant Committee
February 2017
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SNOD Report 2016/17
As the SNOD – Specialist Nurse Organ Donation for the trust, my working week is spent trying to be as visible as possible in Chichester and Worthing ITU’s and A&E’s. My job is varied. Some of my time is spent auditing the deaths in those units to ensure we do not miss any potential organ donors. I also spend a lot of time on call - usually twice a week for 24 hours at a time. I can be called to cover a very large area and regularly mobilise to referrals anywhere in the South East. We even cover Jersey and Guernsey.
For the most part I spend as much time as possible on the units. Updating through education and training, and interacting with the Nurses and Doctors in an effort to make organ and tissue donation the norm. This is done so that when end of life discussions are reached I will be included as part of the multi-disciplinary team who are planning end of life care.
There are challenges associated with this. Having worked for some years as a Sister in ITU in Chichester before I took on this role I was very active as the Link Nurse for Organ Donation, and therefore it was already embedded to some extent within the unit. The nurses there continue to follow best practice and rarely miss a potential organ donor.
Worthing has proved trickier, and they have had to work harder to change practice. However they have made the most improvement and despite the occasional missed referral I am incredibly proud of them and believe my aim of achieving 100% referral rates of potential organ donors from Western Sussex Hospital Trust will happen.
At present much of what we are measured on is above the national average. This shows commitment and belief from everyone in the ITU’s and A&E’s. Most importantly it has meant that 29 patients nationally have received the gift of a life saving transplant due the extraordinary generosity of patients and their families from within our trust.
Looking forward……….
Every patient who dies in hospital should have their End of Life wishes surrounding Organ and Tissue Donation considered and honoured. A huge proportion of those patients will have expressed those wishes by signing on to the Organ Donor Register, and unless that patient has died in ITU it is rare that those wishes are addressed. Many would be suitable for Tissue donation; most would be suitable for corneal donation, both of which happen after death.
This is something I would like to focus on and actively promote within the trust over the next year. This needs to become a usual part of every patients EOL care.
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3. Policy Framework
There has been a Trust wide Organ Donation policy in place at Western Sussex Hospital Trust written in February 2009 and is currently under review – to include an ‘organ donation from A&E’ section. The policy was written by the CLOD prior to the embedding of the SNOD, and has gone through the ratification process. There are also a number of national documents, publications and consultation papers which have been referred to in order to correctly shape any organ donation policy frame work for Western Sussex Hospital Trust:
• WSHT Organ Donation Policy (review underway) • Department of Health (DOH). Organs for Transplant Taskforce Report (ODTF) 2008 + Final report December 2011 • Academy of Medical Royal Colleges (AMRC). A Code of Practice for the Diagnosis and Confirmation of Death + Form for the Diagnosis of Death using Neurological Criteria (November 2014) • Mental Capacity Act (2005) • Human Tissue Act (2006) • DOH. Legal Issues relevant to Non Heart-beating Organ Donation (2009) • Donation after Circulatory Death. (UKDEC) Final ( December 2011) • NHSBT. Donor Contraindications to Organ Donation (2010) • DOH. End of Life Care Strategy. (2008) • General Medical Council (GMC). Treatment and Care Towards the end of life: Good Practice in Decision Making. Guidance document for doctors. (2010) • SaBTO – Guidance on Microbiological Safety of Human Organs, Tissues, and Cells used in Transplantation (2011) • NHSBT. Strategic Objective for ODT. (2010-2013) • NHSBT and British Transplant Society. Guidance for Solid Organ Transplant in Adults. • NICE guidelines December 2011 – CG135 • NHSBT. Donor optimization guideline for management of the brain dead donor – Oct 2012 • NHSBT. Donation after Brainstem Death (DBD) - Donor Optimisation Extended Care Bundle – Nov 2012 • NHSBT. Approaching the families of potential organ donors – best practice guidance – March 2013
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• Intensive Care Society Website - Organ Donation in Intensive Care: http://www.ics.ac.uk/professional/organ_donation • NHSBT: ODT microsite: http://www.odt.nhs.uk/ • Taking Organ Donation to 2020: a detailed strategy – www.nhsbt.nhs.uk/to2020 • Hospice UK - Care after Death – April 2015 • CLOD position Terms and Conditions January 2015 • Care of Severely Brain injured patient in A&E – WSHFT April 2015 • Brainstem Death Form and Guidance 2014 • Catastrophic Brain Injury Pathway • Organ Donation and the Emergency Department - A Strategy for Implementation of Best Practice 2017
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4. Trust Organ Donation Team Structure
TRUST NHSBT
ASSISTANT DIRECTOR
TRUST BOARD Anthony Clarkson Mike Viggers Marianne Griffiths Tim Taylor REGIONAL MANAGER Lizzie Peers
Mattew Cardwell
REGIONAL CLINICAL LEAD TEAM MANAGER Pardeep Gill HOSPITAL MANAGEMENT TEAM Louise Davey Argy Zoumprouli Tracy Gibson
DONATION COMMITTEE CHAIR CLINICAL LEAD (CLOD) SPECIALIST NURSE (SNOD) (Non- CLOD) Ryck Albertyn Tracey Thomas Angela Fisher Dom Melville
Western Sussex Hospitals NHS TRUST
ORGAN DONATION COMMITTEE
DONOR FAMILY CRITICAL CARE EMERGENCY THEATRES END OF LIFE REPRESENTATIVE DEPARTMENT Facilitators Angela Fisher
Louise Skelt – ITU WH – WH – ? ? MORTUARY manager Matt Stanniforth REPRESENTATIVE WH – Helen Lane Sarah Hall SRH – Leslie (TBC) Laura Reed Guppy
SRH - Emma SRH - COMMUNICATIONS D’Arcy Sue Howard REPRESENTATIVE Mouse Cookepriest Kim Matthews Jonathan Keeble Sue Hughes Dr. Patrick Carr CLERICAL Rachel Bennet Una Dalrymple
FINANCE Samuel Tetley
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CL-OD Deputy CL-OD Dr Ryck Albertyn St Richards
Dr Dom Melville Chair / Non – SN-OD Clod Tracy Thomas Angela Fisher
Communication Theatres Department ICU/Renal Chaplaincy ED Consultant ICU Manager WH Physician Jonathan Keeble ICU Links Rachel Bennett / WH Louise Skelt ? Patrick Carr Sue Hughes Una Dalrymple SRH Jon Burton SRH
Sr Emma D’arcy ED Sister Leslie Guppy Emma Eels ? Mouse SRH Cookepriest Senior Management Representation: Volunteer Corps: Sue Howard Financial WH • Marianne Griffiths (CEO) Department • Betty McAnn
Samuel Tetley Helen Lane • Tim Taylor (Medical Director) • Kate Claisse Laura Reed • (Finance Director) 14
5. Organ Donation Rates / PDA Benchmarking 2016/17
Donors, patients transplanted and organs per donor, 1 April 2016 - 31 March 2017 (1 April 2015 - 31 March 2016 for comparison)
Donor type Number of Number of Average number of organs donors Patients donated per donor transplanted Trust UK DBD 8 (8) 23 (18) 3.8 (2.8) 3.8 (3.9) DCD 4(5) 6 (9) 2.8 (2.0) 2.8 (2.8)
Organs transplanted by type, 1 April 2016 - 31 March 2016 (1 April 2015 - 31 March 2016 for comparison)
Donor type Number of organs transplanted by type Kidney Pancreas Liver Heart Lung DBD 15 (12) 0 (1) 5 (6) 1 (0) 4 (0) DCD 4 (8) 0 (0) 1 (2) 0 (0) 2 (0) Totals 19 (20) 0 (1) 6 (8) 1 (0) 6 (0)
Between 1 April 2016 and 31 March 2017, Western Sussex Hospitals NHS Foundation Trust had 12 deceased solid organ donors, resulting in 29 patients receiving a transplant with 32 organs transplanted.
DBD & DCD Key Rates
15 WSHT Trust key metrics data 2016/17 (National PDA derived) The percentages for each key metric are shown in below along with the number of patients at each stage. A national comparison and a time period comparison are again provided. A comparison against funnel plot boundaries has been applied by highlighting the key rates for the Trust as gold, silver, bronze, amber, or red. Note that caution should be applied when interpreting percentages based on small numbers.
16
Overview of lost opportunities
17
Neurological Death Testing
18
Referral to Specialist Nurse (SNOD)
19
Contra- indications
20
Family Approach
21
Proportion of approaches involving the SNOD
22
Consent Rates
23
24
Hospital Specific Data A. DBD
25
B. DCD
26
PDA Benchmarking Rates
Reflection on potential Donation after Brain Death (DBD) for period of report. This year there were 11 potential DBD donors. 8 of the 11 potential donors went on to become actual donors. The number of actual donors is equivalent to 2015/16. The WSHf trust also continues to eclipse national and regional targets on multiple metrics. Brain stem death testing is performed universally where appropriate: 2016/17 BSD testing rates have improved from 75% to 91%. A single suspected BSD donor was NOT tested was due to family decline of organ donation. Referral rates continue at 100%, as does SNOD involvement in the family approach. The consent rate remains static at 90% is also unavoidable – 1 x patient’s previous wishes not to donate. The conversion of consented donors to actual shows a drop of 11% (1 donor) due to the medical unsuitability of the organs as deemed by the transplant centres) As for Key Metrics the Trust has continued to perform well in all areas: • Referral rate 100% • Neurological testing 91% • Family approach rate 100% • SNOD involved in approach 100% • Consent rate 90% • Conversion rate 89% (organs medically unsuitable)
There has been a significant improvement in number of organs per donor [WSHFT 2016/17 3.8 (WSHFT 15/16 = 2.8); UK = 3.8)]. Continued efforts to ensure brainstem death testing in all appropriate cases is essential as the organ condition is superior with resultant greater success and longevity within the recipients. This will be continuously emphasized to all relevant practitioners. Focus wrt. to DBD donors should continue to be:
1. EARLY referral and involvement of the SNOD is now part of best practice and needs to be continuously encouraged and emphasized. SNOD involvement impacts positively on consent rates. 2. Early and robust donor optimization via clearly defined protocols resulting in better organ quality and recipient benefit. The official algorithms for donor management have been ratified and are locally available for implementation. Additionally, the traumatic brain injury protocol from St Georges for optimal management of brain injured patients is being implemented pre BSD testing which dovetails ultimately with the donor management pathway once brain death has been established. These protocols are now part of established practice esp. with SNOD oversight.
Reflection on potential Donation after Circulatory Death (DCD) for period of report.
Donation after Circulatory Death (DCD) – The trust has had a drop in DCD donors from 5 to 4 over 2016/17.
27
In summary: Positive • Referral rate up again from 82% to 93% - this is predominantly as a result of the regional initiative of ‘100% referral’ – i.e. referral of all patients with suspected brainstem death and ALL ventilated patients to undergo withdrawal of life –sustaining treatment. Large numbers of the ‘universal referral’ patients will be triaged out of contention during the initial referral phone call to the SN-OD but the theory is that no potential donor would be missed. • The consent rate has risen to 77% from 50%. A 27% improvement! • There was only 1 true ‘missed’ (unrecognized potential) DCD donor across the trust over the past year. A remarkable achievement
Negative • Conversion rate down from 63% to 40%
Neutral/Maintained • Family approach rate • SNOD involvement in consent process
Hard work by link nurses and the SNOD must be recognized. St. Richards ITU has again elevated their DCD referral rate, this time to 100% (2015/6 = 97%) with Worthing Hospital increasing its referral rate from 74%% to 86%. The inclusion of assessment of organ donation potential on the critical care unit at the morning safety briefing has improved awareness and referral rates. Individual follow-up (sometimes a difficult communication) by the SNOD has also proved very effective. Robust analysis of ‘missed’ donors is undertaken and follow-up with the involved members of the clinical team is undertaken. Rates are expected to continue to improve over the next year.
Organ Donation from A&E
Although A&E remains a viable source of organ donors (following an apparently life-ending brain injury, this has shifted somewhat as a result of recognition of the need for transfer to ITU for a period of observation to allow more accurate prognostication irrespective of any organ donation potential. This is being looked upon as current best practice. Strategies are being put in place nationally to recognise this as a key component in EOL care. There is now a formal initiative from NHSBT to actively involve A&E in the recognition and referral of organ donors.
A & E continues to be a challenge from an organ donation perspective. Ongoing education remains the key to encouraging early referral of potential donors enabling collaborative working between SNOD, ITU and ED staff. However challenges remain due to A&E workload and availability of staff for teaching sessions. Work continues to ensure that donor potential however small is maximised with education and training and a SNOD presence on a regular basis. Nursing and medical link personnel remain in place on both sites with
28 the expectation that over the coming year they will become even more involved with encouraging staff to identify not only potential organ donors but Tissue donors too.
Organ donation from A&E is a complex process and currently within this trust must always be undertaken via the respective ITUs. This is due to the complex and specific management requirements of both the Donor and the Donor Family during this difficult time. Hence PRIOR to approaching the family in A&E all the usual best practice elements such as collaborative requesting and SNOD presence should be ensured. Additionally, close communication between the A&E staff and the ITU consultant is essential to ascertain that there is space on ITU to accommodate the potential donor prior to any discussion with the next of kin. This is due to the fact that donation currently cannot be facilitated from any location other than the ITU. Unfulfilled expectation may be harmful to the family and organ donation in general.
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6. Performance against 2016/17 Objectives
Measurable Outcome / Item Objectives for 2016/17 Actions Required to Deliver Objective Outcome Milestones
o PDA – 100% identification and COMPLETED referral of all Increased DCD referral rates from 97% to 100% referral rate for potential • Widespread adherence to ‘100% referral’ ventilated patients 1 100% at SRH and from 74% to 86% at initiative across both sites undergoing withdrawal DCD donors WH of treatment • Increased DCD donor DCD donor approach numbers static approaches • Increase in number of organs per donor from 100% implementation of Donor • 100 % implementation of DMP in all BSD pts. • COMPLETED (Trust 3.4 vs 2.8) 2 Trust compared to Management Protocols for • To include use of Catastrophic Brain Injury • Audit of CBI treatment and DMP potential DBD donors Pathway national average utilization • Audit of practice showing compliance
• Films produced COMPLETED Film Project – Complete filming, 3 • Film schedule and production editing & strategy of usage
• Displays at various Broader use of Organ Donation • Complete training 4 community locations – COMPLETED Volunteers • Identify community projects GPs/pharmacies etc.
30 Trust OD Policy review 5 • SNOD & CLOD to meet to finalise • Updated policy COMPLETED
31
7. Strategic Responses to Issues Identified in 2016/17
Issues from 2016/17 Risk to Delivery Action to be Taken to Minimise Risk Delivery Lead
• Publicize widely to Drs of all levels; ITU sisters via 1. 100% referral rate for monthly meetings who will then cascade to bedside SNOD potential DCD donors - • Lack of awareness of nurses ‘100% referral’ policy CLOD continued • Continue to emphasize potential donation at morning ITU huddle 2. Establish greater ‘buy in’ • Introduce NHSBT ED strategy to ED clinical staff from both A&E’s to • Lack of training • Establish solid ED leadership and OD policy/traffic light opportunities/time for encourage potential donor system SNOD nursing staff recognition and referral to • Identify ED consultant champion (CLOD/N- CLOD) • Lack identified A&E ITU. As well as increasing clinician link • Active /enthusiastic link nurses tissue donation from A&E • Analyse ED PDA • Make available draft checklist/proforma within ITU 3. 100% utilization of DBD • Lack of awareness/availability of donation files and advertise widely amongst nursing Care Bundle with an CLOD care bundle and medical staff increase in number/quality SNOD • Introduce available donor • Convert SOP document to editable PDF for use on ICIP of organs optimization app • Training in DBD donor management
32
8. Objectives for 2017/18 and Monitoring Arrangements
Actions Required to Deliver Measurable Outcome / Objectives for 2017/18 Objective Milestones Delivery Lead Delivery Date
• Widespread adherence to ‘100% • PDA – 100% identification and referral’ initiative across both referral of all ventilated 1. 100% referral rate for sites patients undergoing withdrawal SNOD potential DCD donors April 2018 • Continue to emphasize potential of treatment – continued efforts CLOD donation at morning ITU huddle • Increased DCD donor approaches
• Increase in number of organs 2. 100% implementation of • 100 % implementation of DMP in per donor from Trust compared Donor Management all BSD pts. CLOD to national average April 2018 Protocols for potential • To include use of Catastrophic SNOD DBD donors Brain Injury Pathway • Audit of practice showing compliance
3. Broader use of Organ • Complete training • Displays at various community N-CLOD April 2018 Donation Volunteers • Identify community projects locations – GPs/pharmacies etc.
4. Introduce NHSBT A&E • Presentation to staff • Increased referrals CLOD April 2018 strategy to A&E staff • Identify a ‘champion’ • Nil missed donors SNOD
33 9. Risks to Delivery of Objectives and Mitigating Actions
Action to be Taken to Objectives for 2017/18 Risk to Delivery Delivery Lead Minimise Risk
• Lack of awareness amongst key staff esp. 1. 100% referral rate for Consultants, bedside nurse and shift leader Further education and SNOD potential DCD donors • Lack of beds to facilitate from ED (movement awareness/ reinforcement CLOD from HDU to wards)
2. 100% implementation of Donor Management • Lack of awareness amongst key staff esp. Further education and SNOD Protocols for potential bedside nurse and shift leader awareness/ reinforcement CLOD DBD donors
3. Broader use of Trust • Continued motivation Constant interaction N-CLOD Volunteers
• Perform CLOD 4. Introduce NHSBT A&E • Identification of a consultant OD champion presentation strategy to A&E staff from ED • ID suitable SNOD consultant
34
10. Appendices
A. Official NHSBT Trust DBD/DCD Data B. Finance C. NHSBT A&E strategy
35
APPENDIX A
NHSBT PDA data:
*Access to the above flowchart analysis can be obtained from the Clinical Lead Organ Donation 36
APPENDIX B – Finance
37 APPENDIX C – NHSBT A&E organ Donation Initiative
38
To: Trust Board Date of Meeting: 26th April 2018 Agenda Item: 9
Title Annual Quality Report 2017/18 Responsible Executive Director George Findlay Prepared by Viv Colleran – Director Clinical Effectiveness, Research and Innovation Status Disclosable Summary of Proposal NHS Foundation trusts must include a report on the quality of care they provide within their annual report and publish a Quality Account as required by the Quality Accounts Regulations. This paper provides the draft of the Annual Quality Report/Account for 2017/18. Please note this is a draft and the following will be updated prior to submission final submission to Trust Board in May and NHS Improvement: There is a small amount of M12 data outstanding. Some adjustments may be required following the assurance review by the external auditors. The Trust Quality Board, QRC and TEC have seen earlier drafts and will receive the final version for information at their June meetings. Implications for Quality of Care The Quality Report/Account is a summary of future priorities for quality improvement 2018/19 and actions taken in 2017/18 to improve quality of care and performance against a range of quality measures. Link to Strategic Objectives/Board Assurance Framework Corporate objectives A, B, C, F (Patient focus, Quality, Safety & Improvement) Financial Implications Failure to deliver constantly improving quality will jeopardise our ability to attract patients, and thus our financial position. Human Resource Implications None identified. Recommendation The Committee is asked to: 1. Note this draft report and provide any further feedback to Helen Evans prior to 1st May 2018. Communication and Consultation
Appendices 1. Annual Quality Report 2017/18
This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288. Western Sussex Hospitals NHS Foundation Trust
QUALITY REPORT 2017-18 THIRD DRAFT
COVER PAGE
Contents
Part 1: Statement on quality from the Chief Executive of Western Sussex Hospitals NHS Foundation Trust 3 What we do 4 Purpose of the Quality Report 4 Statement on quality from the Chief Executive 6 Part 2.1: Priorities for improvement 8 Our Trust approach to Quality Improvement 9 Priorities for improvement in 2018/19 11 Part 2.2: Statements of assurance from the Board 16 Review of services 17 Participation in clinical audits and confidential enquiries 17 Research 26 Goals agreed with commissioners: use of the CQUIN payment framework 26 Statements from the Care Quality Commission (CQC) 27 Data Quality 27 Identifying, Reporting, Investigating and Learning from Deaths in Care 29 Part 2.3: Reporting against core indicators 31 Performance against the 2017/18 core set of indicators 32 Part 3.1: Review of quality performance 39 Performance against 2017/18 quality improvement priorities 40 Reducing preventable mortality and improving outcomes 41 Avoiding harm 54 Improving patient experience 69 Improving staff engagement 73 Part 3.2: Other Information 81 Local quality indicators 82 Single Oversight Framework indicators 86 Annex 1 – Statements from our commissioners, local Healthwatch organisation and Overview and Scrutiny Committee 87 Annex 2 – Statement of Directors’ responsibilities for the quality report 88 Annex 3 – Limited Assurance Report on Quality 90 Glossary of terms and acronyms 91
Part 1: Statement on quality from the Chief Executive of Western Sussex Hospitals NHS Foundation Trust
(photo page – Marianne – smiling in front of Western Sussex branding)
What we do
Western Sussex Hospitals NHS Foundation Trust The organisation was created in 2009 by a merger serves a population of around 450,000 people of the Royal West Sussex and Worthing and across a catchment area covering most of West Southlands Hospitals NHS Trusts, and has been Sussex. an NHS Foundation Trust since 2013.
The Trust runs three hospitals: St Richard’s Our services are delivered through four clinical Hospital in Chichester, Southlands Hospital in divisions – Medicine, Surgery, Women & Children Shoreham-by-Sea, and Worthing Hospital in the and Core Services – and two enabling ones: centre of Worthing. Corporate, and Facilities & Estates.
St Richard’s and Worthing hospitals provide 24- We were inspected by the Care Quality hour A&E, acute medical care, maternity and Commission, the independent regulator of health children’s services, while Southlands specialises in and social care in England, during December day-case procedures, diagnostics and outpatient 2015, and awarded the highest possible rating, appointments. Outstanding.
In addition to our three hospitals, we provide a Our ambition now is to build further on this range of services in other community settings, achievement and continue to improve the quality including: Bognor War Memorial Hospital, Crawley of care we can offer our community. Hospital, health centres, GP surgeries, and sexual health clinics.
Purpose of the Quality Report
Patients deserve to know about the quality of care The quality of our services is measured by looking they receive, and at Western Sussex Hospitals we at patient safety, the effectiveness of treatments aim to ensure that this is the very best quality of that patients receive and patient feedback about care every time. the care provided.
Our Quality Report is a narrative to patients, NHS Improvement requires all NHS Foundation carers, professionals and the public about the Trusts to report on the quality of care they provide quality and standard of services we provide. It is as part of their annual reports. Foundation Trusts an important way to show improvements in the are also required to publish a quality account each services we deliver to local communities and year by the Government. Our Quality Report stakeholders. combines both requirements in this one document.
Ten facts about the Trust in comms standard ‘about us’ template (full page with photo) – to be finalised for final version
In 2017-18 the Trust: 1. Employed 6,598 members of staff across all our sites 2. Was supported by around 900 core volunteers, who help in everything from serving meals to performing clerical duties. In addition we also have volunteers supporting our cardiac departments, chaplaincy team, flower ladies, hospital radio, league of friends and Samaritans. 3. Delivered 5076 babies 4. Saw 139,472 patients in A&E 5. Held 585,267 outpatient appointments and treated 133,131 inpatient and day cases 6. Cared for patients in 1000 acute beds 7. Benefited from a membership of more than 14,000 staff, patients and members of our community as an NHS Foundation Trust 8. Received 2393 (End Q3 2017/18) compliments and plaudits from patients and relatives 9. Averaged 240,000 public website page views per month plus 3,268 Facebook and 2,982 Twitter followers 10. Received just over £1 million in donations for hospital services and equipment from the Love Your Hospital charity
Statement on quality from the Chief Executive
At Western Sussex Hospitals we are committed to initiate improvement ideas through daily team continually improving the quality of care our huddles and lean projects. Sir Bruce was clear that patients receive and despite many challenges the NHS must mobilise the intellectual capacity of 2017/18 has been another successful year for the those who work for the health service in order to Trust. improve quality in the face of increasing demand, escalating costs and restricted finances. In July 2017 we won the much-coveted Best Organisation prize at the national Patient Safety In February, the Secretary of State for Health Awards in Manchester. The judges commended Jeremy Hunt MP paid his third visit to the Trust the Trust’s stalwart commitment to continuous and reiterated his support for our Patient First improvement and authentic leadership that puts approach while speaking to staff about the patient care, safety and experience at the centre of Department of Health’s ambition to make the NHS everything we do. the safest health service in the world. Mr Hunt championed Western Sussex Hospitals as a Such recognition is also an excellent endorsement leading trust contributing to this ambition and he of Patient First, our ambitious Trust-wide reaffirmed his belief that we are the best example transformation programme which we launched of a learning culture that he has seen anywhere in nearly four years ago in order to help our staff the NHS. always improve patient care and experience with the application of lean management best practice. In March, this year’s NHS Staff Survey results proved a further highlight for our organisation As a result of Patient First, we are now seeing when we were absolutely thrilled to be ranked as fantastic results for our patients. For example, one the very best hospital trusts in the country to with collective focus on the biggest cause of work for. The confidential survey of more than 4,000 patient harm, we have prevented more than 370 members of staff at Western Sussex, and nearly half inpatient falls in the past 12 months. Winning Best a million nationwide, also placed our Trust among Organisation for patient safety is a great mark of the top five trusts in England where employees are confidence in what we are doing and yet more most likely to recommend the care their hospitals evidence that Patient First really is making a provide. For the first time, our Trust was also difference to our patients. ranked in the top 20% of all NHS organisations
with the highest levels of staff engagement. In August 2017, Sir Bruce Keogh, who was at the Evidence shows that better engaged staff provide time NHS England’s National Medical Director, better patient care, so our survey results are real visited the Trust and praised both the enthusiasm cause for celebration at a time when engagement of staff as well as the Trust’s commitment to enabling them to solve problems locally and Page 7 | Quality Report 2017/18 third draft
scores across the NHS have deteriorated and As we look forward to 2018/19 and the challenges pressure on staff has never been greater. ahead, it is our common values and shared purpose, fostered by our Patient First approach Once again this year, demand for our services has and highly engaged workforce that will ensure we continued to grow and the workload for our staff continue to provide outstanding care. This will of has never been greater, both at the frontline and course be supported, once again, by our for all those who support the delivery of care at commitment to continuous improvement. Western Sussex Hospitals. Our wards, for Pressures of demand, staffing and budgets will example, have never been busier with bed inevitably continue to test us but we are occupancy rates reaching new highs, especially determined to push beyond those barriers and over the winter period when we cared for make further progress on our Quality Priorities and unprecedented numbers of more elderly people True North metrics. In 2018/19 these efforts will with more complex health needs. Despite our very focus on improvement programmes around sepsis, real staffing and bed pressures though, the mental health, orthopaedics, falls, pressure dedication and hard work of our outstanding staff damage and patient experience. ensured the quality of care we provide was maintained. For example, our mortality figures I am pleased to confirm that the Trust Board has continue to improve and we are currently placed in reviewed the 2017/18 Quality Report and confirm the top 15% of hospitals in the country in terms of that it is a true and fair reflection of our Dr Foster’s Hospital Standardised Mortality Ratio. performance. We hope that this Quality Report provides you with a clear picture of what we have Western Sussex staff and volunteers are not only achieved over the past year and how we will hard working, but undertake their work with continually build upon these foundations and exemplary skill, kindness and compassion. There deliver against our 2018/19 quality improvement is a unique feeling and ambience at Western priorities. Sussex in the way in which we care for and support each other, as well as our patients. Time We have written the report in plain English and time again, visitors to the Trust also feel wherever possible to ensure it is widely accessible it. England’s new Chief Inspector of Hospitals, for all interested parties, and will continue to refine Ted Baker, and CQC colleagues visited us in the all our literature to meet this ambition. winter, meeting colleagues from housekeeping, nursing, medicine, management and the Kaizen The information contained within the Quality Office. The delegation particularly highlighted our Report is, to the best of my knowledge, accurate. common values and approach and enthused about Signed: the positive feel of Western Sussex Hospitals, Date: 25th May 2018 explaining they how they do not experience such a Marianne Griffiths consistent culture in other hospitals. Chief Executive, Western Sussex Hospitals NHS Foundation Trust Part 2.1: Priorities for improvement
(photo page – frailty/deteriorating patient)
Our Trust approach to Quality Improvement
How we learn accredited by the Royal College of Physicians and sponsored by the Kent Surrey and Sussex Quality We have robust systems in place for reviewing and Patient Safety Collaborative (KSS AHSN). incidents, complaints and claims within our clinical The programme was facilitated by staff from the divisions. Each clinical division has a governance Trust and Healthcare Safety Investigation Branch lead to coordinate this activity and help the and provided training on how to investigate serious Divisions to track and complete the actions arising incidents using a Human Factors approach, the out of each of these areas. Divisions also use Duty of Candour and involving the patient, their safety huddles, newsletters and staff meetings to family and carers. The programme was extremely help communicate changes made in response to well received with a recommendation that all staff learning. investigating serious incidents should attend the
training in the future. Another training programme When things go wrong for patients, talking to the is planned for spring 2018 with an annual training person affected or their family provides crucial programme under development. context to any investigation. We continue to develop and encourage an open and honest approach to supporting patients who have been Learning from deaths harmed, or their families, as candour and During 2017/18 the Trust has developed a transparency are core values for Western Sussex comprehensive policy for learning from deaths in Hospitals. line with national guidance. We have implemented an electronic process for the screening of all Learning from incidents deaths in our hospitals from 1st April 2017. The Trust has also recruited and trained senior clinical The Trust Patient Safety Team is currently reviewers to undertake full reviews using the undertaking an improvement project regarding the Structured Judgement Review process Datix incident reporting system. We aim to recommended by the Royal College of Physicians understand and improve shared feedback and programme. Learning from this activity has been learning, implement staff survey user and focus shared through regular reports to Trust Board and groups, recruit and train a Datix Manager and information sharing with health economy partners. design a revised and improved methodology and This work will continue to progress through system. 2018/19 with an aim to increase the volume of
reviews and further improve the learning and In January 2018 we hosted a two day Serious sharing process both internally and across Incident Investigator training programme organisational boundaries.
