agenda - part 1...gynaecologists report will be shared with the cqc. although ydh has not yet...

BOARD OF DIRECTORS

Wednesday 18 June 2014 at 11:00am Boardroom, Level 1, Yeovil District Hospital NHS Foundation Trust

AGENDA - PART 1

Presenter Timings Enclosure 1 WELCOME AND APOLOGIES FOR ABSENCE PW 11:00 Verbal 2 DECLARATIONS OF INTEREST RELATING TO ITEMS ON

THE AGENDA ALL Verbal

3 To APPROVE THE MINUTES OF THE MEETING HELD ON

21 MAY 2014 AND DISCUSS ANY MATTERS ARISING PW 11:05 Appendix 1

4 ACTION SHEET PW Appendix 2

EXECUTIVE DIRECTOR REPORTS 5 CHIEF EXECUTIVE REPORT JH 11:10 Appendix 3 6 MEDICAL DIRECTOR REPORT TS 11:20 Appendix 4 7 DIRECTOR OF NURSING REPORT, INCLUDING SAFER

STAFFING REPORT HR 11:30 Appendix 5

8 CHIEF FINANCE AND COMMERCIAL OFFICER REPORT TN 11:40 Appendix 6

ITEMS TO APPROVE 9 ANNUAL SELF-CERTIFICATIONS UNDER THE NHS

PROVIDER LICENCE, RISK ASSESSMENT FRAMEWORK AND THE HEALTH AND SOCIAL CARE ACT 2012 To APPROVE the Academic Health Science Network, Corporate Governance Statement and Training of Governors Certifications

JR 11:50 Appendix 7

CASE STUDY

10 EXPERIENCE OF PROJECT SEARCH 12:00 Verbal

PERFORMANCE 11 OPERATING & FINANCIAL PERFORMANCE OVERVIEW TN 12:20 Appendix 8 To DISCUSS the Overall Performance of the Trust

12 MONITOR Q4 2013/14 ASSESSMENT AND

ANNUAL PLAN 2014/15 REVIEW To NOTE the Assessment and Annual Plan Review

JR 12:40 Appendix 9

ITEMS TO NOTE

13 ORGAN DONATION ANNUAL REPORT 2013/14

To NOTE the Organ Donation Report, Local Progress on Organ Donation and Receive Assurance that NICE Guidelines Are Being Met.

HR 12:50 Appendix 10

14 ANY OTHER BUSINESS PW 13:00 Verbal 15 EXCLUSION OF THE PUBLIC PW Verbal To RESOLVE that representatives of the press and other members of the public be excluded from

the remainder of the meeting due to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

16 DATES AND TIMES OF FUTURE MEETINGS AND

EVENTS

Wednesday 16 July 2014 at 9.00am in the Boardroom, Level

1, Yeovil District Hospital

1

APPENDIX 1 BOARD OF DIRECTORS

18 JUNE 2014

BOARD OF DIRECTORS

Minutes of the meeting of the Board of Directors held on Wednesday 21 May 2014 at Yeovil District Hospital

Present: Peter Wyman Chairman Paul Mears Chief Executive Maurice Dunster Non-Executive Director Julian Grazebrook Non-Executive Director Jane Henderson Non-Executive Director Paul von der Heyde Non-Executive Director Mark Saxton Non-Executive Director Jonathan Howes Deputy Chief Executive Tim Newman Chief Finance & Commercial Officer Helen Ryan Director of Nursing & Clinical Governance Tim Scull Medical Director In Attendance: Mark Appleby Head of Workforce and Organisational Development Simon Blackburn Head of Communications Lou Evans Appointed Governor (Observer) Jonathan Higman Director of Urgent Care & Long Term Conditions Mark Marriott PMO Director John Park Public Governor (Observer) Jade Renville Company Secretary Action 1-66/14 APOLOGIES AND WELCOME

The Chairman welcomed everyone present to the meeting and extended a particular welcome to John Park and Lou Evans as governor observers. There were no apologies for absence.

1-67/14 DECLARATIONS OF INTEREST The Chairman declared that he is Treasurer and a member of the Council of the University of Bath.

1-68/14 MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 16 April 2014 were approved as a true and accurate record, subject to clarification at 1-59/14 to note that the end of year financial position was in surplus.

JR

1-69/14 ACTION SHEET The Board noted that all actions from previous meetings will be followed-up by the Company Secretary. The Director of Nursing and Clinical Governance confirmed that she will provide an update at each Board meeting on the actions that have occurred following the previous month’s patient story. The Head of Communications advised that action 1-24/14 concerning the filming a patient story is in progress.

JR

The Public Governor asked for an update on the actions relating to the staff survey. The Chief Executive advised that a corporate response plan has been developed and progress is being made with its implementation. A revised action sheet will be presented at the next meeting of the Board to be held on 18 June 2014.

1-70/14 MATTERS ARISING There were no matters arising not on the agenda.

1-71/14 PATIENT STORY The Director of Nursing and Clinical Governance and the Director of Urgent Care and Long Term Conditions provided an update in response to the previous month’s patient story which involved the transition of a patient from child to adult services. They advised that progress had been made in streamlining their care pathway and in identifying a care co-ordinator. They also reflected more generally on the symphony project and its aspirations to integrate care services, which would have particular benefits for those with complex, long term conditions. The Director of Nursing and Clinical Governance introduced Mandy Carney to the meeting to describe a case study relating to the admission of a patient who required tailored care co-ordination. In doing so, she expressed the close, collaborative working arrangements of the various agencies involved in the patient’s admission. Due to the level of detail discussed which could enable the patient to be identified, it was agreed that the minutes of this item would be recorded within the part 2 confidential section.

1-72/14 CHIEF EXECUTIVE BRIEFING The Chief Executive presented highlights from his written report, from which the Board NOTED that: • Monitor is reviewing the 2 year plans submitted by NHS

foundation trusts in April 2014 and had issued their initial sector findings in which they expressed concern that, in general, the plans were overly optimistic in demonstrating a recovery in 2015/16 given the continued decline in income in 2014/15. Monitor had consequently invited trusts to revisit their submissions for 2015/16. The Chief Finance and Commercial Officer confirmed that YDH had submitted realistic plans and were therefore not anticipating reviewing its plans at this stage. Monitor had queried the Trust’s cash position at the end of 2015/16, but the Chief Finance and Commercial Officer explained that YDH’s plans predict surplus by 2018/19. YDH will continue to work with Monitor and keep them regularly informed. Progress is also being made on the development of the Trust’s 5 year strategic plan which is due to be submitted to Monitor at the end of June 2014, a draft of which will be shared with the Board beforehand.

• Dr Elizabeth Warburton (a stroke physician from Cambridge) had visited YDH to review the options being considered for the configuration of stroke services in the county. Her report will form part of the deliberations of the Somerset CCG on 4 June 2014.

PM/JR

The Chief Executive and Director of Urgent Care and Long Term Conditions had presented the various options to the South Somerset District Council. Early discussions had also been held with the clinical stroke teams at Taunton and Somerset NHS Foundation Trust about the practicality of collaboration. The Head of Communications spoke of the media interest and confirmed that he is liaising with his counter-part at the Somerset CCG. An update will be provided to the Board once the Somerset CCG has made its decision. The Non-Executive Directors asked about the recruitment of a stroke consultant and it was confirmed that there is a locum in place and interest in the role, recruitment to which would be undertaken subject to the outcome of the stroke review.

• Demand for CT scanning is increasing and the Hospital

Management Team has considered a proposal to procure a second CT scanner, the financing of which is being reviewed. The ongoing radiology workforce review will help support the resourcing of the new scanner.

• The Director of Elective Care post is currently out to advert.

The Deputy Chief Executive verbally advised the Board of a data breach where, as a result of human error, the names and addresses of some patients had been sent to an external contractor. He advised that a full investigation had been undertaken, resulting in changes to the way in which future processes are managed. He confirmed that a SIRI had been raised and the information commissioner (ICO) informed. The ICO had not issued any further recommendations.

PM

1-73/14 MEDICAL DIRECTOR REPORT The Medical Director presented highlights from his written report, from which the Board NOTED that: • Progress had been made on the implementation of actions

following the Deanery visit on the 17 January 2014.

• While there had been staff capacity issues within HDU, there were also areas of progress, such as the facilitation of a structured ward round of all ‘high risk’ patients.

• YDH recently subscribed to the ‘Qlikview’ system which enables

real time uploading of data and a number of dashboards to help monitor performance with ease. A team is being set up to oversee the clinical outcomes data project, which building on the Dr. Foster Intelligence system, will focus on the collection of clinical outcome measures and enable individual clinicians to identify measures of value to them.

1-74/14 DIRECTOR OF NURSING AND CLINICAL GOVERNANCE REPORT The Director of Nursing and Clinical Governance presented highlights from her written report, from which the Board NOTED that:

• YDH is continuing to work on the National Quality Board guidance

for reporting staffing levels. From May 2014, expected and actual ward staffing levels started to be recorded and input into a national data warehouse which will then calculate shift fill rate. This information will be reported monthly on the NHS Choices website along with RAG rated staffing indicators. There is internal work to ensure wards have appropriate staffing levels and to rationalise the data that is input into the national data warehouse as there are variations in how trusts calculate and upload raw data. In future, the Board will receive bi-annual updates on staffing levels, along with monthly exception reports.

• The Director of Nursing and Clinical Governance had a constructive meeting with the Trust’s new CQC Inspector, Mandy Eddington. The draft CCG assurance visit report, CCG Kingston Wing review and Royal College of Obstetricians and Gynaecologists report will be shared with the CQC. Although YDH has not yet appeared on the list of hospitals due for inspection under the new style regime, YDH is assessing its state of readiness and undertaking a gap analysis. A briefing will be provided at HMT forum and at induction to junior doctors.

• Following a review of YDH’s governance structure, there are new opportunities for governors to become involved with work to improve patient experience. To avoid duplication, it may be beneficial to disband the governor Patient Experience Working Group, although the Director of Nursing and Clinical Governance will continue to hold quarterly catch-up sessions with the governors to listen to feedback in relation to quality, patient safety and experience and respond to any concerns. Further proposals will be considered by the Council of Governors before a final decision is made.

HR

HR

1-75/14 CHIEF FINANCIAL AND COMMERCIAL OFFICER’S REPORT The Board NOTED the previously circulated briefing note and the Chief Financial and Commercial Officer verbally updated the Board on the April 2014 financial position, the details of which had not been finalised before the writing of the report: • The April 2014 financial position was in deficit and demonstrating

adverse variance to plan. Due to demand, YDH had been unable to close its escalation ward as originally intended and agency and locum costs remained high. There were additional challenges in reducing agency (nursing) and locum (medical) spend in the urgent care strategic business unit, especially in respiratory, FOPAS and the emergency department. There are plans in place seeking to address these issues and to understand levels of demand and utilisation.

The Head of Communications asked when the successful Smartcare bidder would be announced and was advised that this would occur the week commencing 26 May 2014.

1-76/14 HR AND WORKFORCE REPORT – EQUALITY AND DIVERSITY The Board NOTED the previously circulated report, the content of which was taken as read. The Head of Workforce and Organisational Development highlighted the centralisation of training budgets, which would help ensure fairness to all staff who wish to undertake external training as part of their continuing professional development. The Board reflected on the importance of initiatives relating to equality and diversity and the importance of collaborative working.

1-77/14 OPERATING AND FINANCIAL PERFORMANCE REPORT AND WORKFORCE REPORT The Board reviewed the previously circulated report and the Chairman asked the executive directors to verbally advise the Board of any areas of particular pressure. The Chief Executive and PMO Director provided an update on the referral-to-treatment (RTT) position and ongoing pressures in meeting the target across certain specialities. They explained that the total RTT fines in March 2014 were £9,500 but that a new system is being introduced in 2014/15 whereby fines will be issued on a fixed penalty basis rather than by proportion of service value. The PMO Director advised that he is currently addressing a case where one patient waited significantly more than 18 weeks RTT. He agreed to provide an update at the next meeting, together with an explanation of the reasons for the increased demand. The Board recognised the complexity in interpreting RTT guidance and reflected on the review of data quality that had been led by the internal auditors. The Non-Executive Directors on the Audit Committee provided context by explaining that the internal auditors had been invited to review key indicators where the Trust is close to target, including cancer waiting times, RTT and A&E waiting times. They advised there was no evidence of deliberate data manipulation but the auditors had identified levels of weaknesses in the system as different interpretations of guidance had led to variations in the collection of data. The Director of Urgent Care and Long Term Conditions conveyed the need for those reviewing the data to have an understanding of the rules and guidance, the complexity of which may not have been fully understood by the internal auditors. The Non-Executive Directors on the Audit Committee and the Chief Finance and Commercial Officer confirmed that the Audit Committee had received assurance that reporting anomalies would not affect the Trust’s overall performance position and advised that regular reviews would be incorporated within the work plan of the internal auditors. The Director of Urgent Care and Long Term Conditions advised that there is a sustained month on month increase in cancer screening referrals, particularly for breast cancer. The Somerset CCG had been informed of the increased pressures. While the team is working efficiently to manage patients within the relevant timescales, the ability to deliver additional improvements, such as operating as a “one stop shop”, becomes more challenging.

