Delivering our Vision · Delivering our vision – How are we doing? January 2018 summary • We...

Delivering our Vision How are we doing?

January 2018

“We will pursue perfection in the delivery of safe, high quality healthcare which puts the people of our community first”

2

Through integration and partnership we aim to become both a provider and employer of choice

Annual priorities

Reduce avoidable

harm

Improve discharge planning

Staff health, well being and working lives

Create best environment for patients

Improve efficiency of elective care

Values

Safety & quality

One team

Dignity & respect Compassion

Vision We will pursue perfection in the

delivery of safe, high quality healthcare which puts the people of

our community first

Patient

Strategic objectives

Safe Effective Well-led Caring Responsive

3

• We declared two serious incidents in January 2018 (one of these incidents was

also declared a never event).

• Patient safety indicators continue to show expected levels of performance.

• There were no MRSA bloodstream infections and 2 Trust-apportioned

Clostridium Difficile cases in January 2018.

• Mortality is lower than expected for our patient group when benchmarked

against national comparators.

• Readmission indicators improved in January 2018 with Emergency

Readmissions within 7 days returning to green performance with 3.7%.

SAFE - People are protected from abuse and avoidable harm

EFFECTIVE - People’s care, treatment and support achieves good

outcomes, promotes a good quality of life and is based on the best

available evidence.

• Friends & Family Test continues to show good patient feedback for the

Emergency department during a time of high demand while Inpatient FFT

reduced to amber on the RAG rating with performance of 94.5% in January.

CARING - service involves and treats people with compassion,

kindness, dignity and respect.

Delivering our vision – How are we doing? January 2018 summary

Serious

Incidents

2

%

Emergency

readmissions

within 7 days

3.7%

%

HSMR

(October-17)

93.4

%

ED FFT

97.6%

Inpatient FFT

94.5%

Safety Thermometer

99.6%

4

• The 4hr ED standard was not achieved in January 2018 with

performance of 88.2%, 1.2% better than January 2017. National

performance for ‘Type 1 Departments’ in January was 77.1% seeing us

perform significantly higher than the national average.

• Cancer TWR and breast symptomatic both achieved the national

standard with performance of 93.3% and 96.9% in January.

• 62 Day GP performance achieved the national standard with 85.9% of

patients starting treatment within 62 days.

• 18 Weeks RTT – We did not achieve the RTT Incomplete pathways

standard with performance of 88.6%. Recovery actions and trajectory

are in place.

• The SASH flu vaccination target for 2017 was met with 70.1% of frontline healthcare

workers vaccinated by 31st December. 66% of non-frontline staff were also vaccinated.

• We have been chosen to join the national streamlining project which is initially focussing on

making the on-boarding process for junior doctors more seamless.

• Significant progress has been made with the introduction of an e-job planning system for all

consultant staff at SASH.

• Results of the 2017 National Staff Survey are expected towards the end of February –

these will be embargoed until the release of benchmarked data in March.

• The SASH One Team Inclusion Strategy has been completed and will be presented for

Board approval in March.

RESPONSIVE - services meet people’s needs.

WELL LED - leadership, management and governance of the organisation assures the delivery of

high-quality person-centred care, supports learning and innovation, and promotes an open and fair

culture


ED 95% seen

in 4 hours

88.2%

%

Vacancy Rate

9.5%

%

Staff

turnover

16.1%

%

RTT

Incomplete

88.6%

62 Day GP

85.9%

5

FINANCE AND USE OF RESOURCES


• We forecast a £11m surplus outturn for 2017/18. This is £10.3m adverse to our £21.3m

surplus control total. NHSi has been notified of this new forecast position in accordance

with the relevant protocols.

• We achieved a £9.8m [adjusted] surplus at the end of Month 10, which is £6.4m adverse

to the year to date (YTD) financial plan. The position includes £5.7m Sustainability &

Transformation Funding (STF).

• £4.8m of savings have been achieved YTD.

• Forecast capital spend is £11.6m which is precisely in line with the new £11.6m Capital

Resource Limit (CRL).

YTD £m

Adjusted

Surplus

£9.8m

Action: The Board are asked to note and accept this report

Legal: All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance

on safe high quality care (Including mortality).

Regulation: The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and

therefore license care services under the Health and Social Care Act 2009 and associated regulations.

Patient experience/

engagement: This paper includes significant detail on both patient experience and access to services.

Risk & performance

management

This is the main Board assurance report for performance against quality and financial measures and is

linked to risk management through the SRR.

NHS constitution; equality

& diversity;

communication.

This report covers performance against access standards with the NHS Constitution.