Patient First Programme comprises four strategic themes: sustainability; our people; quality improvement; and systems and We recognise that the strength of our hospitals lies partnerships; to enable excellent care for patients. in our staff, and have built an organisational culture that empowers teams and individuals to In simple terms, the main aim of our Patient First make lasting changes that benefit our patients and Improvement Programme is to empower and community. To do this, we have developed Patient enable everyone to be passionate about delivering First – the Trust's bespoke approach to sustaining excellent care every time. Further information a culture of continuous improvement. about Patient First can be found on the Trust
website: The Patient First programme drives quality www.westernsussexhospitals.nhs.uk/your- improvement at Western Sussex Hospitals. It trust/performance/patient-first
True North and provide a system-wide improvement focus. True North is the compass that keeps our Our top priorities relate to the Trust’s ‘True North’ hospitals heading in the right direction – a fixed quality and safety improvement metrics. These point we should always refer to when identifying establish a measure of our organisational health which improvements and projects to prioritise.
Note: HSMR is Hospital Standardised Mortality Ratio. RTT is Referral To Treatment waiting times. A&E is Accident and Emergency.
For Quality Improvement our True North Metrics Breakthrough objectives are not likely to be are the reduction in preventable mortality, and confirmed for 2018/19 until the end of March 2018. provision of harm free care. Over the last year we have focused relentlessly on our Breakthrough Our breakthrough objectives will be regularly Objectives, those that will take us furthest and reviewed to ensure that we focus on the key fastest towards our overall True North, as the key improvements that will deliver our True North objectives to deliver this. Metrics.
Priorities for improvement in 2018/19
Our Quality Priorities for 2018/19 form part of our forthcoming year under the Quality Strategy goals: broader ambition set out in our Quality Strategy for Reducing avoidable mortality and improving 2015-18, and our True North metrics. In order to outcomes, delivering harm free care, improving develop our annual quality priorities and quality patient experience and improving staff improvement breakthrough objectives we analyse engagement. Divisional improvement priorities quality indicators and benchmarking data and were presented to the Quality Board in November engage widely. 2017 and discussed alongside the Trust Quality scorecard data, quality improvement programme In the autumn of 2017 our divisions engaged with progress through 2017/18 and other strategic their stakeholders about the priorities for the developments. The Quality Board, Quality & Risk Page 12 | Quality Report 2017/18 third draft
Committee, Trust Executive Committee and Trust Our improvement programme in 2017/18 focused Board then agreed a final set of quality priorities on improving the time to administration of for improvement in 2017/18. The following groups antibiotics and delivery of the full sepsis care were invited to review our quality improvement bundle to our patients. Whilst our focused priorities: WSHFT Council of Governor’s, Coastal approach enabled A&E teams to deliver dramatic West Sussex CCG, Healthwatch West Sussex and improvements in the early identification and the County Council’s Health and Adult Social Care treatment of patients arriving with sepsis, we did Select Committee. not deliver the level of improvements we set out to with regard to the timely administration of The delivery of key Quality Priorities will be antibiotics or compliance with delivery of the full monitored by the Trust Executive Board through sepsis care bundle. the regular Quality Report and scorecard. The Trust Quality Board will monitor the delivery of In 2018/19 we will drive forward our sepsis detailed quality improvement programmes set out improvement programme to further improve the in the Trust Quality Strategy and annual plans. early identification of sepsis, timely treatment of Divisional accountability for elements of our quality patients with antibiotics and delivery of the full improvement programme is achieved through sepsis six care bundle; there is robust evidence to early engagement work relating to setting show that focusing on these areas will provide the meaningful annual improvement priorities and best outcomes for patients with sepsis. local objectives and the cascade of accountabilities through our strategy deployment We will continue to monitor time to identification, processes. time to antibiotic administration and delivery of the sepsis six care bundle through weekly sepsis We would like to highlight the following priority review meetings with our A&E and Emergency quality improvement programmes for 2018/19: Floor teams. This work will be overseen by the Medicine Division Board and reported through to Reducing preventable mortality the Trust Quality Board. and improving outcomes: sepsis Reducing preventable mortality improvement programme and improving outcomes: mental Sepsis is a rare but serious complication of an infection; delays in the recognition and treatment health improvement programme of sepsis can lead to multiple organ failure and Through our improvement programme we aim to death. bridge the gap between mental health and physical health in our hospitals in response to the National Confidential Enquiry into Patient Outcome Page 13 | Quality Report 2017/18 third draft
and Death (NCEPOD) ‘Treat as One’ study. We published by the British Orthopaedic Association in will take action in line with NCEPOD March 2015 highlighted areas of unjustifiable recommendations. variation in practice; it also provided examples of best practice for how to improve and enhance the We will work with local health economy partners, quality of care that can be delivered. such as Sussex Partnership, South East Coast Ambulance and local GPs to better support people Over the next year we will work to improve our with primary mental health needs. orthopaedic service provision across a variety of areas. With local partners we will aim to reduce A&E attendance in a further cohort of frequent We plan to consistently deliver improved attenders presenting with primary mental health performance for surgical site infections (SSIs) for issues as part of the second year of a two year patients who have received total hip or total knee Commissioning for Quality and Innovation replacements. SSI rates are currently monitored (CQUIN) target. A&E attendance will be through operational and oversight infection control measured and monitored by the CQUIN Delivery groups which report to the Trust Quality Board. Group, reporting through to the Trust Quality Board for oversight and to NHS England. Another way we plan to improve care is by sustainably delivering fractured neck of femur (hip) Finally we will identify improvements required to patients to theatre within 36 hours of arrival. Hip better support patients with condition specific fractures are associated with a high rate of pathways including those with dementia, perinatal mortality and evidence shows that prompt surgery mental health issues, children and young people, promotes better functional outcome and lower substance misuse and social needs. This work rates of perioperative complications and mortality will be overseen by the Mental Health Board and in the patient population. We will monitor time to reported through to the Trust Quality Board. theatre through monthly reporting to the Trauma & Updates will be received by Trust Board during the Orthopaedic Directorate operational meeting and year. onward to the Surgical Division Board.
Reducing preventable mortality We will also look to rationalise procedure type by surgeon based on benchmarked numbers across and improving outcomes: the Sustainability and Transformation Partnership Orthopaedic improvement and use model hospital data to establish efficiency opportunities in elective care. programme
The national review of adult elective orthopaedic services in England (Getting it Right First Time) Page 14 | Quality Report 2017/18 third draft
Avoiding harm: falls improvement existing skin damage, we have seen a significant rise in hospital acquired pressure damage since programme 2015/16. We are now undertaking a robust Patient falls are the largest cause of patient harm programme of improvement, with Kaizen Team in our hospitals. Through our Quality Strategy we support, to fully understand opportunities for aim to continue our successful improvement work improvement and address the deteriorating to further reduce the number of in-hospital patient picture. Our aim for 2018/19 will be to have zero falls across the Trust. category three and above pressure ulcers.
Over 2018/19 we will work to ensure that learning Over the coming year we will implement a rapid and incremental change in falls management improvement approach, previously used for falls across divisions is ongoing. We will specifically learning, to reduce hospital acquired pressure work on reducing the number of falls causing ulcers. We will specifically work with wards that harm. Our falls metrics are monitored have high numbers of patients developing operationally by the Harm Free Care Group and pressure damage to ensure they have the support reported through to the Trust Quality Board. required to implement remedial actions using the Patient First Improvement System. In the coming year there will be a focused programme around the awareness of We aim to link with the deconditioning work in the deconditioning amongst staff, patients and falls quality improvement programme to realise relatives; the aim is to ensure that all patients benefit in reducing pressure ulcers; evidence receive the best possible outcome and return shows that the earlier patients are active in home wherever possible. hospital decreases the likelihood of them developing a pressure ulcer. We also plan to train and implement a new Clinical Activities Volunteer role across the Trust; we hope We will also work with our partner colleagues at to develop these valuable assistants in to Sussex Community Trust to improve the Wellbeing Volunteers to provide a range of continence pathway in hospital and on transitions wellbeing activities, advice and support to our of care. patients. Pressure damage rates will continue to be monitored by the Harm Free Care Group reporting through to the Trust Quality Board. Avoiding harm: pressure damage improvement programme Whilst a high proportion of our patients with pressure ulcers are admitted to hospital with Page 15 | Quality Report 2017/18 third draft
Improving patient experience We will work with our local partner Sussex Community Trust on a number of local discharge improvement programme improvement workstreams over the next year to We know from existing feedback there are many ensure that the patient experience of discharge is examples of excellent care and experience being firmly embedded in our daily work. delivered by our staff; however there are occasions where we know this is not the case for Patient experience will continue to be monitored every patient, every time. by the Patient Engagement & Experience Committee, reported through to Quality Board as a Our national inpatient survey and real-time patient quality improvement programme and also to Trust feedback indicate that there are improvements we Board. must to make for our patients and their families to ensure safe and positive discharge experiences.
Part 2.2: Statements of assurance from the Board
(PHOTO PAGE – simulation photo)
Page 17 | Quality Report 2017/18 third draft
Review of services
During 2017/18 the Western Sussex Hospitals The income generated by the relevant health NHS Foundation Trust provided and/or sub- services reviewed in 2017/18 represents 100% of contracted 131 relevant health services. the total income generated from the provision of relevant health services by The Western Sussex The Western Sussex Hospitals NHS Foundation Hospitals NHS Foundation Trust for 2017/18. Trust has reviewed all the data available to them on the quality of care in 131 of these relevant health services.
Participation in clinical audits and confidential enquiries
National clinical audits During 2017/18, 42 national clinical audits and five The national clinical audits and national national confidential enquiries covered relevant confidential enquiries that Western Sussex health services that Western Sussex Hospitals Hospitals NHS Foundation Trust participated in NHS Foundation Trust provides. during 2017/18 are as follows.
During that period Western Sussex Hospitals NHS The national clinical audits and national Foundation Trust participated in 90% national confidential enquiries that Western Sussex clinical audits and 100% national confidential Hospitals NHS Foundation Trust participated in, enquiries of the national clinical audits and and for which data collection was completed national confidential enquiries which it was eligible during 2017/18, are listed below alongside the to participate in. number of cases submitted to each audit or enquiry as a percentage of the number of The national clinical audits and national registered cases required by the terms of that confidential enquiries that Western Sussex audit or enquiry. Hospitals NHS Foundation Trust was eligible to participate in during 2017/18 are as follows.
Page 18 | Quality Report 2017/18 third draft
National clinical audits Eligible Participated Percentage submitted Acute Coronary Syndrome or Acute Myocardial Infarction Y Y Ongoing (MINAP) BAUS Urology Audits: Cystectomy Y Y Ongoing BAUS Urology Audits: Nephrectomy Y Y Ongoing BAUS Urology Audits: Percutaneous nephrolithotomy Y Y Ongoing BAUS Urology Audits: Radical prostatectomy Y Y Ongoing BAUS Urology Audits: Urethroplasty Y Y Ongoing BAUS Urology Audits: Female stress urinary incontinence Y Y Ongoing Bowel Cancer (NBOCAP) Y Y Ongoing Cardiac Rhythm Management (CRM) Y Y Ongoing Case Mix Programme (CMP) Y Y Ongoing Child Health Clinical Outcome Review Programme Y Y Ongoing (NCEPOD) Coronary Angioplasty/National Audit of Percutaneous Y Y Ongoing Coronary Interventions Diabetes (Paediatric) (NPDA) Y Y Ongoing Elective Surgery (National PROMs Programme) Y Y Ongoing Endocrine and Thyroid National Audit Y Y Ongoing Falls and Fragility Fractures Audit programme (FFFAP) Y Y 100% Head and Neck Cancer Audit (HANA) (TBC) Y Y Ongoing Inflammatory Bowel Disease (IBD) programme Y N N/A Learning Disability Mortality Review Programme (LeDeR) Y Y Ongoing Major Trauma Audit Y Y Ongoing Maternal, Newborn and Infant Clinical Outcome Review Y Y Ongoing Programme Medical and Surgical Clinical Outcome Review Programme Y Y 100% (NCEPOD) National Audit of Breast Cancer in Older Patients (NABCOP) Y Y Ongoing National Audit of Dementia Y Y 100% National Audit of Seizures and Epilepsies in Children and Y Y 100% Young People National Bariatric Surgery Registry (NBSR) Y Y Ongoing National Cardiac Arrest Audit (NCAA) Y Y Ongoing National Chronic Obstructive Pulmonary Disease Audit Y Y 100% programme (COPD) National Comparative Audit of Blood Transfusion programme Y Y 100% National Diabetes Audit - Adults Y N N/A National Emergency Laparotomy Audit (NELA) Y Y Ongoing National Heart Failure Audit Y Y 100% National Joint Registry (NJR) Y Y Ongoing Page 19 | Quality Report 2017/18 third draft
National clinical audits Eligible Participated Percentage submitted National Lung Cancer Audit (NLCA) Y Y Ongoing National Maternity and Perinatal Audit Y Y Ongoing National Neonatal Audit Programme (NNAP) (Neonatal Y Y Ongoing Intensive and Special Care) National Ophthalmology Audit Y N N/A National Sentinel Stroke Programme (SSNAP) Y Y Ongoing Oesophago-gastric Cancer (NAOGC) Y Y 100% Royal College of Emergency Medicine (RCEM) Fractured Y Y (SRH only*) 100% Neck of Femur RCEM Pain in Children Y Y 100% RCEM Procedural Sedation Y Y 100% * Worthing site Emergency Department undertake regular local audit of fractured neck of femur
National Confidential Enquiries Eligible Participated Percentage submitted Young People’s Mental Health Y Y 100% Cancer in Children, Teens and Young Adults Y Y 100% Chronic Neurodisability Y Y 100% Acute Heart Failure Y Y 100% Perioperative Diabetes Y Y Ongoing
The reports of 19 national clinical audits were take the following actions to improve the quality of reviewed by the provider in 2017/18 and Western healthcare provided. Sussex Hospitals NHS Foundation Trust intends to
Title Action taken or planned
Case Mix Programme (CMP) Delayed discharges of greater than eight hours were above the national (Intensive Care National average, but not statistically significant outliers. These may result in Audit & Research Centre) delayed admission of critically ill patients with potential for patient harm. Delayed admissions to the Critical Care Unit (CCU) are now being actively captured on the CCU electronic documentation information systems at both hospitals. Plans are in place to audit the deterioration in NEWS scoring (patient ‘wellness’) between the time of acceptance on the ward and time of arrival on the Critical Care Unit. National Neonatal Audit The audit identified that both hospitals were performing above national Programme (NNAP) average for all areas. To further improve the care provided a care bundle is to be introduced and a written resource for parents on ROP (Retinopathy of Prematurity Screening) to be provided. National Emergency Across the majority of outcome measures, both hospitals outperformed Page 20 | Quality Report 2017/18 third draft
Title Action taken or planned Laparotomy Audit national standards. One area identified for improvement was access to care of the elderly support; this is being taken forward through divisional leadership. Myocardial Ischaemia Timeliness of angiography following non-ST segment elevation National Audit Project myocardial infarction is achieved for a high proportion of patients, but (MINAP) inequity of provision cross site requires continuing work to ring fence cardiology beds for cardiac patients; remove the use of the catheter lab recovery bay as an escalation ward. A proposal is in progress to address these barriers. Audit of Red Cell and There were 48 national recommendations made as a result of this audit, Platelet Transfusion in Adult just two needed to be addressed by the Trust, resulting in the updating of Haematology Patients the laboratory standard operating procedures. National Paediatric Asthma The audit identified the need to improve the proportion of children Audit advised to see their GP within two working days of discharge, advice has been added to the discharge page of the care pathway, with staff educated to sign and document the giving of this advice. A local audit of the discharge checklist has since been completed, highlighting the need for further education. Plans are in place to update the pathway with the British Thoracic Society’s care bundle and further changes to the discharge checklist. National Clinical Audit of Good practice was identified in the screening, prescribing and follow-up Biological Therapies – UK of adult patients administered biologics for IBD. The Trust also Inflammatory Bowel Disease participates in the research study Personalising Anti-TNF Therapy in (IBD) Audit Crohn’s Disease (PANTS), as recommended in the national audit.
National Audit of Current Royal College of Obstetricians and Gynaecologists Group B Practice in Preventing Early- Streptococcus infection Patient Information Leaflet now used Trust wide, onset Neonatal Group B to ensure up to date information is provided to patients. Streptococcal Disease UK Parkinson’s Audit Newly diagnosed patients are notified to the Parkinson’s Disease Nurse Specialist by email so that an information pack is sent to them; an activity of daily living score has been added to the assessment process and funding is being sort for information stands suitable for use in the outpatient department to provide greater access to information when attending clinics. National Paediatric This audit demonstrated high standards of care, in line with national Pneumonia Audit results. Clinicians were reminded that chest x-rays are not required on a routine basis, also that amoxicillin is the preferred antibiotic for community acquired pneumonia. National Female Genital There is a low incidence of women and girls with female genital Mutilation Audit mutilation presenting to the Trust, all were identified as type 4 which includes piercings. No recommendations or actions were deemed necessary in relation to the audit results. National Heart Failure Audit Results were, in the main, better than the national average. Plans in progress include improving the time to follow-up by a heart failure specialist nurse at Worthing Hospital by seeing patients in outpatients (requiring a side room to give intravenous frusemide) and increasing the number of heart failure specialist nurses. Meeting with CCG to discuss a community heart failure team in the Worthing area, only currently Page 21 | Quality Report 2017/18 third draft
Title Action taken or planned available in Chichester. National Paediatric Diabetes Overall the team are working hard to improve outcomes for patients. The Audit (NPDA) national audit made 29 recommendations, of these the Trust only needed to take action on three; a new annual review form is in progress, the Trust is part of the Royal College of Paediatrics and Child Health quality improvement collaborative looking to improve care and outcomes in 2017/18 and is in discussion with the IT Department develop or identify a suitable database to improve the completeness of the recording and submission of treatment regimen data. National Hip Fracture Of the ten national recommendations only one remains to be Database (NHFD) implemented, the Trust is addressing the shortfall in achieving the Best Practice Tariff. As an example of the recommendations achieved, the Trust now has local NHFD leadership including an anaesthetist as well as an orthopaedic surgeon and an orthogeriatrician. A further recommendation was to participate in the Physiotherapy Hip Fracture Sprint Audit, which has been completed. The NHFD is part of the Falls & Fragility Fractures Audit Programme; falls in hospital have been reduced through a successful improvement project plan over the last year. National Joint Registry (NJR) The Trust achieved an 88% rate of operations submitted to the NJR, the target being to achieve 95% or more. However, at Worthing Hospital only emergency hip and knee replacements are undertaken, making consent for submission of data to the NJR difficult; all consultants who performed these emergency operations at Worthing Hospital have discussed improving submission rates to the NJR and this will continue to be raised at Clinical Governance meetings. National Prostate Cancer All of the national recommendations are met locally, with the exception of Audit (NPCA) sexual function support which is no longer commissioned by the CCG. National Dementia Audit The national audit measured care across six audit themes and benchmarked hospitals against seven scores. Our Trust achieved above the national average for five scores at St Richard’s Hospital and four scores at Worthing Hospital. Since the audit was undertaken the Dementia Team have worked hard to improve the care provided introducing a Carers’ Charter in June 2017 and having Dementia Champions at both ward and directorate level. The Trust needed to improve the level of initial screening for delirium and ensure symptoms were summarised for discharge; to address these a ‘Delirium Awareness Week’ was arranged and teaching provision reviewed. In addition, the Trust participated in the Delirium Spotlight Audit and will be participating in the 2018 National Dementia Audit. Royal College of Emergency Time of arrival in the Emergency Department was not robustly recorded Medicine (RCEM) Audit of meaning that five of the fifteen audit criteria were reported as zero Moderate & Acute Severe percent compliance (it had not been possible to ascertain whether Asthma observations or treatment were carried out on arrival or within a specific time to meet the standard). Of the other ten criteria, six achieved above the national median score. The recording of time of arrival has since been addressed and a local re-audit has shown significant improvement in arrival time recording. All five audit criteria that were zero percent compliance in the national audit are now well above the national median in the local re-audit due to the improvement in recording time of arrival. RCEM Consultant Sign-off The Trust achieved above the national average for all standards but Page 22 | Quality Report 2017/18 third draft
Title Action taken or planned Audit recognises that there is still improvement required to meet the RCEM standards. A poster presentation of the results and recommendations has been produced and shared with relevant teams and learning points are included in the Emergency Department safety huddles and junior doctor induction.
Local clinical audits The reports of 76 local clinical audits were points of action for a sample of local clinical audits reviewed by the provider in 2017/18 and Western reported in 2017/18 are shown below. Further Sussex Hospitals NHS Foundation Trust intends to information regarding local clinical audits and the take the following actions to improve the quality of resulting actions to improve the quality of healthcare provided. healthcare provided will be detailed in the Trust’s Clinical Audit Annual Report for 2017/18. Reports of local clinical audits are disseminated to the Trust's Clinical Divisions for their actions. Main
Specialty Title Action taken or planned
A&E Management of patients with The audit identified the need for improved management of Parkinson’s Disease in the patients with Parkinson’s Disease (PD) in the ED, particularly Emergency Department (ED) to ensure that no PD medications are delayed or omitted. Posters and stickers to be used to raise awareness. Discussion with pharmacy to provide medications for a “Parkinson’s Box” including patches for patients who are nil by mouth in the ED. Anaesthetics Audit of short-acting opioid Many patients sent home on newly prescribed medications did medications prescribed on not have discharge letters documenting reason for discharge prescription, intended length of course or discontinuation i.e. not compliant with WSHFT Medical Prescribing Policy. Increased education and communication at Clinical Governance and Sisters’ meetings, also introduced into junior doctor (Foundation Year One) teaching and a “Theme of the Week” email. Anaesthetics The use of capnography during During the audit period capnography (monitoring carbon in hospital cardiac arrests in dioxide concentration in respiratory gases) was never non-specialist areas immediately available during cardiac arrests in non-specialist areas. Capnography equipment now purchased, one device placed in cardiac arrest pack taken by the on-call anaesthetist to each cardiac arrest and another carried by the Critical Care Outreach Team who also attend every cardiac arrest. Re- audit planned once equipment has been in place for six months. Breast Surgery An audit of breast reconstruction MDT notes updated to include section on discussion regarding surgery discussion with patients immediate breast reconstruction and reasons for any diagnosed with breast cancer exceptions. requiring mastectomy Breast Surgery Patient reported outcomes Patient satisfaction with breast reconstruction surgery at Page 23 | Quality Report 2017/18 third draft
Specialty Title Action taken or planned (PROMS) of breast WSHFT is high and exceeds National Standards. However, reconstruction / oncoplastic postal return of completed PROMS is only about 50%. All surgery patients will now be asked to complete BREAST-Q (a questionnaire evaluating outcomes in women who have had breast surgery) at their one year follow-up outpatient appointment and analysis undertaken once the whole year’s cohort is complete. ENT Pain at home following A new analgesic regime has been introduced and the data paediatric day case Ear, Nose & collection tool is to be improved before re-auditing. Throat surgery Gynaecology Re-audit of colposcopy clinic Overall positive findings noted with no major problem patient satisfaction identified, patients were happy with the care they received. Recommended by the Screen Quality Assurance Service (SQAS) that regular annual patient satisfaction surveys are carried out at both sites to maintain the standard and to identify any room for improvement. Gynaecology Re-audit of all types of The audit identified that to reduce complication rates hysterectomies associated with abdominal hysterectomy more training in laparoscopic surgery needs to be encouraged. Women should be provided with more realistic and local rates of complications by continuing to collect hysterectomy complication rates, to enable more informed decisions at time of consent. Nurse phone follow-up immediately after discharge and six weeks post-surgery to be organised. Gynaecology Audit of hysteroscopic myosure Majority of patients accepted and tolerated the One-Stop ‘See morcellation (a gynaecological & Treat’ outpatient service. The findings of the audit are used procedure used to remove to inform future patients and GPs to provide reassurance and polyps and fibroids) at a one- allow the service to develop further. stop outpatient hysteroscopy clinic Medicine Audit to identify the safety of Several areas identified for action: improved recording of gentamicin prescribing and gentamicin level timing on blood reports, facilitated by Lead monitoring on the emergency Biochemical Scientist educating laboratory staff; improved floor at Worthing Hospital education of junior doctors being discussed with microbiology team, to be incorporated into current junior doctor education programme. Medicine Subarachnoid haemorrhage As a result of the audit a WSHFT acute headache investigation and management protocol has been developed and included in the ‘Grey Book’ (the Trust’s handbook for medical emergency protocols). Presentations undertaken as part of ‘Curious Clinician’ (weekly clinical presentations open to all staff) and ongoing as part of rolling junior doctor teaching topics. Medicine Re-audit of methotrexate Many areas of improvement identified since the previous audit. prescribing and monitoring in Further improvement needed in the provision of hand held the dermatology department at records and documentation that this has been actioned – Worthing and Southlands nurses supervising psoriasis clinic to keep hand held records Hospitals on the table as a prompt. Secretaries aware to ensure that methotrexate and folic acid doses and tablet size are stated clearly in bold at top of GP letter. Consistency of care to be ensured by all new psoriasis referrals attending the specialist psoriasis clinic. MFU Accuracy of clinical coding for Inaccuracies identified in coding of maxillofacial procedures, procedures in oral and new local policy written by the coding manager on coding maxillofacial surgery bimaxillary osteotomies (corrective jaw surgery). Page 24 | Quality Report 2017/18 third draft
Specialty Title Action taken or planned
Obstetrics Re-audit of screening for Early screening programme introduced following previous gestational diabetes audit. Re-audit identified benefits of early screening, therefore the programme will continue and be re-audited again in one year with a focus on fetomaternal outcomes. Ophthalmology Cataract surgery outcomes in Senior trainees in ophthalmology were producing results in ophthalmic trainees keeping with national standards for cataract surgery and therefore can be allowed to operate independently in the future, further improving training and productivity provided the results are audited regularly. Ophthalmology Audit of Trust compliance with Pro-forma revised to aid clinicians in following NICE guidance, NICE glaucoma guidance with reasons documented if guidance not followed. Plans to increase service capacity through recruitment and extended roles of existing clinical staff, also innovative practices such as virtual clinics. Clinics not to be overbooked to ensure necessary diagnostic tests are done and patient safety is safeguarded. Ophthalmology Squint Surgery Outcomes Squint surgery outcomes compared favourably against the standards used in this audit. The recommendations made were that more than one set of squint measurements is achieved prior to listing for squint surgery and that large angle squints are considered for three muscle surgery. Orthopaedics Re-audit of the adequacy of Adequacy of plain radiographs had improved since the original plain radiographs performed audit, but still required improvement. Education of junior pre- and post- operatively for doctors in Emergency and Orthopaedic Departments to patients with femoral neck request x-ray of both hips, rather than just pelvis, teaching fractures already ongoing and included in last junior doctors’ induction. Departmental posters created and distributed to relevant departments, including radiographers. Orthopaedics Audit of fluoroscopy and x-ray A small audit sample, but identified a lack of knowledge personal protective equipment regarding the risk of x-ray and staff not using the appropriate (PPE) use in Trauma & protective devices e.g. thyroid guards. Knowledge was also Orthopaedics poor on how to reduce x-ray dose to patients and that pulsed fluoroscopy is better and safer than continuous. Awareness has been raised through education and by presenting/discussing results at the departmental clinical governance meeting to improve staff and patient safety. Orthopaedics Audit of the spinal referral The ‘refer a patient pathway’ was used for all patients audited system “Refer a patient” who had been discussed/referred with the tertiary centre, but recording of the response was poorly documented in the case notes. Presented at clinical governance meeting, pathway included in induction pack for new doctors and pathway displayed in the Emergency Department. Paediatrics Local audit based on the Actions agreed as a result of the audit are to revise the febrile ‘Second national audit of febrile neutropenia pro-forma and repeat the audit, to improve neutropenia management in documentation of date and time of arrival and time antibiotics children and young people with given, also the reason if antibiotics delayed; more specific cancer – results for Worthing documentation on patient information system and ward book; documentation of risk stratification level on review; to develop a febrile neutropenia pathway and to feedback results in next oncology update. Paediatrics Promoting a family friendly This re-audit found that all aspects were now rated as good or healthcare environment in the excellent, an improvement on the previous audit. Children’s Centre dermatology clinics Page 25 | Quality Report 2017/18 third draft
Specialty Title Action taken or planned
Paediatrics Re-audit NICE Management of The re-audit shows an improvement in the history taking of anaphylaxis in children and children and young people with allergic reactions. Actions young people taken following the current audit were to ensure multi- disciplinary team appointments are available within three months and that early responses are received from the Paediatric Allergy Team following email referrals from A&E. Pharmacy Re-audit: Gentamicin Whilst prescribing and monitoring have improved since the Prescribing and monitoring in previous audit, there are still further improvements to be made. accordance with Trust Audit results have been presented at Clinical Governance; guidelines for the treatment of training for junior doctors (Foundation Year One) during intra-abdominal sepsis teaching and induction; ward-based pharmacist guided help to new prescribers or others needing advice; regular email reminders and ward sisters encouraged to complete the phlebotomy course. Safeguarding Mental Capacity Act (MCA) Continuing to provide MCA/DoLS training to wards and Audit of DoLS (Deprivation of departments, also regularly providing support in undertaking Liberty Safeguards) Requests capacity assessments where required with regular re-audit. Safeguarding Independent Mental Capacity Session plan written for training on Lasting Power of Attorneys Advocate Audit 2017 (LPAs) and Advance Decisions to Refuse Treatment (ADRTs); ward staff to ensure that patients (or family/friends) are asked about LPAs and ADRTs. Regular re-audits planned. Sexual Health Audit of HIV and AIDS Audit findings were similar to three other localities in our area. Reporting System (HARS) The results have been shared with the HIV Clinical Reference recording of patient complexity Group and the HIV Specialist Commissioner. Surgery Venous thromboembolism Poster and local guidance developed; ongoing prospective prophylaxis after abdominal and data collection to be undertaken with three monthly reviews. pelvic cancer surgery Surgery Location of hand gel at the Recommended location of hand gel to be included in written bedside at Worthing Hospital – a policy; provision and fixing of metal holders to be arranged for prospective audit wards where currently not available at end of beds; nursing leads to be provided with presentation to aid education of ward staff. Therapies Conditioning lower limb class The audit identified that 100% of patients attending the audit conditioning lower limb class had their patient specific functional scale (PSFS) and visual analogue scale (VAS) completed at the start and end of all classes across the three sites, which was above the standard set. Annual audits will be carried out. Therapies A re-audit to review the current Actions planned include goal attainment scaling and rehab neurological physiotherapy folders to be implemented to facilitate improved patient and practice for stroke rehabilitation carer involvement; to explore opportunities to incorporate cardiovascular training into current practice, to be discussed with neurotherapy team and to provide further training on hemiplegic shoulder pain identification and treatment. Therapies Audit to assess newly Formal tube feeding study days have been introduced and the commenced nasogastric feeding information already included in the nursing staff induction presentation is given greater emphasis along with the possible adverse outcomes of not adhering to the protocol. Awareness raised using ‘Theme of the week’ and during safety huddles.