MM

The Board queried performance against the targets for patients who have had a stroke being admitted directly to the stroke ward within 4 hours and stroke patients spending >90% of their time on the stroke ward. The Director of Urgent Care and Long Term Conditions explained that a root cause analysis had been undertaken which identified there had been some subversion from the pathway, which is now being rectified. The Board reflected on the purchase of the new CT scanner and the opportunities to improve access for patients that require it for thrombolysis. Recognising low performance in the number of patients discharged by the estimated due date, it was confirmed that there is an ongoing review of discharges data. The Director of Nursing and Clinical Governance verbally updated the Board that in April 2014 there had been increases in falls and pressure ulcers. She agreed to provide an update on the actions being taken at the next meeting. The Board spoke of the difficulties in encouraging emergency department attendees to provide feedback as part of the friends and family test. Commenting on length of stay and long stayers, the Board commented on the challenges in co-ordinating external services to which the patient can be discharged. The Head of Workforce and Organisational Development conveyed that from April 2014 data, he is expecting an improvement in appraisal and mandatory training uptake following the implementation of new policies covering these areas. The Board NOTED the Operating and Financial Performance Report and Workforce Report.

HR

1-78/14 G6 AND COS7 CERTIFICATION The Company Secretary presented the G6 and CoS7 declarations, and asked the Board to confirm that: • Following a review for the purpose of paragraph 2(b) of licence

condition G6, [they] are satisfied, as the case may be 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 imposed on it under the NHS Acts and have had regard to the NHS Constitution.

• Yeovil District Hospital NHS Foundation Trust continues to meet the criteria for holding a licence.

• After making enquiries [they] have a reasonable expectation that

the Licensee will have the Required Resources available to it after taking account distributions which might reasonably be expected to be declared or paid for the period of 12 months referred to in this certificate.

The Board APPROVED the G6 and CoS7 declarations.

1-79/14 MINUTES OF THE AUDIT COMMITTEE - 4 MARCH 2014 The Board NOTED the minutes of the Audit Committee held on 4 March 2014.

1-80/14 ANY OTHER BUSINESS There was no further business to discuss.

1-81/14 DATE OF NEXT MEETING The next meeting will be held on Wednesday 18 June 2014.

1


18 JUNE 2014 BOARD OF DIRECTORS – ACTION SHEET

18 JUNE 2014 Minute Action Outcome Due By

ACTIONS FROM 20 NOVEMBER 2013 190/13 Consider holding seminar on the

pathway administration project To consider Spring

2014 JHig

ACTIONS FROM 22 JANUARY 2014 1-6/14 Patient Story

Set up working group to review learning and training requirements

Complete – actions from previous

patient story now discussed at subsequent meetings

May 2014 HR

1-12/14 Update on the Trust’s response plan to the staff survey

In progress June 2014 MA

ACTIONS FROM 19 FEBRUARY 2014 1-24/14 Patient Story

Review learning and training for staff, particularly on communicating with patients and their families – update on progress to be provided. Patient story to be filmed to enhance staff training

Complete

In progress

May 2014

HR

SB

1-25/14 Leadership Programme (LDP) Coordinate NED observation of LDP

In progress March 2014

PM/MA/ MD

1-27/14 Consider options for displaying ward information electronically

In progress March/April 2014

HR /SB

1-29/14 Future seminar session on the contact strategy to be organised

Not yet due June 2014

JR/JHig /SS

1-29/14 Operating and Financial Performance Report Members to notify the CFO of comments on the quantity, quality and formation of information provided and what is required by the assurance committees - Future seminar on the topic to be held

Not yet due – deferred until July

Seminar session

arranged for July

All

TN/NK

1-29/14 Review terms of reference with the chairs of the assurance committees (if required)

In progress (development

sessions with the committees have

been held)

Deferred – Summer

2014

JR

ACTIONS FROM 19 MARCH 2014 1-39/14 Once preferred bidder is identified

and implementation plans are in place, a demo on EHR to be provided at a seminar

Not yet due Summer / Autumn

2014

TN

2

1-39/14 VitalPAC demo to be provided at a seminar

Complete - undertaken at

Council of Governors

June 2014 HR

1-45/14 Ernst & Young Report Action plan to be developed to ensure the recommendations contained within the report are taken forwards

In progress Deferred July/August

2014

JR/PW

ACTIONS FROM 16 APRIL 2014 1-55/14 Patient Story

Update on implementation of actions to ensure smooth transition of patient from child to adult services and ongoing co-ordination of care.

Complete June 2014 HR/JHig

1-56/14 Consider arranging a seminar session on the NHS Leadership Fast Track Programme with Dr Meredith Kane and Dr Andy Sant

Not yet due Autumn 2014

PM

1-60/14 Information required on non-violent incidents and what this might comprise

Complete 21 May 2014

HR

1-63/14 Review whether key risks set out within the risk register could be more clearly identified

In progress July 2014 HR

ACTIONS FROM 21 MAY 2014 1-72/14 Draft of 5 year strategic plan to be

shared with the Board and governors for comment.

In progress 19 June 2014

JR/PM

1-72/14 Outcome of stroke review to be shared with the Board once CCG has made its decision.

Complete 4 June 2014

PM

1-74/14 Draft CCG assurance visit report, Kingston Wing review and Royal College of Obstetricians and Gynaecologists report to be shared with CQC

Complete June 2014 HR

1-74/14 A briefing on preparing for CQC inspections will be provided at HMT forum and at induction to junior doctors.

Not yet due July /August

2014

HR

1-77/14 Update on RTT position to be provided at the next meeting.

Will be complete 18 June 2014

PM/MM

1-77/14 Update on falls and pressure ulcers to be provided at the next meeting.

Will be complete 18 June 2014

HR


18 JUNE 2014

Report to: Board of Directors Report from: Chief Executive Subject: Chief Executive Report Date: 18 June 2014 Monitor Annual Plan Following the submission of our two year annual plan to Monitor we had a follow up conference call with our relationship management team to discuss our financial plans. Monitor raised some queries on the financial assumptions, particularly in relation to the delivery of CIP plans in year 2 and the potential impact on our financial position. We have agreed to undertake a further piece of work on this in the coming weeks and share this with Monitor as part of our ongoing discussions about the long-term plans for the organisation. Stroke Review The Somerset CCG Governing Body met on the 4 June 2014 to review the proposals to reconfigure stroke services in the county. At the meeting, they agreed to maintain two centres for acute stroke services at Yeovil Hospital and Musgrove Park Hospital and have asked that further collaboration between the two sites is undertaken to ensure sustainability, particularly at weekends. We have also been asked to move forward with the purchase of a second CT scanner and additional medical staff to support the stroke service. We will be procuring the CT scanner in the next few months and are developing a plan around medical staffing for stroke services. We are pleased that the Somerset CCG has confirmed their decision to maintain the acute stroke service in Yeovil. We are committed to working with colleagues at Musgrove Park Hospital and the Somerset CCG to continue to improve stroke services in the county. I would like to thank all of our stroke team, in particular Dr Khalid Rashed for their hard work and commitment to the service at Yeovil over the past two years whilst the review was being undertaken. There has been a considerable period of uncertainty for all of our stroke team and they have continued to provide an excellent service for our patients despite this for which they deserve our thanks. National Work on Small Hospitals Following Simon Stevens’ appointment as Chief Executive of NHS England there has been much interest in small hospitals and how to ensure they have a strong and sustainable future. We are involved with a significant number of national organisations (Monitor, Nuffield Trust and the Foundation Trust Network) looking at this challenge and it is encouraging to see there is an ambition for a strong and sustainable future for these hospitals in the future.

There is also the recognition that hospitals will have to look very different in the future to the way in which they have operated in the past and many of the suggested solutions are part of the strategy of this organisation in the coming years. Paul Mears Chief Executive


18 JUNE 2014 Report to: Board of Directors

Report from: Medical Director Subject: Medical Director Report

Date: 18 June 2014

Research and Development The YDH research and development (R&D) department continues to be an exemplar model. We are currently bidding to host a multicentre trial entitled CEDAR, this being a study involving laparoscopic bowel surgery. The bid is for £1.3 million. If successful, this will be the largest study hosted by YDH and it will be led by Mr. Nadar Francis. Our recruitment this year to other trials is strong with over 200 recruits against an annual target of 650. The budget from the Peninsula Network has been cut this year by 8%, the traditional lump sum given to each clinical department in September/October will therefore be decreased by a similar proportion. We are now a member of a new R&D Network covering the whole of the South West, which will lead to changes in administration processes. However, we feel that funding streams will be easier to access especially as one of our surgeons is the lead in his clinical area. Patient involvement is strong and a patient event is being planned for June, the last event having been acknowledged as a great success. The department is launching a rebranding campaign with the involvement of Simon Blackburn, Communications Manager. It is intended to brand the department as the Clinical Research Unit (CRU). Medical Recruitment YDH has recently appointed Mr Richard Dalton, a General Surgeon with an interest in Laparoscopic Surgery, and Mr Matthew Hoare, an Orthopaedic Surgeon operating on the hand and forearm. Mr and Mrs Shah recently started as our Ophthalmic Surgeons and they are settling in well. Simon Knowles, a Histopathologist who worked with us and Taunton and Somerset NHS Foundation Trust recently retired, leaving YDH with a half time vacancy. I would like to thank Simon Knowles for his work at the hospital and wish him well in the future. There have been some difficulties in recruiting to certain specialties, including pathology, anaesthesia, respiratory medicine and care of the elderly. These difficulties are a national issue and are not confined to YDH. Tim Scull Medical Director



Report from: Associate Director of Patient Safety and Quality on behalf of the Director of Nursing and Clinical Governance

Subject: Director of Nursing Report on Quality, Safety and Patient Experience

Date: 18 June 2014

Safer Staffing YDH achieved full compliance with the upload of safer staffing data to in line with national requirements. A detailed report is attached at Appendix 1 and 2 and constitutes evidence of Board level reporting in accordance with guidance from NHS England. The intention to RAG score fill rates and performance of actual against planned staffing levels and to publish this information on NHS Choices has been deferred by NHS England. Patient Safety The rise in inpatient falls and hospital acquired pressure ulcers in April 2014 was followed with a decrease during May 2014. Analysis has demonstrated that, whilst incidence increased in April, the rate of these harms per 1000 bed days remained largely unchanged. A similar rise was seen at the beginning of 2013 but was not sustained. Key actions include completion of root cause analysis on Grade 2 pressure ulcers and piloting of a virtual falls team to support rapid assessment and care planning. Three incidents have been reported as Serious Incidents Requiring Investigation. Staff have attended a number of regional and national patient safety events and are collating feedback to inform improvement work. Patient Experience The Somerset CCG carried out a quality assurance visit on 22 April 2014 and the team visited wards 6a, 6b and 7a. The Trust has received the final report, including a summary statement setting out a positive response and a number of low level recommendations. These include: • consider use of ipads/skype to improve communication with relatives unable to visit patients • increased awareness and training of Mental Capacity Act • all staff to introduce themselves by name • introduce corporate information for patients and visitors – welcome leaflets/ contact cards Action has already been taken to progress these recommendations. The full report will be subject to review and consideration by the Patient Experience Committee and the Clinical Governance Assurance Committee.

CQC Update The Trust has now met with the appointed CQC Inspector and Regional Manager to establish joint working arrangements. An outline of current inspection priorities and focus on key lines of enquiry was discussed. The CQC Intelligent Monitoring Report will be subject to scrutiny from the Clinical Effectiveness Committee. The Trust's current level of rating remains 5 out of 6 with elevated risks still reported against the Junior Doctor GMC survey results, data quality issues and a lower than expected harm rate resulting in catastrophic harm/death. Quality Account Governor Indicator The Governors have agreed the final indicator for the Quality Accounts as: The patient experience of discharge, to be measured by regular patient surveys. The proposal includes a baseline survey for compliance in June/July and then repeat at intervals until the end of the year to demonstrate progress. Helen Ryan Director of Nursing and Clinical Governance

Appendix 1 BRIEFING ON THE REQUIREMENTS FOR THE TRUST TO COMPLY WITH ‘HARD TRUTHS COMMITMENTS REGARDING THE PUBLISHING OF STAFFING DATA’

Executive Summary

Purpose To provide the Board with an update on its responsibilities for ensuring safe nurse staffing levels across the organisation. Key Points: The guidance published by the Chief Nursing Officer for England in November 2013 - How to ensure the right people, with the right skills, are in the right place at the right time (‘Hard Truths’) - and the draft NICE guidance published in May 2014, Safe Staffing for nursing in adult inpatients wards in acute hospitals has been summarised into the key actions required by the Board. Boards must be able to demonstrate to their patients, carers and families, commissioners, the CQC and Monitor, that robust systems are in place to assure themselves that the nursing, midwifery and care staffing capacity and capability in the Trust is sufficient to deliver safe and effective care. The first report is attached to this paper.