YTD £m

Savings

£4.8m

https://bi01/ReportServer?/015 Performance Investigator/D07 Trust Performance Dashboard - Money and Resource

Are we safe?

Section 2

6

Delivering our vision – How are we doing?

Safe – People are protected from abuse and avoidable harm

7

• Positive Safety Thermometer performance continued for the “New Harm” measure with performance of

99.6% in January 2018.

• We declared two serious incidents in January 2018 (one of these incidents was also declared a never

event).

• 2018/1675 – Maternity incident, vaginal swab retained post instrumental birth and perineal suturing.

This incident has been recorded as a never event and a full investigation initiated. Immediate action

taken:

• the retained swab was removed and infection screen undertaken to exclude infection along

with an abdominal x-ray to provide reassurance to the patient. The team have apologised to

the patient and she is aware that investigation will take place.

• the maternity team have issued a “Safety Pin” relating to the avoidance of retained foreign

objects which has been displayed in all clinical areas.

• a safety huddle took place immediately to alert all staff to this adverse outcome. Awareness

is included as part of ongoing safety huddles and as part of all shift handovers.

• the maternity team have removed all swabs without tapes (to enable them to be secured

externally) from the Delivery Suite.

• written communication reiterating the expected practice and processes that must be followed

to prevent an unintentional retained ‘foreign object’ have been distributed to all obstetric and

midwifery staff with a requirement that they provide a signed receipt of knowledge.

• 2018/2003 – Fall. The patient, a 95 year old male, had a witnessed fall resulting in a fractured neck

of femur and a shoulder fracture.

Never Event

1

Safety

Thermometer

99.6%

Safety

Serious

Incidents

2



8

• Daily staffing - We continue to monitor ward nursing numbers and skill mix on a daily basis and are

assured that adequate staffing is in place.

• Nurse recruitment - Continues both locally and from overseas. Nurse recruitment events are planned for

Medicine and Surgery in January.

• Retention - The Trust continues to imbed the various work streams outlined in the retention strategy.

• The Trust has now received feedback from NHS Improvement in relation to the retention improvement plan.

The plan was positively received and the constructive suggestions for improvement will be fed in to the

retention work stream going forward.

• The Deputy Chief Nurse is planning a retention focus group with a variety of staff in early 2018, facilitated by

‘Clever Together ‘ who co-produced the staff retention analysis with Health Education Kent Surrey and

Sussex.

Ward staffing

RN Fill Rate

Day

93.1%

RN Fill Rate

Night

95.8%



9

• There were 0 cases of MRSA blood stream infection in January 2018

• There were 2 cases of Trust-apportioned Clostridium difficile.

• Twenty nine cases of Clostridium difficile for 2017/18 have been reviewed by the CCG and 7 cases

have been viewed as a ‘lapse in care.’

Infection control

MRSA

0

C-Diff

2

Delivering our vision – How are we improving?

Safe – Reduce avoidable harm

10

• In January 2018, inpatient falls were 5.45 per 1000 bed days. In the last 13 months our

falls rate has consistently remained below the national average.

• In January we had 1 Serious Incident relating to falls which is currently being investigated,

any learning will be shared.

• The Monthly Falls Focus Group continues to meet and share the learning from falls and is

undertaking focused work around repeat fallers, where weekly ward rounds are being

piloted with the Clinical Lead for falls, Deputy Chief Nurse for Innovation and Improvement

and Nurse Consultant for Dementia.

Reduce falls

• In January, we reported seven Grade 2 and three Grade 3 pressure damage.

• The newly appointed Nurse Consultant for Patient Safety/Outcomes has started

and will be focusing on continence prevention and management, moisture lesion

identification and staff education.

• The identification processes for investigating pressure damage and determining

the Root Cause Analysis (RCA) has changed and with case now being presented

to the Serious Incident Review Group.

• The monthly Pressure Damage Focus Group has been reviewed and now has

wider representation from each division where key learning is shared and

disseminated across the divisions.

Reduce pressure damage

Total Falls

108

Falls / ‘000

Bed days

5.45

Total

Pressure

Damage

18

Pressure

Damage / ‘000

Bed days

0.91


Safe – Scorecard

11

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Trend

No of Never Events in month 0 0 0 0 0 0 0 0 0 0 0 0 1

Serious Incidents - No declared in month 4 2 2 1 4 4 6 3 4 8 4 5 2

Serious Incidents - No per 1000 Bed Days 0.21 0.11 0.10 0.05 0.21 0.21 0.31 0.16 0.21 0.41 0.21 0.26 0.10

Patient Safety Incidents causing Severe harm or Death - Number in Month 1 0 0 2 1 3 5 1 4 2 1 4 2