Research
Participation in clinical research (2012) places a statutory duty on the NHS to promote research. The NHS Constitution includes The number of patients receiving relevant health a commitment to promote, conduct and use services provided or sub-contracted by Western research to improve the current and future health Sussex Hospitals NHS Foundation Trust in and care of the population. Research and 2017/18 that were recruited during that period to innovation within the Trust supports the aims of participate in research approved by a research our Patient First Programme - to empower and ethics committee was 1487. enable everyone to be passionate about delivering excellent care every time. Research as a driver for improving Our research and innovation goals for 2017-20: the quality of care and patient Increase opportunities for patients to experience participate in high quality clinical research In 2016 we developed a new Research and that aims to improve patient care. Innovation Strategy to set out the Trust’s ambition Implement innovative improvements in for the development of research and innovation patient care at pace through over the next three years. The Strategy received standardisation, robust improvement board approval in May 2017 and runs to 2020. science, partnership and shared learning. Continue to support roll out of the Patient The Trust undertakes research and promotes First Improvement System empowering all innovation because high quality clinical research staff to lead change and improvements in and innovation improve clinical outcomes for care for patients. patients. Our ambition is to deliver high quality Deliver a Clinical Academic Nursing, patient care through innovation and continuous Midwifery and Allied Health Professional quality improvement, education and research. Strategy that promotes a professional, well- trained and up to date healthcare workforce Clinical research is now carried out as a core part leading best practice and innovation. of NHS services. The Health and Social Care Act
Goals agreed with commissioners: use of the CQUIN payment framework
A proportion of Western Sussex Hospitals NHS conditional on achieving quality improvement and Foundation Trust income in 2017/18 was innovation goals agreed between Western Sussex Page 27 | Quality Report 2017/18 third draft
Hospitals NHS Foundation Trust and any person The above 2017/18 value is based on the or body they entered into a contract, agreement or reconciled position for months 1-9 with estimates arrangement with for the provision of relevant for the full year. The final value may differ from health services, through the Commissioning for this. Quality and Innovation (CQUIN) payment Associated CQUIN payments received in 2016/17: framework. £8,006,742. Further details of the agreed goals for 2017/18 and Two year CQUIN schemes have been agreed for for the following 12 month period are available 2017-2019 with Coastal West Sussex CCG, NHS electronically at: England and Public Health England. A further http://www.westernsussexhospitals.nhs.uk/your- CQUIN is currently being developed for our sexual trust/performance health contract. Details of our 2018/19 CQUIN programme will be published on the Trust web site Income in 2017/18 conditional on achieving quality as soon as the final details are confirmed. improvement and innovation goals through the Commissioning for Quality and Innovation (CQUIN) payment framework: £6,931,729.
Statements from the Care Quality Commission (CQC)
Western Sussex Hospitals NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust is required to register with the Care Quality has not participated in any special reviews or Commission and its current registration status is investigations by the CQC during the reporting “registered without conditions”. period.
The Care Quality Commission has not taken enforcement action against Western Sussex Hospitals NHS Foundation Trust during 2017/18.
Data Quality
NHS Number and General Medical Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in Practice Code Validity the latest published data. Western Sussex Hospitals NHS Foundation Trust submitted records during 2017/18 to the Page 28 | Quality Report 2017/18 third draft
The percentage of records in the published data: Statement on relevance of Data - which included the patient’s valid NHS number was: Quality and your actions to 99.8% for admitted patient care; improve your Data Quality 99.9% for outpatient care; and Western Sussex Hospitals NHS Foundation Trust 98.5% for accident and emergency care. will be taking the following actions to improve data
quality: - which included the patient’s valid General 1. Internal training and audit program: Clinical Medical Practice Code was: Coding have created a program of training 100% for admitted patient care; and audit. In three year cycles we will provide 100% for outpatient care; and training and auditing on each of the major 100% for accident and emergency care. specialties we code in the Trust.
2. Information Governance (IG) audit: An annual Information Governance Toolkit audit of 200 episodes is provided by an NHS attainment levels Digital approved Auditor for IG purposes. Coding errors are turned into learning and Western Sussex Hospitals NHS Foundation shared with the coding team. Trust’s Information Governance Assessment 3. National Standards NHS Digital approved Report overall score for 2017/18 was 79% and training: Every new member of staff attends a was graded green (satisfactory). 25 day NHS Digital National Standards course
provided by an approved experienced This equates to a very robust Level 2 result (to Classification Service Certified Trainer. Every achieve this a minimum score of Level 2 on each experienced coder attends a four day NHS of the 45 requirements must be met, along with an Digital National Standards Refresher course overall score of at least 66%). provided by an approved experienced
Classification Service Certified Trainer. We Clinical coding error rate also encourage staff to further their Western Sussex Hospitals NHS Foundation Trust understanding by studying for a professional was not subject to the Payment by Results clinical qualification and we provide a four day NHS coding audit during the reporting period 2017/18 Digital National Standards Revision course by by the Audit Commission. an approved experienced Classification Service Certified trainer to help staff achieve ‘Accredited Clinical Coder’ Status.
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Identifying, Reporting, Investigating and Learning from
Deaths in Care Comment [e1]: We have been in discussion with NHSI regarding the definition of deaths required to be Concern about patient safety and scrutiny of Deaths in 2017/18 reported. Currently these numbers include all adult and paediatric patient mortality rates has intensified with investigations deaths (not including stillbirths or During 2017/18 2158 of Western Sussex Hospitals neonatal deaths). into NHS hospital failures that have taken place NHS Foundation Trust patients (adult and Comment [e2]: Tim Taylor will review over the last few years. There is an increased this section and provide a statement paediatric) died. This comprised the following regarding current process of mortality drive for NHS Trust boards to be assured that review and direction of travel for 2018/19 number of deaths which occurred in each quarter when it is anticipated there will be tie up of deaths are reviewed and appropriate changes SJRs with investigations. Also to include of that reporting period: themes arising from SJRs which are not made to ensure patients are safe. reportable in the mandated section 476 in the first quarter; because they do not relate to deaths due to problems in care. 447 in the second quarter; Comment [e3]: Currently only total 547 in the third quarter; SJRs (data to be updated early May to include late Q4 figs). 688 in the fourth quarter. To add paeds, stillbirths and neonatal data case record review numbers from RR when received. N.B. may need to split by Deaths in 2017/18 category depending on NHSI final requirements for mortality reporting. HE Deaths Apr- Deaths Jul- Deaths Oct- Deaths Jan- Total deaths 19/04/18.
Jun 2017 Sep 2017 Dec 2017 Mar 2018 2017/18 Comment [e4]: Includes SIs and coroner’s investigations – data to be Adults 476 447 546 688 2157 updated early May to include late Q4 figs. HE 19/04/18. Paediatrics 0 0 1 0 1 N.B. These figures include all patient Data source: WSHFT categories including stillbirths – may need to split by category depending on NHSI final requirements for mortality reporting. Other deaths in 2017/18 Comment [e5]: Need hospital numbers to cross check against SJRs and paeds/neonatal/stillbirth list. Deaths Apr- Deaths Jul- Deaths Oct- Deaths Jan- Total deaths Comment [e6]: Update against late Q4 Jun 2017 Sep 2017 Dec 2017 Mar 2018 2017/18 data in early May. N.B. One SI and coroner’s investigation were for the same Neonatal 1 2 3 4 10 patient. HE 19/04/18. Stillbirths 5 8 6 1 20 Comment [e7]: Check wording – detailed requirements has it as “included in Data source: WSHFT item 27.1” Comment [e8]: At end of Feb 2018 this was zero. Cross check investigation cases number of deaths in each quarter for which a case against SJRs in early May to include check Mortality reviews against late Q4 data.
st record review or an investigation was carried out Comment [e9]: To be updated early By 31 March 2018, 53 case record reviews and May with late Q4 data from SJR process was: 68 investigations have been carried out in relation and coroner’s investigations HE 19/04/18. 14 in the first quarter; Comment [e10]: N.B.1. These figures to 120 of the deaths included in the item above. include all patient categories including 29 in the second quarter; stillbirths – may need to split by category depending on NHSI final requirements for 42 in the third quarter; mortality reporting. In zero cases a death was subjected to both a N.B.2. These do not total to 120 deaths. 36 in the fourth quarter. 121 SJRs and investigations have taken case record review and an investigation. The place as one death has been subject to an SI and coroner's investigation. Page 30 | Quality Report 2017/18 third draft
Patient deaths judged to be more in relation to the deaths identified more likely than not to have been due to problems in the care likely than not to have been due to provided to the patient – present the information problems in the care provided to required as a narrative]
Comment [e11]: Currently no patient the patient deaths judged to be more likely than not to Actions following our learning have been due to problems in the care [Number] representing [number as percentage of provided to the patient. However awaiting [A description of the actions which the provider paeds, stillbirths and neonatal data from total number of deaths at WSHFT in 2017/18]% of RR and late Q4 data re: SJRs and coroner’s has taken in the reporting period, and proposes to investigations. HE 19/04/18. the patient deaths during the reporting period are take following the reporting period, in judged to be more likely than not to have been due Comment [e13]: Currently no patient consequence of what the provider has learnt deaths judged to be more likely than not to to problems in the care provided to the patient. In have been due to problems in the care during the reporting period in relation to the deaths provided to the patient. However awaiting relation to each quarter this consisted of: paeds, stillbirths and neonatal data from identified more likely than not to have been due to RR and late Q4 data re: SJRs and coroner’s [Number] representing [number as percentage of investigations. HE 19/04/18. problems in the care provided to the patient – the number of deaths which occurred in Q1 at present the information required as a narrative] WSHFT in 2017/18]% for the first quarter;
[Number] representing [number as percentage of Comment [e14]: Currently no patient the number of deaths which occurred in Q2 at The impact of our actions deaths judged to be more likely than not to have been due to problems in the care WSHFT in 2017/18]% for the second quarter; [An assessment of the impact of the actions taken provided to the patient. However awaiting paeds, stillbirths and neonatal data from [Number] representing [number as percentage of during the reporting period in relation to the deaths RR and late Q4 data re: SJRs and coroner’s investigations. HE 19/04/18. the number of deaths which occurred in Q3 at identified more likely than not to have been due to WSHFT in 2017/18]% for the third quarter; problems in the care provided to the patient – [Number] representing [number as percentage of present the information required as a narrative] the number of deaths which occurred in Q4 at WSHFT in 2017/18]% for the fourth quarter; An update on deaths in 2016/17
This section is not applicable - Statements of Learning from case record reviews assurance regarding items 27.7, 27.8 and 27.9 do not apply to Quality Reports this year: this is the Comment [e12]: Currently no patient and investigations deaths judged to be more likely than not to first year that trusts have been required to record have been due to problems in the care [A summary of what the provider has learnt from provided to the patient. However awaiting and publish ‘Learning from Deaths’ data. paeds, stillbirths and neonatal data from case record reviews and investigations conducted RR and late Q4 data re: SJRs and coroner’s investigations. HE 19/04/18.
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Part 2.3: Reporting against core indicators
(PHOTO PAGE – call centre photo)
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Performance against the 2017/18 core set of indicators
Since 2012/13, NHS foundation trusts have been Summary Hospital-level Mortality required to report performance against a core set of indicators using data made available by NHS Indicator (SHMI) Digital. The following core quality indicators are The Western Sussex Hospitals NHS Foundation relevant to Western Sussex Hospitals NHS Trust considers that this data is as described for Foundation Trust and relate to the NHS Outcomes the following reasons: Mortality rates over the past Framework (NHS OF). A full description of each 12 months have been around the national core indicator is available in the glossary section of average, and within the expected range. The this report. mortality rate has been reducing steadily since 2011/12. This reduced from 1.03 in 2014/15 to The tables in this section show our performance 0.95 in 2016/17. Provisional 2017/18 data shows for these core indicators, by NHS OF domain, over that the mortality rate is continuing to remain within the last four reporting periods and, where the data the expected range. source allows, a comparison with the national average and the highest and lowest performing The Western Sussex Hospitals NHS Foundation trusts. The majority of core indicators are reported Trust intends to take the following actions to by financial year, e.g. from 1st April 2017 to 31st improve this number, and so the quality of its March 2018, however some indicators report on a services, by: calendar year or partial year basis. Where Maintaining monthly reporting of mortality indicators report on a non-financial year time statistics to Divisions and the Board; period this is stated in the data table. It is Continuing to focus on the implementation of important to note that some national data sets care pathways in key mortality areas; report in significant arrears and therefore not all Strengthening arrangements for identifying data presented are available to the end of the and treating patients who deteriorate current reporting period (31st March 2018). suddenly.
Indicator: Summary Hospital-level Mortality Indicator Domain: Preventing people from dying prematurely Best Worst National 2016/17 2017/18 performing performing (Figures updated average Latest available from last year’s 2015/16 2014/15 data October 2016- Latest available data Trust Trust quality report due to September 2017 October 2016- Latest available data Latest available data more recent data September 2017 October 2016- October 2016- being available) September 2017 September 2017 0.95 1.00 0.73 1.25 0.95 1.00 1.03 Higher than Lower than As expected As expected As expected As expected As expected expected expected Data source: NHS Digital
Palliative care indicators are included below to established Palliative Care Team working to a assist in the interpretation of SHMI by providing a reinvigorated End of Life Care Strategy. summary of the varying levels of palliative care coding across non-specialist acute providers. The Western Sussex Hospitals NHS Foundation Trust intends to take the following actions to The Western Sussex Hospitals NHS Foundation improve this number, and so the quality of its Trust considers that this data is as described for services, by: the following reasons: the Trust has a well- Maintaining monthly reporting of mortality statistics to Divisions and the Board.
Indicator: Percentage of patient deaths with palliative care coded at either diagnosis or specialty level Domain: Enhancing quality of life for people with long-term conditions Best Worst National 2016/17 2017/18 performing performing (Figures updated average Latest available from last year’s 2015/16 2014/15 data October 2016- Latest available data Trust Trust quality report due to September 2017 October 2016- Latest available data Latest available data more recent data September 2017 October 2016- October 2016- being available) September 2017 September 2017 34.4% 31.5% 59.8% 11.5% 32.6% 33.5% 26.6% Data source: NHS Digital
Patient Reported Outcome The Western Sussex Hospitals NHS Foundation Trust intends to take the following actions to Measures (PROMs) improve this number, and so the quality of its The Western Sussex Hospitals NHS Foundation services, by: Trust considers that this data is as described for Ensuring regular feedback of PROMs data to the following reasons: This data, which is based clinical teams; on quality of life measures, shows that our Working with commissioners to ensure that treatments are effective in improving the health of treatments are offered to those groups of our patients. patients most likely to benefit from the particular treatment. Indicator: Patient Reported Outcome Measures EQ 5D Index (casemix adjusted health gain) Domain: Helping people to recover from episodes of ill health or following injury 2016/17 2015/16 (Figures Best Worst (Figures 2017/18 National updated from Latest available updated from performing performing last year’s Surgery data average last year’s quality report 2014/15 (provisional) April 2017- quality report type Trust Trust due to more April 2017- September due final April 2017- April 2017- recent data September 2017 2017 figures being September 2017 September 2017 being available) available) Groin hernia 0.080 0.089 0.417 -0.378 0.097 0.067 0.079 (final data) Varicose WSHFT does not carry out sufficient numbers of varicose vein procedures to be included in vein PROMS data. Page 34 | Quality Report 2017/18 third draft
Indicator: Patient Reported Outcome Measures EQ 5D Index (casemix adjusted health gain) Domain: Helping people to recover from episodes of ill health or following injury 2016/17 2015/16 (Figures Best Worst (Figures 2017/18 National updated from Latest available updated from performing performing last year’s Surgery data average last year’s quality report 2014/15 (provisional) April 2017- quality report type Trust Trust due to more April 2017- September due final April 2017- April 2017- recent data September 2017 2017 figures being September 2017 September 2017 being available) available) Hip 0.448 replacement 0.423 0.465 1.016 0.114 (provisional 0.399 0.422 (primary) data) Knee 0.346 replacement 0.411 0.328 0.841 0.131 (provisional 0.317 0.283 (primary) data) Data source: NHS Digital
Readmissions Continuing to work closely with commissioners and other health organisations The Western Sussex Hospitals NHS Foundation to identify patients at risk of readmission and Trust considers that this data is as described for putting in place services to prevent them the following reasons: While the Trust works hard requiring further immediate hospital care; to plan discharges appropriately, in some We will identify those cases where instances readmissions still occur. The rate of readmissions could have been prevented by readmissions is in line with peers. organising care differently and make the
appropriate changes to reduce the level of The Western Sussex Hospitals NHS Foundation readmissions. Trust intends to take the following actions to improve this number, and so the quality of its services, by:
Indicator: Patients readmitted to a hospital within 28 days of being discharged Domain: Helping people to recover from episodes of ill health or following injury Best Worst National 2017/18 performing performing 2016/17 2015/16 2014/15 (Trust data) average (Trust data) (Trust data) (Trust data) Trust Trust Patients aged 13.41% Please note that this indicator was last updated 13.97% 13.09% 13.43% 0 to 15 years by NHS Digital in December 2013 and future Patients aged releases have been temporarily suspended 16 years or 14.01% pending a methodology review; we are therefore 12.56% 13.28% 12.66% unable to provide comparative data for 2017/18. over Data source: NHS Digital has not updated this metric since 2013 and we have therefore used our own locally collected data to report against this core indicator.
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Indicator: Emergency readmissions within 30 days of discharge from hospital Domain: Local Trust indicator Best Worst National 2017/18 performing performing 2016/17 2015/16 2014/15 (Trust data) average (Trust data) (Trust data) (Trust data) Trust Trust Please note that this indicator was last updated by NHS Digital in March 2014; we are therefore All patients 14.31% unable to provide comparative data for 14.24% 13.70% 13.20% 2017/18. Data source: NHS Digital has not updated this metric since 2013 and we have therefore used our own locally collected data to report against this core indicator.
Responsiveness to the personal The Western Sussex Hospitals NHS Foundation Trust intends to take the following actions to needs of patients improve this number, and so the quality of its The Western Sussex Hospitals NHS Foundation services, by: Trust considers that this data is as described for Using results from real time patient the following reasons: The Trust’s involvement in experience tracking to constantly identify Care and Compassion Reviews has ensured areas for improvement; responsiveness to the personal needs of patients Identifying areas for further improvement from in line with its peers. the care and compassion peer review programme. Indicator: Responsiveness to the personal needs of patients Domain: Ensuring people have a positive experience of care Best Worst National performing performing 2017 average 2016 2015 2014 (2016) Trust Trust (2016) (2016) Not available until May 2018 68.1% 85.2% 60% 66.9% 69.1% 67.0% Data source: NHS Digital
Staff who would recommend the improve this number, and so the quality of its services, by: trust to their family or friends Using regular feedback opportunities to The Western Sussex Hospitals NHS Foundation capture staff views about how we can Trust considers that this data is as described for improve; the following reasons: An increasing proportion of We have also reviewed staffing ratios, staff are positive about the overall quality of the particularly in ward areas; services and care offered by the Trust. We have improved our staff engagement (including communications) such that staff feel The Western Sussex Hospitals NHS Foundation more able to contribute to, and be aware of, Trust intends to take the following actions to service improvements. Indicator: Percentage of staff who would recommend the Trust as a provider of care to their family or friends Domain: Ensuring people have a positive experience of care Best Worst National performing performing 2017 average 2016 2015 2014 (acute non- Trust Trust specialist trusts) (acute non- (acute non- specialist trusts) specialist trusts) 81% 70% 86% 47% 79% 73% 71% Data source: NHS Staff Survey Coordination Centre (Picker Institute Europe)
Patients who would recommend improve this number, and so the quality of its services, by: the trust to their family or friends We aim improve response rates to ensure we The Western Sussex Hospitals NHS Foundation gather feedback from sufficient people to Trust considers that this data is as described for know that information is reliable, particularly in the following reasons: We aim to give every our A&E departments where response rates patient the opportunity to take the Friends & are below national average. Family Test, either at discharge or within 48 hours We will work to address themes arising from of discharge. Recommendation rates are in line the survey to improve patient experience. with peers and results are monitored on a monthly We have developed a new Patient Experience basis. Strategy with seven broad ambitions: with focussed working groups we will develop our The Western Sussex Hospitals NHS Foundation ambitions and deliver the actions required to Trust intends to take the following actions to improve patient experience across the Trust.
Indicator: Percentage of Patients who would recommend the trust to their family or friends Domain: Ensuring people have a positive experience of care Best Worst 2016/17 National 2017/18 performing performing (Figure updated from last year’s Latest available average quality report 2015/16 2014/15 data April to Latest available Trust Trust due to more December 2017 data April to Latest available Latest available December 2017 data April to data April to recent data December 2017 December 2017 being available) Inpatients 96.79% 95.68% 100% 75.26% 96.06% 95.20% 92.40% Patients discharged 85.25% 86.24% 98.49% 54.46% 89.01% 91.39% 90.60% from A&E Data source: NHS England
Patients admitted to hospital who The Western Sussex Hospitals NHS Foundation Trust considers that this data is as described for were risk assessed for venous the following reasons: The Trust has focused on thromboembolism (VTE) this area and made good progress on embedding Page 37 | Quality Report 2017/18 third draft
it into normal practice with a sustained increase in Continuing focus in this area; the proportion of patients screened. Increasing the emphasis on improving The Western Sussex Hospitals NHS Foundation outcomes such as reducing rates of harm Trust intends to take the following actions to from VTE. improve this number, and so the quality of its services, by:
Indicator: The percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism Domain: Treating and caring for people in a safe environment and protecting them from avoidable harm
Best Worst 2016/17 National 2017/18 performing performing (Figure updated from last year’s Latest available data average 2015/16 2014/15 quality report due to to December 2017 Latest available data Trust Trust to December 2017 Latest available data Latest available data more recent data to December 2017 to December 2017 being available) 95.20% 95.20% 100% 77.40% 95.60% 94.90% 95.90% Data source: NHS Digital - Full year data for 2017/18 is not expected to be published until June 2018.
Rate of C.difficile infection The Western Sussex Hospitals NHS Foundation Trust intends to take the following actions to The Western Sussex Hospitals NHS Foundation improve this number, and so the quality of its Trust considers that this data is as described for services, by: the following reasons: A relentless and constant Enhancements to our antibiotic prescribing focus is required to minimise the level of C.difficile policies; infection. Particular challenges include the need Heightened environmental cleaning; for antibiotic usage in a frail and ill patient Targeted review of the patient pathway for population and balancing this with the risk of these patients. causing C.difficile disease. Indicator: The rate per 100,000 bed days of trust apportioned cases of C. difficile infection that have occurred within the trust amongst patients aged 2 or over Domain: Treating and caring for people in a safe environment and protecting them from avoidable harm Best Worst 2016/17 National 2017/18 performing performing (Figure updated (Trust data) average from last year’s 2015/16 2014/15 Latest available data Latest available Trust Trust quality report due to to February 2018 data: 2016/17 Latest available Latest available more recent data data: 2016/17 data: 2016/17 being available) 10.6 13.6 11.1 12.6
Count of Trust 13.2 0.0 87.2 Count of Trust Count of Trust Count of Trust apportioned apportioned apportioned apportioned cases: 35 cases: 45 cases: 36 cases: 38 Data source: Public Health England - national data for 2017/18 is not expected to be published until July 2018.