Implications: The Board will receive a monthly exception report which will include shifts not covered, vacancy and sickness rates. The Board may have to agree in year changes or additional actions should there be concerns over capacity within the nursing and midwifery workforce. Publishing of the data at ward level will be required on our websites and on the NHS Choices website which increases transparency but may also bring adverse media coverage. The Board is asked to NOTE the progress and actions being taken. CONFIRM support of the layout and information contained in the attached report which will be uploaded on to the Trust website monthly. CONFIRM the support and give the authority to the Director of Nursing and Clinical Governance to be the senior responsible officer.

1.0 Introduction 1.1 The following briefing sets out the actions required by the Board of Directors to comply

with the recommendations from the ‘Hard Truths’ report published in November 2013. 2.0 Background

2.1 The Board of Directors has continually received reports on staffing establishment but

there is now a requirement for there to be formal reporting processes in place. There are further requirements which will need to be put in place as this national agenda is continues to progress.

3.0 Expectations of the Board

3.1 Boards 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. Responsibilities include:

• Managing staffing capacity and capability by agreeing staffing establishments; • Considering the impact of wider initiatives (such as cost improvement plans) on

staffing; • Monitoring staffing capacity and capability through regular and frequent reports on

the actual staff on duty on a shift-by-shift basis versus planned staffing levels; • Examining trends in the context of key quality and outcome measures; • Asking about the recruitment, training, skills and experience, and management of

nurses, midwives and care staff and giving authority to the Director of Nursing and Clinical Governance to oversee and report on this at Board level.

4.0 How must Boards do this?

4.1 The Board should receive a report every six months on staffing capacity and capability

which has involved the use of an evidence-based tool (where available), includes the key points set out in NQB report page12 and reflects a realistic expectation of the impact of staffing on a range of factors.

This report:

• Draws on expert professional opinion and insight into local clinical need and context; • Makes recommendations to the Board which are considered and discussed; • Is presented to and discussed at the public Board meeting; • Prompts agreement of actions which are recorded and followed up on; • Is posted on the Trust’s public website along with all the other public Board papers.

5.0 What should the Board papers look like?

Papers to the Board on establishment reviews (reported every six months as a minimum) should aim to be relevant to all wards and cover the following points: • Demonstration of the use of evidence based tool(s); • What allowance has been made in establishments for planned and unplanned leave; • The difference between current establishment and recommendations following the

use of evidence based tool(s); • The skill mix ratio before the review, and recommendations for after the review; • The difference between the current staff in post and current establishment and

details of how this gap is being covered and resourced;

• Details of any element of supervisory allowance that is included in establishments for the lead sister / charge nurse or equivalent;

• Evidence of triangulation between the use of tools and professional judgement and scrutiny;

• Details of any plans to finance any additional staff required; • Details of workforce metrics - for example, data on vacancies (short and long-term),

sickness / absence, staff turnover, use of temporary staffing solutions (split by bank / agency / extra hours and over-time);

• Information against key quality and outcome measures - for example, data on safety thermometer or equivalent for non-acute settings, serious incidents, healthcare associated infections (HCAIs), complaints, patient experience / satisfaction and staff experience / satisfaction.

5.1 The paper should make clear recommendations to the Board, which should be

considered and discussed at a public Board meeting. Actions agreed by the Board should be detailed in the minutes of the meeting, and evidence of sustained improvements in the quality of care and staff experience should be considered periodically.

5.2 There is a requirement for our Board to receive its first report in June 2014, which is

attached. There will continue to be monthly exception reports reported to the Board and a full report on safer staffing will be submitted every six months.

6.0 Board and Executive responsibilities

6.1 The Board should ensure that systems, policies and procedures are in place to support

decision making for staffing decisions on a shift-by-shift basis. To comply with this the following actions are required to be put into place:

• Staffing is supported by a national acuity tool and this would need to be monitored daily with escalation alerts in place; • A planned workforce review will be undertaken to fully understand actions

required to the meet the 1:8 ratio as recommended in the National Safe Staffing Alliance for relevant adult wards; The Director of Nursing and Clinical Governance, through the Associate Directors of Nursing and Matrons, monitors staffing shift by shift and adjustments take place as required;

• The Trust will be investing in an E-Rostering software, Allocate, which is designed to measure how we manage our workforce at ward level. There

are four key areas of the software: - Ward Establishment - Staff Supply, Rostering and Roster Management - Temporary Staffing Process and Bank Management - Payroll and Timesheet Management

• A planned bed reduction has been modelled in order to meet the ratio recommendations and this will progress during the month of June with the closer of Ward 9A (escalation ward) in the first instance followed by reduction in beds per bay across identified inpatient wards.

7.0 Publishing and displaying data

7.1 It is now a requirement that we publish the planned and actual staffing and description

of the team so that it is visible to patients and visitors at ward level, and in the future across all clinical areas.

7.2 We have therefore put in place across all of our wards, safer staffing boards, which are updated at the start of every shift that includes planned and actual staffing available.

7.3 We are in the process of developing a report which will be uploaded on to our website

and NHS Choices webpage from June 2013. 8.0 Governance on managing staffing capacity

8.1 The Director of Nursing and Clinical Governance is proposing the following in order to

strengthen the governance structure for managing safer staffing and this is set out below.

• The strategic business units (SBU) will be required to discuss the current staffing

capacity at their monthly performance management review and the actions they are taking. This will ensure that the Board is not receiving information that has not been considered by the SBU’s Directorates.

• The Director of Nursing and Clinical Governance, will lead a review of all staffing teams directly with the Associate Directors of Nursing and Matrons every six months and will provide a six monthly full report to the Board.

• The Associate Directors of Nursing will work with their strategic business units to agree their workforce actions and support them to achieve these.

9.0 Recommendation

The Board of Directors is asked to;

• NOTE the progress and actions being taken. • CONFIRM support of the layout and information contained in the attached report

which will be uploaded on to the Trust website monthly • CONFIRM the support and give the authority to the Director of Nursing and Clinical

Governance to be the senior responsible officer.

Appendix 2

MONTHLY REPORT OF NURSE MIDWIFERY STAFFING LEVELS

1 MAY 2014 – 31 MAY 2014

Executive Summary Purpose: • To provide the Board with an overview of nurse midwifery staffing levels in inpatient areas

as outlined in the Nurse Staff Guide ‘How to ensure the right people, with the right skills are in the right place at the right time!’ Published by the National Quality Board and NHS Commissioning Board.

• To provide the Board with an overview of nurse midwifery shifts not covered, vacancies and sickness rates. • To bring to the attention of the board any workforce risks. Methodology and scope of review: This report is focused on the following areas: • All in-patient adult wards including critical care • All in-patient maternity wards and departments on the acute site • All in-patient paediatric wards including neonates This report does not yet include non-in-patient areas such as the operating theatres, day surgery, endoscopy and emergency department. At the present time there is no requirement to report the planned and actual numbers of staffing for our escalation ward or bays. Key Points:

• To demonstrate compliance with new staffing expectations and staffing guidance. • Ward establishments are based on evidence based assessments of acuity and

dependency which is recorded on Swiftplus, alongside professional judgment and key clinical indicators. The Trust has utilised the (Association of UK University Hospitals (AUKUH) tool for a number of years and will continue to apply this methodology for the workforce establishment review

• We are now collecting the number of times shifts fell below agreed staffing levels, as this is currently being undertaken manually there may be slight inaccuracies in the data. It is expected we will be able to automate this by the winter, following the purchase of the E-Rostering software, Allocate.

• Staffing during May was challenging, due to high acuity, vacancies and sickness, however 663 shifts were covered by bank and agency staff. Staff were also been moved from wards following professional clinical judgment, this would have been possible due to low patient numbers on a ward, for example Kingston Wing, therefore allowing for staff moves.

The national return on Unify for the month of May 2014, demonstrated that EAU were the highest staffed area with HCA’s during the day with 106.9% and the lowest staffed area was Freya with HCA’s during the night with 90.3%. The Trust’s overall return was 100.4%.

Ward name

Registered midwives/nurses Care Staff Registered

midwives/nurses Care Staff Average fill rate

- registered nurses/midwives

(%)

Average fill rate -

care staff (%)

Average fill rate - registered

nurses/midwives (%)

Average fill rate -

care staff (%)

Total monthly planned staff hours

Total monthly actual staff hours

Total monthly planned

staff hours

Total monthly actual staff

hours


staff hours


hours


staff hours


hours

Jasmine 1488 1488 1002 1002 1488 1488 1159.5 1159.5 100.0% 100.0% 100.0% 100.0% Kingston Wing 604.5 604.5 638 638 644 644 365.5 365.5 100.0% 100.0% 100.0% 100.0%

6A 1031 1042.5 1444 1488.5 713 713 589 589 101.1% 103.1% 100.0% 100.0% 6B 2139 2186 2371.5 2394.5 713 730.5 713 701.5 102.2% 101.0% 102.5% 98.4% 7A 1293 1316.5 960.5 960.5 713 713 713 713 101.8% 100.0% 100.0% 100.0% EAU 1376.5 1376.5 1223 1307.5 1069.5 1069.5 713 747.5 100.0% 106.9% 100.0% 104.8% 8A 2122 2122 2015 2038 713 713 713 713 100.0% 101.1% 100.0% 100.0% 8B 2360 2354.5 2015 2061.5 713 713 713 713 99.8% 102.3% 100.0% 100.0% 9B 2139 2145 2268 2302.5 713 713 713 742 100.3% 101.5% 100.0% 104.1% 10 1069.5 1087 356.5 368 1069.5 1081 11.5 101.6% 103.2% 101.1% ICU 2495.5 2555 155 160 2495.5 2541.5 11.5 102.4% 103.2% 101.8% CCU 1395 1383.5 883.5 860.5 99.2% 97.4% Freya 2671.5 2596.5 868 800.5 1953 2005.5 325.5 294 97.2% 92.2% 102.7% 90.3%

SCBU 930 936 453 447.5 465 465 294.5 283 100.6% 98.8% 100.0% 96.1%

Trust Wide 100.3% 101.3% 100.7% 100.5%

When the data is broken down on a shift by shift basis, there were a total of 52 shifts which were not covered in the month of May.

• 17 HCA shifts during the day (2 due to sickness, 1 agency DNA and 14 no reason has been documented

• 9 HCA shifts during the night (3 due to sickness, 1 agency DNA and 5 no reason documented)

• 17 Registered Nurse shifts during the day (1 due to sickness, 1 agency DNA and 15 no reason documented)

• 9 Registered Nurse shifts during the night (2 due to sickness, and 7 no reason has been documented)

Ongoing work continues with the Nurse Bank to ensure that where shifts have not been covered that the reason why is clearly documented, so that Board can be fully informed of staffing shortfalls.

• Ward Staffing Boards are now in place on all in-patient wards which records the planned number of registered nurses, health care assistants and therapy staff with the actual staff on duty, this is recorded for early, late and night shifts.

• Acuity, dependency and complexity of patients is escalated to senior nursing and midwifery teams and if a change in staffing skill mix is required in order to meet the acuity needs of patients this is actioned in order to maintain patient safety.

• Where individual shifts triggered the acuity measure agreed Trust escalation process were triggered and contingency plans implemented. However staffing levels remained safe with flexing of staff across wards and department, utilisation of temporary staff and the use of the specials team to care for the unwell patient requiring one to one care

• Vacancy levels vary across wards and departments. There is a continued central drive to recruit.

• 3 new staff nurses and 2 endoscopy nurses were appointed in May 2014, 1 Health Care Assistant and 1 Nursery Nurse were given temporary contracts.

• Staffing numbers planned versus actual published on each ward on a shift by shift basis, commenced May 2014.

• Vacancy shortfall covered by the use of temporary staff • Maternity staffing has been challenging in the month of May with a lack of

midwifery staff. There are also no agency or bank midwives which the Trust can call upon. The home birth service has been stopped on two occasions. Staffing on the maternity unit has been escalated to the Risk Register.

The following table shows the number of bank and agency staff used for the month of May 2014, which has been broken down by ward and specialty.

A total of 678 bank and agency staff was used in May 2014 to cover shifts on the ward, of this 377 were agency staff and 310 were booked from the YDH bank.