Patient Safety Incidents causing Severe harm or Death - Percentage of all patient safety

incidents0.2% 0.0% 0.0% 0.3% 0.1% 0.6% 0.8% 0.2% 0.7% 0.5% 0.3% 0.8% 0.3%

Safety Thermometer - % of patients with harm free care (new harm) 94.2% 97.9% 98.7% 99.0% 99.3% 98.0% 99.0% 98.8% 98.8% 99.3% 98.7% 98.3% 99.6%

Percentage of patients who have a VTE risk assessment 95% 95% 95% 95% 95% 95% 95% 97% 97% 97% 97% 97% 97%

MRSA BSI (incidences in month) 1 0 1 0 0 0 0 0 0 0 0 0 0

CDiff Incidences (in month) 1 5 5 3 4 2 4 6 4 3 2 2 2

MSSA Trust Incidence 3 2 6 8 4 1 1 1 0 1 1 0 0

E-Coli Trust Incidence 3 6 4 5 4 5 7 2 4 5

Average fi l l rate – registered nurses/midwives (%) - Day 97.5% 96.7% 95.6% 95.4% 96.9% 95.9% 94.4% 93.4% 93.5% 95.4% 93.2% 91.8% 93.1%

Average fi l l rate – care staff (%) - Day 91.9% 96.4% 93.0% 96.5% 96.6% 94.7% 94.9% 92.3% 96.3% 94.4% 95.2% 93.8% 95.8%

Average fi l l rate – registered nurses/midwives (%) - Night 97.3% 97.9% 97.4% 96.7% 97.9% 97.0% 97.5% 96.7% 96.0% 95.8% 96.5% 95.5% 95.8%

Average fi l l rate – care staff (%) - Night 95.4% 95.0% 94.9% 96.1% 95.3% 96.6% 96.5% 95.4% 95.1% 94.3% 96.8% 95.7% 96.5%

Falls - Total in month 116 92 101 97 84 96 115 101 76 102 82 98 108

Falls per '000 Bed days 6.00 5.16 5.20 5.15 4.31 5.06 5.91 5.25 4.07 5.23 4.40 4.99 5.45

Pressure Damage (Hospital Aquired) - Total in Month 14 14 17 8 14 16 8 15 19 13 12 17 18 15.0%

Pressure Damage per '000 Bed days 0.72 0.78 0.87 0.43 0.72 0.84 0.41 0.78 1.02 0.67 0.64 0.88 0.91

Safety

Ward Staffing

Infection Control (Trust Aquired)

Reduce Avoidable Harm

Are we effective?

Section 3

12


Effective – People’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence

13

• The Latest HSMR data for the in month rate improved from the September 17 position.

Overall the HSMR increased slightly but still remained ‘better than expected’.

• Our latest SHMI data continues to show positive performance.

• There was a small increase in 28 Day readmissions – whilst this is not statistically

significant we continue to monitor this closely.

Mortality and readmissions

• Our Audit Programme completeness is improving.

• The findings from the National Falls Audit, Intensive Care National Audit & Research

Centre (ICNARC) and the National Chronic Obstructive Pulmonary Disease Audit

(COPD) have been presented to the Clinical Effectiveness Committee.

• A detailed audit is underway examining a wide variety of information relating to

Emergency C-Section rates.

• There was a small rise in the number of adult patients over both 7 and 14 days

however the overall trend is decreasing.

Other effectiveness

HSMR

(October-17)

93.4

SHMI

(Jun-17)

0.95

7 day

Readmission

3.7%

28 day

Readmission (Dec-17)

8.2%


Effective – Improve discharge planning

14

• Daily calls with Senior Leaders from partner organisations to discuss ‘Delayed Transfer of Care’ (DTOC)

patients continue with additional twice weekly calls with Chief Executive Officers.

• There has been a modest but sustained increase in the number of discharges to the community over the

seven day period.

• The post holder to support delivery of the CQUIN ‘Supporting proactive and safe discharge’ has started

in post and is working with the Emergency Dept and Acute Medical Wards to embed processes aimed at

prompt and safe discharge within seven days.

Discharge Planning

• The Trust continues to roll out the ‘ live’ bed board which will further support the embedding

of SAFER.

• An internal working group is being established to improve discharge planning and take

specific actions in response to patient feedback about the discharge process.

• The revised discharge policy is complete and is ready for presentation to the Executive

Team.