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Patient Safety Incidents improve this number, and so the quality of its services, by: The Western Sussex Hospitals NHS Foundation Continuing to promote the reporting of patient Trust considers that this data is as described for safety incidents across the organisation in the following reasons: The Trust has a systematic order to learn and improve. approach to the management and investigation of Themes, trends and learning from incidents events and we analyse these on an aggregated will continue to be discussed and analysed basis to ensure that safety lessons are learned through a variety of forums including the and shared widely, leading to improvements in the divisional clinical governance sessions, quality and safety of care we provide. Triangulation Group, the Trust Brief newsletter
and Divisional Governance Reviews. The Western Sussex Hospitals NHS Foundation Trust intends to take the following actions to
Indicator: Patient safety incidents Domain: Treating and caring for people in a safe environment and protecting them from avoidable harm April Best Worst National October April October 2017 to performing performing average 2016 to 2016 to 2015 to September Trust Trust Latest available March September March 2017 data: April to Latest available Latest available Latest available September 2017 data: April to data: April to 2017 2016 2016 data September 20177 September 2017 Rate of patient 25.8 28.55 25.45 25.88
safety 42.84 23.47 111.69 Count of Acute non- Acute non- Acute non- Count of Count of Count of incidents incidents: specialist trusts specialist trusts specialist trusts incidents: incidents: incidents: (per 1,000 bed 4302 4982 4245 4271 days) Percentage of patient 0.33% 0.50% 0.24% 0.42% safety 0.37% 0.00% 1.98% Acute non- Acute non- Count of incidents Count of Acute non- Count of specialist trusts specialist trusts specialist trusts Count of incidents: (resulting in incidents: 14 incidents: 10 incidents: 25 18 severe harm or death) Data source: NHS Improvement (Previously we have reported local patient safety data; this year NHS Improvement data has been reported to allow for national comparison)
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Part 3.1: Review of quality performance
(photo page – infection control photo or Sepsis Lead photo or lady in non-slip socks)
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Performance against 2017/18 quality improvement priorities
Below is a list of 2017/18 quality improvement Programmes are explained in more detail in the programmes and their current status. following individual programme sections.
Programme Trust Target Close to Behind plan achieved / target on plan Deteriorating patient programme: sepsis ▲ Mortality review and learning programme ▲ Seven Day Services Clinical Standards programme ▲ Mental Health Care programme ▲ Cancer pathway improvement programme ▲ Care for older people with frailty programme ▲ Better Births programme ▲ Falls reduction programme ▲ Skin damage reduction programme ▲ Medicines optimisation programme ▲ Infection prevention and control programme ▲ Diagnostic resulting programme ▲ Safer staffing programme ▲ Reducing complaints and improving the timeliness of ▲ complaint responses Improving communication programme ▲ Staff Wellbeing programme ▲ Developing a resilient and affordable workforce ▲ Patient First Improvement System ▲ Clinical Academic Pathway ▲
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Reducing preventable mortality and improving outcomes
True North goal: To be in the top 20% of NHS organisations for the Hospital Standardised Mortality Ratio (HSMR)
2017/18 achievement: Top 17% of NHS organisations for HSMR
About half of all deaths in the UK take place in that patients die who might not have, had we done hospital. The overwrwhelming majority of these things differently. This is what we mean by deaths are unavoidable. The person dying has ‘avoidable mortality’. More often, if things go wrong received the best possible treatment to try to save with care, patients fail to achieve the optimal level his or her life, or it has been agreed that further of recovery or improvement. By concentrating on attempts at cure would not be in the patient’s best this area we will end up with safer hospitals, save interest and the person receives palliative lives, and ensure the best possible clinical treatment. outcomes for patients.
We know, however, that in all healthcare systems The primary indicator for our ‘reducing preventable things can and do go wrong. Healthcare is very mortality and improving outcomes’ goal is hospital complex and sometimes things that could be done mortality. The Trust uses Dr Foster’s HSMR risk for a patient are omitted or else errors are made adjusted mortality tool to monitor this. which cause patients harm. Sometimes this means
Data source: Dr Foster Our HSMR score improved from 107.48 in As described in our Quality Strategy we would like 2011/12 (ranked 112 of 141 acute trusts; 79th to continue to improve and remain in the top 20% centile) to 90.42 in 2016/17 (the last full financial of trusts with the lowest HSMR. We will focus years’ worth of data). Due to the delay for Dr specifically on our ‘True North’ goal of zero Foster data (to allow for coding and processing) avoidable deaths. the graph below shows the 12 months to December 2017 as the most recent data point with performance at 88.07 (ranked 22nd of 134 trusts; 16th centile).
Deteriorating patient programme: sepsis Severe sepsis is the most common and least recognised complication of infective illness that causes at least 37,000 deaths and 100,000 hospital admissions in the UK per year. For every hour antibiotic treatment is delayed the chance of a patient with sepsis dying increases by 8%.
Trust target: 80% compliance with the Sepsis 6 care bundle
By when: March 2018
Outcome: 57% for 2017/18
Progress: Behind plan
CQUIN target: 90% of patients to receive antibiotic therapy within one hour in year one, 95% in year two
By when: March 2019
Outcome: 75.2% for 2017/18
Progress: Close to target
We know that early recognition and treatment has teams at Worthing and St Richard’s to deliver a significant impact on the outcome for patients dramatic improvements in the early identification with severe sepsis. Our sepsis programme, and treatment of patients arriving with sepsis. supported by the Kaizen Team, has enabled A&E
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Data source: WSHFT
Data source: WSHFT Improvements achieved: Further improvements identified: Delivery of education package to A&E staff Whilst our focused approach in 2017/18 and general outreach study days, including enabled our teams to deliver dramatic sepsis simulation sessions, to wider clinical improvements in the early identification and staff. treatment of patients arriving with sepsis, we Introduction of weekly cross-site sepsis review did not deliver the level of improvements we meetings between the Emergency Floors and set out to. In 2018/19 we will push to deliver a A&E. 90% compliance with the Sepsis 6 care Establishment of Sepsis Teams; a doctor and bundle and aim for 95% of patients diagnosed nurse responsible for antibiotic treatment and with sepsis to receive antibiotic therapy within sepsis bundle delivery in A&E who now start one hour. treatment at the patient’s bedside. Continued focus on sepsis education: delivery Introduction of sepsis trolleys which keep all of specialist teaching sessions and simulation equipment, medication and paperwork for for A&E and Emergency staff and general sepsis treatment in one easily accessible awareness training for other clinical staff. place. Continuation of weekly cross-site sepsis Upgrade to Patientrack system to improve review meetings between the Emergency collection of sepsis data, alerting of potential Floors and A&E. sepsis patients to clinical staff and electronic prescribing.
Mortality review and learning programme In response to the Care Quality Commission’s publication ‘Learning, candour and accountability’ the Secretary of State made a range of commitments to improve how the NHS learns from reviewing the care provided to patients who die.
Trust target: 100% of inpatient deaths are reviewed reviewed
By when: March 2018
Outcome: 82.2%
Progress: Close to target
In accordance with the new national mortality avoidable mortality. We introduced screening, guidance, the Trust has developed a ‘Learning carried out by a junior doctor and the patient’s from Deaths’ policy, screening and a structured consultant, for all deaths occurring in one of our judgement review process to identify and learn hospitals from April 2017. Screening reviews from any identified problems in patient care or which trigger concerns are then referred for Page 45 | Quality Report 2017/18 third draft
structured judgement mortality review (SJR). about the quality of care provision for their loved Deaths may also be referred for further review due one. The in-depth reviews are undertaken by a to other circumstances, for example if a bereaved consultant independent of the patient’s care. family or carer has raised a significant concern
Mortality review data (deaths within the remit of the improvement programme) Quarter 1: Quarter 2: Quarter 3: Quarter 4: TOTAL April – July – October – January – 2017/18 June 2017 September December March 2017 2017 2018 Total number of deaths 476 447 546 688 2157 Total number of deaths screened 425 394 490 463* 1772 Percentage of deaths screened 89.3% 88.1% 89.7% 67.3% 82.2% Total number of in-depth reviews 0 12 24 17* 53 Percentage of deaths subject to in- 0% 2.7% 4.4% 2.4% 2.5% depth review Number of deaths where the quality of care was judged more likely than 0 0 0 0 0 not to have contributed Data source: WSHFT * The lower compliance with screening in Q4 is related to the timing of the data collection. Figures will be updated again early May 2018 for the final version of the Quality Report.
The recruitment and training of in-depth reviewers Systems have been put in place to identify remains at an early stage. The Trust is focusing and learn from any identified problems in care on increasing capacity to undertake SJRs moving and avoidable mortality through regular into 2018-19. mortality panel meetings which triangulate learning. Improvements achieved: Data relating to learning from case record The Trust became an early adopter of the review of in-patient deaths / avoidable national mortality review programme and tool mortality has been published quarterly through for full mortality review including reviewer 2017/18 in line with NHS Improvement and training. CQC recommendations. An electronic screening tool has been A policy on Learning from Deaths has been designed and implemented to enable published and is available on the Trust consultant-led mortality reviews. website. A group of six mortality reviewers has been trained to undertake structured judgement Further improvements identified: mortality reviews and began reviews in Respond to anticipated further national January 2018. guidance on involving families/carers in the review process. Page 46 | Quality Report 2017/18 third draft
Work will continue with the hospital chaplain Further develop systems and methods of and bereavement teams staff to encourage feedback to individual clinicians and relatives and carers to feedback any issues or specialties concerns with patient care at an early stage. Further develop Trust Board reporting in Increasing capacity and throughput of SJR’s response to feedback. now the Trust has a body of trained reviewers. Provide on-going feedback on end of life care Establish a multidisciplinary panel including to the End of Life Board to inform future palliative and primary care members to review service development. the output from reviews and undertake second stage SJR as necessary.
Seven Day Services Clinical Standards programme We aim to deliver sustainable Seven Day Services across the Trust by 2020 to ensure our patients receive consistent high quality safe care every day of the week.
Trust target: Priority standard 2: Admitted patients to receive a consultant review within 14
hours of admission (76% weekday, 75% weekend)
By when: March 2018
Outcome: Standard 2: 68% weekday, 63% weekend
Progress: Close to target
In 2013 the NHS Services, Seven Days a Week site but will be working towards the 2020 Forum developed ten clinical standards to end implementation target. variations in outcomes for patients treated at the weekend. Four key priority standards were NHS England has asked all Trusts to complete a identified as the minimum set of clinical standards self-assessment survey on a six-monthly basis to needed to address variation in mortality, patient measure current position against the four priority flow and experience: Standard 2: Time to clinical standards. The Trust undertook the third consultant review; Standard 5: Diagnostics; national survey in autumn 2017 which focused Standard 6: Consultant directed interventions; solely Standard 2: to improve the gap between Standard 8: Ongoing consultant–directed daily weekday and weekend performance (percentage review. We are continuing to progress with our of patients reviewed by a consultant within <14 delivery plan, however we have informed NHS hours of admission). The results are presented in England that we do not plan to be an early adopter the table below.
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NHS England Seven Day Services audit results Best Worst National performing performing Autumn WSHFT average Spring Autumn Trust Trust 2017 target (March 2017 2016 (March (March 2017) 2017) 2017) Weekday 68% 76% 73% 100% 0% 71% 53% Weekend 63% 75% 70% 100% 28% 60% 43% day Total 67% 75% 72% 100% 25% 68% 50% Data source: NHS England
The next round of national data collection will take valuable data that will support further gap place between April and May 2018 and include analysis at divisional level to achieve the 2020 assessment of all four standards. Submission of full implementation milestone across the data to NHS England will be completed in June Trust. 2018. Further improvements identified: Improvements achieved: Divisional service prioritisation in 2018/19 will The gap between weekday and weekend include Seven Day Services. consultant review of newly admitted patients Develop a business case for additional has reduced significantly from our 2016 workforce to deliver the required standards. baseline and timeliness of consultant review Restructure of medical rotas to meet has improved. compliance ahead of 2020. A more detailed analysis was carried out on Roll out upgrades to electronic whiteboards in all cases when a patient did not receive a surgery division to enable real-time monitoring consultant review within 14 hours, providing and improve quality and depth of data.
Mental Health Care programme This year we have been identifying the improvements we need to make to bridge the gap between mental health and physical health in our hospitals, working with local health economy partners, in response to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) ‘Treat as One’ study.
CQUIN & Reduce by 20% attendances to A&E for those within a selected cohort of Trust target: frequent attenders, and establish improved services to ensure reduction is sustainable
By when: March 2018
Outcome: 40% reduction in A&E attendances within the cohort
Progress: Target achieved
Our improvement programme this year has draw upon the expertise of Mental Health Liaison focused on meeting the national CQUIN target to teams to enable people to attend the most reduce A&E attendances in a selected cohort of appropriate service for their needs. frequent attenders who would benefit from mental health and psychosocial interventions. We want to The grey dotted line on the graph below shows the ensure that patiennts presenting at A&E with cumulative target we must not breach in order to primary or secondary mental health and/or have reduced A&E attendances in the cohort of underlying psychosocial needs have these needs frequent attenders by 20%. The blue solid line met more effectively through an improved shows the actual number of cumulative attendance integrated services offer, with the result that by the cohort group. Our improvement project has attendances at A&E are reduced. Our achieved a 40% reduction in attendances from the improvement programme recognises the need to baseline attendance rate in 2016/17.
Data source: WSHFT
Improvements achieved: the A&E environment, staff training plus We have met the requirements of year one of appropriate audit and monitoring. the Mental Health CQUIN. We have implemented a new missing persons Development of a standard operating policy working closely with Sussex Police and procedure to identify new frequent attenders other agencies to ensure vulnerable patients in A&E who have mental health needs and are prioritised. who would benefit from assessment, review, and care planning with specialist mental Further improvements identified: health staff. Reduce A&E attendance in a further cohort of Joint working with Sussex Partnership Trust’s frequent attenders presenting with primary care coordinators to enable them to be aware mental health issues. of when their clients are attending A&E. Identify improvements required to better Improved development of care plans for the support patients with condition specific cohort of frequent attenders, co-developing pathways including those with dementia, plans with patients where possible. perinatal mental health issues, children and Implementation of the nationally mandated young people, substance misuse and social Emergency Care Data Set across our A&E needs. Departments. Establish links with other service providers Plans agreed for partnership working with and work with them to better support people South East Coast Ambulance Trust and local with primary mental health needs. General Practitioners. Shared care plans will Continue roll out of training programme to key provide patients with more appropriate staff. alternatives than attending A&E. Continue with work to ensure we meet the Updated Mental Health Act procedures have requirements of NCEPOD ‘Treat as One’. been introduced along with improvements to
Cancer pathway improvement programme We are working in key cancer specialties to make our services fit for purpose, improving on current quality standards and patient experience.
Trust target: Improved cancer pathways in the following areas in the first instance: lung, urology, colorectal and upper gastrointestinal
By when: March 2020
Outcome: In progress
Progress: On plan
The Trust currently has longer than desirable they see a GP and are referred to secondary care, pathways in some cancer specialties, in particular to the moment they receive a diagnosis and lung, colorectal, upper gastrointestinal and urology options for treatment, living with and beyond prostate. The current pathways result in referral to cancer. the specialist tertiary cancer treatment centre after day 38 of the time to treatment timeline and can Improvements achieved: contribute to overall delays in meeting the 62 day Cancer dashboard and performance data treatment target set by NHS England. A collated to support prioritisation of specialty significant number of patient pathways are delayed pathway improvement work. due to the need for multiple diagnostic tests to Lung value stream mapping took place on support both diagnosis and cancer staging (which 27th February 2018 and was well attended determines the type of surgery, chemotherapy or with a cross section of medical, administrative other treatment options). and allied health professionals, together with external participation from Brighton & Sussex Macmillan UK and Western Sussex Hospitals have University Hospitals, Macmillan UK and jointly funded two key additional posts for the Coastal West Sussex CCG. Cancer Services Team, to help review and support Discussions with tertiary centre colleagues to pathway changes and improvements. Since help improve pathway management and October 2017, our new Service Improvement reduce waiting times have taken place with Manager has gathered performance data for all Brighton & Sussex University Hospitals, cancer specialties to support decision making and Surrey & Sussex Healthcare and East Sussex allowed targeted focus on areas that are currently Healthcare. These discussions have challenged with longer than desired waiting times. produced a collaborative approach between Following approval at the Trust Cancer Board it trusts with a genuine will to improve pathways was agreed that four pathways would be prioritised for our patients. Further meetings have been in the improvement programme: lung, upper arranged with Portsmouth Hospitals and gastrointestinal, colorectal and urology prostate. Royal Surrey Hospital. Launch of a new two week rule referral form As well as maintaining Trust compliance against from the NICE Guideline (NG12) for current national performance metrics, we are suspected cancer: recognition and referral. preparing specialities for a new cancer metric The new form, introduced in October 2017, st which is being implemented from 1 April 2018. will help improve the quality of referrals and The new metric relates to referrals to specialist appropriate sign-posting in the first part of the providers for patient treatment by day 38 of the 62 pathway. We are currently auditing use of the day pathway. We want to provide patients with form bi-weekly to assess better information and set expectations of their improvements/issues. treatment pathway and timescales from the time Page 51 | Quality Report 2017/18 third draft
“Orange sticker use” project ongoing since Management of abnormal x-rays within September 2017 to monitor use of the priority secondary care to avoid delays in GP referrals identification sticker of histology and radiology being received and quicker access to CT investigations. Audit results have identified scans for patients who have an abnormal x- certain specialty areas where use of the ray. sticker is sub-optimal and actions have been A different approach to Multi-Disciplinary taken to address this. Team (MDT) meetings in respiratory to ensure diagnostic plans and treatment plans are not Further improvements identified: only made quickly, but are protocolled to allow Streamlining of pathway for patients requiring the MDT meetings to focus on more complex specialist maxillofacial / ear, nose and throat patients. treatment at Brighton & Sussex University Consideration for a patient support/navigator Hospitals. role to ensure patients are informed and Review of patient pathway for urology patients supported to move through the early requiring tertiary referral for specialist diagnostic phase of the pathway, enhancing treatment. patient experience and setting timescale Admin support from Macmillan key workers to expectations. release Clinical Nurse Specialist nursing time Further pathway work to focus on urology, to clinics. upper gastrointestinal and colorectal.
Care for older people with frailty programme Improvement in frailty pathway – implementation of new frailty assessment tool: Over 23% of the 480,000 of the Coastal West Sussex population is over 65 compared to the national average of 16%.
Trust target: Improve the identification of patients with frailty syndrome
By when: March 2018
Outcome: Frailty assessments are now routinely carried out in A&E
Progress: Target achieved
The Coastal West Sussex population is one of the other, with longer lengths of stay, the worst level of oldest in England with a high proportion of people mortality, greater numbers of stranded patients over the age of 85 years. The growth rate of the and the most in-patient harm. number of older people in our local population exceeds that of the rest of the country and is An excess of older people with frailty are admitted fastest in the very old. The attendance rate and to hospital because they do not have access to conversion of this age group is higher than for any timely comprehensive geriatric assessment (CGA). Page 52 | Quality Report 2017/18 third draft
There are currently different pathways for older emerging improvement programme and look people with frailty on our two acute sites and at options for moving forward with addressing delays in CGA compared with best practice (NHS ‘front door’ frailty. Elect, Acute Frailty Network principles for an acute A form of rapid response for older people with frailty pathway: commencement of CGA within one frailty is now available at Worthing following hour). the introduction of a Needs-related Frailty On- Call Doctor. Improvements achieved: There is now a standardised, centrally Further improvements identified: recorded method of identifying all older people Full work up of an improvement programme with frailty on presentation at our acute and business case to support the hospitals. development of a pathway with which to We have completed a small pilot in A&E on provide robust care for this patient group. both sites during 2017/18 to inform this
Better Births programme We have continued our focus on normalising birth and reducing caesarean section rates.
Trust target: Reduction in caesarean section rates to less than 26.5%
By when: March 2018
Outcome: 28.50%
Progress: Behind plan
Reducing caesarean section rates remains a an area of focus for us and rates are closely challenge; with the national rate increasing in line monitored via monthly divisional performance with the Trust rate. Whilst 2017/18 has seen a reviews. slight reduction in caesarean section rates from 28.60% in 2016/17 to 28.50% we have not The maternity service at WSHFT was part of the managed to meet our improvement target. Each AFFIRM trial, a care bundle specifically for case where a woman has a caesarean delivery mothers who report a reduction in the movements undergoes review to look for learning of their unborn baby with the aim or reducing the opportunities. No systemic causes or trends have risk of stillbirth. The bundle includes earlier been identified in relation to caesarean section induction of labour than under the previous rates and care continues to be in line with national approach. This has resulted in an almost doubling recommendations for safe practice and NICE of the induction rate in this group of mothers. guidance. Increasing normal birth continues to be Interventions of this kind can inevitably lead to the Page 53 | Quality Report 2017/18 third draft
increased risk of subsequent intervention and Furthermore delivery by spontaneous method of ultimately the need for caesarean delivery. onset of labour has reduced by 14% and inductions of labour have increased to 29.4%. We NHS Digital report for Maternity Statistics in will therefore be reviewing our target reduction for 2016/17 shows a national caesarean section rate caesarean section rates to reflect national of 27.8%; it is acknowledged that there was a changes. decrease in deliveries nationally of 1.8%.
Caesarean section rates National WSHFT average 2017/18 2016/17 2015/16 2014/15 target (2016/17 most recent data available) 28.50% 26.50% 27.80% 28.60% 27.30% 26.90% Data source: WSHFT
Improvements achieved: Further improvements identified: All caesarean births continue to be reviewed Following the publication of the results of the and findings fed back either individually to AFFIRM trial there will be a review of the care clinicians or as themes to the maternity bundle for mothers presenting with reduced service. movements to assess the evidence from the There is a strong team focus with an study and the level of intervention required. extensive multidisciplinary handover every There will be a focus in the year ahead to morning to identify care priorities and to increase the number of women who give birth ensure that there is a robust plan of care for in their home environment or low risk hospital women with senior midwifery, obstetric and environment. anaesthetic input. The service will be working with women to A midwifery led programme for increasing further develop the birth environment within women’s opportunity for normal birth is being the hospital to optimise the opportunities for a implemented with a key focus on the ability to mother to mobilise in labour and to make use mobilise in labour (‘Mums Up and Mobile’). of the birthing pool even when there are risk Telemetry to encourage mobilisation in labour factors that require continuous monitoring of for women who require continuous fetal her baby. monitoring in in place.
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Avoiding harm
True North goal: 99% of patients receiving safe, harm free care as measured by the NHS Patient Safety Thermometer
2017/18 achievement: 98.3% of patients suffered no harm during their inpatient stay
Western Sussex is committed to providing safe, This tool looks at point prevalence of four key high quality services. We aim to provide safe, harms in all patients on a specific day in the harm-free care for all patients. Whilst we recognise month: falls, pressure ulcers, urinary tract that this is a challenging goal, we are committed to infections plus the venous thromboembolisms reviewing all harms to ensure that we learn and (VTE) deep vein thrombosis and pulmonary continuously improve care. embolism. It distinguishes between harms that have occurred prior to admission, such as falls in Hospital acquired infections; pressure sores and care homes, and those that have occurred since other complications are examples of harm which admission, known as ‘new harms’. are sadly commonplace across hospitals in the UK. Despite the extraordinary hard work of The Safety Thermometer includes harms suffered healthcare professionals patients are harmed in by the patient in healthcare settings prior to hospitals every day. Most harm experienced by admission. The actual number of patients who patients is minor or very minor, but in some cases suffered no new harm during their inpatient stay at it can be life-changing for the patient and their WSHFT in 2017/18 was 98.3% against a national family, or can even tragically result in death. average of 97.8% and close to achieving the challenging internal target of 99% set by the Trust. The Trust uses the national NHS Patient Safety This positive position sets us up well in aiming to Thermometer to monitor overall harm free care. achieve our 99% target next year.
Data source: NHS Improvement
Of the four types of harm currently measured by continue to focus on all four of these areas as well the patient safety thermometer, all four occurred at as other aspects of ward safety. WSHFT during 2017/18. Future work streams will
Data source: NHS Improvement Page 56 | Quality Report 2017/18 third draft
Falls reduction programme Falls are one of the highest causes of patient harm across the Trust. They cause both physical and psychological harm, leading to loss of confidence, poor patient outcomes and increased length of stay.
Trust target: 30% reduction in in-hospital falls (from baseline of 2015/16)
By when: March 2018
Outcome: 26%
Progress: Close to target
Falls are one of the most challenging harms to falls. This methodology ensures a bespoke address with a complexity of factors contributing to approach to the challenge as solutions will vary an individual patient’s risk of falling. The reduction depending on the particular patient group and in in-hospital falls programme therefore continued ward environment. Alongside this focused to be a major improvement area for the Trust in approach to problem solving the Trust has 2017/18 with the work supported by the Patient continued to embed the two core interventions that First Improvement System and led by divisional have been shown to have a positive impact: teams. SWARM, an immediate multidisciplinary review of the patient post-fall and ‘Baywatch’, a requirement Wards have worked through improvement cycles to keep bays where patients are known to be at to try to address the underlying reasons for patient risk of falling manned at all times.
Data source: WSHFT Improvements achieved: patients to remain active whilst in hospital and A reduction of 26% in all falls and an 17% help to prevent deconditioning. reduction in falls causing significant harm or death (compared to baseline 2015/16). Further improvements identified: Successful roll out of the 'Let’s Get You Home' Training and implementation of the Clinical campaign, a local initiative in partnership with Activities Volunteer role across the Trust, Coastal West Sussex CCG to provide patients aiming to develop this initiative in to Wellbeing with information about getting home and Volunteers to provide a range of wellbeing staying active while in hospital to prevent activities, advice and support. deconditioning (a known risk factor with falls). In the coming year there will be a focused Wards with high patient fall rates have been programme around the awareness of visited by the Harm Free Care team to review deconditioning amongst staff, patients and current practices in line with best practice. relatives; the aim is to ensure that all patients A new volunteer role has been developed for receive the best possible outcome and return the Trust: Clinical Activities Volunteers. home wherever possible. These specially trained volunteers will support
Skin damage reduction programme Continued reduction in in-hospital acquired pressure damage.
Trust target: 10% reduction in grade 2+ avoidable pressure damage (from baseline of Jan- Dec 2016)
By when: March 2018
Outcome: We have not reduced grade 2+ pressure ulcers in 2017/18
Progress: Behind plan
Pressure damage is one of the highest causes of acquired pressure damage in 2015/16 and patient harm across the Trust. It can cause 2016/17 but changes to the way we were required physical harm, pain and can lead to poor patient to report pressure ulcers largely accounted for this outcomes; in severe cases pressure damage can increase. cause long term debilitation resulting in a life changing impact on the patient. As can be seen in the graph below we have significant challenges in relation to patients Whilst a high proportion of patients with pressure developing pressure ulcers. The awareness ulcers are admitted to hospital with existing skin campaign across the Trust last year, featuring the damage, we saw a significant rise in hospital launch of the new risk assessment tool Purpose-T, Page 58 | Quality Report 2017/18 third draft
has led to very high levels of reporting. We are to address this deteriorating picture. Our aim for now undertaking a robust programme of 2018 will be to have zero category 3 and above improvement, with Kaizen support, to fully pressure ulcers. understand opportunities for improvement in order
Data source: WSHFT
Improvements achieved: Further improvements identified: Successful launch of our pressure ulcer Implementation of the rapid improvement prevention module, co-designed with our approach, previously used for falls learning, to Sussex Community NHS Foundation Trust reduce hospital acquired pressure ulcers. partners through the Harm Free Care An intensive programme working with wards Collaborative. This training will build tissue who have high numbers of patients viability expertise across our clinical areas. developing pressure damage to ensure they Full implementaation of the pressure ulcer risk have the support required to implement assessment tool on Patientrack. remedial actions using PFIS. Ongoing project to assure the prompt Link with the deconditioning work in the falls availability of pressure relieving mattresses programme to realise benefit in reducing when required. pressure ulcers; evidence shows that the earlier the patients are active in hospital the less likely they are to develop pressure ulcers. Page 59 | Quality Report 2017/18 third draft
Working with Sussex Community Trust in hospital and on transitions of care. colleagues to improve the continence pathway
Medicines optimisation programme This year we have continued to roll out our Medicines Optimisation Strategy which sets out the vision and goals for development and quality improvement in all aspects of medicines use.
We practice medicines optimisation to ensure that Medicines optimisation also helps to reduce the medicines we use and prescribe in our medicines wastage and improve medicines safety. hospitals are both clinically and cost effective. It is important to ensure that our patients are well Our focus over the last year included elements informed about their medicines, have the right which linked to improving safety, improving choices at the right time, and are involved in outcomes and improving patient understanding of decision making with their clinical care team. taking their medicines.