Implications: • Constant focus on recruitment required. • Continue to review nurse midwifery staffing levels and patient acuity on a shift by shift basis, using escalation procedures as required. • Director of Nursing and Clinical Governance to report staffing levels to the Board monthly. • A planned workforce review will be undertaken to fully understand actions required to the meet the 1:8 ratio as recommended in

the National Safe Staffing Alliance for relevant adult wards. Recommendations:

• The Board of Directors is asked to NOTE the information contained in this summary report and the actions we have in place

Jasmine Kingston 6A 6B 7A EAU 8A 8B 9B 10 ICU CCU Freya SCBU HCA Agency 12 1 9 13 15 20 13 11 32 6 4 1 1 Agency D Grade 8 10 37 60 16 15 17 31 23 1 9 3

Bank Band 1 5 12 6 4 12 7 20 16 1 2

Bank Band 2 7 12 6 5 11 9 16 10

Bank Band 3 2 2

Bank Band 5 3 14 2 39 7 7 6 12 7 8 22 3 7

Bank Band 6 1 7

Total 35 25 72 124 47 65 52 92 91 16 37 7 1 14

Agency Total 20 11 46 73 31 35 30 42 55 7 13 4 1 0

Bank Total 15 14 26 51 16 30 22 50 36 9 24 3 0 14


18 JUNE 2014

Report to: Board of Directors Report from: Chief Finance and Commercial Officer Subject: Chief Finance and Commercial Officer Report Date: 18 June 2014 Estates Update I expect a final draft of the site masterplan to come to the Board in the next couple of months, incorporating feedback received which has largely been very positive. The physical demolition of the Cheverton building has now started after a short delay as further asbestos was discovered during the soft strip. However we are on schedule and it is still expected that cars will be able to park on the site by September 2014. We have appointed a project manager to progress the economics and design programme of the multi-storey car park. In addition we are discussing financing options with the district council. The combined heat and power (boiler) project continues and is on schedule. Planning permission has been requested for the upgrade of the special care baby unit, and works are planned to start in the autumn together with the refurbishment of Freya Ward. The improved YDH restaurant opened at the end of May 2014, and has been well received. The team are working on an awareness campaign and continuing to develop the menus. Financial Position At the time of writing, the May 2014 results have not been finalised. I will provide an update at the Board on 18 June 2014. Strategic Estates Partner We have a shortlist of five bidders in the competitive dialogue stage of the procurement. This is expected to last until July 2014 when we reduce the bidders down to two. So far we have held one round of face to face meetings with the bidders, which featured some high quality discussions. The plan is for the preferred bidder to be selected by September 2014, with Paul Mears, Chief Executive, joining the selection panel for the final stage. The partnership should be operational by October 2014. SmartCare YDH has selected its preferred supplier, which is Intersystems. A separate Part 2 Board paper will present the final business case which then needs to be submitted to the Southern Acute Clinical Programme Board, the Department of Health and the Treasury for final sign off for funding. Tim Newman Chief Finance and Commercial Officer



Report from: Company Secretary Subject: Annual Planning Monitor Declarations

Date: 18 June 2014

INTRODUCTION Previously, foundation trusts were required to submit an annual governance statement to Monitor. This is no longer being collected in the same way as part of the annual planning process and these statements are being collected separately and consolidated within two templates with the following sections: 1&2) systems for compliance with licence conditions - in accordance with general condition

6 (G6) of the NHS provider licence 3) availability of resources and accompanying statement - in accordance with continuity

of services condition 7 (CoS7) of the NHS provider licence 4) corporate governance statement - in accordance with the Risk Assessment

Framework 5) certification on AHSCs and governance - in accordance with appendix E of the Risk

Assessment Framework 6) certification on training of governors - in accordance with s151(5) of the Health and

Social Care Act RECOMMENDATION Declarations 1, 2 and 3 were submitted to Monitor on 30 May 2014. Declarations 4, 5 and 6 are set out below as these are required to be returned to Monitor by 30 June 2014. To enable compliance, the Board is required to respond "confirmed" or "not confirmed" to the following statements: CORPORATE GOVERNANCE STATEMENT 1 The Board is satisfied that the Trust applies those principles, systems and

standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS.

Examples of evidence and actions include: internal and external audit, annual audit letter, head of internal audit opinion, strategic and operational plans, monthly operational, financial and performance reports to the Board, risk management framework (including maintaining risk registers) assurance framework received on a quarterly basis by the assurance committees and the Board, patients association review of the complaints process and CQC compliance reports.

2 The Board has regard to such guidance on good corporate governance as may

be issued by Monitor from time to time Guidance is implemented on an ongoing basis. 3 The Board is satisfied that the Trust implements:

(a) Effective board and committee structures; (b) Clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees; and (c) Clear reporting lines and accountabilities throughout its organisation.

Examples of evidence and actions include: The Trust’s constitution, standing orders, standing financial instructions and scheme of reservation and delegation, committee terms of reference, minutes of committee meetings, internal audit review of the Trust’s governance arrangements and external review of Board effectiveness. 4 The Board is satisfied that the Trust effectively implements systems and/or

processes: (a) To ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively; (b) For timely and effective scrutiny and oversight by the Board of the Licensee’s operations; (c) To ensure compliance with health care standards binding on the Licensee including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions; (d) For effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensee’s ability to continue as a going concern); (e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making; (f) To identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence; (g) To generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and (h) To ensure compliance with all applicable legal requirements.

Examples of evidence and actions include: cost improvement programme embedded within the strategic business units of the organisation (the details of which are reviewed by the Board on a monthly basis), internal and external audit, strategic and operational plans, monthly operational, financial and performance reports to the Board, risk management framework (including maintaining risk registers), assurance framework received on a quarterly basis by the assurance committees and the Board, patient safety walk arounds, clinical audit, invited peer reviews - CCG assurance visit, CCG Kingston Wing review and Royal College of Obstetricians and Gynaecologists Review, compliance with standards and CQC outcomes, seminar session on the duty of candour, monthly patient story to the Board, external audit report on the 2013/14 annual accounts, annual report and quality report, review of the draft 2013/14 annual accounts, annual report and quality report, and the associated auditor reports, by the Audit Committee and the Board, overview of regular items presented to the Board and its committees as per regular meeting cycle, quarterly reporting

to Monitor, monthly Chairman’s report and executive director reports to the Board and report presented to the Board on 19 March 2014 confirming the Trust will operate as “going concern”. 5 The Board is satisfied that the systems and/or processes referred to in

paragraph 5 should include but not be restricted to systems and/or processes to ensure: (a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided; (b) That the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations; (c) The collection of accurate, comprehensive, timely and up to date information on quality of care; (d) That the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care; (e) That the Trust, including its Board, actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and (f) That there is clear accountability for quality of care throughout the Trust including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.

Examples of evidence and actions include: annual performance review of the Chief Executive by the Chairman, annual performance review of each executive director by the Chief Executive, annual personal development plan agreed for the Chief Executive and executive directors, compliance with CQC registration standards, review of the content of the quality report by the governors, the Board and the clinical governance assurance committee, implementation of the friends and family test and progress reports on feedback, clinical audit, patient safety walk arounds, review by the patients association of the Trust’s complaints process, patient experience committee being established, governor patient experience development working group, CCG assurance visit, minutes from the clinical governance assurance committee received by the Board, monthly reports from the director of nursing and clinical governance to the Board and monthly operational, financial and performance reports to the Board. 6 The Board is satisfied that there are systems to ensure that the Trust has in

place personnel on the Board, reporting to the Board and within the rest of the organisation who are sufficient in number and appropriately qualified to ensure compliance with the conditions of its NHS provider licence.

Examples of evidence and actions include: Board development days and monthly seminar sessions, recruitment of senior roles overseen by the remuneration committee (and in the case of the chairman and non-executive directors, by the governors), regular 360 review undertaken by Board members, external review of Board effectiveness, robust staff recruitment process, staff induction, ongoing staff development, training and annual appraisal process. CERTIFICATION ON ACADEMIC HEALTH SCIENCE NETWORKS AND GOVERNANCE 7 For NHS foundation trusts:

• that are part of a major Joint Venture or Academic Health Science Centre

(AHSC); or • whose Boards are considering entering into either a major Joint Venture or an AHSC.

The Board is satisfied it has or continues to: • ensure that the partnership will not inhibit the trust from remaining at all times compliant with the conditions of its licence; • have appropriate governance structures in place to maintain the decision making autonomy of the trust; • conduct an appropriate level of due diligence relating to the partners when required; • consider implications of the partnership on the trust’s financial risk rating having taken full account of any contingent liabilities arising and reasonable downside sensitivities; • consider implications of the partnership on the trust’s governance processes; • conduct appropriate inquiry about the nature of services provided by the partnership, especially clinical, research and education services, and consider reputational risk; • comply with any consultation requirements; • have in place the organisational and management capacity to deliver the benefits of the partnership; • involve senior clinicians at appropriate levels in the decision-making process and receive assurance from them that there are no material concerns in relation to the partnership, including consideration of any re-configuration of clinical, research or education services; • address any relevant legal and regulatory issues (including any relevant to staff, intellectual property and compliance of the partners with their own regulatory and legal framework); • ensure appropriate commercial risks are reviewed; • maintain the register of interests and no residual material conflicts identified; and • engage the governors of the trust in the development of plans and give them an opportunity to express a view on these plans.

Yeovil District Hospital NHS Foundation Trust works with the South West Peninsula Academic Health Science and is part of Southwest Pathology Services (SPS) which is a joint venture between Taunton and Somerset NHS Foundation Trust, Yeovil District Hospital NHS Foundation Trust and private sector partners, Integrated Pathology Partnerships (iPP). Processes are in place to ensure compliance with the above statements. 8 Training of Governors

The Board is satisfied that during the financial year most recently ended the Trust has 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.

Examples of evidence and actions include: seminar sessions held after each council of governors meeting, items discussed at the council of governors meetings, induction information pack provided to governors, weekly conect emails and an ongoing development programme will be developed.

Operating & Finance

Performance Overview

April 14 / May 14

2

Section Title Page

CONTENTS

1 Operational Performance

2 Workforce

3 Financial Performance Summary

4 Appendix - Financial Detail

Operating


March 14 / April 14

Mortality

4

HSMR in February 14 was 86.3 (1.6 lower than February 13). Actual number of deaths in May 14 was 47, (May 13 54)

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Actual number of deaths


RTT [1/3]

5

In April 2014 91.0% (target 90%) of admitted patients and 96.3% (target 95%) of non-admitted patients completed consultant-led treatment within 18 weeks of referral.

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

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RTT completed pathways - 18 week - admitted

6 month moving average RTT target

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RTT completed pathways - 18 week - non admitted


40.0%

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90.0%

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110.0%

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4RTT incompleted pathways - 18 week - admitted


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RTT incompleted pathways - 18 week - non admitted


RTT [2/3]

6

Total RTT fines in April 14 were £13,100, £10,400 relating to Admitted, £1,700 Non-Admitted and £1000 Incompletes

Incomplete Non-Admitted Admitted

£2,400

£6,400

£800

£800

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£100

£1,000

£- £1,000 £2,000 £3,000 £4,000 £5,000 £6,000 £7,000

Gynaecology

T&O

ENT

Oral

General Surgery

Neurology

ENT

Oral

Thoracic

Neurology

RTT Fines -April 14

RTT [3/3]

7 Patients that delay treatment through choice are counted as an incomplete pathways until they receive their treatment, or it is decided that they don’t need treatment. Patient choice only changes things once they have received an admitted treatment (non-admitted stops aren’t adjusted for patient choice)

96 admitted patients and 101 non-admitted patients were waiting longer than 18 weeks as at the end of March 2014, 62 of these patients were waiting over 26 weeks, and 1 was waiting longer than 52 weeks. Neurology was the only specialty with more than the 8% target of patients waiting over 18 weeks, at 14.2%.

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RTT incomplete pathways > 18 weeks


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RTT Incomplete pathways - Aging

Non Admitted Admitted

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Waiting lists

8

At the end of May 14, the inpatient and day case waiting list had reached 1650 patients an increase over previous months, but a decrease of 78 patients year on year (-4.5%). The outpatient waiting list in on a increasing trend and reached 2,824 at the end of April, an increase of 327 patients vs prior year (+13.1%), but this is mostly due to the Ophthalmology service restarting, along with an higher than usual number of fast track referrals in Dermatology.

Numbers above are live waiting list patients, they include patients that have chosen to delay their treatment. Currently it is difficult to identify these patients due to the booking methods i.e. this information is only in the form of a “comment”. Previously we used a separate waiting list code, which enabled us to exclude these patients from our reports. This was stopped in order to increase visibility of all patients. The above numbers do not include planned or suspended patients i.e. medically unfit or regular future bookings i.e. five year endoscopies.

Outpatients waiting list - patients that have been referred but not yet seen. Inpatients/Day cases – patients that have been referred for elective admissions but not yet treated.