SAFER Flow


Effective – Scorecard

15


HSMR (56 Monitored diagnoses - 12 Months) 96.7 95.9 96.5 96.2 94.8 93.6 92.3 91.2 93.9 93.4

SHMI 0.95 0.95

Emergency readmissions within 7 days 3.6% 3.5% 3.7% 3.7% 3.8% 3.9% 3.5% 3.5% 3.7% 3.8% 4.1% 4.1% 3.7%

Emergency readmissions within 28 days 7.5% 7.2% 7.8% 7.6% 8.0% 8.0% 7.5% 7.7% 7.8% 7.7.% 8.4% 8.2%

Maternity - C Section Rate - Emergency 12.8% 17.9% 17.1% 20.0% 20.0% 19.4% 16.4% 18.2% 15.2% 15.9% 21.2% 20.6% 17.0%

YCM - Were you kept informed of your estimated date of discharge from hospital? 71 68 67 70 64 68 67 67 69

YCM - When you were ready to be discharged, were you satisfied with the plan that was put in

place?84 79 79 82 79 77 83 74 78

Average No of Adults Over 7 Days 297 293 277 293 280 290 295 285 280 289 273 250 264

Average No of Adults Over 14 Days 184 179 171 182 171 185 188 180 174 182 166 139 156

Discharge Planning

Mortality and Readmissions

Other Effectiveness

Are we caring?

Section 4

16


Caring – service involves and treats people with compassion, kindness, dignity and respect

17

Outpatient

FFT

89.3%

• Inpatient FFT – Inpatient FFT is down slightly from 96.2% to 94.5%. The response rate has

decreased to 24%.

• Daycase FFT – Daycase FFT increased to 97.3% in January with the response rate also

increasing to 17.49% (12.43% in December).

• Emergency Department FFT - The FFT score has increased from 96.5% in December to

97.6% in January. The response rate has also increased to 10.36% for January (5.98% in

December).

• Maternity FFT – The FFT score for the postnatal ward has increased from 93.68% for

December to 97.5% for January. The Delivery/birthing centre score is 100% up from 83.3%

however, there were only 5 responses. The combined score for all maternity touch points is

97.31% and the response rate is 11.98%

• Outpatients FFT - The FFT score for outpatients has increased to 89.3% in January with an

increase in responses from 1157 in December to 1599 in January.

Friends and family test

ED FFT

97.6%

Inpatient FFT

94.5%

Raising awareness and supporting carers –The carers steering group continues to meet regularly and the two

carer support organisations visit wards throughout the week to identify and provide assistance to carers of patients.

Carers


Caring – service involves and treats people with compassion, kindness, dignity and respect

18

• Mixed Sex Breaches – We continue to report zero mixed sex breaches in January

• Complaints – The number of complaints increased by 30% in January to 47, compared to 33 in December 2017. 100% of

complaints have been acknowledged within 3 working days, as per statutory requirements, consistently for the last 10

months. 97% of complaints were closed within the agreed timeframe in January compared to 95% in December. The

same number of complaints (6) were re-opened and no cases were referred to the Parliamentary and Health Service

Ombudsman (PHSO).

• Accessible Information Standard – The testing phase for producing patient letters in alternate formats is currently

underway.

• Way Finding – Signage has been installed to the ‘Chipstead’ area and we are currently undergoing a period of evaluation.

Surveys are being conducted by the provider in order to plan for full installation.

Other Patient Experience

Complaints

per 10,000 pt.

contacts

10

Mixed Sex

Breaches

0

• Responsiveness to feedback – Automated actions generated by the Meridian system require key staff to make

appropriate and continuing improvements in their areas. Areas with a low or decreasing FFT score are monitored and

work streams arise from this feedback. The Patient Experience Committee (PEC) always begins with a patient story

which is discussed and focusses the committee.

• Focusing on priorities for improvement at ward/departmental level – Priorities are consistently being raised to key

staff through the alerts system on the reporting platform and by the monthly batch reports provided to the clinical areas

by Meridian. The monthly PEC analyses data from Meridian. Performance maps which allow areas to understand their

top priorities for patient experience are being used more widely.

Patient experience platform


Caring – Create best environment for patients

19

• Work continues on the design work for the different elements of the Neonatal project. These will be used to inform the tenders

which will be issued in spring 2018.

• The capital programme for 2018/19 is currently being put together – the largest development of which will be the Neonatal Unit

refurbishment.