Trust target 1: Maintain / improve the Medicines Reconciliation completion rates (baseline Jan-Mar 2017)
By when: March 2018
Outcome: 70% overall (69% overall target)
Progress: Target achieved (YTD Dec 2017)
The ‘Medicines Reconciliation’ is the check medication administration, promotes discussion performed at or close to admission to confirm that with patients about their medicines and helps to the medicines that a patient normally takes at ensure accurate and quality information about home have been correctly prescribed and medicines is passed back to Primary Care or other identified on the hospital in-patient prescription. healthcare settings at discharge. The process reduces the risk of incorrect
Trust Medicines Reconciliation (MR) rates in 2017/18 2017/ Qtr1 Apr- May Jun- Jul- Aug Sep Oct- Nov Dec- Parameter 18 16/17 YTD 17 -17 17 17 -17 -17 17 -17 17 average MR completed 25% 37% 28% 37% 36% 32% 37% 40% 44% 48% 31% <24 hours MR completed 48% 62% 51% 71% 58% 56% 61% 67% 68% 73% 55% up to 48hrs Page 60 | Quality Report 2017/18 third draft
Trust Medicines Reconciliation (MR) rates in 2017/18 2017/ Qtr1 Apr- May Jun- Jul- Aug Sep Oct- Nov Dec- Parameter 18 16/17 YTD 17 -17 17 17 -17 -17 17 -17 17 average Total MR 77% 85% 82% 86% 83% 79% 87% 89% 85% 91% 85% completed Total completed for 90% 94% 95% 97% 93% 85% 98% 98% 87% 97% 98% patient staying >4 days Overall total 60% 70% 64% 73% 68% 63% 71% 74% 71% 77% 67% Data source: WSHFT
Improvements achieved: Completion rate has generally been Further improvements identified: maintained or improved compared to 2016/17. To link elements of Medicines Reconciliation Full documentation within JAC (pharmacy to information with discharge summaries. software) Electronic Prescribing and Medicines Administration records.
Trust target 2: Anticoagulants: 50% of patients on New Oral Anticoagulants to have documented counselling
By when: March 2018
Outcome: 43% average YTD
Progress: Close to target
Incident reporting at the Trust has highlighted an increased risk to patient safety when patients are initiated on New Oral Anti-Coagulants (NOACs). Whilst these medicines carry a similar risk to warfarin they do not share the formal pathways of long term monitoring and review; NOACs are also less well understood and recognised by patients. In order to improve patient understanding and reduce the likelihood of significant risk, work has been carried out to develop a more comprehensive pack of information and a counselling checklist for patients taking NOACs. Medical, pharmacy and nursing staff are working together to educate our patients to ensure that they receive the necessary information to support their treatment.
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Data source: WSHFT
Improvements achieved: delays linked to anticoagulants in patients Documented NOAC counselling has improved undergoing surgery or invasive procedures. from 24% to an average of 43% (YTD) and involves pharmacy staff and other clinical Further improvements identified: staff. In ten out of 28 weeks we have reached Further work is required to target counselling the 50% target with the trend of documenting for the remaining patients who are newly NOAC counselling improving steadily. prescribed NOACs (of the remaining 50% of The rate of patients’ prescriptions with venous patients without documented counselling 4% thromboembolism prophylaxis omitted has are newly prescribed the medication and reduced by a third, following the introduction therefore a priority for counselling). of an additional prompt for prescribers within The VTE prophylaxis prescribing will continue the clerking paperwork during pilot periods of to be a key focus for 2018/19 and process work. mapping will be used to identify the next New anticoagulant bridging guidelines have series of opportunities in this area. been introduced to reduce the risks and
Trust target 3: Improve the quality of information relating to medication at discharge to GPs, community hospitals and community pharmacists
By when: March 2018
Outcome: New system implemented
Progress: Target achieved Ensuring accurate information about medicines discharge summary and final prescription when patients are transferred back to Primary together. This has reduced errors and Care after a stay in hospital is an important inaccuracies and improved the quality of key priority; medicines are often adjusted or altered information which is sent to GPs. and it is an essential element of on-going care to ensure that the GP is aware of these changes. Further improvements identified: The Trust will explore opportunities to involve Improvements achieved: community pharmacies in the share of In the Department of Medicine for the Elderly information at discharge including referring a new system has been introduced where the patients for a discharge medication or new junior doctor and pharmacist prepare the medicine review after discharge.
CQUIN target: Antimicrobial stewardship and consumption reduction in total antibiotic consumption (2%), carbapenem reduction (1%) and piperacillin-tazobactam (1%) compared to 2016/17
By when: March 2018
Outcome: One Public Health England targets achieved (Piperacillin-tazobactam)
Progress: Behind plan
Antimicrobial resistance is a significant threat to there will be 10 million deaths a year globally due patient safety. It has been predicted that by 2050 to antibiotic resistance - more than cancer.
Antimicrobial stewardship and consumption
Percentage 2017/18 reduction in consumption 2016/17 consumption YTD consumption (Defined daily Antimicrobial 2017/18 YTD (Defined daily doses per compared to doses per 1000 bed baseline 1000 bed days) days) Carbapenem +0.9% 333.5 330.6 Piperacillin- -37% 303 486 tazobactam All antibiotics +6.2% 49,062 46,701 Data source: WSHFT
Improvements achieved: advised by Public Health England through the The level of review of antimicrobials by senior CQUIN. staff has increased over the year to the level Page 63 | Quality Report 2017/18 third draft
Total antimicrobial usage remains low within Further improvements identified: the organisation and there is good Continued focus on good practice prescribing antimicrobial stewardship and compliance with and regular review will be a key objective for the formulary. Reducing the total usage of 2018/19. antimicrobials has proved challenging particularly with the specific drugs used within our formulary.
Infection prevention and control programme Infection prevention and control is a vital part of the care we give to patients in our hospitals. Healthcare associated infections are well good basic infection prevention and control recognised as a cause of increased morbidity and practices such as hand hygiene, cleanliness and mortality, and whilst some are not preventable, our antimicrobial stewardship. objective is to prevent them where possible by
Trust target 1: Reduction in surgical site infection (SSI) rate for total hip replacement (<1.1%) and total knee replacement (<1.5%)
By when: March 2018
Outcome: Hip SSI rate: 1.5% (April to December 2017) Knee SSI rate: 2.8% (April to December 2017)
Progress: Behind plan
Surgical patients who are operated on in the The Trust still remains an outlier for total hip and categories for which we are undertaking SSI total knee replacement surgery. surveillance are monitored for signs of infection both during their initial admission and up to one year post surgery for hip and knee replacements.
Surgical site infection data – total rate including superficial infections 2017/18 National Latest benchmark 2014/15 available WSHFT Latest (Oct 2014 Surgical site data April 2016/17 2015/16 available – Sep to target data Oct to 2015) December December 2017 2017 Total hip 1.5% <1.1% 1.0% 2.0% 2.7% 3.2% replacement Total knee 2.8% <1.5% 1.3% 3.3% 4.2% 1.9% replacement Data source: Public Health England Improvements achieved: exposure of these patients to ‘dirty’ wounds of SSI Surveillance Team are now part of the patients being treated by other specialties of Surgical Division and an SSI Operational surgery. Group has been formed with the focus of A wound clinic has been established for post- ensuring the NICE Quality Standards for operative review of total hip and total knee reducing SSIs are embedded into theatre replacement patients who are concerned practice. about their wounds. Standard work practices agreed for pre- operative care including microbial Further improvements identified: decolonisation and warming of enhanced British Orthopaedic Association review early recovery programme hip and knee replacement January 2018 – Recommendations received patients. and under review. Chilgrove ward has been ring-fenced for elective arthroplasty cases reducing the
Trust target 2: Reduction health care associated infection rate for MRSA (0 cases) and
C.difficile (<39 cases)
By when: March 2018
Outcome: MRSA: 3 cases C.diff: 35 cases
Progress: Close to target
Clostridium difficile disease (CDI) is a potentially aureus (MRSA) continues to be a concern in the life-threatening condition often associated with healthcare setting as well as in the wider healthcare intervention and cross-infection. The community. In most people it causes no harm, but control of this organism requires a truly multi- if normal defences are weakened by other illness disciplinary approach involving excellent infection or injuries then the bacterium can get into their control practice, good antimicrobial prescribing bodies and cause blood stream and other and sound environmental cleanliness and infections that are very serious and difficult to management. Meticillin-resistant Staphylococcus treat.
Healthcare associated infection data – number of cases Causal WSHFT 2017/18 2016/17 2015/16 2014/15 agent target C.difficile 35 39 45 36 38 infections MRSA 3 0 1 0 1 infections Data source: WSHFT
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Improvements achieved: completed during this project to help the Executive representation at the post infection correct weekly MRSA screens to be taken reviews of hospital acquired Clostridium within clinical areas. difficile and MRSA bacteraemia cases. Multi-disciplinary working group formed to Further improvements identified: identify actions to reduce hospital acquired Deep clean and Bioquell programme to begin Clostridium difficile. This was tabulated into an in March 2018 across sites. action plan and has been worked on MRSA bacteraemia action plan to be throughout the year, discussing at Infection formulated, post infection review. This will Control Operational Group (ICOG) and improve correct screening, prompt Sisters’ meetings across site. decolonisation and reduce contaminant rates. Patientrack have supported the Infection This will be discussed at ICOG and Prevention & Control (IP&C) Team and are in Sister/Matron meetings. the process of working on a project that will High Impact Intervention reporting is essential help all clinical staff within the Trust. but it is recognised that the collating of Patientrack are currently pulling through Trust monthly data, to bring to ICOG, takes time. infection control alerts to their system and The Trust and Brighton & Sussex University through to nursing and doctor hand over Hospitals IP&C Teams are to meet to discuss sheets. This has been put as a priority due to best practice for reporting compliance, non- the MRSA bacteraemia cases that the Trust compliance and assurance from all divisions. has had recently. Other work will be
Diagnostic resulting programme To ensure all ordered diagnostic tests are undertaken, reviewed, acted upon, escalated appropriately and finally communicated to the patient/GP within the timeframe required.
Trust target: Further progress with specification, procurement and implementation of a new diagnostic resulting programme
By when: March 2022
Outcome: In progress
Progress: On plan
This programme aims to ensure we have a robust finally communicated to the patient/GP within the and consistent Trust wide programme in place to timeframe required. Our eventual aim is to ensure that all ordered tests are undertaken, implement a fully integrated auditable system for reviewed, acted upon, escalated appropriately and ordering tests which includes a robust feedback Page 66 | Quality Report 2017/18 third draft
mechanism to ensure that all results are prioritised GP and patient of their biopsy results together and reviewed with timely communication to the with a tracking system for all biopsies taken. patient and their GP. Although the group is focused on finding a trust wide IT solution for Further improvements identified: managing test results, identified risks are being Various IT solutions within the Trust which will addressed with simple solutions. interface with OCS (Order Comms System) within the Pathology department (where tests The initial work in this programme has required us outside of pathology and radiology occur) to to undertake a review of the ordering and ensure that there are failsafe systems in place communication practice for each group of for managing results and communicating the diagnostic tests, and a review of the resulting results to the patient which are understood by practice within every specialty within the Trust. all staff. This has helped us to understand the issues faced Consultant to consultant referrals (within the that cause missed, lost, delayed and DOCMAN system) will be looked at within the uncommunicated test results and enable action next scope which will have a huge impact on plans to be put in place to address the issues lost referrals and improve patient safety. found. Electronic ‘To Come In’ cards this will improve lost referrals, inputting the wrong consultant This programme of work will help to prevent details and improve patient safety. delayed diagnosis and treatment and reduce the Standardising working practices across the number of repeat diagnostics undertaken. Trust including the standardisation of diagnostic resulting policies. Improvements achieved: Agree a communication Strategy to ensure Review of endoscopy operational policies, Trust consultants are clear on the purpose of request forms, patient information leaflets, the Code Red process, the expectations booking letters and prep instructions to around acknowledgement and transfer of procedures and expectations are managed. responsibility and the requirement to have fail Endoscopy secretarial practices have been safe procedures in place within each specialty reviewed to ensure standardised working for periods of absence. The communication practice to improve resulting timescales. should also include the importance of correct Endoscopy biopsy result letters updated to completion of request forms. introduce standard practice for advising the
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Safer staffing programme Our Safer staffing quality improvement programme aims to roll out an information system to provide a Trust wide view of safe staffing.
Trust target: Roll out SafeCare Live information system to all adult inpatient wards
By when: March 2018
Outcome: SafeCare Live implemented by all adult inpatient wards plus A&Es, Emergency Floors, ITUs, high dependency areas and paediatrics.
Progress: Target achieved
The SafeCare Live system brings together completing the patient acuity and dependency information on actual staffing levels with the needs level information required. and number of current patients in the organisation. Visibility of supernumerary staff and student It is recognised that to deliver safe and effective nurses on placement across our inpatient care to patients there is a balance of staffing wards. numbers and skill mix that is required. The idea is Improved capabilities in the management of that the system provides a real-time picture of the staff sickness and absence. actual versus required staffing needed and Improved visibility of clinical skills therefore aids decision making around delivering competencies held by individual staff, and safer care for our patients. This programme therefore at ward level, for each shift. focused on the roll out of the system to all general wards across the Trust in 2017/18. Further improvements identified: Successfully Implement SafeCare Live system Improvements achieved: to the remainder of our more complex phase SafeCare Live has been successfully rolled two areas: Maternity. out to all adult inpatient wards across the Build reliance on SafeCare Live and move to Trust allowing ward managers to better reporting of Safe Staffing levels to the manage staffing deficits and ensure correct Department of Health from the new system staff skill mixes are achieved. alone. Implementation in some of our more complex Improve in-hours redeployment of staff across areas including both A&E departments, wards thereby reducing reliance on Site Emergency Floors, ITUs, High Dependency Managers to address safe staffing out of areas and paediatrics. hours. Staffing data entry is now live across 44 wards Provision of robust staffing level information to and clinical areas with 36 of these also aid discussions at clinical site meetings re: patient flow and escalation. Page 68 | Quality Report 2017/18 third draft
Networking across the South with other NHS Potential to roll out the system across other organisations to provide peer support and staff disciplines, such as portering and best practice working. domestics; this would allow an improved ability to manage staffing levels in real-time.
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Improving patient experience
True North goal: 97% recommendation for Friends and Family Test feedback
2017/18 achievement: 95% of patients would recommend the Trust through the Friends and Family Test
Western Sussex Hospitals NHS Foundation Trust Our Friends and Family Test (FFT) patient is committed to the delivery of patient centred care feedback consistently ranks higher than the for all patients. Patients can expect to experience national average. We now seek to build on our exceptional care which meets both their physical past achievements and enter the top 20% of NHS and emotional needs. Improving patient Trusts for FFT recommendation score. To do this experience is at the heart of the Trust’s vision and we have set a ‘True North’ long term goal to values, and is a central aspect of our Patient First achieve 97% recommendation for FFT feedback, Programme. and reduce ‘not recommend’ rates.
The experience that a person has of their care, The opportunity to hear the voice of the patient treatment and support is one of the three parts of through the FFT gives staff the opportunity to high-quality care, alongside clinical effectiveness listen to patients’ experiences and to make and safety. A person’s experience starts from their improvements. Feedback is responded to on a very first contact with the health and care system, regular basis and immediate and longer term right through to their last, which may be years after actions taken to improve the experience for their first treatment, and can include end-of-life patients. Wards use the information to feedback care. within their area using the ‘you said…we did’ principle. Friends and Family Test recommend rates Best Worst 2016/17 National 2017/18 performing performing (Figure updated from last year’s Latest available average quality report 2015/16 2014/15 data to February Latest available Trust Trust due to more 2018 data to February Latest available Latest available 2018 data to February data to February recent data 2018 2018 being available) A&E 85.64% 86.60% 99.0% 47.0% 89.01% 91.39% 90.60% Maternity 97.80% 96.50% 100% 7.9% 97.64% 96.20% 97.00% delivery Inpatients 96.84% 95.65% 99.3% 76.0% 96.06% 95.20% 92.40% Not launched Outpatients 96.94% 93.54% 98.9% 84.4% 95.43% 92.4% until 2015/16 Not Overall rate 95.05% 92.87% 99.1% 59.7% 94.20% 93.03% available Data source: NHS England Page 70 | Quality Report 2017/18 third draft
Reducing complaints and improving the timeliness of complaint responses Our improvement focus this year has been on reducing complaints and improving the timeliness of complaint responses.
Trust target: 60% of formal complaints to be closed within 25 days, increasing to 80%
By when: December 2017, March 2018
Outcome: 68.5% December 2017, 68.0% March 2018
Progress: Close to target
When people have a poor experience of care it is Improvements achieved: essential that they are supported to raise their Significant reduction in open formal concerns and that these concerns are responded complaints from 110 at the beginning of April to in a timely manner. Currently this is not the 2017 to 80 at the end of March 2018. case; we have undertaken a full review our Improvement in responding more quickly to complaints system to put in place processes that formal complaints; in March 2018 68% of will address the backlog of complaints and ensure formal complaints were resolved within 25 smooth and efficient future system. Divisions are working days (previously 11.8% in at the end beginning to embed a more proactive response to of April 2017). new complaints to try to facilitate resolution quickly Closure of formal complaints in a shorter for patients and families, avoiding the need for timeframe; 89% of formal complaints were escalation to formal complaint. closed within 60 days between January and March 2018 compared to only 30% between Our Customer Relations Team is now holding April and June 2017. weekly meetings with divisional input to enable a The introduction of a new procedure whereby more accurate and visible complaints workflow. a relevant senior manager telephones The new process is proving to be very successful complainants within three days of receiving a in focusing on the target dates for complaint written complaint has reduced formal responses and understanding reasons for delays. complaints from on average 48 per month in The meetings also provide divisions with the ability 2014/15 and 2015/16 to an average of 36 per to tackle some of the delay reasons much earlier month in 2017/18. on in the process. Identifying and supporting teams receiving higher volumes of Patient Advice and Liaison Service (PALS) concerns and formal complaints to provide support to deliver improvements in patient experience.
Data source: WSHFT
Further improvements identified: Train our managers to quickly resolve Address the increase in PALS enquiries about concerns, and assist enquiries. clinical treatment, reducing the number of Improved management of social media for formal complaints. responding to and taking action on complaints Monitor the number of re-opened formal feedback posted on the NHS Choices complaints to ensure satisfaction for the website. patient and their family and to measure impact on timeframes.
Improving communication programme Real-time surveys and comments from our Friends and Family Test results show communication and information continues to be a challenge.
Trust focus: 97% recommendation rate for Friends and Family Test feedback and reduce
‘not recommend’ rates
By when: March 2018
Outcome: 95.05% (overall Trust score)
Progress: Close to target Patient experience feedback tells us that Ability to report and triangulate patient and communication and information are key factors staff experience at clinical department/unit affecting our Friends and Family Test recommend level. rates. Common concerns raised by those Response rates for the inpatient FFT have receiving outpatient care include communication improved from 34.3% in 2016/17 to 37% in regarding waiting times when booking 2017/18 and for maternity (delivery) from appointments via the call centre, missed 29.1% to 52.0% over the same period. appointments and time spent waiting to be seen in Improving FFT response rates is one solution our Outpatient Departments. The most common to ensure we have robust feedback to review areas of concern for inpatients relate to and act upon. communication about discharge planning and medication. Further improvements identified: Embed the collection of patient feedback This year we have focused on two specific projects within departments as ‘business as usual’ as part of improving communication with patients: driving up response rates to ensure we gather improving discharge experience; improving feedback from sufficient people to know that outpatient appointment booking experience. information is reliable. Wards and Departments to use comments to Improvements achieved: celebrate success and to generate ideas for Development of a Patient Experience Strategy improvement. with key stakeholders and identification of Consider our frail local population who may priority improvement workstreams. not be able to express their views effectively Promoting earlier communication with patients without support; review current feedback and families to manage expectations approaches to ensure the voice of the carer is regarding discharge options as part of a pan heard and acted on. Sussex and Surrey campaign ‘Let’s Get You Continue to improve communication so that all Home’. patients have access to the information they need.
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Improving staff engagement
True North goal: To be in the top 20% performing acute NHS trusts in the country – NHS Staff Survey engagement score
2017/18 achievement: 3.88 NHS Staff Survey engagement score – this places us in the top 20% of acute NHS trusts
‘Our People’ is a strategic theme in our Patient elements that make up our staff engagement First Programme; we cannot deliver Patient First score are: without engaging really well with our staff. Staff • Staff recommendation of the trust as a place to determine the experience of their workplace and work or receive treatment organisation by the many interactions, or not, with • Staff motivation at work their line manager. Effective team working, led • Staff ability to contribute towards improvements and managed by great leaders, delivers better at work outcomes for patients and increases staff productivity and satisfaction. During 2017/18, the Trust’s engagement score remained stable at 3.88, above the national The national NHS Staff Survey assesses the average for acute trusts of 3.79. For the seventh quality of staff experience through a number of year, the Trust rolled out the NHS staff survey to questions linked to the NHS Constitution. Scores all permanent staff and achieved its highest range from 1 to 5, indicating low to high response rate of 66%, an increase of 7% on last engagement. We have identified that the key year.
NHS Staff Survey engagement scores Best Worst National performing performing 2017 2016 2015 2014 average Trust Trust (acute trusts) (acute trusts) 3.88 3.79 3.96 3.54 3.88 3.78 3.73
Data source: NHS Staff Survey Coordination Centre (Picker Institute Europe)
In 2017/18 we have continued to focus on the managers to equip them with the tools needed to breakthrough objective with those departments facilitate great staff engagement: coaching, lean where the percentage of staff who feel unable to improvement methodology, change management, make improvements happen in their workplace is effective rostering and good human resource lowest. We have strengthened the development management. programme for our clinical leaders and operational Staff Wellbeing programme The Trust continues to focus on staff health and wellbeing as one of our key quality objectives.
Trust target: Implementation of programmes to support emotional wellbeing and
musculoskeletal problems.
By when: March 2018
Outcome: Wellbeing Wednesday programme launched. Targeted musculoskeletal programme commenced.
Progress: Target achieved
CQUIN target: 5% improvement in NHS Staff Survey 2017 health and wellbeing scores from 2015 results.
By when: March 2018
Outcome: 8% improvement in one indicator, 1% improvement in other two indicators
Progress: Close to target
The Trust’s health and wellbeing plans over the staff feedback. The CQUIN encouraged a focus on last few years have been designed to deliver those proactive initiatives that reduced the improvements to the physical and mental negative impacts of work, alongside continuing to wellbeing of staff, based on sickness absence provide a broad range of wellbeing schemes. data, staff survey results and other methods of
NHS Staff Survey 2017 – health and wellbeing CQUIN specific results
Best Worst National performing performing average 2017 (acute non- Trust Trust 2016 2015 specialist (acute non- (acute non- (from 2015) trusts) specialist specialist Improvement trusts) trusts) 9a.Does your organisation take positive action on health and well- 8% 42% 32% 50% 20% 37% 34% being? (Yes, definitely) 9b.In the last 12 months have you experienced musculoskeletal 1% 72% 74% 80% 66% 71% 71% problems (MSK) as a result of work activities? (No) 9c.During the last 12 months have you felt unwell as a result of work 1% 66% 63% 72% 54% 66% 65% related stress? (No) Data source: NHS Staff Survey Coordination Centre (Picker Institute Europe)
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Improvements achieved: focused training to particular staff groups and The Trust was in the top 20% of acute trusts education over the types of exercise that may for the key finding of organisation and reduce the likelihood of injury. management interest in health and wellbeing Access to the Physiotherapy gym for staff at in the NHS Staff Survey 2017. St Richards and Worthing on a programme Improved branding and communication of facilitated by the Staff Physiotherapy service. wellbeing events to better promote the full Launch of the Colleagues as Carers forum for range of initiatives on offer to all staff. our staff, in partnership with Carers Support The Trust launched Wellbeing Wednesdays in West Sussex. The forum operates groups to September 2017, which now take place on the share experiences with like-minded people, an first Wednesday of every month. They opportunity to explore work-life balance and provide a regular opportunity for staff and advice on caring roles and support available. volunteers to enjoy a variety of health and Ongoing provision of a broad range of Health wellbeing activities across the Trust, such as and wellbeing services for staff including Staff lunchtime walks, physio workshops, yoga, Counselling service, Emotional Resilience emotional resilience, hand massages and courses for staff, Schwartz rounds, group singing. Mindfulness and on-site exercise In the 2016 staff survey 29% of our staff programmes. stated that they had experienced musculoskeletal related problems as a result Further improvements identified: of a work related injury. The Trust was in the Review and further development of education process of reviewing beds and the health and sessions conducted by Staff Physiotherapy wellbeing group identified that the introduction and Back Care team. of electric beds would play a significant part in Further work on reducing stress will begin in reducing the incidence of work related injury. pilot areas to focus on initiatives to address In November 2017 the Trust ordered more stress triggers. This work will be supported by than 1,000 new electric profiling beds to replace the Kaizen improvement team utilising the current bedstock on the wards from January improvement methodology. Learning from 2018. these pilots will support the development of Specific focused events run by Staff ongoing plans for the wider organisation. Physiotherapy services and the Trust’s Back Ongoing development of the Wellbeing Care team to provide a combination of Wednesday programme.
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Developing a resilient and affordable workforce Ensuring the Trust has the appropriate workforce capacity in place to deliver and sustain high quality services.
Trust target: 10% reduction in staff vacancy and turnover rates compared to 2016/17 baseline
By when: March 2018
Outcome: 10.2% vacancy reduction and 5.1% turnover reduction compared to baseline
Progress: Close to target
Improving the number of permanent staff attractive and establishing new roles where employed improves quality of care to patients and workforce supply is scarce. Staff turnover reduces the reliance on agency staff. This undermines recruitment strategies and results in a requires the development of careers that are loss of valuable skills and knowledge.
Workforce data: rolling 12 month staff turnover and staff vacancy rates Actual 2017/18 reduction 2016/17 2015/16 2014/15 2017/18 (from 2016/17) Staff turnover rates 7.5% 5.1% 7.9% 8.7% 8.4% Staff vacancy rates 8.8% 10.2% 9.8% 11.1% 9.3% Data source: WSHFT
Improvements achieved: Pharmacists. We have also explored the Successful implementation of new terms and option of using Doctors’ Assistants to conditions of service for over 350 junior undertake some traditional doctor-level doctors since October 2016, including procedures. introduction of generic work schedule with Improved market management of nursing regular educational review meetings and rota workforce and cap compliance of agencies to redesign to comply with new safety rules improve the volume and quality of agencies governing working hours. supplying to the Trust. In addition we have Introduction of new/extended roles to mitigate eliminated very high cost agency use and recruitment challenges for example Resident introduced a bank bonus scheme to Medical Officers, Clinical Fellows, Resident encourage the uptake of bank shifts rather On-Call Consultants and other staff groups than booking agency staff to fill vacant shifts. such as Clinical Nurse Specialists, extended Agency staff switch initiative to encourage scope Allied Health Practitioners (AHPs) and workers back in to permanent nursing Page 77 | Quality Report 2017/18 third draft
positions: successfully converted 25 agency Further improvements identified: nurses on protected terms and conditions to Extend the number of apprentices and our Trust staff bank and a further five to apprenticeship qualifications available in our substantive posts with the Trust. clinical areas including HCAs, registered Continued work to support domestic and nurses, occupational therapy staff, pharmacy international recruitment: net increase of 56 staff and biomedical scientists. nurses and 111 Health Care Assistants Introduce an Associate Nurse role at Band 4 (HCAs) in the last 12 months. This to mitigate registered nurse vacancies as part recruitment drive has successfully filled all of a consortium in Surrey. vacancies in the HCA staff group. Explore the use of Clinical Fellows in a wider Continued focus on improving staff retention, number of specialties. employing PFIS problem solving methodology Following our offer of 60 nurse posts on our to address the numbers of HCAs leaving overseas recruitment trip in October 2017 we within first 2 years’ of employment and need to progress professional registration and growing future pipelines through the use of visa requirements. apprenticeships. Roll out ESR self-service to clinical areas on Roll out of HR IT systems to support completion of the upgrade of Evolve and workforce management including medical internet explorer. revalidation, job planning, annual leave, Continue to explore the use of digitised electronic rostering and Electronic Staff technology to improve bank booking Record (ESR) manager and employee self- processes and fill rates. service systems. Work in collaboration with Brighton & Sussex Continued embedding of cultural change University Hospitals to identify common areas through staff engagement, health and where workforce challenges can be mitigated wellbeing, appraisal, Welcome Days, health (eg. shared staff bank arrangements, joint and safety training, employee relations and posts, skills swaps). leadership development.