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Waiting Lists

OP Waiting List Size - GP/DP Referred IP/DC Waiting List Size

Day Case Admissions

9

Day case admissions (1,303) were 81% of total elective admissions in May 2014. This mix has remained stable between 80% and 86% since April 2010. In the year 14/15 we have seen a total of 2,786 day cases. 60% of all day cases this financial year to date are in 4 specialities –Gastroenterology (18.9%), General Surgery (18.6%), Oncology (17.6%) and Ophthalmology (8.0%).

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c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Day Case admissions

Total Elective admissions Day Case admissions

0

100

200

300

400

500

600

Ge

ne

ral S

urg

ery

Uro

log

y

T&

O

EN

T

Op

hth

alm

olo

gy

OM

F

Pla

stic

Su

rger

y

Ge

ne

ral M

ed

icin

e

Ga

stro

en

tero

logy

Ha

emat

olo

gy

Car

dio

log

y

De

rma

tolo

gy

Th

ora

cic

Me

dic

ine

Me

dic

al O

nco

logy

Neu

rolo

gy

Rh

eu

mat

olo

gy

Pae

dia

tric

s

Car

e o

f th

e E

lder

ly

Gyn

aec

olo

gy

FY day case mix April 2014 - March 2015

A&E [1/2]

10

In May 14 95.3% (target 95%) of patients were seen and discharged within 4 hours from A&E. Average A&E overall attendances are higher than this time last year (133). Ambulance arrivals averaging 37 for the last 12 months

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

A&E 4 hour performance - All Attendances


100

110

120

130

140

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Avg A&E attendance per day

0

20

40

60

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Avg A&E ambulance arrivals per day

Average attendances per day

Day May-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14

Monday 132 128 135 117 130 145 134 150

Tuesday 124 117 114 107 119 125 123 134

Wednesday 118 115 125 116 115 130 123 133

Thursday 119 115 123 115 123 123 116 126

Friday 120 116 119 107 112 127 131 126

Saturday 127 121 127 108 119 125 130 124

Sunday 126 135 133 108 127 142 132 143

Grand Total 123 121 125 111 121 132 127 133

0

20

40

60

80

100

120

140

160

180

0

2

4

6

8

10

12

14

16

18

20

Th

u 1

Fri 2

Sat

3

Su

n 4

Mo

n 5

Tu

e 6

Wed

7

Th

u 8

Fri 9

Sat

10

Sun

11

Mo

n 1

2

Tue

13

Wed

14

Thu

15

Fri 1

6

Sat

17

Sun

18

Mo

n 1

9

Tue

20

Wed

21

Thu

22

Fri 2

3

Sat

24

Sun

25

Mo

n 2

6

Tue

27

Wed

28

Thu

29

Fri 3

0

Sat

31

May 14 Activity & Breaches

Breaches Atts

A&E [2/2]

11

A&E activity in April and May 14 was 7916 compared to 7653 in the same period in 2013. There has been an increase of 7.2% in May 14 compared to May 13 Reductions in attendances were experienced in 9 months of the previous 12 months, particularly in Jan 14 (-8.5%) and Feb 14 (-4.5%). May 14 activity has increased compared to May 13 by (4119 vs. 3821)

3000

3200

3400

3600

3800

4000

4200

4400

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

A&E Activity


-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

% increase/decrease vs LY

Ambulance targets

12

We have achieved the 30 minute handover target (98%) for the last 12 months running The last 12 months fines total £15,000. In the same period in the previous 12 months the fines were £46,710. Mainly due to spikes in October 12 (£10,980) and April 13 (£16,800)

NOTES: Ambulance fines for over 30mins only began in April 2011 Imposed Fines have changed each year but have always been based on breaching 30 mins or more

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

£0£2,000£4,000£6,000£8,000

£10,000£12,000£14,000£16,000£18,000

Ap

r-1

2M

ay-

12

Jun

-12

Jul-

12

Au

g-1

2Se

p-1

2O

ct-1

2N

ov-

12

De

c-12

Jan

-13

Feb

-13

Ma

r-13

Ap

r-1

3M

ay-

13

Jun

-13

Jul-

13

Au

g-1

3Se

p-1

3O

ct-1

3N

ov-

13

De

c-13

Jan

-14

Feb

-14

Ma

r-14

Ap

r-1

4M

ay-

14

Ambulance handovers - Fines Ambulance Handover <30mins

Cancer 2 week waits

13

In April 2014 we achieved the 93% target for 2 Week Waits in suspected cancers (93.2%). The 2 week wait target for exhibited breast referrals was not met at 91.6%. All breaches were a result of patient choice.

0

20

40

60

80

100

0

100

200

300

400

500

600

Ap

r-1

0Ju

n-1

0A

ug-

10

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1Ju

n-1

1A

ug-

11

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2Ju

n-1

2A

ug-

12

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3Ju

n-1

3A

ug-

13

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4 no

. ref

erra

ls -

bre

ast

sym

pto

ns

no

. ref

erra

ls -

susp

ecte

d c

an

cer

Number of referrals

2 week wait suspected cancer 2 week wait exhibited breast symptoms

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

2 week cancer targets

2 wk wait suspected cancer 2 wk wait Breast

Cancer 31 day and 62 day targets

14

In April, we achieved the 96% target of delivering treatment within 31 days of the decision to treat (1st treatment)

We achieved the 62 day 85% target in April 14 (89.4%). Though we underachieved the screening standard at 66.6% (one breach out of three referrals).

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

85.0%

87.0%

89.0%

91.0%

93.0%

95.0%

97.0%

99.0%

101.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

31 day treatment first

Achievement % Target % 6 month rolling %

85.0%

87.0%

89.0%

91.0%

93.0%

95.0%

97.0%

99.0%

101.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

31 day treatment first subsequent drugs

Monthly data Target % 6 month rolling %

75.0%77.0%79.0%81.0%83.0%85.0%87.0%89.0%91.0%93.0%95.0%97.0%99.0%

101.0%103.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

31 day treatment subsequent surgery

Monthly data Target % 6 month rolling %

0

1

2

3

4

5

6

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

62 day treatment screening

Achievement % Target % Number of referrals

0

10

20

30

40

50

60

70

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

62 day treatment standard


0

5

10

15

20

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

62 day treatment upgrades


15

-50 0 50 100 150 200

Exhibited (non-cancer) breast symptoms -…

Suspected breast cancer

Suspected skin cancers

Suspected head & neck cancers

Suspected upper gastrointestinal cancers

Suspected urological cancers (excluding…

Suspected gynaecological cancers

Suspected brain/central nervous system…

Suspected lower gastrointestinal cancers

Suspected testicular cancers

Suspected haematological malignancies…

Suspected childrens cancer

Suspected lung cancer

Growth in referrals for the period Jan 14-Apr14year on year

Cancer Referrals

-20.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

-20

0

20

40

60

80

100

120

<20 20-49 50-59 60-69 70-79 80-89 90+

All Breast 2WW Referrals

Absolute Increase % Increase

Over a 4 month period all 2WW referrals have increased by 282 (+13.8%) vs last year The biggest increase is in breast referrals as well as within the 20-49 age group Potential risks; • The 31 and 62 day standards in future

months • Patient choice element in relation to

Two Week Wait

DNA - Outpatients

16

In April our overall DNA rate (consultant led clinics) stayed at 10.4%, our 1st appointment DNA rate increased to 6.2% (185 patients) and follow up DNA rate decreased to 12.4% (676 patients) There are two initiatives about to start with the aim to reduce our overall DNA rate to 5%. SMS reminder text messaging goes into testing w/c 19 May and an outbound appointment reminder call service is also starting w/c 19 May, concentrating on clinics with the highest DNA rate areas

£0

£20

£40

£60

£80

£100

£120

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Ap

r-10

Jun

-10

Au

g-10

Oct

-10

Dec

-10

Feb

-11

Ap

r-11

Jun

-11

Au

g-11

Oct

-11

Dec

-11

Feb

-12

Ap

r-12

Jun

-12

Au

g-12

Oct

-12

Dec

-12

Feb

-13

Ap

r-13

Jun

-13

Au

g-13

Oct

-13

Dec

-13

Feb

-14

Tho

usa

nd

s

DNA rate

Overall DNA rate (Cons led) First DNA rate

Follow up DNA rate DNA Cost

Figures above only relate to consultant led clinics Cost assumption; £75 per follow up appointment and £150 per first appointment

First to follow up

17

1st to follow up ratio for consultant led activity in April 2014 was 1:2.2, higher than the 6 month rolling average 1st to follow-up ratio of 1:1.8. Orthodontics and Ophthalmology have the highest first to follow up ratios

1.5

1.7

1.9

2.1

2.3

2.5

Ap

r-1

0Ju

n-1

0A

ug-

10

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1Ju

n-1

1A

ug-

11

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2Ju

n-1

2A

ug-

12

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3Ju

n-1

3A

ug-

13

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

New:Follow ratio


0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

0

100

200

300

400

500

600

700

800

Ort

ho

pae

dic

s

Op

hth

alm

olo

gy

Gen

eral

Su

rger

y

ENT

Uro

logy

Ort

ho

do

nti

cs

Gas

tro

ente

rolo

gy

Car

dio

logy

rate

atte

nd

ance

s

April 2014 - March 2015 1st to Follow Up Ratio by Speciality

1st Follow Up Rate

Stroke

18

In April we achieved 89%, which is above the 80% target for stroke patients spending >90% of their time on the stroke ward. 68% of patients were admitted directly to the stroke ward within 4 hours, this remains below the target of 90%.

75% of high risk Transient Ischaemic Attack (TIA) patients were treated within 24 hours in March 36% of patients that were subsequently diagnosed with a stroke had a CT scan within 1 hour of arrival

0%

20%

40%

60%

80%

100%

120%

Ap

r-1

0Ju

n-1

0A

ug-

10

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1Ju

n-1

1A

ug-

11

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2Ju

n-1

2A

ug-

12

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3Ju

n-1

3A

ug-

13

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Stroke Unit Stay >90%

Stroke Unit Stay >90% Target

0%

20%

40%

60%

80%

100%

Ap

r-1

2M

ay-

12

Jun

-12

Jul-

12

Au

g-1

2Se

p-1

2O

ct-1

2N

ov-

12

De

c-12

Jan

-13

Feb

-13

Ma

r-13

Ap

r-1

3M

ay-

13

Jun

-13

Jul-

13

Au

g-1

3Se

p-1

3O

ct-1

3N

ov-

13

De

c-13

Jan

-14

Feb

-14

Ma

r-14

Ap

r-1

4

4Hr Direct Admission

4Hr Direct Admission Target

0%

20%

40%

60%

80%

100%

120%

Ap

r-1

0

Jul-

10

Oct

-10

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

Ap

r-1

4

High Risk TIA <24Hrs

0%

10%

20%

30%

40%

50%

60%

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Achievement 1HrCTScan

Discharges

19

44.8% of inpatients had an EDD (estimated discharge date) recorded, of these only 41% were discharged by the estimated due date. Top 3 largest specialities (% discharged by EDD where date recorded) - General medicine 32%, General Surgery 52%, Orthopaedics 45% Paediatrics 50%

0

500

1000

1500

2000

2500

3000

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Discharges by Day of the Week (Excluding Day Cases) (Apr 13 - May 14)

Elective Emergency

0

500

1000

1500

2000

2500

3000

3500

4000

4500

GeneralMedicine

General Surgery Orthopaedics Paediatrics Gynaecology Care of theElderly

Urology ColorectalSurgery

Inpatient Discharges with EDD Status - Top 8 Specialties (Excluding EAU and Maternity)(April 13 - May14)

disch on EDD no EDD recorded not disch on EDD

0

10

20

30

40

50

60

70

80

90

8 or more days before On the day 2-7 days before 1 day before

Timing of Hospital Clinical and Non Clinical Cancelled OperationsApr 14 - May 14

0 10 20 30 40 50 60

PATIENT CANCELLED - TCI / APPOINTMENT…

PATIENT FAILED TO ARRIVE / DNA

TCI / APPOINTMENT RESCHEDULED - DATE…

PATIENT CANCELLED - UNFIT FOR…

PATIENT UNFIT FOR SURGERY (PRE-…

SESSION CANCELLED

CONSULTANT / CLINICIAN UNAVAILABLE

MORE URGENT CASE TOOK PRIORITY -…

NO ANAESTHETIST AVAILABLE

TCI / APPOINTMENT RESCHEDULED -…

SURGERY / APPOINTMENT NOT REQUIRED

Top 10 Reasons for Cancellation of Elective Operations Apr 14 - May 14

Cancelled operations

20

For any elective operation cancelled by the trust on the day of the operation/admission, an offer of a new date must be made within 5 calendar days, and the newly offered date must be within 28 days of the cancelled operation date. May 14, 16 operations have been cancelled by the trust on the day for non-clinical reasons, all of these patients were offered a new date within 5 days and all newly offered dates were within 28 days of the cancelled operation.