Estate / Building Developments – Major Schemes

A variety of improvement works have been undertaken across the hospital wards and the following table summarises the main

activities:

Ward Improvement Works

Ward Works Status

Abinger MDT Room Complete Abinger/Meadvale Corridor Lighting Complete Buckland Over-bed lighting and power Complete Burstow MDT Room (CF) Underway Chaldon Flooring In plan Charlwood Create quiet room In plan Delivery Suite Bathrooms Complete Delivery Suite Sluice and SANDs room In plan Holmwood General refurbishment Complete Holmwood Circulation area decoration In plan Leigh Over-bed lighting and power Complete Leigh and Newdigate Sluice, Store room Complete Leigh and Newdigate Staff WC Underway Meadvale MDT room Complete Newdigate Over-bed lighting and power Underway Outwood Bathrooms Underway Outwood External windows Underway Rusper Telephone Triage room (CF) Underway Tandridge General refurbishment In plan Various Yellow toilet and shower doors Underway Various New Nurse Call System Complete


Caring – Create best environment for patients

20

In addition to work in ward areas a number of other smaller projects have taken place or are planned, these are shown below:

Estate / Building Developments – Other Improvement Works

Area Works Status

Angio Modular Office New Temporary Office Accommodation Complete Audiology Sound booth In plan Bereavement New office Complete Car Park New Hard Surface and relining Complete Camomile Courtyard New dementia garden Designer Appointed Chipstead New OPD consulting room, ECG room and assessment space Complete

Diagnostic Imaging Various works Complete Diagnostic Imaging Changing cubicles (P&D) In plan ED New flooring Complete Fire Doors Replacement of Fire Doors across East Surrey Underway Hand Therapies Redesign and refurb In plan Kitchen New Ventilation System Complete Lung Function Refurbishment Complete Modular 1 Refurbishment and office moves Underway Mortuary Visitors’ Room Refurbishment Complete Outpatients / ECG General refurbishment Complete

PGEC New reception and seating for lecture theatre In plan

Phlebotomy and Haematology Minor works including new back-door Complete

Security New office Complete

Sunshine Day Nursery Garden (Health & safety) In plan

Sunshine day Nursery Kitchen (charitable funds awaited) In plan

Trust HQ Toilet refurbishment Complete

Trust HQ Entrance canopy Complete

Wayfinding Improved wayfinding throughout ESH Underway

Delivering Our Vision – How are we doing?

Caring – Scorecard

21


Emergency Department FFT - % positive responses 96.3% 96.6% 96.9% 96.3% 95.7% 93.8% 95.7% 93.7% 95.5% 96.7% 98.3% 96.5% 97.6%

Inpatient FFT - % positive responses 96.7% 96.2% 95.8% 96.6% 95.6% 95.2% 96.2% 95.2% 95.7% 94.5% 93.8% 96.2% 94.5%

Day Case FFT - % positive responses 96.7% 96.2% 95.8% 96.6% 96.9% 94.4% 94.7% 93.9% 96.1% 95.5% 95.4% 92.8% 97.3%

Outpatient FFT - % positive responses 89.7% 90.7% 90.6% 88.0% 88.7% 88.6% 88.0% 90.5% 89.0% 88.8% 89.7% 88.3% 89.3%

Maternity FFT - Antenatal - % positive responses 98.5% 95.2% 95.9% 100.0% 94.7% 90.6% 87.5% 96.8% 100.0% 100.0% 100.0% 100.0% 100.0%

Maternity FFT - Delivery - % positive responses 97.8% 97.3% 98.8% 96.7% 100.0% 100.0% 83.3% 100.0% 100.0% 80.0% 100.0% 83.3% 100.0%

Maternity FFT - Postnatal Ward - % positive responses 92.3% 89.0% 92.1% 95.8% 91.0% 94.9% 95.2% 97.3% 95.6% 89.6% 96.8% 93.6% 97.5%

Maternity FFT - Postnatal Community Care - % positive responses 100.0% 92.0% 100.0% 97.7% 96.2% 100.0% 96.6% 97.2% 100.0% 100.0% 96.6% 97.8% 95.9%

Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0

Complaints - Number received in month 56 43 57 41 50 55 37 42 36 51 36 33 47

Complaints - Rate per 10,000 patient contacts 12 10 11 10 10 11 8 9 8 11 7 8 10

Friends and Family Test

Other Caring

Are we responsive?

Section 5

22


Responsive – services meet people’s needs

23

ED 4hr

88.2%

Amb

Handover

over 60min

87

• The ED 4hr standard was not achieved in January 2018 with performance of 88.2%. National

performance for ‘Type 1 Departments’ in December was 77.1% showing our performance

significantly exceeded the national average.

• SASH system LAEDB performance was 92.8% for January 2018 placing performance in the top

decile of non-specialist hospitals.

• Ambulance turnaround performance dropped with 87 breaches of the 1hr standard. We are

working with the wider system and will launch an initiative to reduce delays in March 2018.

Emergency department

• The TWR national standard was delivered with performance of 93.3% in January. TWR breast

symptomatic also achieved the standard with performance of 96.9%.

• 62 Day GP performance returned to green performance achieving the national standard with

performance of 85.9%.