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Patient First Improvement System Our Patient First Improvement System (PFIS) is the Trust’s tailored lean management system which helps our wards and departments to support and sustain large scale improvement projects.
Trust target: Continued roll out across all clinical areas - focus on A&E and Emergency
Floor
By when: March 2018
Outcome: A&E and Emergency Floors fully trained and operational in PFIS
Progress: Target achieved
Our PFIS system involves four months of training Yellow Belts trained; 415 now in total across for each ward or department team through the organisation (as at end of Jan 2018). attendance at a series of modules and team days. We trained our second cohort of 12 Trust staff Staff learn to implement PFIS in their areas and to Green-belt level with delivery of adopt new lean management techniques including appropriately scaled and aligned projects. We A3 problem solving, testing solutions using a Plan now have 29 trained Green Belts working Do Study Act (PDSA) approach, standard work, across the organisation. and process observation, as well as implementing We have developed our Trust Lean an improvement huddle. Practitioners (Patient First Kaizen Office) to Black-belt status. The PFIS is supported by a community of Lean The Kaizen Team have provided coaching Practitioners amongst our staff, ranging from and support to improvement projects including Yellow Belts through to Green Belts to advanced Stroke, Sepsis, Non-Elective Flow, Theatre Black Belts. This programme is developing our Optimisation, Flu Vaccination and Health & ‘Trust-wide’ network of Lean professionals and Wellbeing. teams empowered to solve problems, improve Rollout of Patient First Improvement System processes and pathways using Lean tools, which to 16 further wards and departments through is sustainable and shows tangible benefits for three waves of training; 37 wards and Patient care, service and experience. departments in total now trained. By engaging staff in improvement at ward and Improvements achieved: department level, PFIS has helped deliver Increased alignment of Yellow-belt training to significant improvements in relation to project delivery: 100% of yellow belt breakthrough objectives and True North graduates will be involved in the delivery of a themes, such as reductions in falls and project aligned to Trust priorities. 150 new agency spend, increased Friends and Family Page 79 | Quality Report 2017/18 third draft
responses and timely clinical observations for earlier in the day to support flow, continued inpatients. emphasis on falls and pressure injuries. A&E departments and Emergency Floors at Building further on our Lean network resource, both Worthing & St Richard’s have completed by training new Yellow Belts, but also the training programme. We welcomed our ensuring that Yellow Belt candidates from first participants from Women & Children to previous cohorts continue to be involved in PFIS in spring 2018. improvement activity and aligned to strategic projects. Further improvements identified: Rollout of Leader Standard Work training to Rollout of PFIS to approximately 21 further key clinical and non-clinical leaders, to wards and departments in 2018/19. This will support active engagement in improvement complete the rollout of general medical, work on a daily basis across the organisation surgical and obstetric ward areas as well as supporting projects, developing resource and main and day case theatres and outpatients. coaching staff for improvement. Continued support for key breakthrough objectives including discharge of patients
Clinical Academic Pathway Our ambition is to provide support for novice researchers at all levels enabling them to grow a research career whilst maintaining close links to clinical practice and collaborative working with Higher Education Institutions.
Trust focus: To develop a clinical academic pathway providing support for novice
researchers at all levels
By when: March 2018
Outcome: Pathway developed and launched
Progress: Target achieved
The Western Sussex Clinical Academic Pathway training in continuous improvement methodology focuses on the development of confident clinical and will be embedded within the Trust’s Patient academic and research aware staff who will First culture of continuous clinical improvement. develop and embed a culture of learning from research to innovate and improve care, outcomes Our new Clinical Academic roles will support and experience for patients and act as ‘agents of innovative improvements in care in priority areas - change’ within the practice environment. Our helping to build Centres of Clinical Excellence in programme includes a specific component for key quality improvement areas such as improving Page 80 | Quality Report 2017/18 third draft
patient outcomes, delivering harm free care, identified as local quality priorities. Build on improving patient experience of care and engaging the Patient First Improvement Programme by and empowering staff to make improvements in developing skilled and confident practitioners front line services. We will work with academic amongst ward level teams to support best partners in areas of shared priority to drive care and practice based on the latest research innovative improvements in patient care. evidence and innovation. Develop and enhance learning opportunities Improvements achieved: for research and EBP. Ensure that all clinical The Clinical Academic Nursing, Midwifery and areas have nominated Evidence Based Allied Health Professionals programme is Practice (EBP) and Research Champions to developing well supported by a grant of from further support the Patient First drive for Kent Surrey Sussex Health Education continuous improvement and to enhance England. opportunities for embedding research in every We are supporting four Clinical Improvement day practice. Ensuring that all areas are fully Scholars this year from September 2017 for engaged with research and innovation will 12 months. support greater access for patients and We have been successful in securing further provide them with more opportunities to funding from Kent Surrey Sussex Health contribute to clinical research within the NHS. Education England to expand our cohort of Develop a ‘virtual’ research communication Clinical Improvement Scholars for entry in network of practice, across new and existing September 2018 and September 2019. communities with supporting links to wider We were awarded the ‘Improvement and health and education economies, to help Innovation Award’ in the Partner Awards 2018 implement new ideas and support the shaping by the National Institute for Health Research of existing knowledge into new practices that Clinical Research Network Kent, Surrey and can help people to do their jobs more Sussex for our CAP programme. effectively. Develop a designated ‘research’ space to Further improvements identified: offer staff a bookable area for collaborative Increase staff engagement with clinical working or a quiet space for writing up their research with particular focus on the areas work.
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Part 3.2: Other Information
(photo page –)
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Local quality indicators
Patient safety indicators 2017/18 2016/17 2015/16 2014/15 2017/18 target Safer Staffing: Average fill rate - registered 94.80% 95% 96.20% 95.93% 96.50% nurses/ midwives (day shifts) Safer Staffing: Average fill rate - registered 94.80% 95% 97.10% 97.46% 97.30% nurses/ midwives (night shifts) Safer Staffing: Average fill rate - care staff 93.10% 95% 91.30% 89.82% 93.70% (day shifts) Safer Staffing: Average fill rate - care staff 94.10% 95% 92.30% 92.26% 95.30% (night shifts) Care Hours Per Patient Day (CHPPD) 6.6 tbc 6.5 n/a n/a Safety Thermometer: % of patients harm-free 94.93% 95.70% 95.30% 95.70% 94.60% Safety Thermometer: % of patients with no 98.42% 99% 98.50% 98.30% 98.20% new harms % of patients with catheters and UTIs where 0.05% 0.06% 0.06% 0.10% 0.20% best practice protocol was not followed. Total incidents (Trust data) 8,122 - 9,150 9,938 9,841 9,508 10,988 Total moderate, severe or death incidents 176 153 162 156 147 (Trust data) Total serious incidents (SIRIs) (Trust data) 53 60 74 79 61 Number of outstanding CAS alerts 0 0 0 0 0 Total incidents involving drug/prescribing 1,056 - 1,016 1,088 1,100 1,242 errors 1,428 Moderate/severe incidents involving 9 5 8 6 5 drug/prescribing errors Number of hospital attributable MRSA cases 3 0 1 0 1 Number of hospital C.diff cases 35 39 45 36 38 Number of C. diff cases where a lapse in the 20 16 24 20 21 quality of care was noted Number of reportable MSSA bacteraemia 94 102 113 85 75 cases Number of reportable E.coli cases 400 375 417 312 313 Full compliance with WHO Surgical Safety 100% 100% 100% 100% 100% Checklist NEVER events 2 0 3 2 0 ~SSIs: Total hip replacement (Rolling 12 months to 1.50% 1.10% 3.00% 1.10% Feb 2018) ~SSIs: Total knee replacement (Rolling 12 months to 2.80% 1.50% 3.20% 0.80% Feb 2018) ~SSIs: Large bowel surgery (Rolling 12 months to Feb 11.50% 12% 11.60% 14.90% 2018) ~SSIs: Breast surgery (Rolling 12 months to Feb 2018) 5.70% 3.80% 5.40% 4.20% Falls resulting in harm (Trust data) 473 451 451 456 510 Falls resulting in severe harm or death (Trust data) 3 1 2 2 1 Repeat falls 106 97 97 Falls assessment within 24hrs of admission 90.00% 80% 86.80% 86.70% 90.90% Avoidable falls identified on the Safety 0.56% 0.65% 0.65% 0.83% 0.98% Thermometer Page 83 | Quality Report 2017/18 third draft
Patient safety indicators 2017/18 2016/17 2015/16 2014/15 2017/18 target Grade 2+ pressure ulcers 356 240 258 199 87 VTE Assessment Compliance 94.10% 95.3% 95.30% *94.903% 95.90%
Clinical effectiveness indicators
2017/18 2017/18 2016/17 2015/16 2014/15 target Trust crude mortality rate (non-elective) 3.10% 3.13% 3.21% 3.13% 3.27% Crude mortality rate (non-elective): 12 month 3.11% 3.13% 3.21% 3.13% 3.27% rolling Trust Hospital Standardised Mortality Ratio (HSMR) (Reported in arrears: 12 months to December 2017 is the 88.10 92 91.1 89.6 95.4 latest available data.) Summary Hospital-level Mortality Indicator (SHMI) (rolling 12M) (Reported in arrears: 2017/18 Q2 is the 0.95 1 0.97 1 1.03 latest available data.) Crude non-elective mortality for Renal failure 16.27% 15.50% 15.50% 14.50% 19.50% SMR for hip fracture (all diagnoses/ procedures) (Reported in arrears: 12 months to December 2017 is 88.54 100 93.6 70.1 80.6 the latest available data.) Worthing SMR for hip fracture (all diagnoses/ procedures) (Reported in arrears: 12 months to December 2017 is 96.13 100 100.1 78.1 112.3 the latest available data.) St Richard's SMR for hip fracture (all diagnoses/ procedures) (Reported in arrears: 12 months to 80.40 100 84.4 58.8 42.7 December 2017 is the latest available data.) 30 day mortality rate following hip fracture (Reported in arrears: 12 months to December 2017 is the latest available 6.80% 5.70% 6.40% 5.20% 8.70% data.) Emergency readmissions within 30 days % 14.31% 13% 14.20% 13.70% 13.20% C-Section Rate 28.50% 26.5% 28.60% 27.30% 26.90% % Mothers requiring forceps for delivery 11.20% <15% 11.80% 11.50% 11.90% % Deliveries complicated by post-partum 0.40% 1% 0.50% 0.50% 0.60% haemorrhage Maternal deaths 0 0 0 0 0 % Admission of term babies to neonatal care 3.20% < 10% 3.30% 3.00% 2.40% % Emergency admissions staying over 72h 91.18% 90% 93.20% 93.70% 92.40% screened for dementia % Patients identified as at risk of dementia for 93.26% 90% 92.20% 91.90% 92.40% whom further investigations are carried out % Patients with identified dementia referred to 100.00% 90% 100.00% 99.40% 98.90% specialist services Number of admissions for patients with 2,645 NA 2,921 2,442 1,832 dementia flag Ward moves for patients flagged with 2,257 2,376 2,638 1,744 1,102 dementia Night-time ward moves for patients flagged 505 500 555 470 492 with dementia Documentation Audit: % patients with 87.24% 75% 92.50% 98.70% 75.40% dementia with Knowing Me document Page 84 | Quality Report 2017/18 third draft
Clinical effectiveness indicators
2017/18 2017/18 2016/17 2015/16 2014/15 target % CT scans undertaken within 12 hours (reported 95.28% 95% 95.50% 92.40% 82.20% one month in arrears) % Stroke thrombolysis within 60 minutes of 71.88% 95% 76.20% 65.40% 60.40% hospital arrival (reported one month in arrears) % Swallow screen for stroke patients within 4 85.70% 95% 85.80% 78.90% 77.00% hours of admission (reported one month in arrears) % of stroke patients admitted to stroke unit within 4 hours of admission (reported one month in 70.75% 90% 73.50% 76.40% 69.80% arrears) % high risk TIA patients seen within 24 hours 15.13% 60% 44.10% 64.80% 77.30% (reported one month in arrears) Patients recruited to interventional studies 436 258 201 179 within CRN portfolio NA Patients recruited to observational studies 1047 980 405 1,093 within CRN portfolio NA Local Clinical Research Network (LCRN) 8,436 6,268 2,271 1,410 1,983 Score NHS IC Data validity summary (reported one month in 99.9 99.9 99.9 99.90% 99.90% arrears) % inpatients with electronic discharge 93.00% 94.20% 94.20% 84.20% 84.20% summaries produced
Patient experience indicators
2017/18 2017/18 2016/17 2015/16 2014/15 target Trust Friends and Family Recommend %: 96.75% 97.00% 96.00% 95.20% 92.70% Inpatient Trust Friends and Family Recommend %: A&E 85.78% 93.00% 89.00% 91.40% 90.90% Maternity Friends and Family Recommend %: 97.59% 97% 96.70% 96.20% 96.10% Antenatal care (36 weeks) Maternity Friends and Family Recommend %: 97.89% 97% 97.60% *96.2% 97.10% Delivery care Maternity Friends and Family Recommend %: 97.89% 97% 97.60% 95.70% 94.50% Postnatal ward Maternity Friends and Family Recommend %: 98.66% 97% 98.80% 98.10% 89.50% Postnatal community care Trust Friends and Family Recommend %: 96.96% 97% 95.40% *92.4% Outpatient Trust Friends and Family Response Rate: 37.05% 40% 34.30% *25.8% 34.50% Inpatient Trust Friends and Family Response Rate: 9.96% 23% 12.50% *17.8% 27.00% A&E Maternity Friends and Family Response Rate: 52.00% 40% 29.10% *11.7% 29.10% Delivery care Percentage of re-booked outpatient 12.50% 7.80% 8.90% 7.80% 8.70% appointments Clinics cancelled with less than 6 week’s 397 278 278 281 340 notice for annual/study leave PALS contacts relating to appointment 0.10% 0.08% 0.08% 0.08% 0.09% Page 85 | Quality Report 2017/18 third draft
Patient experience indicators
2017/18 2017/18 2016/17 2015/16 2014/15 target problems (% of total appts) Reduce patients cancelled on the day of 354 337 361 337 399 surgery for non-clinical reasons Breaches of mixed sex accommodation 0 0 6 1 0 arrangements Compliance with MUST tool after 24 hours 85.21% 80% 76.00% 60.90% 81.80% Compliance with MUST tool after 7 days 98.87% 95% 97.80% 91.20% 94.90% Internal PLACE compliance : St Richard's 95% 95% 94% 93.30% 97.80% Hospital Internal PLACE compliance : Worthing 96% 95% 95% 95.80% 95.10% Hospital Number of complaints 438 570 585 587 574 Complaints where staff attitude or behaviour is 42 54 59 54 67 an issue Complaints where staff communication is an 25 49 54 66 49 issue Complaints about nursing 46 39 59 39 46 Note 1: Complaints section relates to formal complaints only, does not include complaints received through PALS. Note 2: Friends and Family Indicators - We report year end unvalidated figures in the Quality Scorecard. The FFT results published in the main body of this report are the validated figures published a month in arrears by NHS England.
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Single Oversight Framework indicators
Western Sussex Hospitals aims to meet all of access and outcome to facilitate assessment of national targets and priorities. All Foundation their governance. As part of this Quality Report, Trusts report performance to NHS Improvement we are required to report on the following national (NHSI) against a limited set of national measures indictors:
Performance against the NHS Improvement Single Oversight Framework NHS 2017/18 Improvement 2016/17 2015/16 2014/15 threshold Maximum time of 18 weeks from point of referral to treatment (RTT) in 88.52% 92% 89.90% 86.88% 90.46% aggregate – patients on an incomplete pathway A&E: maximum waiting time of four hours from arrival to 92.86% 95% 94.37% 96.13% 95.02% admission/transfer/discharge All cancers: 62-day wait for first treatment from: Urgent GP referral for 88.69% 85% 87.47% 86.59% 86.96% suspected cancer All cancers: 62-day wait for first treatment from: NHS cancer screening 94.90% 90% 96.47% 96.2% 92.3% service referral C.difficile: variance from plan Already reported under section 2.3: Reporting against core indicators Summary Hospital-level Mortality Already reported under section 2.3: Reporting against core indicators Indicator Maximum 6-week wait for diagnostic 0.93% 1% 1.21% 2.79% 1.90% procedures VTE risk assessment Already reported under section 2.3: Reporting against core indicators Annex 1 – Statements from our commissioners, local Healthwatch organisation and Overview and Scrutiny Committee
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Annex 2 – Statement of Directors’ responsibilities for the quality report
The directors are required under the Health Act o feedback from Overview and Scrutiny 2009 and the National Health Service (Quality Committee dated XX/XX/20XX
Accounts) Regulations to prepare Quality o the trust’s complaints report published Accounts for each financial year. under regulation 18 of the Local Authority Social Services and NHS NHS Improvement has issued guidance to NHS Complaints Regulations 2009, dated foundation trust boards on the form and content of XX/XX/20XX annual quality reports (which incorporate the o the [latest] national patient survey above legal requirements) and on the XX/XX/20XX arrangements that NHS foundation trust boards o the [latest] national staff survey should put in place to support the data quality for XX/XX/20XX the preparation of the quality report. o the Head of Internal Audit’s annual opinion of the trust’s control environment In preparing the Quality Report, directors are dated XX/XX/20XX required to take steps to satisfy themselves that: o CQC inspection report dated Comment [e15]: Removed item from list: the content of the Quality Report meets the XX/XX/20XX [this point is only required where the foundation trust is not reporting requirements set out in the NHS foundation the Quality Report presents a balanced performance against an indicator that otherwise would have been subject trust annual reporting manual 2017/18 and picture of the NHS foundation trust’s to assurance] as the trust is currently not reporting performance against supporting guidance performance over the period covered the indicator [xxx] due to [xxx], the directors have a plan in place to the content of the Quality Report is not the performance information reported in the remedy this and return to full reporting by [xxx] inconsistent with internal and external sources Quality Report is reliable and accurate of information including: there are proper internal controls over the
o board minutes and papers for the period collection and reporting of the measures of April 2017 to [the date of this statement] performance included in the Quality Report,
o papers relating to quality reported to the and these controls are subject to review to board over the period April 2017 to [the confirm that they are working effectively in date of this statement] practice
o feedback from commissioners dated the data underpinning the measures of XX/XX/20XX performance reported in the Quality Report is o feedback from governors dated robust and reliable, conforms to specified data XX/XX/20XX quality standards and prescribed definitions, is o feedback from local Healthwatch subject to appropriate scrutiny and review and organisations dated XX/XX/20XX Page 89 | Quality Report 2017/18 third draft
the Quality Report has been prepared in By order of the board accordance with NHS Improvement’s annual reporting manual and supporting guidance ...... (which incorporates the Quality Accounts Date regulations) as well as the standards to ...... support data quality for the preparation of the Chairman Quality Report...... The directors confirm to the best of their Date knowledge and belief they have complied with the ...... above requirements in preparing the Quality Chief Executive Report.
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Annex 3 – Limited Assurance Report on Quality
Glossary of terms and acronyms
AFFIRM trial Crude mortality rate The AFFIRM study is a national research study which will test The number of deaths in hospital as a percentage of the total to see if rates of stillbirth may be reduced by introducing an number of patients discharged. We use the crude non- interventional package of care based around reporting and elective mortality rate as an immediate indicator of progress management of decreased fetal movements. or to identify areas of concern and to sense check that
Audit Commission improvements are real and not the result of changes in coding Please note the Audit Commission closed 31st March 2015, or recording. however reference is made to it in a mandated statement. Datix incident reporting system From 2014 responsibility for coding and costing assurance An electronic, web based reporting incident reporting system transferred to Monitor and then NHS Improvement. From used by many NHS organisations including Western Sussex. 2016/17 this programme applied new methodology and there is no longer a standalone ‘costing audit’ with errors rates. Defined Daily Doses per 1000 bed days
A statistical measure used to compare drug usage between Bioquell machine different drugs or healthcare settings. A mobile cleansing unit which uses high concentrations of hydrogen peroxide vapour to eliminate bacteria, thereby Deconditioning promoting robust infection prevention and control. Frail older people in hospital are more at risk of losing muscle
strength and mobility from prolonged hospital stays and Care Quality Commission (CQC) therefore are at an increased risk of falls, confusion and The independent regulator of all health and social care demotivation. services in England.
DOCMAN system Care bundle An online workflow management system which the Trust uses Care bundles are small sets of evidence-based interventions to manage patient referrals. which, when used together consistently by a single healthcare team, have been shown to significantly improve patient Electronic whiteboard outcomes. A web based application designed by our IT developers to
manage non-elective admissions to the Trust. Clinical audit
The process by which clinical staff measure how well we Emergency Care Data Set perform certain tests and treatments against agreed A new national data set which all emergency departments standards. Plans for improvement are developed if required must contribute to. The data set will allow national data by the findings of an audit. comparison and provide a better picture of all emergency
attendances across the country. Code red process
A process used in radiology services for the rapid Evolve communication of findings that are both significant and The new electronic medical records system used in the Trust unexpected. which provides staff with instantaneous access to patient
health care records via secure log in. Commissioning for Quality and Innovation (CQUIN)
The CQUIN framework supports improvements in the quality Friends and Family Test (FFT) of services and the creation of new, improved patterns of care A feedback tool which offers patients of NHS-funded services by linking a proportion of providers’ income to the the opportunity to provide feedback about the care and achievement of agreed quality improvement goals. Page 92 | Quality Report 2017/18 third draft
treatment they have received. Patients are asked how likely clinical effectiveness, and patient experience. Quality they are to recommend the service they have used and indicators reported to the Board are selected to provide a provide further detail about their experience. NHS comprehensive picture of clinical quality in areas identified organisations monitor the number of patients who complete a through our clinical quality strategy and the priorities for survey by looking at FFT response rates. quality improvement set out in our quality reports. We consult with external stakeholders and patient representatives, as well Healthcare associated infections as our own staff, about quality, ensuring that a broad range of Healthcare associated infections (HCAI) are infections interests are reflected in the planning of quality developments resulting from clinical care or treatment in hospital, as an and reporting of quality indicators. The Trust reviews the set inpatient or outpatient. of key metrics that it provides to the Trust Board each year to
ensure that they remain appropriate to providing assurance Healthcare Safety Investigation Branch (HSIB) about the high quality and safety of patient care. HSIB offers an independent service for England, guiding and supporting NHS organisations on investigations, and also Mortality review conducting safety investigations. A process in which the circumstances surrounding the care of
a patient who died during hospitalisation are systematically Hospital Standardised Mortality Ratio (HSMR) examined to establish whether the clinical care the patient A risk adjusted mortality tool produced by Dr Foster received was appropriate, provide assurance on the quality of Intelligence reviewing in-hospital deaths from 56 diagnosis care and identify learning, plans for improvement and groups (medical conditions) with the highest mortality. A rate pathway redesign where required. greater than 100 suggests a higher than average standardised mortality rate and a rate less than 100 a better MUST (Malnutrition Universal Screening Tool) than average mortality rate. A screening tool to identify and treat adults at risk of
Human Factors malnutrition. An established scientific discipline used by many safety National Confidential Enquiries critical industries especially the aviation industry. It aims to These are similar to clinical audits but use in depth reviews of optimise human performance through better understanding of what occurred in order to develop new recommendations for individual behaviour and staff interactions with each other and better care of patients. their environments; improving patient safety and clinical excellence. National Confidential Enquiry into Patient Outcome and Death
(NCEPOD) Integrated services NCEPOD assists in maintaining and improving standards of A person-centred, co-ordinated approach to meet the needs healthcare for adults and children by reviewing the of patients in a more holistic way as opposed to single management of patients and by undertaking confidential episodes of care. surveys and research.
Kaizen National Inpatient Survey Kaizen is a Japanese concept that, loosely translated, means A CQC commissioned annual inpatient survey which is part of “continuous improvement”. It comes from two words, Kai = a national programme aimed at improving patients’ change and Zen = ideal state; to break down or change the experiences while in hospital. It includes measures that relate current situation and then build it into the ideal state. strongly to the care and compassion shown by individual staff
Local quality indicators and the organisation as a whole. Our local quality indicators are drawn from the Trust Quality
Scorecard which is reviewed by the Trust Board each month.
They relate to the three domains of quality: patient safety, Page 93 | Quality Report 2017/18 third draft
National Early Warning Score (NEWS) improve performance. Further information can be found here: Developed by the Royal College of Physicians for use in http://www.westernsussexhospitals.nhs.uk/your- acute and ambulance settings to improve detection and trust/performance/patient-first/ response to clinical deterioration in adult patients.
Patientrack NHS Foundation Trust Our electronic advanced observation and assessment system Foundation trusts are a form ‘public benefit corporation’ – that gives our nurses and doctors early warning if a sick healthcare organisations that exist solely for the benefit of patient’s condition is deteriorating; this helps early and their patients but which operate in a similar way to a effective intervention to get things back on course. commercial business. They are subject to less central government control and are free to set their own strategy for Patient Reported Outcome Measures (PROMs) (core improving and developing services in line with local priorities indicator) and needs, as well as to borrow money and invest surplus PROMs provide a patient perspective (via before and after income in new services, equipment and innovations. patient questionnaires) on the outcomes or quality of care
following four types of surgery in the NHS (currently hip and NHS Improvement knee replacements, groin hernia and varicose vein surgery). The organisation responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide Perinatal mental health issues NHS-funded care. They hold providers to account and help Mental health issues occurring during pregnancy or in the first the NHS to meet its short-term challenges and secure its year following the birth of a child. They affect up to 20% of future. women and cover a wide range of conditions.
NHS Outcomes Framework Readmissions (core indicator) A set of indicators developed by the Department of Health to If a patient does not recover well, it is more likely that further monitor the health outcomes of adults and children in hospital treatment will be required, which is the reason that England. The framework provides an overview of how the hospital readmission are commonly used as an indicator of NHS is performing. the success in helping patient recovery.
NHS Safety Thermometer Responsiveness to the personal needs of patients (core A point of care measurement tool for improvement that indicator) focuses on the four most commonly occurring harms in The indicator value is based on the average score of five healthcare: pressure ulcers, falls, urinary tract infections (in questions from the National Inpatient Survey, which measures patients with a catheter) and venous thromboembolisms. the experiences of people admitted to NHS hospitals.
Novel oral anticoagulants (NOACs) Risk adjusted mortality tool A new class of anticoagulant drug which prevent or interrupt In order to compare mortality rates between different NHS the formation of blood clots. NOACs are less influenced by Trusts it is necessary to consider the mix of patients treated. diet and other medicines compared to the traditional For example a trust with a very elderly, complex patient group anticoagulant warfarin. might have a higher crude mortality rate than one that had
younger or less acutely ill patients. To adjust for this it is Order Comms System necessary to standardise the mortality rate for trusts, thereby An electronic system to allowing diagnostic tests and taking into account the patient mix. This is usually done by treatment services to be requested instantly. calculating an ‘expected’ mortality rate based on the age,
Patient First Improvement System (PFIS) diagnosis and procedures carried out on the actual patients PFIS is the Lean management programme designed by the treated by each trust. Trust to develop our people’s ability to solve problems and Page 94 | Quality Report 2017/18 third draft
Sepsis Sustainability and Transformation Partnership A life threatening condition that arises when the body’s New partnerships between NHS and local councils across response to an infection injures its own tissues and organs. England which will develop proposals to improve health and care.
Summary Hospital-level Mortality Indicator (SHMI) (core Serious incident indicator) An incident where the consequences are so significant or the The SHMI is a risk adjusted mortality tool used to provide a potential for learning so great, that additional resources are ratio of the actual number of patients who die following justified to produce a comprehensive response. They can hospitalisation at the Trust and the number who would be affect patients directly but also include incidents which may expected to die on the basis of average England figures. It indirectly impact on patient safety or an organisation’s ability covers all deaths reported of patients who were admitted to to deliver on-going healthcare. non-specialist acute trusts in England and either die while in Single Oversight Framework (SOF) hospital or within 30 days of discharge. NHS Improvement’s monitoring system to oversee NHS providers’ performance across five themes. To Come In (TCI) card They ensure all the teams involved in a patient’s journey, from Staff who would recommend the trust to their family or friends recommendation for surgery through booking and pre- (core indicator) assessment and the operation itself, have the right A question in the national NHS Staff Survey which assesses information to make sure the patient receives safe, high how likely staff are to recommend the Trust as a provider of quality care. care to their friends and family.