Most common reason of cancelling an operation is “patient cancellation” For Hospital Clinical and Non Clinical Cancellations – 35% are cancelled on the day, while 49% give at least 8 days notice Patient Cancellations – 63% on the day, 25% give at least 8 days notice.

Safety

21

Since April 14 there have been 153 patient falls compared to 130 April – May 13. In May 14 there was 1 CDiff case reported. There were 9 in 2013/14. The last reported case of MRSA was in Mar 13 with only 4 cases in the last 3 years. Pressure ulcers are on a decreasing trend, total of 114 in the last 12 months compared to 202 in the previous 12 months.

0

1

2

Ap

r-1

0

Jul-

10

Oct

-10

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

MRSA

Monthly data 6 month moving average

0

20

40

60

80

100

120

140

Ap

r-1

0

Jul-

10

Oct

-10

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

Patient falls


0

1

2

3

4

5

6

7

8A

pr-

10

Jul-

10

Oct

-10

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

C difficile cases


0

5

10

15

20

25

30

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Pressure ulcers +2


Friends and Family Test

22

YTD response rate 20.0%, low A&E response rate of 7.1%.

76%

69% 68%72% 71% 73%

76% 76%71% 73%

67% 69%

20%26%

23% 21% 23% 22% 20% 21% 23% 21%27%

24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Friends and Family Test Inpatient and ED Response to 'extremely

likely' and 'likely' to recommend YDH

Extremely Likely Likely

398 368 495 468 537 581 633 475 451 523 532

2,8062,565

2,5592,844 2,729 2,550

2,7652,614 2,530

2,628 2,414

2,671

0%

5%

10%

15%

20%

25%

0

500

1000

1500

2000

2500

3000

3500

4000

Friends and Family Test % of Responses

No of Respondants No of eligible Patients % of Responses

A&E IP TOTAL A&E IP TOTAL A&E IP TOTAL

Apr-13 30 368 398 1,815 991 2,806 1.7% 37.1% 14.2%

May-13 50 318 368 1,642 923 2,565 3.0% 34.5% 14.3%

Jun-13 133 362 495 1,631 928 2,559 8.2% 39.0% 19.3%

Jul-13 85 383 468 1,894 950 2,844 4.5% 40.3% 16.5%

Aug-13 81 456 537 1,828 901 2,729 4.4% 50.6% 19.7%

Sep-13 144 437 581 1,705 845 2,550 8.4% 51.7% 22.8%

Oct-13 166 467 633 1,815 950 2,765 9.1% 49.2% 22.9%

Nov-13 98 377 475 1,700 914 2,614 5.8% 41.2% 18.2%

Dec-13 121 330 451 1,657 873 2,530 7.3% 37.8% 17.8%

Jan-14 135 388 523 1,657 971 2,628 8.1% 40.0% 19.9%

Feb-14 149 383 532 1,612 802 2,414 9.2% 47.8% 22.0%

Mar-14 129 405 534 1,820 851 2,671 7.1% 47.6% 20.0%

TOTAL 1,321 4,674 5,995 15,687 8,275 23,962 8.4% 56.5% 25.0%

No of Respondants No of eligible Patients % of Responses

Patient complaints and compliments

23

YTD there have been 1307 compliments to Clinical Departments and Medical Staff and 1238 complaints There has been an increase in number of PALs contacts in Q4, Jan-March (318) compared to 265 in Q3

Under Investigation

1200

1220

1240

1260

1280

1300

1320

YTD complaints & PALS YTD compliments

April 13 to March 2014

0 20 40 60 80 100 120 140

Out-Patient Department

Emergency Department

Radiology

Orthopaedic Outpatients

Ophthalmology

Ward 7A - Lydford

EAU - Emergency Admissions Uni

Ward 9B - Merriott

Ward 8B (9A Sparkford)

Medical Records

Complaints - Highest 10 Departments April 13 - March 14

0 20 40 60 80 100 120 140 160

Kingston Wing

Emergency

EAU

Ward 8A

Ward 10

Freya Ward

Ward 9A

Ward 7A

Ward 6B

Ward 8B now Jasmine

Compliments - Highest 10 Deparments April 13 - March 14

Admissions

24

Total elective admissions in May 14 were 1,607 compared to non-elective 1674. For the last 12 months the mix has remained at approximately a 50:50 equal split, the May 14 split was 49% Elective to 51% Non Elective admissions. The average length of stay in May 14 was 2.2 days for Elective SBU and 5.2 days for UCLTC SBU.

The is ongoing work to monitor the actual length of stay vs.

the expected length of stay based on estimated discharge

date.

Average LOS May-11 May-12 May-13 May-14

Elective 3.1 2.9 2.7 2.2

Non Elective 5.4 5.6 5.3 5.2

6mth avg

Elective

Non Elective

LOS

Elective

Non Elective0

500

1,000

1,500

2,000

2,500

3,000

3,500

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Admissions

Total Elective admissions Non Elective admissions

Total admissions (6 mths avg)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Average Length of Stay (days)

LOS Elective LOS Non Elective

Length of stay – long stayers

25

As at 04/06/14 the current longest stay for an inpatient is 117 days because they are not medically fit for discharge

As at 04/06/14 there are 19 inpatients that have had a length of stay greater than or equal to 15 days that are medically fit for discharge

0

0.5

1

1.5

2

2.5

3

3.5

WARD 6A WARD 6B WARD 8A WARD 8B WARD 9A WARD 9B

Patients with length of stay >= 15 daysMedically fit for discharge

15-30 30-60 60-100

0%-9% -11%

-29%

-8%

-23%-16%

-23%

-51% -49%

-19% 0%

-43%

0% 0%

-55%

0%9% 8%

14% 12%

23% 23%19%

6% 3%

26%

50%

3%

48%

0%6%

-100.00%

-80.00%

-60.00%

-40.00%

-20.00%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

CA

RD

IOLO

GY

DER

MA

TOLO

GY

END

OSC

OP

Y

ENT

GA

STR

OEN

TER

OLO

GY

GEN

ERA

L M

EDIC

INE

GEN

ERA

L SU

RG

ERY

GYN

AEC

OLO

GY

OP

THA

LMO

LOG

Y

OR

AL

SUR

GER

Y

OR

THO

PA

EDIC

S &

TR

AU

MA

PA

EDIA

TRIC

S

PLA

STIC

SU

RG

ERY

PR

IVA

TE S

ESSI

ON

(EN

DO

SCO

PY)

PR

IVA

TE S

ESSI

ON

(FL

EXIB

LE C

YSTO

SCO

PY)

UR

OLO

GY

UnderRuns are only Calculated if they end over 45 minutes early. OverRuns are only calculated if they are over 30 minutes

. %Overrun

. %UnderRun

Theatre utilisation (YTD March 2014)

26

Since April 14, Urology, Ophthalmology, Oral Surgery, Plastic Surgery are the areas most prone to theatre lists ending at least 45 minutes earlier than scheduled

Conversely, private endoscopy sessions and paediatric sessions have overrun in 47% of cases and 50% of cases respectively, and never ended early.

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

AN

AES

THET

ICS

CA

RD

IOLO

GY

DER

MA

TOLO

GY

EN

DO

SCO

PY

ENT

GA

STRO

ENTE

ROLO

GY

GEN

ER

AL

MED

ICIN

E

GEN

ERA

L SU

RG

ERY

GYN

AEC

OLO

GY

OP

TH

ALM

OLO

GY

OR

AL

SUR

GER

Y

OR

THO

PA

EDIC

S &

…

PA

ED

IAT

RIC

S

PLA

STIC

SU

RG

ERY

PRIV

ATE

SESS

ION

…

PRIV

ATE

SESS

ION

…

UR

OLO

GY

Theatre Utilisation by Specialty (Jan 13 - May 14)

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Theatre Utilisation by Month (Jan 13 - May 14)

Monitor

27

Q1 Q1

RTT 18 week RTT admitted wait - All specialties 90% M 91.0% 0

RTT 18 week RTT non-admitted wait - All specialties 95% M 96.3% 0

RTT 18 week RTT Incomplete pathways - All Specialties 92% M 96.7% 0

A&E A&E Clinical Quality: Total time of 4 hours in A&E 95% M 97.1% 0

Cancer Max waiting time of 2 weeks from urgent suspect cancer GP referral to first outpatient appt 93% Q 93.2%

Cancer Max waiting time of 2 weeks for symptomatic breast patients (cancer not initially suspected) 93% Q 91.6%

Cancer Max waiting time of 31 days from diagnosis to first treatment for all cancers 96% Q 98.8% 0

Cancer Max waiting time of 31 days for subsequent DRUG treatments for all cancers 98% Q 100.0%

Cancer Max waiting time of 31 days for subsequent SURGICAL treatments for all cancers 94% Q 100.0%

Cancer Max waiting time of 62 days from urgent GP referral to first treatment for all cancers 85% Q 89.3%

Cancer Max waiting time of 62 days from consultant screening service referral for all cancers 90% Q 66.7%

SafetyC.Diff year on year reduction

(DH target - Post 72hrs only)9 pa Q 0 0

Safety Access to health care for people with a learning disability 9 pa Q

2

1

0

Period

1

Monitor Score

MONITOR SCORE

MonitorResults

TH

28

Workforce Performance

April 2014 – Month 1

FTEs

29

Total Workforce Capacity outturn for Month 1 was 1,772 full time equivalent (FTE).

Contracted Workforce Capacity remained the same at 1,643 FTE.

Temporary Workforce Capacity decreased by the equivalent of 28 FTE.

Temporary Workforce Capacity accounted for 7.2% of the Total Workforce Capacity (a decrease of 1.5%).

FTEsYTD

avg

PY YTD

avgvar

Nursing and Midwifery Registered 504 508 -0.7%

Administrative and Clerical 381 375 1.6%

Additional Clinical Services 256 248 3.3%

Medical and Dental 209 215 -2.7%

Estates and Ancillary 159 162 -1.8%

Allied Health Professionals 83 80 3.4%

Add Prof Scientific and Technic 45 41 10.6%

Healthcare Scientists 6 5 18.3%

Total 1,643 1,633 0.6%

Substantive Workforce Capacity Movement

30

The number of Substantive Staff (i.e. directly employed staff) remained the same in Month 1.

Additional Clinical Services (+6 FTE), Admin & Clerical (+2 FTE), Nursing & Midwifery (-8 FTE).

Mandatory Training

31

The percentage of staff remaining in date for all elements of their Mandatory Training has increased from 79% in March to 82% in April, against a revised target of 90%.

Appraisal

32

The percentage of staff remaining in date for their Annual Appraisal remained the same at 81%, against a target of 90%.

Sickness Absence

33

The Sickness Absence Rate for Month 12 was 3.2%, (0.4% lower than the Month 11 performance) representing an adverse variance of 0.2% against target. All areas with high levels of sickness absence have action plans in place to improve attendance.

Staff Turnover

34

Staff Turnover increased slightly to 12.5% (against a target upper limit of 15%). The rolling twelve-month average is 12.8%.

Recruitment Efficiency

35

The average time from advert to ‘ready to start’ has increased in Month 1 to 90 days against a target of 60 days.

The average time taken to send a letter of confirmation has also increased to 36 hours against a target of 48 hours.