• Performance against the 62 day screening standard was 80.0% against a target of 90% as a

result of four breaches. Three on the Breast pathway (2 delayed referrals and 1 complex

pathway) and one colorectal pathway (internal delay).

Cancer treatment

Two Week

Wait

93.3%

62 Day GP

85.9%


Responsive – services meet people’s needs

24

• We improved performance against the RTT Incomplete pathway standard with performance of 88.6%

in January.

• Whilst we did not achieve the national 92% standard, maintaining performance and continuing our

improvement journey during a time of significant system pressure provides assurance that our

organisation continues to make progress against individual improvement trajectories.

• Delivery of RTT standards remain a challenge with the impact of emergency pressures, increased

trauma, as well as specialty specific capacity issues being the root causes of the under performance.

Improvement trajectories are in place and being monitored by the executive committee.

• Whilst we continue to commit to the reduction of patients waiting over 52 weeks for treatment. Due to

the impact of patient choice over the Christmas period and the on-going challenge in Neurology, we

did not see reduction in the number of patients waiting over 52 weeks, with 17 patients in January.

Individual treatment plans are in place for all patients and we continue to work closely with the clinical

team to ensure that patients move through the Neurology pathway as quickly as is clinically

appropriate .

• No patient harm has been identified from RTT 52 week breaches and root cause analysis of the

pathway is undertaken by clinical divisions.

• The 6 week diagnostic standard was achieved in January with performance of 0.7%.

RTT and diagnostics

RTT

Incompletes

88.6%

6 Week

Diagnostic

0.7%


Responsive – Improve efficiency of elective care

25

• Outpatients continues to see positive performance with £940k of savings YTD. The

DNA rate increased slightly in January to 7.3% while the un-booked rate reduced

from 11.4% to 9.3%. Clinic utilisation was 84.1% which is the best performance

since measurement began.

• Recruitment to the Outpatient Booking Office continues with a number of new

starters in February. Final moves to the central booking centre are also being

progressed over coming months.

• Theatres productivity remains behind plan, although NHS Improvement

benchmarking shows us above average when compared nationally.

• Theatre cases per session decreased to 2.90, although some specialties are

continuing to show improvements compared to prior year. Cancellations were a

significant driver with 147 patients cancelled in January, with bed pressures being a

major contributor with 40 cancellations.

• A number of new task and finish groups are now in place to support the theatres

programme and the existing work underway around scheduling. These include Pre-

Assessment, cancellations and Cerner EPR usage.

• Endoscopy productivity remains positive with £88k of savings YTD but in month

performance was impacted with patients and points per session being adverse to

trajectory as a result of the area being used for escalation. Performance to date in

February is positive.

OPD (OBO)

DNA Rate

7.3%

OPD (OBO

Un-booked

Rate

9.3%

THR - Cases

Per Session

2.90

THR

Cancellation

Rate

9.5%

Endo -

Patients Per

Session

5.71

Endo - Points

Per Session

7.81

Overview of January 2018


Responsive – Scorecard

26


ED 95% in 4 hours 87.0% 90.9% 95.1% 92.9% 92.6% 92.8% 93.6% 94.4% 94.1% 93.2% 95.0% 92.3% 88.2%

Patients Waiting in ED for over 12 hours following DTA 0 0 0 0 0 0 0 0 0 0 0 0 0

Ambulance Turnaround - Number Over 30 mins 253 194 249 188 253 199 246 306 225 299 206 319 290

Ambulance Turnaround - Number Over 60 mins 66 34 19 27 46 50 33 47 40 38 38 73 87

Cancer - TWR 94.7% 94.4% 95.0% 92.2% 93.0% 93.7% 90.6% 91.1% 91.6% 94.0% 94.6% 94.9% 93.3%

Cancer - TWR Breast Symptomatic 95.4% 93.0% 95.7% 93.0% 93.5% 93.5% 95.7% 90.5% 85.7% 94.1% 83.9% 96.5% 96.9%

cancer - 62 day Referral to Treatment Standard 87.9% 86.0% 86.4% 87.9% 86.0% 85.2% 86.9% 85.7% 86.3% 90.4% 85.8% 100.0% 85.9%

Cancer - 62 Day Referral to Treatment Screening 100.0% 100.0% 100.0% 71.4% 100.0% 81.8% 75.0% 80.0% 87.5% 75.0% 91.7% 100.0% 80.0%

Cancer - 31 Day Diagnosis to Treatment 97.7% 99.0% 98.7% 100.0% 99.2% 98.6% 99.2% 95.5% 95.2% 97.3% 96.6% 96.6% 96.2%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.5% 100.0% 100.0% 92.3% 80.0% 100.0%