Value stream mapping Structured judgement mortality review One of the tools used in our PFIS for assessing a current A validated mortality review process in which trained clinicians process and redesigning it to make it more efficient. review medical records in a critical manner to comment on the Venous thromboembolism (VTE) (core indicator) quality of healthcare in a way that allows any judgement to be A condition in which blood clots forms, such as deep vein reproducible. thrombosis (most often in the deep veins of the leg) or
pulmonary embolism (a clot in the lungs).
Page 95 | Quality Report 2017/18 third draft
Western Sussex Hospitals NHS Foundation Trust Worthing Hospital Lyndhurst Road Worthing West Sussex BN11 2DH
01903 205111
www.westernsussexhospitals.nhs.uk
@westernsussex
Western Sussex Hospitals
To: Trust Board Date of Meeting: 26th April 2018 Agenda Item: 10
Title Provider Self-Certification Responsible Executive Director Marianne Griffiths, Chief Executive Prepared by Brian Courtney, Interim Director of Corporate Governance Status Disclosable Summary of Proposal The Board of Directors is asked to Approve that the attached statement (Annex 1), which are required by NHS Improvement under the NHS Provider Licence, Risk Assessment Framework and the Health and Social Care Act 2012. Implications for Quality of Care No direct implications. Link to Strategic Objectives/Board Assurance Framework Good Corporate Governance standards. Financial Implications No direct implications. Human Resource Implications N/A Recommendation The Board is asked to APPROVE that the self-certifications are made and signed by the Chair and Chief Executive. Communication and Consultation N/A Appendix 1. Provider Self-Certification FTG6(3) and FT4(8) 2. Certificate on Training of Governors
BOARD CORPORATE GOVERNANCE STATEMENT – April 2017
1.0 PURPOSE AND RECOMMENDATION
The Board of Directors is asked to approve the signing of the following certificates:
1. Licence Condition 6 self-certification (Annex 1)
The Board must certify that it has taken all necessary precautions to comply with the Trust Provider Licence, the NHS Act and NHS Constitution. Confirmation statements are provided but further detail is captured within the Annual Governance Statement as part of the Trust Annual Report.
2. Certificate on Training of Governors (Annex 2)
Confirmation statements are not required for this self-certification. However, the development of Governors forms part of the Annual Report, the content for this section has been agreed by the Lead Governor.
2.0 SUMMARY AND CONCLUSION
The Board is asked to APPROVE that the self-certifications are made and signed by the Chair and Chief Executive.
Annex 1
Annex 2
Appendix 1
Annex 1
Certification on training of governors (FTs only)
The Board are required to respond "Confirmed" or "Not confirmed" to the following statements. Explanatory information should be provided where required.
2 Training of Governors
1 The Board is satisfied that during the financial year most recently ended the Licensee has Confirmed provided the necessary training to its Governors, as required in s151(5) of the Health and Social Care Act, to ensure they are equipped with the skills and knowledge they need to undertake their role.
Signed on behalf of the Board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
Signature Signature
Name Mike Viggers Name Marianne Griffiths
Capacity Chair Capacity Chief Executive
Date 25 May 2017 Date 25 May 2017 Appendix 3
Declarations required by General condition 6 and Continuity of Service condition 7 of the NHS provider licence
The board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming another option). Explanatory information should be provided where required.
1 & 2 General condition 6 - Systems for compliance with license conditions (FTs and NHS trusts)
1 Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Confirmed Licensee are satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements OK imposed on it under the NHS Acts and have had regard to the NHS Constitution.
3 Continuity of services condition 7 - Availability of Resources (FTs designated CRS only) EITHER: 3a After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee Confirmed will have the Required Resources available to it after taking account distributions which might Please fill details in cell E22 reasonably be expected to be declared or paid for the period of 12 months referred to in this OR 3b After making enquiries the Directors of the Licensee have a reasonable expectation, subject to what is explained below, that the Licensee will have the Required Resources available to it after taking into account in particular (but without limitation) any distribution which might reasonably be expected to be Please Respond declared or paid for the period of 12 months referred to in this certificate. However, they would like to draw attention to the following factors (as described in the text box below) which may cast doubt on the ability of the Licensee to provide Commissioner Requested Services. OR 3c In the opinion of the Directors of the Licensee, the Licensee will not have the Required Resources Please Respond available to it for the period of 12 months referred to in this certificate.
Statement of main factors taken into account in making the above declaration In making the above declaration, the main factors which have been taken into account by the Board of Directors are as follows: key risks are set out in the Trust Annual governance Statement and include workforce availability and financial pressures in the Local Health economy.
Signed on behalf of the board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
Signature Signature
Name Mike Viggers Name Marianne Griffiths
Capacity Chairman Capacity Chief Executive
Date 25 May 2017 Date 25 May 2017
To: Trust Board Date of Meeting: 26th April 2018 Agenda Item: 11
Title Notification of Sealed Documents Responsible Executive Director Marianne Griffiths, Chief Executive Prepared by Andy Gray, Director of Corporate Governance Status Disclosable Summary of Proposal
It is a requirement of the Trust Standing Orders (Part C : Section 17 and 18) that a register of sealing is maintained and use of the Common Seal is reported to the Trust Board Quarterly.
This report notifies the Board of an item signed under Seal during the period 1st January 2018 to 30th march 2018. Appendix 1 details use of the Common Seal during this period. Implications for Quality of Care None Identified Link to Strategic Objectives/Board Assurance Framework Links to good governance requirements, Trust standing Orders state reporting requirement to Trust Board. Financial Implications Financial implications in relation to possible sales receipts and associated costs. Human Resource Implications None Identified Recommendation The Board is asked to: Note the contents of this report. Communication and Consultation Not applicable Appendices Appendix I: Register of Use of Common Seal
Appendix 1
REGISTER OF SEALING
It is a requirement of the Trust Standing Orders (Part C: Section 17 and 18) that a register of sealing is maintained and use of the Common Seal is reported to the Trust Board Quarterly.
For the period 1st January 2018 to 31st March 2018
No. Date of Title of Sealed Document, Signed in Presence Of Signed in Presence of Seal (1) (2) 36 19th Alterations (internal) to Ridgeworth House in Karen Geoghegan Denise Farmer (Chief January Liverpool Gardens. Signed under Seal as this (Chief Finance Officer) Workforce and 2018 property is subject to a lease. Organisational Development Officer)
To: Trust Board Date of Meeting: 26 April 2018 Agenda Item: 12
Title Trust Constitution - Amendments Responsible Directors Mike Viggers, Chair Prepared by Andy Gray, Corporate Governance Director Status Disclosable Summary of Proposal
It has been recognised by the Council of Governors that the Governor sections of the Trust Constitution had not been reviewed in detail since the formation of Western Sussex Hospitals NHS Foundation Trust in 2013. As such they undertook a review and proposed that mainly minor changes, clarifications and updating of the Constitution should be considered at the current time. The main changes proposed relate to the composition of the Council in terms of Elected and Appointed Governors.
It is recommended that the Trust Board approve the amendments, as proposed, to Governor sections of the Western Sussex Hospitals NHS Foundation Trust Constitution.
The Council of Governors approved the amendments to the Governor sections of the Constitution at their meeting which took place on the 15th March 2018. The Council of Governors Terms of Reference will also be reviewed and be brought to the meeting in June 2018 for approval. Implications for Quality of Care No direct implications Link to Strategic Objectives/Board Assurance Framework No direct implications Financial Implications No direct implications Human Resource Implications No direct implications
Recommendation The Council of Governors is asked to agree the proposed amendments to the Western Sussex Hospitals NHS Foundation Trust Constitution as outlined in Annex 4 and 6 Communication and Consultation Chair, NHS Improvement , Board Appendices 1. Updated Annex 4 – Composition of Council of Governors - with tracked changes 2. Updated Annex 4 Composition of Council of Governors - final version 3. Updated Annex 6 – Additional Provisions – Council of Governors with tracked changes 4. Updated Annex 6 – Additional Provisions - final version
This report can be made available in other formats and in other languages. To discuss your requirements please contact, Company Secretary, on [email protected] or 01903 285288.
This report can be made available in other formats and in other languages. To discuss your requirements please contact, Company Secretary, on [email protected] or 01903 285288.
To: Trust Board Agenda Item: 12 From: Mike Viggers, Chair Date: 26 April 2018
FOR DECISION
PROPOSAL TO AMEND THE TRUST CONSTITUTION
1. INTRODUCTION
1.1. The Western Sussex Hospitals NHS Foundation Trust’s (WSHFT) Constitution sets out the way in which the Trust will be governed and operate its key governance structures.
1.2. The Constitution is based on the Foundation Trust national model.
1.3. The Trust Board is asked to approve for the proposed amendments to the Governor sections of the Trust Constitution.
1.4. It should be noted that amendments to the Trust Constitution require the dual approval of the Council of Governors and the Trust Board.
1.5. The proposals to update the Governor sections of the Trust Constitution were discussed and agreed as outlined below at the Council of Governors meeting held on the 15th March 2018.
1.6. Following approval of the final amendments from both the Council of Governors and the Trust Board the updated Constitution will be lodged with NHS Improvement in accordance with the Trust’s Constitution.
2. BACKGROUND
2.1 It had been recognised by the Council of Governors that the Governor sections of the Trust Constitution had not been reviewed in detail since the formation of Western Sussex Hospitals NHS Foundation Trust in 2013
2.2 A working group of Governors was established and met twice during the autumn of 2017 to review the relevant sections of the Trust Constitution and to make any recommendations for change to the Council of Governors.
2.3 The group considered possible forthcoming changes which might emerge from the establishment of the Sussex and East Surrey Sustainability and Transformation Plan and any ongoing working relationship with Brighton and Sussex University Hospitals. As a result they proposed that mainly minor changes, clarifications and updating of the Constitution and the Council of Governors Terms of Reference would be appropriate at the current time.
2.4 The working group reviewed in detail the following areas:-
• The size of the Council of Governors – 28 Members of Council was considered the right size.
• The composition of the Council of Governors – to ensure that it remained representative of the local population at the current time.
• The tenure of Governors – other Trusts have different periods of periods of tenure. On balance it was agreed leave the period of tenure at two periods of three years. Retiring Governors would be welcome to continue their work as volunteers within the Trust and apply for re-election as Governors in due course.
• The role and commitment of Governors – it is important for Governors, especially prospective Governors, are clear about the full role and the commitment expected of them if they are to fulfill their responsibilities effectively.
• Recognition and operation of the Pre-Council of Governors Meetings – these meeting are an important precursor to Council Meetings
• Recognition and role of the Lead and Deputy Lead Governor – these Governors provide both day to day leadership of the elected governors and an effective conduit between the Council and the Chairman and senior staff of the Trust.
• Review of the Terms of Reference of the Council of Governors – these were agreed when the Foundation Trust was created and need to reflect current working practices.
2.5 It is proposed that a review of the Terms of Reference of the Council of Governors takes place after approval is gained for the suggested amendments to the Trust Constitution.
3. PROPOSED AMENDMENTS TO THE GOVERNOR SECTIONS OF THE TRUST CONSTITUTION
3.1 The Council of Governors proposes the following amendments.
3.2 It should be noted that with these changes, that the overall membership of the Council of Governors would stay the same at 28.
• There should be one Patient (Out of area) Governor. Currently there are three Patient Governors representing a constituency of 264.
• That the representation of the Public Elected Constituencies should be :
Current number of Proposed number of Governors Governors Adur 2 2 Arun 4 5 Chichester 3 3 Horsham 1 1 Worthing 3 3 Patient (Out of area) 3 1
• Arun District has the largest population within the area covered by the Trust. To reflect this it is proposed that there is one additional elected Governor for this constituency. Page 2 of 3
• Arun District Council should also be asked to nominate an appointed Governor to represent them on the WSHFT Council of Governors. Currently both Chichester District Council and Worthing Borough Council are represented on the Council of Governors.
• The possible tenure of Governors should remain at two periods of three years in line with the terms of office on the Trust’s Non-Executive Directors.
• There should be reference in the Trust’s Constitution to the Pre-Council of Governors meeting.
• There should be reference in the Trust’s Constitution to the Role of Lead and Deputy Lead Governors.
4. RECOMMENDATION
4.1. It is recommended that the Trust Board approves amendments to Annex 4 and 6 of the Governor Sections of the Western Sussex Hospitals NHS Foundation Trust Constitution.
5. NEXT STEPS
5.1 As part of the review the Council of Governors proposed that the role that all volunteers within the Trust play should be recognised and as such should be represented on the WSHFT Council of Governors. At their meeting which took place on the 15th March 2018 the Governors debated in detail representation of the Trust Volunteers and the Friends Groups on the Council of Governors. The Council of Governors agreed to discuss this further and to bring an update to a future meeting.
Page 3 of 3 Appendix 1 Formatted: Right
ANNEX 4 – COMPOSITION OF COUNCIL OF GOVERNORS
Elected Governors
Constituency Area/Class Number Public Adur 2 Public Arun 4 5 Public Chichester 3 Public Horsham 1 Public Worthing 3
Patients None 3 1
Staff Medical and Dental (registered practitioners) 1 Staff Nursing & Midwifery 1 Staff Scientific, Technical and Professional (including Allied Health Professionals) 1 Staff Additional Clinical Services 1 Staff Estates and Ancillary 1 Staff Administrative and Clerical 1 Total Number of Elected Governors 22 21
Appointed Governors
Type Governor Appointed By: Number Local Authority Arun District Council 1 Chichester District Council 1 Worthing Borough Council 1 West Sussex County Council 1 Partnership* Brighton & Sussex Medical School 1 Partnership* University of Brighton 1 Partnership* A governor shall be appointed, by agreement amongst all the following 1 organisations, from time to time for a 3-year appointment (Subject to Section
13.3 and 13.4 of the constitution). In the absence of agreement amongst the
organisations, the appointment shall be by rotation in the order listed
below. A governor appointed by these organisations may hold office for a
period of up to 3 years and at the end of his/her term s/he shall be eligible for
re-appointment for one further term of up to 3 years only – maximum of 6
years
The Friends of Chichester Hospitals
The Friends of Worthing Hospitals
The League of Friends of Southlands Hospital Total Number of Appointed Governors 6 7
Total Number of Governors 28
1 Appendix 1 Formatted: Right
*Note: For the purposes of the Trust Constitution a Partnership organisation is a body as detailed in Schedule 7 of the National Health Service Act 2006 (as amended from time to time).
2 Appendix 2
ANNEX 4 – COMPOSITION OF COUNCIL OF GOVERNORS
Elected Governors
Constituency Area/Class Number Public Adur 2 Public Arun 5 Public Chichester 3 Public Horsham 1 Public Worthing 3
Patients None 1
Staff Medical and Dental (registered practitioners) 1 Staff Nursing & Midwifery 1 Staff Scientific, Technical and Professional (including Allied Health Professionals) 1 Staff Additional Clinical Services 1 Staff Estates and Ancillary 1 Staff Administrative and Clerical 1 Total Number of Elected Governors 21
Appointed Governors
Type Governor Appointed By: Number Local Authority Arun District Council 1 Chichester District Council 1 Worthing Borough Council 1 West Sussex County Council 1 Partnership* Brighton & Sussex Medical School 1 Partnership* University of Brighton 1 Partnership* Partnership* A governor shall be appointed, by agreement amongst all the following organisations, from time to time for a 3-year appointment (Subject to Section 13.3 and 13.4 of the constitution). In the absence of agreement amongst the organisations, the appointment shall be by rotation in the order listed below. A governor appointed by these organisations may hold office for a period of up to 3 years and at the end of his/her term s/he shall be eligible for re-appointment for one further term of up to 3 years only – maximum of 6 1 years
The Friends of Chichester Hospitals The Friends of Worthing Hospitals The League of Friends of Southlands Hospital Total Number of Appointed Governors 7
Total Number of Governors 28
*Note: For the purposes of the Trust Constitution a Partnership organisation is a body as detailed in Schedule 7 of the National Health Service Act 2006 (as amended from time to time).
1 Appendix 3 Formatted: Right
ANNEX 6 – ADDITIONAL PROVISIONS – COUNCIL OF GOVERNORS
1. INTERPRETATION
1.1 In these Provisions, the clauses relating to Interpretation in the Constitution shall apply and the words and expressions defined in the Constitution shall have the same meaning.
2. APPLICATION OF THESE PROVISIONS
2.1 These Provisions apply to all meetings of the Council of Governors (“the Council”) and all other relevant activities of the Governors. All Governors, Non-executive Directors and staff are required to abide by these Provisions, which also apply to any persons attending meetings of the Council.
2.2 Except where required by law or the constitution, at any meeting of the Council the Chairman (or in his absence, the person deputising for him) shall be the final authority on the interpretation of these Provisions (on which he should be advised by the Chief Executive and the Secretary).
2.3 Whilst the Secretary shall be responsible for ensuring that relevant staff are made aware of these Provisions, staff members are expected to familiarise themselves with the Provisions.
2.4 In the event of any actual or suspected non-compliance with these Provisions, the Governor or member of staff identifying such shall report it to the Secretary within 14 calendar days of the actual or suspected non-compliance being identified. The Secretary shall be responsible for taking action in respect of the report, which shall, where non-compliance is identified, include a report to the next scheduled meeting of the Council. Such a report shall be recorded in the minutes of the Council meeting and, subject to the Chairman’s decision, shall be reported to the Board of Directors (“the Board”).
3. APPOINTMENT AND REMOVAL OF GOVERNORS
Election and Appointment to Office
3.1 Governors shall be elected or appointed by the means and on terms of office as prescribed by this constitution.
3.2 As more fully detailed in clauses 3.3-3.10 below, the first election to the Council shall, in order that future elections shall occur on a phased basis, be conducted in such a way as to result in the initial terms of office for Governors set out below:
Constituency Class 3-year 2-year Total terms terms Public Adur 1 1 2 Public Arun 2 2 4 Public Chichester 2 1 3 Public Horsham 1 0 1 Public Worthing 2 1 3 Appendix 3 Formatted: Right
Patients None 2 1 3 Staff Medical and Dental 1 0 1 Staff Nursing & Midwifery 0 1 1 Staff Additional Clinical Services 1 0 1 Staff Scientific, Technical, 0 1 1 Professional Staff Estates & Anciliary 1 0 1 Staff Administrative and Clerical 0 1 1 Totals 12 10 22
3.3 In relation to the first election to the Council, for the Adur class of the public constituency, the candidate with the highest number of votes shall hold office for a period of three years, except as otherwise provided by this Constitution, before the next election in relation to his office takes place. The candidate with the second highest number of votes shall hold office for a period of two years, except as otherwise provided by this Constitution, before the next election in relation to his office takes place.
3.4 In relation to the first election to the Council, for the Arun class of the public constituency, the two candidates with the first and second highest number of votes shall each hold office for a period of three years, except as otherwise provided by this Constitution, before the next election in relation to their respective offices takes place. The candidates with the third and fourth highest number of votes shall each hold office for a period of two years, except as otherwise provided by this Constitution, before the next election in relation to their respective offices takes place.
3.5 In relation to the first election to the Council, for the Chichester and Worthing classes in the public constituency, the two candidates with the first and second highest number of votes shall each hold office for a period of three years, except as otherwise provided by this Constitution, before the next election in relation to their respective offices takes place. The candidate with the third highest number of votes shall hold office for a period of two years, except as otherwise provided for by this Constitution, before the next election in relation to his office takes place.
3.6 In relation to the first election to the Council, for the Horsham class in the public constituency, the candidate with the highest number of votes shall hold office for a period of three years before the next election in relation to his office takes place.
3.7 In relation to the first election to the Council, for the patients constituency, the two candidates with the first and second highest number of votes shall each hold office for a period of three years, except as otherwise provided by this Constitution, before the next election in relation to their respective offices takes place. The candidate with the third highest number of votes shall hold office for a period of two years before the next election in relation to his office takes place.
3.8 In relation to the first election to the Council, for the Medical & Dental, Additional Clinical Services and Estates & Anciliary classes in the staff constituency, the candidate with the highest number of votes shall hold office for a period of three years before the next election in relation to his office Appendix 3 Formatted: Right
takes place. For the Nursing & Midwifery, Scientific, Technical and Professional and Administrative & Clerical classes in the staff constituency, the candidate with the highest number of votes shall hold office for a period of two years before the next election in relation to his office takes place.
3.9 In all cases described within clauses 3.3 to 3.7 above, in relation to the first election to the Council, in the case of an uncontested election terms of office shall be decided by drawing lots, which will take place at a meeting of the Council of Governors.
3.10 With the exception of the initial terms of office, in relation to the first election to the Council set out above, Governors will be elected for three-year terms.
3.11 A Governor shall be eligible for re-election or re-appointment at the end of his first term, for one further term. A Governor may not serve as a Governor for more than two consecutive terms (resulting in a maximum of six years) without a break of at least two years. A Governor who resigns or whose tenure of office is terminated shall not be eligible for re-appointment or to stand for re-election for a period of three years from the date of his resignation or removal from office or the date upon which any appeal against his removal from office is disposed of whichever is the later except by resolution carried by a majority of the Council present and voting at a general meeting.
3.12 A Governor shall within 21 days of election or appointment sign and deliver to the Secretary a declaration in the form prescribed at Appendix A. No Governor shall be entitled to vote or count in the quorum at a meeting of the Council of Governors until his declaration has been received by the Secretary. Such a declaration shall be valid for the Governor’s term of office.
Removal or Resignation from Office
3.13 A person shall not be eligible to become or continue in office as a Governor if:
3.13.1 any of the grounds contained in paragraph 14 of the Constitution apply to him;
3.13.2 in the case of an Elected Governor, he ceases to be eligible to be a member of the Trust or constituency. For the avoidance of doubt and in accordance with Constitution clause 13.2, a Public Governor who ceases to be eligible to be a member of that Public Constituency by virtue of moving to another area, shall cease to hold office. Subject to clause 3.11 of these Provisions and the Constitutional provisions in respect of eligibility for holding office as a Governor, a person ceasing to hold office by the means described in this clause shall be eligible to stand for election in the area to which he has moved.
3.13.3 he is a member of a Staff Class and any professional registration relevant to his eligibility to be a member of that Staff Class has been suspended for a continuous period of more than six months;
3.13.4 in the case of an Appointed Governor, the appointing organisation withdraws its appointment of him or the organisation ceases to exist; Appendix 3 Formatted: Right
3.13.5 he has within the preceding two years been lawfully dismissed otherwise than by reason of redundancy from any paid employment with a health service body;
3.13.6 he is a person whose term of office as the chair or as a member or director of a health service body has been terminated on the grounds that his continuance in office is no longer in the best interests of the health service, for non-attendance at meetings or for non-disclosure of a pecuniary interest;
3.13.7 he has had his name removed by a direction under Section 154 of the 2006 Act from any list prepared under Part 4 of that Act and has not subsequently had his name included in such a list;
3.13.8 he has failed to make, or has falsely made, any declaration as required to be made under Section 60 of the 2006 Act or has spoken or voted in a meeting on a matter in which they have direct or indirect pecuniary or non-pecuniary interest and he is judged to have acted so by a majority of not less than three quarters of the Council.
3.13.9 Monitor has exercised its powers to remove him as a Governor of the Trust or has suspended him from office or has disqualified him from holding office as a Governor of the Trust for a specified period or Monitor has exercised any of those powers in relation to him on any other occasion whether in relation to the Trust or some other NHS Foundation Trust;
3.13.10he has received a written warning from the Trust for verbal and/or physical abuse towards any person;
3.13.11he does not agree to (or, having agreed, fails to) abide by the values as published by the Trust;
3.13.12he has been placed on the registers of Schedule 1 Offenders pursuant to the Sexual Offences Act 2003 (as amended) and/or the Children and Young Person's Act 1933 to 1969 (as amended) and his conviction is not spent under the Rehabilitation of Offenders Act 1974;
3.13.13he is incapable by reason of mental disorder, illness or injury in managing and administering his property and/or affairs;
3.13.14he is a member of the UK Parliament;
3.13.15he is a Director of the Trust or a Governor of another NHS Foundation Trust;
3.13.16he is a member of a relevant local authority Overview and Scrutiny Committee; or
3.13.17he is not 16 years of age, or older, at the closing date for nominations for election or appointment.
Appendix 3 Formatted: Right
3.13.18his term of office is terminated pursuant to paragraph 3.14 below;
Termination of Office
3.14 A Governor’s term of office shall be terminated:
3.14.1 by the Governor giving notice in writing to the Secretary of his resignation from office at any time during that term of office;
3.14.2 by a majority of the Governors present and voting at a meeting of the Council if any grounds exist under paragraph 3.13 above
3.14.3 by a majority of the Governors voting at a meeting of the Council if he has failed to attend two successive meetings of the Council unless the Council is satisfied that:
(a) the absence was due to reasonable cause; and
(b) that the Governor will resume attendance at meetings of the Council within such period as it considers reasonable in the circumstances.
3.14.4 if the Council resolves to terminate his term of office on the grounds that in the reasonable opinion of three quarters of the Governors present and voting at a meeting of the Council convened for that purpose that his continuing as a Governor would or would be likely to:
(a) prejudice the ability of the Trust to fulfill its principal purpose or of its purposes under this Constitution or otherwise to discharge its duties and functions; or
(b) prejudice the Trust’s work with other persons or body with whom it is engaged or may be engaged in the provision of goods and services; or
(c) adversely affect public confidence in the goods and services provided by the Trust; or
(d) otherwise bring the Trust into disrepute or be detrimental to the interests of the Trust.
3.14.5 if three quarters of the Governors present and voting at a meeting of the Council resolve that:
(a) it would not be in the best interests of the Trust for that person to continue in office as a Governor; or
(b) the Governor is a vexatious or persistent litigant or complainant with regard to the Trust’s affairs and his continuance in office would not be in the best interests of the Trust; or
(c) the Governor has failed to or refused to undertake and/or satisfactorily complete any training which the Council has Appendix 3 Formatted: Right
required him to undertake in his capacity as a Governor by a date six months from the date of his election or appointment; or
(d) he has in his conduct as a Governor failed to comply in a material way with the values and principles of the National Health Service or the Trust, the Constitution, and/or the Terms of Authorisation; or
(e) he has committed a material breach of any Role Description or Code of Conduct applicable to Governors of the Trust and/or these Provisions.
3.15 Where a person has been elected or appointed to be a Governor and he becomes disqualified from that appointment he shall notify the Secretary in writing of such disqualification as soon as practicable and in any event within 14 calendar days of first becoming aware of those matters which rendered him disqualified, and the Secretary shall report the matter to the Council and the Board.
3.16 Upon a Governor resigning or ceasing to be eligible to continue in office that person shall cease to be a Governor and his name shall be removed from the Register of Governors.
Vacancies
3.17 Where a Governor resigns or his office is terminated, elected Governors shall be replaced in accordance with paragraphs 3.19 and 3.20 below and, in the case of Appointed Governors, the Trust shall within 30 days of the vacancy having arisen invite the appointing body to appoint a new Governor to hold office for the remainder of the term of office.
3.18 Where a Governor is declared ineligible or disqualified from office or his term of office as a Governor has been terminated (otherwise than as a consequence of his own resignation) and that person disputes the decision, he shall as reasonably practicable be entitled to attend a meeting with the Chairman and Chief Executive of the Trust, who shall use their reasonable endeavours to facilitate such a meeting, to discuss the decision with a view to resolving any dispute which may have arisen but the Chairman and Chief Executive shall not be entitled to rescind or vary the decision which has already been taken.
3.19 Where an Elected Governor ceases to hold office during (the first six months) his term of office, the Trust shall offer the unsuccessful candidate who secured the highest number of votes in the last election for the area or class in which the vacancy has arisen, the opportunity to assume the vacant office for the unexpired balance of the retiring Governor’s term of office. If that candidate is unwilling, or unable, to fill the vacancy it will then be offered to that unsuccessful candidate who secured the next highest number of votes.
3.20 If there is no reserve candidate, or the reserve candidate is unable or unwilling to fill the vacancy, the office will stand vacant until the next scheduled election unless by so doing this causes the aggregate number of Governors who are Public or Patient Governors to be less than half the total membership of the Council. In that event an election will be held in Appendix 3 Formatted: Right
accordance with the Election Scheme as soon as reasonably practicable. A candidate elected mid-term, in this manner, shall have a period of tenure expiring at the next general election and, if elected at that general election, shall be deemed to have served two terms at the expiry of the further term.