Financial


April 2014 – Month 1

Finance

37

YTD Deficit £700k, £230k adverse against budget, Monitor risk rating YTD of 3 , YTD capital expenditure £734k, Cash balance £7.2m

Variance: Favourable/(Adverse)

Financial Summary

Actual Variance Actual Variance

Income 9,343 16 9,343 16

Pay (6,499) (194) (6,499) (194)

Non Pay (3,106) (50) (3,106) (50)

EBITDA (262) (228) (262) (228)

Other (438) (2) (438) (2)

Surplus / (Deficit) (700) (230) (700) (230)

EBITDA Margin % -2.9% -2.4% -2.9% -2.4%

Surplus % -7.5% -2.5% -7.5% -2.5%

In Month Year to Date

(3,000)(2,500)(2,000)(1,500)(1,000)

(500)0

5001,000

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Trend of Cumulative Surplus / Deficit

Surplus / (Deficit) Budget Surplus / (Deficit) Actuals 2013/14 Actuals

-

500

1,000

1,500

2,000

2,500

Ap

r -

13

Jun

- 1

3

Au

g -

13

Oct

- 1

3

Dec

- 1

3

Feb

- 1

4

Ap

r -

14

Jun

- 1

4

Au

g -

14

Oct

- 1

4

Dec

- 1

4

Feb

- 1

5

Capital Capital ProgrammePlan

Capital ProgrammeActual

-500

1,500

3,500

5,500

7,500

9,500

11,500

13,500

Ap

r -

13

Jul -

13

Oct

- 1

3

Jan

- 1

4

Ap

r -

14

Jul -

14

Oct

- 1

4

Jan

- 1

5

Ap

r -

15

Jul -

15

Oct

- 1

5

Jan

- 1

6

Cash Plan

Actual

38

APPENDIX

Financial Detail

Summary (£’000)

39

YTD: £700k deficit, £230k adverse against budget


Financial Summary

Feb-14 Mar-14 Actual Variance Actual Variance

Income

Clinical Income 8,585 9,480 8,086 33 8,086 33

Non NHS Clinical Income 247 188 257 17 257 17

Other Income 1,042 1,311 999 (34) 999 (34)

Total Income 9,874 10,979 9,343 16 9,343 16

Pay

Nursing (2,347) (2,471) (2,340) (124) (2,340) (124)

Medical Staff (2,115) (2,138) (2,162) (125) (2,162) (125)

Estates, Admin & Clerical (1,073) (1,135) (1,085) 64 (1,085) 64

Pay - Scientific, Therapeutic & Technical (629) (608) (582) 5 (582) 5

Pay - Ancillary (332) (333) (330) (10) (330) (10)

Pay - CIP 0 0 0 (4) 0 (4)

Total Pay Expenditure (6,496) (6,685) (6,499) (194) (6,499) (194)

Non Pay

Drugs (837) (924) (887) (26) (887) (26)

Consumable M&SE (702) (803) (615) 19 (615) 19

High Cost M&SE (212) (202) (232) 27 (232) 27

Other (1,737) (1,929) (1,373) (70) (1,373) (70)

Total Non Pay Expenditure (3,488) (3,858) (3,106) (50) (3,106) (50)

EBITDA (110) 436 (262) (228) (262) (228)

Other (423) (880) (438) (2) (438) (2)

Surplus / (Deficit) (533) (444) (700) (230) (700) (230)

EBITDA Margin % -1.4% 3.5% -2.9% -2.4% -2.9% -2.4%

Surplus % -5.4% -0.8% -7.5% -2.5% -7.5% -2.5%

Prior Months Actuals In Month - April Year to Date

Monitor Risk Ratings

40

The Trust is achieving a continuity of service risk rating of

In Month YTD In Month YTD

219 1,712 130 130

(23) 4,585 (261) (261)

(0.1) 2.7 (2.0) (2.0)

1 4 1 1

1,539 1,539 572 572

(10,543) (112,061) (9,605) (9,605)

4.4 4.1 1.8 1.8

4 4 4 4

3 4 3 3

* Calculation is based on Cash for Continuity of Service divided by Operating Expenses x 30 days per month

Liquidty Metric *

Liquidty Rating

Continuity of Service Risk Rating

Revenue available for Capital

Service

Capital Servicing Capacity Metric

Capital Servicing Capacity Rating

Liquidity

Cash for Continuity of Service

Operating Expenses

Monitor Continuity of Service Risk

Month 12 Month 1

Debt Service Cover

Capital Service

Income (£’000)

41

Income in month £9,343k (£16k favourable to budget)

Clinical Income – There is a favourable variance of £33k in month. This relates to additional income received from the cancer drugs fund. Non NHS Clinical Income – There is a favourable variance in month of

£17k. Injury benefit income has a favourable variance of £43K (this is

partly due to a one off benefit due to a change in how this is accounted)

and this is offset by £28k under-achievement of private patient income

due to high NHS occupancy on the Kingston Wing.

Other Income – There is an adverse variance of £34k in month. £13k

relates to lower pharmacy contract drugs income, this is offset against

lower drugs expenditure. Catering income is £10k adverse due to the

refurbishment works being carried out.

N.B. Main components of Other Income include Research & Development, Education & Training funding and Donated Asset Income. Other significant income streams include services provided to external organisations for pharmacy & facilities contracts.

0

200

400

600

800

1000

1200

1400

Non NHS Clinical Income Other Income

5,000

6,000

7,000

8,000

9,000

10,000

11,000

12,000

NHS Clinical Income Total Income - Actual

Summary of Clinical Activity Performance

42

• Gastroenterology and Haematology are the main over-performances in day cases, accounting for half of the total day case over-performance.

• We continue to improve our data capture for procedures carried out in outpatient settings, particularly in Trauma and Orthopaedics. This is seen in the Outpatient Procedure over-performance, and partially explains the underperformance seen in Outpatient Attendances (both in terms of year on year and contract performance)

• The ‘Other’ category includes the Pathology activity, which includes a high volume of low-cost items. • Maternity data collection has improved significantly since this same period in last year, hence the large

year-on-year movement.

Patient Type Annual Plan

Year to

date

plan

Year to

date

actuals Variance

%

variance Variance

%

variance

Elective inpatients 3,139 248 236 (12) -5% (14) -6%

Elective day case patients (Same day) 14,956 1,182 1,303 121 10% 44 3%

Emergency inpatients 16,468 1,354 1,366 12 1% (238) -15%

Outpatient Attendances 144,228 11,403 11,311 (92) -1% (738) -6%

Outpatient Procedures 18,238 1,442 1,525 83 6% 274 22%

A and E Attendances 46,218 3,799 3,786 (13) 0% (46) -1%

Maternity 4,437 365 362 (3) -1% 133 58%

Direct Access 29,461 2,329 2,327 (2) 0% (89) -4%

Other 822,855 67,523 73,562 6,039 9% 2,815 4%

TOTAL 1,100,001 89,643 95,777 6,133 6.84% 2,141 2.29%

Contract Performance Year on Year

(-) is a reduction in

activity compared to

previous year.

43

Clinical Activity Performance against Plan by Activity Type and Commissioner

*The biggest activity % variances are on the Specialist Commissioning and ‘Other’ baselines: however, these are relatively small in ‘real’ terms and

have a negligible financial value compared to the activity on the Somerset CCG baselines. In this instance given that this only shows one month of

performance such small swings can show as large percentage variances.

*These graphs exclude ‘non PbR’ and ‘Other’ elements such as High Cost Drugs, Critical Care and SCBU. These are shown on the following slide.

*‘Other’ commissioners include Local Authority, Out-of-Area work and Public Health and Military work (the latter are both commissioned by NHS

England). The relatively low baselines for this activity means that the variance % can be misleadingly high compared to the actual financial value of

the other variances.

44

Best Practice Tariffs – We are under-performing for both

our Stroke and Fragility of Hip Best Practice Tariffs.

Critical Care– Our over-performance on Somerset CCG is mainly due to a small number of long staying patients.

High Cost / Chemo Drugs– The SWSCG (NHS England

South West Specialist Commissioning Group) over-

performance is funded through a pass-through

arrangement with NHS England.

‘Other’ commissioners activity in this area is relatively

immaterial and so has been excluded for purposes of

presentation.

Non Tariff Performance against Plan by Activity Type and Commissioner

45

Activity Comparison, Year on Year

This graph shows the difference between this year to date

activity with the same period in 13-14. The bars are in % terms,

with the numbers of additional or lesser activity described on the

chart.

Outpatients– The biggest increase is in outpatient procedures,

although it is fair to note that this is largely a data issue in addition

to YDH performing more work in this setting.

The remaining movements are relatively consistent with the overall contract performance.

Note: Maternity is recorded on a different tariff currency (being pathway -rather than activity- based) and so for consistency maternity work has been excluded from this graph.

Substantive &Total Pay (£’000)

46

Pay in month £6,499k; (£194k adverse variance to budget)

Nursing – There is an adverse variance of £124k in month. This is mainly due to additional costs of the escalation ward (£90k) and 6 additional beds

on ward 6B (£20k) being open.

Medical Staffing – Adverse variance of £125k in month. This is due to high use of agency and locum staff across the trust. Significant areas of spend

are; £34k for agency staff in FOPAS, £27k to cover middle grade vacancies across specialities, £31k for emergency medicine locums, £20k for an

agency locum in Respiratory, £19k for acute physicians and £13k for Ophthalmology locums to cover vacancies.

Admin & Clerical – Favourable variance of £64k. This is due to vacancies across the Trust, including the information department and elective care

managers - these posts are being recruited into.

4000

4500

5000

5500

6000

6500

7000

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

Ap

r-1

4

Jul-

14

Oct

-14

Jan

-15

Total Pay Expenditure Total Pay Expenditure Forecast Substantive Actual

Pay Non Substantive (£’000)

47

Non substantive Pay in month £661k; (£133k greater than 13/14)

Locum Bank Agency Total Locum Bank Agency Total

Medical & Dental 87 0 189 276 87 0 189 276

Nursing & Midwifery 0 103 161 264 0 103 161 264

Other 0 45 76 121 0 45 76 121

Total 87 148 426 661 87 148 426 661

In Month YTD

0

100

200

300

400

500

600

700A

pr-

12

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-12

Dec

-12

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-13

Dec

-13

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

Agency Actual Locum Actual Bank Actual

Drugs (£’000)

48

Drugs spend in month £887k; (£26k adverse variance to budget)

Drugs are reporting an overspend of £26k year to date. This is offset by increased income of £34k. In addition the Dorset and Somerset CCG contract is reporting an over-performance on drug costs of £9k.

400

500

600

700

800

900

1000

1100M

ay-1

3

Au

g-1

3

No

v-1

3

Feb

-14

May

-14

Au

g-1

4

No

v-1

4

Feb

-15

Drugs Budget Drugs Expenditure

Non Pay (£’000)

49

Non Pay (excl drugs) spend in month £2,219k; (£24k adverse variance to budget)

In month:

– High Cost M&SE – £27k favourable variance in month. Mainly due to £10k favourable variance in Pathology from a patient using high cost treatment no longer being treated at Yeovil. Underspend of £6k in Orthopaedic theatres due to lower activity.

– Consumable and M&SE – £19k favourable variance in month. £17k favourable variance in Orthopaedic theatres due to lower activity.

– Other Non Pay – £70k adverse variance in month. £22k due to costs incurred for Symphony offset by additional income. £37k due to Somerset Academy expenditure which will be offset by income next month. £13k adverse variance due to under-achievement of the planned health informatics contract savings.

100

150

200

250

300

Apr-14 Jul-14 Oct-14 Jan-15

High Cost M&SE

Budget 2014/15 Exp 2013/14 Exp 2014/15

200

300

400

500

600

700

800

900


Consumable M&SE

Budget 2014/15 Exp 2013/14 Exp 2014/15

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

2,200


Other Non-Pay

Budget 2014/15 Exp 2013/14 Exp 2014/15

Use of Capital (£’000)

51

Total Capital spend in month is £734k, Planned spend was £929k

Operational Capital Site Capex is underspent by £15k due to Fire Alarms works now scheduled later in the year. Medical Equipment is underspent by £40k as the planned order of Cardiac output monitors is now scheduled for later in the year. Radiology equipment is underspent by £58k due to change in phasing of works. Projects in other include – contingency and IT developments. Major Developments Energy Project - there was a slippage of works (£271k) from 13/14 into 14/15, total project due for completion in June 14. Car Park - delays occurred in the demolition of Cheverton due to issues with asbestos works; completion is expected at end of August 14. Kingston Wing Refurbishment - project currently under review, variance’s represent a timing delay.

Capital Expenditure

Actual Variance Actual Variance

Operational Capital

Site Capex 52 15 52 15

Medical Equipment 0 40 0 40

Radiology Equipment 427 58 427 58

Other 63 2 63 2

Major Developments

Energy Project 50 0 50 0

Car Park Phase 1 78 72 78 72

IT - Smartcare 40 3 40 3

Ward Refurb - Kingston Wing 2 18 2 18

Other 14 (4) 14 (4)

Donated schemes 7 (7) 7 (7)

Total Annual Budget 734 195 734 195

In Month Year to Date

-

500

1,000

1,500

2,000

2,500

Ap

r -

13

May

- 1

3

Jun

- 1

3

Jul -

13

Au

g -

13

Sep

- 1

3

Oct

- 1

3

No

v -

13

Dec

- 1

3

Jan

- 1

4

Feb

- 1

4

Mar

- 1

4

Ap

r -

14

May

- 1

4

Jun

- 1

4

Jul -

14

Au

g -

14

Sep

- 1

4

Oct

- 1

4

No

v -

14

Dec

- 1

4

Jan

- 1

5

Feb

- 1

5

Mar

- 1

5

Capital Capital Programme Plan

Capital Programme Actual


52

Cash (£’000)

Cash outflow in month is £809k.

Key Cash Movements Cash is £249k lower than plan. This is mainly due to the lower than planned in month EBITDA figure, the remaining balance is offset between changes in receivables and payables.