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% 86.7% 100.0%

RTT Incomplete Pathways - % waiting less than 18 weeks 90.5% 90.0% 90.1% 88.7% 87.3% 87.3% 86.9% 86.4% 86.1% 86.6% 87.9% 87.9% 88.6%

RTT Patients over 52 weeks on incomplete pathways 13 15 19 19 53 51 33 23 20 22 19 17 17

Percentage of patients waiting 6 weeks or more for diagnostic 0.4% 0.3% 0.2% 0.4% 0.7% 1.0% 0.9% 0.7% 0.8% 1.19% 0.7% 0.3% 0.7%

No of operations cancelled on the day not treated within 28 days 7 3 9 7 18 21 15 5 11 19 8 15 22

Cancer Access

RTT

Emergency Department

Are we well led

Section 6

27


Well led – leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture

28

Vacancy Rate

9.5%

• Vacancy rates across all staff groups has reduced by 0.7% to 9.5%. For Nursing, vacancy rates have also

reduced this time by 0.3% to 17.1%.

• Turnover has reduced by 0.7 to 16.1% for all staff groups, and for nursing has reduced by 0.1% to 17.3%.

• We continue to review opportunities for recruitment and retention and are developing a campaign to recruit

from the local community.

• We continue to liaise with NHSi regarding our retention plan which aims to reduce overall turnover by 1%

across all staff groups in the 12 months from October 2017 to November 2018.

• We will commence work in February with an external provider to support the development of the SASH

Leadership Framework, talent management and succession planning programmes. This work has been funded

following a successful bid to Health Education England Kent, Surrey and Sussex.

• The Nursing Associate apprenticeship is following the procurement process; staff will commence training in

March 2018.

Establishment

Turnover

Rate

16.1%

• MAST figures have fallen slightly to 77.04%.

• All clinical Divisions have a compliance rate of at least 77%, with Cancer & Diagnostics and Surgery achieving

83% or more (against a green RAG rating KPI of 80%).

• There has been a considerable increase in compliance in Estates & Facilities, (increasing from 55% to 62%),

and we are reviewing other bespoke solutions to increase this further.

• Achievement Review completion rates continue to increase and we are currently at 92.2%, as at the end of

December, having met the 90% target in November.

• Our HR Business Partners are working with Divisions to ensure all relevant staff who are yet to have their

achievement review have this undertaken.

Training and Achievement Review

MAST

Compliance

77.0%

Achievement

Review

92.2%


Well Led – Staff health, well being and working lives

29

• Overall Sickness has increased by 0.4% to 4.7%.

• There has been an on-going increase in absences for ‘seasonal’ conditions (i.e. ‘colds,

coughs, and flu’), and this is currently the highest reason for sickness absence.

• Absence for issues related to mental health conditions fell compared to last month however it

remains the second highest reason for absence and absence for this reason is higher than

the same period last year.

• Training provided by SLaM on resilience and techniques for coping with stress is being very

well received.

Sickness

• We have had a very successful Flu vaccination campaign with 70.1% of frontline staff vaccinated by

31st December. This enabled us to meet our CQUIN target.

• We are moving to the second phase of the mental health impact assessment work which we are

undertaking with South London & the Maudsley, (SLaM). This will support staff managing their mental

health.

• The Smokefree SASH campaign, which aims to make the East Surrey Hospital site Smokefree, as

well as offering support to all staff, patients and visitors in giving up smoking, is being developed.

• We are delivering updated training on Conflict Resolution, Conflict Management, Communicating

Excellence (customer care), Assertiveness, Wellbeing, & Resilience.

• We have been asked by a neighbouring Trust to provide details of our ‘It’s Not Okay’ campaign as

they are keen to learn from our positive experiences of this.

Health and Well being strategy

Sickness %

4.7%


Well Led – Scorecard

30


Total Establishment (WTE) 3952 3925 3932 3929 3944 3950 3961 4006 4006 4027 4031 4030 4033

Vacancy Rate (All Staff) 11.0% 9.8% 9.4% 9.5% 9.5% 9.6% 10.4% 11.1% 11.6% 10.9% 10.0% 10.2% 9.5%

Staff Turnover rate 16.4% 16.1% 15.8% 16.0% 15.7% 15.8% 15.9% 16.1% 16.5% 16.2% 16.4% 16.8% 16.1%

% of Staff who have had an Achievement Review YTD 97.0% 97.2% 97.6% 1.3% 11.5% 19.5% 39.7% 53.0% 65.0% 84.0% 90.3% 92.0% 92.2%

%age of staff who have completed MAST training in the last 12 months 80.3% 76.8% 78.0% 77.2% 76.0% 77.0% 75.0% 77.0% 76.6% 76.1% 76.0% 77.9% 77.0%

Overall Sickness Rate 4.1% 3.7% 3.5% 2.8% 3.5% 3.6% 3.8% 4.1% 3.8% 4.1% 4.5% 4.3% 4.7%

Establishment and Training

Staff health, well being and working lives

Do we use resources effectively

Section 7

31



Effective use of resources

32

• We are forecasting a £11m surplus outturn for 2017/18. This is £10.3m adverse to the £21.3m surplus

control total. NHSi has been notified of this new forecast position in accordance with the relevant

protocols.