3.21 No defect in the election or appointment of a Governor nor any deficiency in the composition of the Council shall affect the validity of any act or decision of the Council.
4. DECLARATIONS AND REGISTER OF GOVERNORS’ INTERESTS
4.1 In accordance with the Constitution, Governors are required to declare on election or appointment and in the manner prescribed below any direct or indirect pecuniary interest and any other interest which is relevant and material to the business of the Trust. The responsibility for declaring an interest is solely that of the Governor concerned.
4.2 Such a declaration shall be made by completing and signing a form, as prescribed by the Secretary from time to time setting out any interests required to be declared in accordance with the Constitution or these Provisions and delivering it to the Secretary within 28 days of a Governor’s election or appointment or otherwise within seven days of becoming aware of the existence of a relevant or material interest. The Secretary shall amend the Register of Interests upon receipt of notification within one month.
4.3 If a Governor is present at a meeting of the Council of Governors and has an interest of any sort in any matter which is the subject of consideration, he shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not vote on any question with respect to the matter and, if he has declared a pecuniary interest, he shall not take part in the consideration or discussion of the matter.
4.4 The term “relevant and material interests” may include (but may not be limited to) the following:
4.4.1 directorships, including non-executive directorships held in private or public limited companies (with the exception of those of dormant companies);
4.4.2 ownership or part-ownership or directorships of companies or other types of organisation which are likely to or are seeking to do business with the NHS;
4.4.3 a position of authority in a charity or voluntary organisation operating in the field of health and social care, including any which are contracting for or are commissioning NHS services;
4.4.4 any connection with an organisation, entity or company considering entering into or having entered into a financial arrangement with the Trust, including but not limited to, lenders or banks;
4.4.5 research funding/grants that may be received by an individual or their department;
Appendix 3 Formatted: Right
4.5 Any traveling or other expenses or allowances payable to a Governor in accordance with this Constitution shall not be treated as a pecuniary interest.
4.6 Subject to any other provision of this Constitution, a Governor shall be treated as having an indirect pecuniary interest in a contract, proposed contract or other matter, if:
4.6.1 he, or a nominee of his, is a director of a company or other body not being a public body, with which the contract was made or is proposed to be made or which has a direct pecuniary interest in the other matter under consideration; or
4.6.2 he is a partner, associate or employee of any person with whom the contract was made or is proposed to be made or who has a direct pecuniary interest in the same.
4.7 A Governor shall not be treated as having a pecuniary interest in any contract, proposed contract or other matter by reason only:
4.7.1 of his membership of a company or other body, if he has no beneficial interest in any securities of that company or other body;
4.7.2 of an interest in any company, body, or person with which he is connected, which is so remote or insignificant that it cannot reasonably be regarded as likely to influence a Governor in the consideration or discussion of or in voting on, any question with respect to that contract or matter.
4.8 In the case of persons living together the interest of one partner or spouse shall, if known to the other, be deemed for the purposes of these Provisions to be also an interest of the other.
4.9 If a Governor has any doubt about the relevance of an interest, he must take advice from the Secretary.
5. STANDARDS OF CONDUCT
5.1 Governors shall comply with the terms of the Role Description for Governors which shall be approved by the Council and the Board, and which the Secretary shall issue to Governors upon election or appointment to the Council. The Governors shall also comply with any codes of conduct or other standards referenced in the Role Description.
5.2 In the event that there are concerns about a Governor’s performance or conduct, the Chairman, with the support of the (Lead Governor and) Secretary where necessary, will address these directly with the Governor concerned. Where necessary, the Chairman will make recommendations to the Council, including in respect of any proposal that the Council should remove the Governor from office in which case the Provisions of section 3 of these Provisions shall apply.
Appendix 3 Formatted: Right
6. REMUNERATION AND BUSINESS EXPENSES
6.1 Governors shall not receive remuneration.
6.2 The Trust is permitted to reimburse traveling expenses to Governors for attendance at meetings of the Council, or for any other business authorised by the Chairman as being reasonably within the role and duties of a Governor, at a rate and in accordance with a policy to be determined by the Board of Directors.
6.3 Expenses will be reimbursed by the Secretary on receipt of a completed and signed expenses form provided by the Secretary.
6.4 A summary of expenses paid to Governors will be published in the Annual Report.
7. COMPOSITION AND ROLE OF COUNCIL OF GOVERNORS
7.1 The composition of the Council shall be as set out in Annex 4 of the Constitution.
7.2 Subject to the 2006 Act (as amended and/or replaced from time to time), the role of the Council is defined in its Terms of Reference which shall be approved by the Council and the Board.
7.3 Subject to the 2006 Act (as amended and/or replaced from time to time), the role of the Chairman shall be as defined in a Role Description which shall be approved by the Council and the Board.
7.4 The role of the Deputy Chairman shall be as defined in a Role Description which shall be approved by the Council and the Board.
7.5 The role of the Lead Governor and Deputy Lead Governor shall be as defined in a Role Description which shall be approved by the Council and the Board.
8. COMMITTEES OF THE COUNCIL
8.1 Subject to the constitution, the Terms of Authorisation and such binding guidance as may be given by Monitor, the Council may and, if so required by Monitor, shall appoint committees of the Council consisting wholly or partly of members of the Trust (whether or not they include Governors) or wholly of persons who are not members of the Trust (whether or not they include Governors). The Council shall not delegate any of its powers to a committee but committees may act in an advisory capacity to assist the Council in carrying out its functions.
8.2 These Provisions of the Council shall apply with appropriate alteration to any committees established by the Council.
8.3 Each such committee or sub-committee shall have such terms of reference. Such terms of reference and the membership of committees or sub- committees shall be subject to approval by the Council.
8.4 The Council shall approve the appointment of the Chair and members for each of the committees which it has formally constituted. Where the Council Appendix 3 Formatted: Right
determines that persons who are neither Governors nor staff shall be appointed to a committee, the terms of such appointment shall be determined by the Council. The Council may request that external advisers assist them or any committee they appoint in carrying out its duties.
8.5 Elected and Appointed Governors may form a sub-committee – the Pre- Council of Governors Committee – to prepare for forthcoming Council Meetings.
9. SUSPENSION, AMENDMENT AND REVIEW OF THESE PROVISIONS
Suspension
9.1 These Provisions shall not be suspended except:
9.1.1 where urgent action is required and the Chairman considers it to be in the interests of the Trust to waive one or more of the Provisions, he may do so subject to such action being reported to the next meeting of the Council 9.1.2 at a meeting of the Council, at least half of the total number of Governors are present, such number to include not less than one third of the Public Governors, not less than one third of the Staff Governors and not less than one third of the Appointed Governors
9.2 Any decision to waive Provisions shall be recorded in the minutes of the next meeting of the Council and shall be reported to the Audit Committee.
Amendment and Review
9.3 These Provisions shall be reviewed one year after approval by the Council and then at least annually every three years thereafter.
9.4 These Provisions shall be amended only if:
9.4.1 the variation proposed does not contravene a statutory provision, the Terms of Authorisation or the Constitution; and 9.4.3 at least three quarters of the Governors present and voting at a meeting of the Council, including one Staff Governor, one Public Governor and one Appointed Governor are in favour of amendment. 9.4.4 The proposed amendment(s) has/have been discussed the Board.
9.5 All amendments to these Provisions shall be subject to approval through any process prescribed by Monitor. APPENDIX A
DECLARATION BY GOVERNOR
WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST (the "Trust")
I, ...... (insert full name) of ...... (insert address)
Hereby declare that I am entitled to:-
(a) be elected to the Council of Governors as a Governor elected by one of the public constituencies/ the staff constituencies* because I am a member of one of the public constituencies/ /staff constituencies *; or
(b) be appointed to the Council of Governors as a governor because I have been appointed by a nominating organisation and that I am not prevented from being a member of the Council of Governors of the Trust by paragraph 8 of Schedule 7 of the National Health Service Act 2006 or under the Constitution of the Trust and that I am entitled to vote at meetings of the Council of Governors as a governor pursuant to such appointment or election.
Signed ......
Print Name………………………………......
Date of Declaration ...... Appendix 4
ANNEX 6 – ADDITIONAL PROVISIONS – COUNCIL OF GOVERNORS
1. INTERPRETATION
1.1 In these Provisions, the clauses relating to Interpretation in the Constitution shall apply and the words and expressions defined in the Constitution shall have the same meaning.
2. APPLICATION OF THESE PROVISIONS
2.1 These Provisions apply to all meetings of the Council of Governors (“the Council”) and all other relevant activities of the Governors. All Governors, Non-executive Directors and staff are required to abide by these Provisions, which also apply to any persons attending meetings of the Council.
2.2 Except where required by law or the constitution, at any meeting of the Council the Chairman (or in his absence, the person deputising for him) shall be the final authority on the interpretation of these Provisions (on which he should be advised by the Chief Executive and the Secretary).
2.3 Whilst the Secretary shall be responsible for ensuring that relevant staff are made aware of these Provisions, staff members are expected to familiarise themselves with the Provisions.
2.4 In the event of any actual or suspected non-compliance with these Provisions, the Governor or member of staff identifying such shall report it to the Secretary within 14 calendar days of the actual or suspected non-compliance being identified. The Secretary shall be responsible for taking action in respect of the report, which shall, where non-compliance is identified, include a report to the next scheduled meeting of the Council. Such a report shall be recorded in the minutes of the Council meeting and, subject to the Chairman’s decision, shall be reported to the Board of Directors (“the Board”).
3. APPOINTMENT AND REMOVAL OF GOVERNORS
Election and Appointment to Office
3.1 Governors shall be elected or appointed by the means and on terms of office as prescribed by this constitution.
3.2 As more fully detailed in clauses 3.3-3.10 below, the first election to the Council shall, in order that future elections shall occur on a phased basis, be conducted in such a way as to result in the initial terms of office for Governors set out below:
Constituency Class 3-year 2-year Total terms terms Public Adur 1 1 2 Public Arun 2 2 4 Public Chichester 2 1 3 Public Horsham 1 0 1 Public Worthing 2 1 3 Appendix 4
Patients None 2 1 3 Staff Medical and Dental 1 0 1 Staff Nursing & Midwifery 0 1 1 Staff Additional Clinical Services 1 0 1 Staff Scientific, Technical, 0 1 1 Professional Staff Estates & Anciliary 1 0 1 Staff Administrative and Clerical 0 1 1 Totals 12 10 22
3.3 In relation to the first election to the Council, for the Adur class of the public constituency, the candidate with the highest number of votes shall hold office for a period of three years, except as otherwise provided by this Constitution, before the next election in relation to his office takes place. The candidate with the second highest number of votes shall hold office for a period of two years, except as otherwise provided by this Constitution, before the next election in relation to his office takes place.
3.4 In relation to the first election to the Council, for the Arun class of the public constituency, the two candidates with the first and second highest number of votes shall each hold office for a period of three years, except as otherwise provided by this Constitution, before the next election in relation to their respective offices takes place. The candidates with the third and fourth highest number of votes shall each hold office for a period of two years, except as otherwise provided by this Constitution, before the next election in relation to their respective offices takes place.
3.5 In relation to the first election to the Council, for the Chichester and Worthing classes in the public constituency, the two candidates with the first and second highest number of votes shall each hold office for a period of three years, except as otherwise provided by this Constitution, before the next election in relation to their respective offices takes place. The candidate with the third highest number of votes shall hold office for a period of two years, except as otherwise provided for by this Constitution, before the next election in relation to his office takes place.
3.6 In relation to the first election to the Council, for the Horsham class in the public constituency, the candidate with the highest number of votes shall hold office for a period of three years before the next election in relation to his office takes place.
3.7 In relation to the first election to the Council, for the patients constituency, the two candidates with the first and second highest number of votes shall each hold office for a period of three years, except as otherwise provided by this Constitution, before the next election in relation to their respective offices takes place. The candidate with the third highest number of votes shall hold office for a period of two years before the next election in relation to his office takes place.
3.8 In relation to the first election to the Council, for the Medical & Dental, Additional Clinical Services and Estates & Anciliary classes in the staff constituency, the candidate with the highest number of votes shall hold office for a period of three years before the next election in relation to his office Appendix 4
takes place. For the Nursing & Midwifery, Scientific, Technical and Professional and Administrative & Clerical classes in the staff constituency, the candidate with the highest number of votes shall hold office for a period of two years before the next election in relation to his office takes place.
3.9 In all cases described within clauses 3.3 to 3.7 above, in relation to the first election to the Council, in the case of an uncontested election terms of office shall be decided by drawing lots, which will take place at a meeting of the Council of Governors.
3.10 With the exception of the initial terms of office, in relation to the first election to the Council set out above, Governors will be elected for three-year terms.
3.11 A Governor shall be eligible for re-election or re-appointment at the end of his first term, for one further term. A Governor may not serve as a Governor for more than two consecutive terms (resulting in a maximum of six years) without a break of at least two years. A Governor who resigns or whose tenure of office is terminated shall not be eligible for re-appointment or to stand for re-election for a period of three years from the date of his resignation or removal from office or the date upon which any appeal against his removal from office is disposed of whichever is the later except by resolution carried by a majority of the Council present and voting at a general meeting.
3.12 A Governor shall within 21 days of election or appointment sign and deliver to the Secretary a declaration in the form prescribed at Appendix A. No Governor shall be entitled to vote or count in the quorum at a meeting of the Council of Governors until his declaration has been received by the Secretary. Such a declaration shall be valid for the Governor’s term of office.
Removal or Resignation from Office
3.13 A person shall not be eligible to become or continue in office as a Governor if:
3.13.1 any of the grounds contained in paragraph 14 of the Constitution apply to him;
3.13.2 in the case of an Elected Governor, he ceases to be eligible to be a member of the Trust or constituency. For the avoidance of doubt and in accordance with Constitution clause 13.2, a Public Governor who ceases to be eligible to be a member of that Public Constituency by virtue of moving to another area, shall cease to hold office. Subject to clause 3.11 of these Provisions and the Constitutional provisions in respect of eligibility for holding office as a Governor, a person ceasing to hold office by the means described in this clause shall be eligible to stand for election in the area to which he has moved.
3.13.3 he is a member of a Staff Class and any professional registration relevant to his eligibility to be a member of that Staff Class has been suspended for a continuous period of more than six months;
3.13.4 in the case of an Appointed Governor, the appointing organisation withdraws its appointment of him or the organisation ceases to exist; Appendix 4
3.13.5 he has within the preceding two years been lawfully dismissed otherwise than by reason of redundancy from any paid employment with a health service body;
3.13.6 he is a person whose term of office as the chair or as a member or director of a health service body has been terminated on the grounds that his continuance in office is no longer in the best interests of the health service, for non-attendance at meetings or for non-disclosure of a pecuniary interest;
3.13.7 he has had his name removed by a direction under Section 154 of the 2006 Act from any list prepared under Part 4 of that Act and has not subsequently had his name included in such a list;
3.13.8 he has failed to make, or has falsely made, any declaration as required to be made under Section 60 of the 2006 Act or has spoken or voted in a meeting on a matter in which they have direct or indirect pecuniary or non-pecuniary interest and he is judged to have acted so by a majority of not less than three quarters of the Council.
3.13.9 Monitor has exercised its powers to remove him as a Governor of the Trust or has suspended him from office or has disqualified him from holding office as a Governor of the Trust for a specified period or Monitor has exercised any of those powers in relation to him on any other occasion whether in relation to the Trust or some other NHS Foundation Trust;
3.13.10he has received a written warning from the Trust for verbal and/or physical abuse towards any person;
3.13.11he does not agree to (or, having agreed, fails to) abide by the values as published by the Trust;
3.13.12he has been placed on the registers of Schedule 1 Offenders pursuant to the Sexual Offences Act 2003 (as amended) and/or the Children and Young Person's Act 1933 to 1969 (as amended) and his conviction is not spent under the Rehabilitation of Offenders Act 1974;
3.13.13he is incapable by reason of mental disorder, illness or injury in managing and administering his property and/or affairs;
3.13.14he is a member of the UK Parliament;
3.13.15he is a Director of the Trust or a Governor of another NHS Foundation Trust;
3.13.16he is a member of a relevant local authority Overview and Scrutiny Committee; or
3.13.17he is not 16 years of age, or older, at the closing date for nominations for election or appointment.
Appendix 4
3.13.18his term of office is terminated pursuant to paragraph 3.14 below;
Termination of Office
3.14 A Governor’s term of office shall be terminated:
3.14.1 by the Governor giving notice in writing to the Secretary of his resignation from office at any time during that term of office;
3.14.2 by a majority of the Governors present and voting at a meeting of the Council if any grounds exist under paragraph 3.13 above
3.14.3 by a majority of the Governors voting at a meeting of the Council if he has failed to attend two successive meetings of the Council unless the Council is satisfied that:
(a) the absence was due to reasonable cause; and
(b) that the Governor will resume attendance at meetings of the Council within such period as it considers reasonable in the circumstances.
3.14.4 if the Council resolves to terminate his term of office on the grounds that in the reasonable opinion of three quarters of the Governors present and voting at a meeting of the Council convened for that purpose that his continuing as a Governor would or would be likely to:
(a) prejudice the ability of the Trust to fulfill its principal purpose or of its purposes under this Constitution or otherwise to discharge its duties and functions; or
(b) prejudice the Trust’s work with other persons or body with whom it is engaged or may be engaged in the provision of goods and services; or
(c) adversely affect public confidence in the goods and services provided by the Trust; or
(d) otherwise bring the Trust into disrepute or be detrimental to the interests of the Trust.
3.14.5 if three quarters of the Governors present and voting at a meeting of the Council resolve that:
(a) it would not be in the best interests of the Trust for that person to continue in office as a Governor; or
(b) the Governor is a vexatious or persistent litigant or complainant with regard to the Trust’s affairs and his continuance in office would not be in the best interests of the Trust; or
(c) the Governor has failed to or refused to undertake and/or satisfactorily complete any training which the Council has Appendix 4
required him to undertake in his capacity as a Governor by a date six months from the date of his election or appointment; or
(d) he has in his conduct as a Governor failed to comply in a material way with the values and principles of the National Health Service or the Trust, the Constitution, and/or the Terms of Authorisation; or
(e) he has committed a material breach of any Role Description or Code of Conduct applicable to Governors of the Trust and/or these Provisions.
3.15 Where a person has been elected or appointed to be a Governor and he becomes disqualified from that appointment he shall notify the Secretary in writing of such disqualification as soon as practicable and in any event within 14 calendar days of first becoming aware of those matters which rendered him disqualified, and the Secretary shall report the matter to the Council and the Board.
3.16 Upon a Governor resigning or ceasing to be eligible to continue in office that person shall cease to be a Governor and his name shall be removed from the Register of Governors.
Vacancies
3.17 Where a Governor resigns or his office is terminated, elected Governors shall be replaced in accordance with paragraphs 3.19 and 3.20 below and, in the case of Appointed Governors, the Trust shall within 30 days of the vacancy having arisen invite the appointing body to appoint a new Governor to hold office for the remainder of the term of office.
3.18 Where a Governor is declared ineligible or disqualified from office or his term of office as a Governor has been terminated (otherwise than as a consequence of his own resignation) and that person disputes the decision, he shall as reasonably practicable be entitled to attend a meeting with the Chairman and Chief Executive of the Trust, who shall use their reasonable endeavours to facilitate such a meeting, to discuss the decision with a view to resolving any dispute which may have arisen but the Chairman and Chief Executive shall not be entitled to rescind or vary the decision which has already been taken.
3.19 Where an Elected Governor ceases to hold office during (the first six months) his term of office, the Trust shall offer the unsuccessful candidate who secured the highest number of votes in the last election for the area or class in which the vacancy has arisen, the opportunity to assume the vacant office for the unexpired balance of the retiring Governor’s term of office. If that candidate is unwilling, or unable, to fill the vacancy it will then be offered to that unsuccessful candidate who secured the next highest number of votes.
3.20 If there is no reserve candidate, or the reserve candidate is unable or unwilling to fill the vacancy, the office will stand vacant until the next scheduled election unless by so doing this causes the aggregate number of Governors who are Public or Patient Governors to be less than half the total membership of the Council. In that event an election will be held in Appendix 4
accordance with the Election Scheme as soon as reasonably practicable. A candidate elected mid-term, in this manner, shall have a period of tenure expiring at the next general election and, if elected at that general election, shall be deemed to have served two terms at the expiry of the further term.
3.21 No defect in the election or appointment of a Governor nor any deficiency in the composition of the Council shall affect the validity of any act or decision of the Council.
4. DECLARATIONS AND REGISTER OF GOVERNORS’ INTERESTS
4.1 In accordance with the Constitution, Governors are required to declare on election or appointment and in the manner prescribed below any direct or indirect pecuniary interest and any other interest which is relevant and material to the business of the Trust. The responsibility for declaring an interest is solely that of the Governor concerned.
4.2 Such a declaration shall be made by completing and signing a form, as prescribed by the Secretary from time to time setting out any interests required to be declared in accordance with the Constitution or these Provisions and delivering it to the Secretary within 28 days of a Governor’s election or appointment or otherwise within seven days of becoming aware of the existence of a relevant or material interest. The Secretary shall amend the Register of Interests upon receipt of notification within one month.
4.3 If a Governor is present at a meeting of the Council of Governors and has an interest of any sort in any matter which is the subject of consideration, he shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not vote on any question with respect to the matter and, if he has declared a pecuniary interest, he shall not take part in the consideration or discussion of the matter.
4.4 The term “relevant and material interests” may include (but may not be limited to) the following:
4.4.1 directorships, including non-executive directorships held in private or public limited companies (with the exception of those of dormant companies);
4.4.2 ownership or part-ownership or directorships of companies or other types of organisation which are likely to or are seeking to do business with the NHS;
4.4.3 a position of authority in a charity or voluntary organisation operating in the field of health and social care, including any which are contracting for or are commissioning NHS services;
4.4.4 any connection with an organisation, entity or company considering entering into or having entered into a financial arrangement with the Trust, including but not limited to, lenders or banks;
4.4.5 research funding/grants that may be received by an individual or their department;
Appendix 4
4.5 Any traveling or other expenses or allowances payable to a Governor in accordance with this Constitution shall not be treated as a pecuniary interest.
4.6 Subject to any other provision of this Constitution, a Governor shall be treated as having an indirect pecuniary interest in a contract, proposed contract or other matter, if:
4.6.1 he, or a nominee of his, is a director of a company or other body not being a public body, with which the contract was made or is proposed to be made or which has a direct pecuniary interest in the other matter under consideration; or
4.6.2 he is a partner, associate or employee of any person with whom the contract was made or is proposed to be made or who has a direct pecuniary interest in the same.
4.7 A Governor shall not be treated as having a pecuniary interest in any contract, proposed contract or other matter by reason only:
4.7.1 of his membership of a company or other body, if he has no beneficial interest in any securities of that company or other body;
4.7.2 of an interest in any company, body, or person with which he is connected, which is so remote or insignificant that it cannot reasonably be regarded as likely to influence a Governor in the consideration or discussion of or in voting on, any question with respect to that contract or matter.
4.8 In the case of persons living together the interest of one partner or spouse shall, if known to the other, be deemed for the purposes of these Provisions to be also an interest of the other.
4.9 If a Governor has any doubt about the relevance of an interest, he must take advice from the Secretary.
5. STANDARDS OF CONDUCT
5.1 Governors shall comply with the terms of the Role Description for Governors which shall be approved by the Council and the Board, and which the Secretary shall issue to Governors upon election or appointment to the Council. The Governors shall also comply with any codes of conduct or other standards referenced in the Role Description.
5.2 In the event that there are concerns about a Governor’s performance or conduct, the Chairman, with the support of the (Lead Governor and) Secretary where necessary, will address these directly with the Governor concerned. Where necessary, the Chairman will make recommendations to the Council, including in respect of any proposal that the Council should remove the Governor from office in which case the Provisions of section 3 of these Provisions shall apply.
Appendix 4
6. REMUNERATION AND BUSINESS EXPENSES
6.1 Governors shall not receive remuneration.
6.2 The Trust is permitted to reimburse traveling expenses to Governors for attendance at meetings of the Council, or for any other business authorised by the Chairman as being reasonably within the role and duties of a Governor, at a rate and in accordance with a policy to be determined by the Board of Directors.
6.3 Expenses will be reimbursed by the Secretary on receipt of a completed and signed expenses form provided by the Secretary.
6.4 A summary of expenses paid to Governors will be published in the Annual Report.
7. COMPOSITION AND ROLE OF COUNCIL OF GOVERNORS
7.1 The composition of the Council shall be as set out in Annex 4 of the Constitution.
7.2 Subject to the 2006 Act (as amended and/or replaced from time to time), the role of the Council is defined in its Terms of Reference which shall be approved by the Council and the Board.
7.3 Subject to the 2006 Act (as amended and/or replaced from time to time), the role of the Chairman shall be as defined in a Role Description which shall be approved by the Council and the Board.
7.4 The role of the Deputy Chairman shall be as defined in a Role Description which shall be approved by the Council and the Board.
7.5 The role of the Lead Governor and Deputy Lead Governor shall be as defined in a Role Description which shall be approved by the Council and the Board.
8. COMMITTEES OF THE COUNCIL
8.1 Subject to the constitution, the Terms of Authorisation and such binding guidance as may be given by Monitor, the Council may and, if so required by Monitor, shall appoint committees of the Council consisting wholly or partly of members of the Trust (whether or not they include Governors) or wholly of persons who are not members of the Trust (whether or not they include Governors). The Council shall not delegate any of its powers to a committee but committees may act in an advisory capacity to assist the Council in carrying out its functions.
8.2 These Provisions of the Council shall apply with appropriate alteration to any committees established by the Council.
8.3 Each such committee or sub-committee shall have such terms of reference. Such terms of reference and the membership of committees or sub- committees shall be subject to approval by the Council.
8.4 The Council shall approve the appointment of the Chair and members for each of the committees which it has formally constituted. Where the Council Appendix 4
determines that persons who are neither Governors nor staff shall be appointed to a committee, the terms of such appointment shall be determined by the Council. The Council may request that external advisers assist them or any committee they appoint in carrying out its duties.
8.5 Elected and Appointed Governors may form a sub-committee – the Pre- Council of Governors Committee – to prepare for forthcoming Council Meetings.
9. SUSPENSION, AMENDMENT AND REVIEW OF THESE PROVISIONS
Suspension
9.1 These Provisions shall not be suspended except:
9.1.1 where urgent action is required and the Chairman considers it to be in the interests of the Trust to waive one or more of the Provisions, he may do so subject to such action being reported to the next meeting of the Council 9.1.2 at a meeting of the Council, at least half of the total number of Governors are present, such number to include not less than one third of the Public Governors, not less than one third of the Staff Governors and not less than one third of the Appointed Governors
9.2 Any decision to waive Provisions shall be recorded in the minutes of the next meeting of the Council and shall be reported to the Audit Committee.
Amendment and Review
9.3 These Provisions shall be reviewed one year after approval by the Council and then at least every three years thereafter.
9.4 These Provisions shall be amended only if:
9.4.1 the variation proposed does not contravene a statutory provision, the Terms of Authorisation or the Constitution; and 9.4.3 at least three quarters of the Governors present and voting at a meeting of the Council, including one Staff Governor, one Public Governor and one Appointed Governor are in favour of amendment. 9.4.4 The proposed amendment(s) has/have been discussed the Board.
9.5 All amendments to these Provisions shall be subject to approval through any process prescribed by Monitor. APPENDIX A
DECLARATION BY GOVERNOR
WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST (the "Trust")
I, ...... (insert full name)
of ...... (insert address)
Hereby declare that I am entitled to:-
(a) be elected to the Council of Governors as a Governor elected by one of the public constituencies/ the staff constituencies* because I am a member of one of the public constituencies/ /staff constituencies *; or
(b) be appointed to the Council of Governors as a governor because I have been appointed by a nominating organisation and that I am not prevented from being a member of the Council of Governors of the Trust by paragraph 8 of Schedule 7 of the National Health Service Act 2006 or under the Constitution of the Trust and that I am entitled to vote at meetings of the Council of Governors as a governor pursuant to such appointment or election.
Signed ......
Print Name………………………………......
Date of Declaration ......