• We achieved a £9.8m [adjusted] surplus at the end of Month 10, which is £6.4m adverse to the year to

date (YTD) financial plan.

• The YTD position includes £5.7m Sustainability & Transformation Funding (STF).

• £4.8m of savings have been achieved YTD.

• The 2017/18 savings programme totals £6.2m.

• The Programme includes:

• £2m saving in agency premium,

• £2.4m productivity savings,

• £1.8m non pay savings,

• YTD achievement is £4.8m (including £2m use of contingency reserves) against a plan of £4.8m.

Savings Plan

YTD Savings

£m - Actual

£4.8m

YTD £m

Adjusted

Surplus

£9.8m

Income and Expenditure





Effective use of resources

33

• Forecast capital spend (excluding donated assets additions) is £11.6m which is precisely in line with the new

2017/18 £11.6m Capital Resource Limit (CRL).

• The £7m of loan funded projects (including EPR and Pathology Joint Venture) included in the original capital

programme have been moved into 2018/19 capital programme.

• The cash balance at the end of January 2018 was £3.3m.

• We repaid £3.5m revolving working capital in April 2017 and borrowed a further £1.3m in July and

£1.8m in Sept . A further £3.1m was been repaid in January 2018 bringing the balance down to

£12.5m at the end of January 2018.

• This cash has supported our Better Payment Practice Code performance which was 73% by

volume, 77% by value in the first ten months of 2017/18.

Capital Plan

Cash Management



Resources – Scorecard

34


Outturn £m Surplus / (Deficit) - Plan 15.2 15.2 15.2 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3

Outturn £m Surplus / (Deficit) - Forecast 5.0 5.0 5.0 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3 11.0

YTD £m Surplus / (Deficit) - Plan 6.8 10.1 15.2 (1.6) (0.3) 1.1 2.7 3.0 4.3 7.1 9.6 9.7 16.2

YTD £m Surplus / (Deficit) - Actual 3.6 2.0 3.5 (1.0) 0.1 1.2 2.7 3.1 4.4 5.3 7.1 9.7 9.8

Annual Outturn UNDERLYING £m Surplus / (Deficit) - Plan 7.5 7.5 7.5 12.5 12.5 12.5 12.5 12.0 12.5 12.5 12.5 12.5 12.5

Annual Outturn UNDERLYING £m Surplus / (Deficit) - Actual (2.8) (2.8) (4.3) 12.5 12.5 12.5 12.5 12.0 12.0 11.9 11.9 11.9 5.3

YTD Savings £m - Actual 6.8 8.0 9.2 0.3 0.7 1.0 1.4 1.8 2.2 2.8 3.5 4.1 4.8

OT Risk £m Surplus / (Deficit) - Assessment (2.5) (2.5) 0.0 (8.0) (8.0) (8.0) (16.3) (16.3) (16.0) (16.0) (16.0) (16.0) (5.5)

Outturn Cash position £m Fav / (Adv) - Forecast 2.5 2.5 5.6 2.7 2.7 2.7 2.7 2.7 2.7 2.7 2.7 2.7 2.7

YTD Cash position £m Fav / (Adv) - Actual 4.4 2.9 5.6 3.8 5.9 2.6 3.9 5.4 5.1 6.0 4.7 4.9 3.3

YTD Liquid ratio - days (7.0) (11.0) (12.0) (14.0) (13.0) (12.0) (11.0) (10.0) (9.0) (8.0) (6.0) 1.0 (3.0)

YTD BPPC (overall) volume £m 82% 83% 83% 94% 93% 92% 88% 86% 82% 74% 67% 70% 73%

YTD BPPC (overall) value £m 80% 82% 82% 97% 94% 91% 87% 87% 83% 78% 74% 75% 77%

Outturn Capital spend Fav / (Adv) - forecast 11.3 11.4 11.4 18.8 18.8 18.8 18.8 18.8 18.8 18.8 18.8 18.8 11.6


Delivering our Vision · Delivering our vision – How are we doing? January 2018 summary • We...

Documents

Transcript of Delivering our Vision · Delivering our vision – How are we doing? January 2018 summary • We...