-500

1,500

3,500

5,500

7,500

9,500

11,500

13,500A

pr

- 1

3

Jul -

13

Oct

- 1

3

Jan

- 1

4

Ap

r -

14

Jul -

14

Oct

- 1

4

Jan

- 1

5

Ap

r -

15

Jul -

15

Oct

- 1

5

Jan

- 1

6

Cash

Plan Actual

53

Statement of Financial Position (£’000)

Key Variances Current Assets Stock has increased by £61k mainly due to Pharmacy drugs. A review of pharmacy drugs is being undertaken. NHS Trade Debtors has decreased by £626 due to contract payments being made at year end. Prepaid contracts have increased by £422k as many high value facilities contracts are paid at the start of the financial year. Current Liabilities PDC dividend creditor has increased as payments are made every six months. Capital creditors have increased due to recognition of the new MRI scanner.

March 2014 April 2014 Mvt In Mth

Non Current Assets 55,754 56,146 3,517

Current Assets

Stock 1,931 1,992 61

NHS Trade Debtors 1,018 392 (626)

Non NHS Trade Debtors 697 1,012 315

Accrued Income 1,190 1,244 54

Prepaid Contracts 599 1,021 422

Non Current Assets Held for Sale 0 0 0

Cash in Hand and at Bank 8,000 7,191 (809)

Total Current assets 13,435 12,852 (583)

Current Liabilities

Trade Creditors (1,358) (1,430) (72)

Other Creditors (2,703) (2,930) (227)

PDC Dividend Creditor (47) (179) (132)

Capital Creditor (882) (1,061) (179)

Accruals (4,662) (4,581) 81

Borrowings <1yr (107) (107) 0

Deferred Income 0 0 0

Current Liabilities (9,759) (10,288) (529)

Net Current Assets 3,676 2,564 (1,112)

Total Assets less Current Liabilities 59,430 58,710 (720)

Trade and other Payables >1yr 0 0 0

Borrowings> 1yr (849) (849) 0

Provisions >1yr (961) (941) 20

Net Assets employed 57,620 56,920 (700)

Financed by:

I&E Reserve Current year (342) (700) (358)

Public Dividend Capital 41,501 41,501 0

I&E Reserve Previous year 6,240 5,898 (342)

Revaluation Reserve 10,221 10,221 0

Donation Reserve 0 0 0

Total Financed 57,620 56,920 (700)

Trust Level Key Ratios

54

EBITDA margin -2.9% in month

Return on pay has decreased compared to the previous month.

Return on non pay has increased compared to the previous month. Notes: Ratios are calculated under the current contract income value and not PbR

1.0

1.2

1.4

1.6

1.8

2.0

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Rev

enu

e/P

ay C

ost

s (£

)

Return on Pay Trend

2012/2013 2013/2014 2014/2015

1.0

2.0

3.0

4.0

5.0

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Rev

enu

e/N

on

Pay

Co

sts

(£)

Return on Non Pay Trend

2012/2013 2013/2014 2014/2015

-10%

-5%

0%

5%

10%

15%

20%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

EBIT

DA

/Rev

enu

e

EBITDA Margin Trend

2012/2013 2013/2014 2014/2015

Service Line Reporting Summary (£’000)

55

The Corporate income figure of £210k includes other income streams such as car parking and Injury Cost Recovery Scheme income. The £2,089k of central costs are overheads and include departments such as Facilities, Management Services, HR, Finance, and also depreciation costs. Apportionments of these costs between the divisions is being reviewed as part of the annual reference costs exercise in order to give an indication of the true profitability of each service.

Elective Care Urgent Care Corporate Total

Revenue 4,246 4,021 210 8,478

Direct Costs (1,894) (2,910) 0 (4,804)

Indirect Costs (1,477) (809) 0 (2,286)

Gross Contribution 876 302 210 1,389

Central Costs 0 0 (2,089) (2,089)

Net Contribution 876 302 (1,879) (700)

Year to Date (as of Month 1)

Service line reporting – Elective Care contribution

• Average full year budget margin for Elective Care is 19% • Apportionments between the specialities is being reviewed as

part of the annual reference costs exercise

56

£000's % £000's %

Month 1 876 21% 684 17%

YTD 876 21% 684 17%

Full Year Budget 9,729 19%

Elective Care Strategic Business Unit Contribution

Actual Budget

Service line reporting – Urgent Care contribution

• Average full year budget margin for Urgent Care is 17% • Apportionments between the specialities is being reviewed as part of

the annual reference costs exercise

57

£000's % £000's %

Month 1 301 7% 494 13%

YTD 301 7% 494 13%

Full Year Budget 8,193 17%

Actual

Urgent Care Strategic Business Unit Contribution

Budget


18 JUNE 2014

Report to: Board of Directors Report from: Company Secretary Subject: Monitor Q4 2013/14 Assessment and Annual Plan 2014/15 Review

Date: 18 June 2014 What is this item about? This paper confirms Monitor’s assessment of the Trust’s performance based on analysis of Quarter 4 of 2013-14 and review of YDH’s two year operational plan. It confirms that YDH, in Q4, was assigned a green governance risk rating and a continuity of service risk rating of 4. Why is this item necessary? This paper informs the Board of Monitor’s regulatory assessment of the Trust’s performance with the governance and continuity of services requirements of its provider licence. In addition, Monitor’s review of operational plans provides an assessment of whether the Trust is effectively planning for the future while maintaining and improving quality. This enables Monitor to make a more informed judgement about future risks to YDH’s compliance with its licence conditions. What is the Board asked to do? The Board is asked to NOTE the assessment from Monitor. 1. How does this paper improve patient care? It provides external assurance on performance against the standards and targets of patient care. 2. How does this paper advance the Annual Plan? It provides external assurance on the achievement of clinical and financial aspects of the plan. 3. How does this advance our strategic objectives? It provides external assurance on the achievement of clinical and financial elements of the objectives. 4. Is further information available? Further information on the performance of all foundation trusts for Q4 and annual planning is available on the Monitor website. Are there implications for the Trust?

• Legally? No • Financially? No • Regarding Workforce? No

Is this paper clear for release under Freedom of Information? Yes

6 June 2014 Mr Paul Mears Chief Executive Yeovil District Hospital NHS Foundation Trust Yeovil District Hospital Higher Kingston Yeovil Somerset BA21 4AT

Dear Paul Q4 2013/14 monitoring and 2014/15 annual plan review of NHS foundation trusts I am writing to you in respect of our review of the two year operational plan phase of the 2014/15 annual plan review (APR) as well as the Q4 2013/14 monitoring cycle. The purpose of Monitor’s review of operational plans is to assess whether foundation trusts (FTs) are effectively planning for the future while maintaining and improving quality. This enables Monitor to make a more informed judgement about future risks to the Trust’s compliance with its licence conditions. Under the APR process all FTs are subject to high-level review of two-year operational plans. Following this, and alongside our Q4 monitoring, Monitor determines if a change in regulatory approach is required on a trust by trust basis. This may include specific planning focused actions1 or Monitor could consider whether to take any regulatory action under the 2012 Act, taking into account as appropriate its published guidance on the licence and enforcement action including its Enforcement Guidance2 and the Risk Assessment Framework3. As set out in our letter dated 16 May 20144, at an aggregate level, Monitor’s review has highlighted significant concerns about the quality of the sector’s planning, particularly that year two of the plans may, on aggregate, be overly optimistic. We ask that you bear this in mind when completing your strategic plan. In addition, where Monitor has identified specific weakness in individual plans we may ask individual FTs to resubmit their plans as part of the strategic plan submission.

1 Please see section 2.5 of Monitor’s Annual plan review 2014/15 guidance

2 www.monitor-nhsft.gov.uk/node/2622

3 www.monitor.gov.uk/raf

4 APR update letter 16 May 2014

Wellington House 133-155 Waterloo Road London SE1 8UG T: 020 3747 0000 E: [email protected] W: www.monitor.gov.uk

http://www.monitor-nhsft.gov.uk/node/5552

http://www.monitor-nhsft.gov.uk/node/2622

http://www.monitor.gov.uk/raf

http://www.monitor.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=47484

Risk ratings Monitor has now completed the review of your two-year operational plans5 and Q4 submissions. Based on this work, the current and forecast risk ratings are:

Q4 13/14 (actual)

Q1 14/15 (plan)

Q2 14/15 (plan)

Q3 14/15 (plan)

Q4 14/15 (plan)

Continuity of service risk rating 4 3 3 3 3

Governance risk rating Green

The governance rating represents Monitor’s current view of governance at the Trust. The Trust therefore has a single rating. These ratings will be published on Monitor’s website in June. We would emphasise that the forecast continuity of service risk ratings are the FT’s own risk ratings as submitted in the operational plan and as such are never adjusted by Monitor. There are currently no further changes to our regulatory response as a result of our review of the Trust’s operational plan. However we note the following risks from this review:

The Trust forecasts deficits of £2.4m in 2014/15 increasing to £3.1m in 2015/16. The

plan forecasts the cash position will reduce over the next two years from £7m at

March 2014 to £118k only at March 2016, putting the Trust at high risk of running out

cash.

The Trust plans to deliver savings of 2.8% of operating expenditure in 2014/15,

increasing to 3.3% in 2015/16. While the Trust must deliver savings from a small

operating cost base the quantum of savings planned is behind its APR benchmark

group indicating the Trust may not be setting sufficiently challenging savings targets,

adding to the forecast financial deficit.

The plan includes ambitious reductions in agency expenditure which, while noting

the reduction in agency expenditure the Trust achieved in 2013/14, may not be

achievable.

The Trust is heavily reliant on the Somerset CCG clinical services review to identify

options to support financial sustainability over the medium term. The timescales for

the review and subsequent planning and mobilisation of options means the Trust is

unlikely to see financial benefits from any options taken forward in the short- to

medium-term.

5 Please note that these findings are interim as we consider both the operational and strategic plans part of

the same process. As previously communicated in our guidance, final APR findings will be provided to FTs in October 2014 following review of the five-year strategic plan submissions.

We are not taking formal regulatory action at this time. However, without further action by the Trust to improve the financial position we will need to consider regulatory action if the Trust’s continuity of services rating deteriorates to a 2 in 2015/16. We therefore expect the Trust to:

review the assumptions supporting the 2015/16 plan, and where you considers these

have changed materially from the 4 April 2014 submission, to update and resubmit

the 2015/16 plan in the five-year plan submission by 30 June 2014;

revisit the 2014 – 16 Cost Improvement Programme to assess whether there are

further savings opportunities available to the Trust over this period that it could use

to strengthen its financial position; and

review internal working capital management arrangements to ensure these are as

robust as possible to preserve the Trust’s cash position and mitigate the need for

external financial support.

Should you choose to resubmit the 2015/16 plan please note we will require a commentary explaining significant variances between the original plan and revised forecasts as an appendix to the five-year strategic plan submission. Next steps A report on the FT sector aggregate performance from Q4 2013/14 will shortly be available on our website (in the News, events and publications section) which I hope you will find of interest. For your information, we will shortly be issuing a press release setting out a summary of the key findings across the FT sector from the Q4 and APR monitoring cycle. We will also publish on our website, under your entry in the Public Register of NHS foundation trusts, the commentary/summary document of the operational plan excluding any appendices in a similar format to previous years. Please note that as previously communicated in April’s FT bulletin6 we are not attaching an executive summary of our quarterly review as we have done previously. If you have any queries relating to the above, please contact me by telephone on 020 3747 0167 or by email ([email protected]). Yours sincerely

Jayne Rhodes Senior Regional Manager cc: Mr Peter Wyman, Chair Mr Timothy Newman, Chief Finance and Commercial Officer

6 FT Bulletin April 2014

http://www.monitor-nhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=46954

20 May 2014

Dear Colleague

ORGAN DONATION

I am pleased to send you the latest report on organ donation in your Trust/Health Board. Although organ donation numbers continued to rise across the UK last year, the rate of growth has slowed recently. This means that opportunities to save and improve more lives through transplantation and to reduce the numbers of people who need renal dialysis and other therapeutic treatment are being missed.

I would be grateful if you would ensure that your Board notes this report, continues to review local progress on organ donation and is assured that NICE guidelines are being met.

The biggest challenge still facing the UK is the number of families who do not feel able to consent to donation. Some Donation Committees are now encouraging discussion of organ donation in communities and families. We would ask you to support your Donation Committee in promoting organ donation to hospital staff and local people. Your Donation Committee can find more information about promoting organ donation in our leaflet (http://www.organdonation.nhs.uk:8001/campaigns/get_involved/publicity_guide) or speak to their Regional Collaborative about other Committees in the region who have worked to promote organ donation.

Yours sincerely

Lynda Hamlyn Chief Executive

Head OfficeOak House

Reeds CrescentWatford

HertfordshireWD24 4QN

Tel: 01923 366804www.nhsbt.nhs.uk

http://www.organdonation.nhs.uk:8001/campaigns/get_involved/publicity_guide

http://www.nhsbt.nhs.uk

Executive SummaryActual and Potential Organ Donors1 April 2013 - 31 March 2014

Yeovil District Hospital NHS Foundation Trust

Donor outcomes

Between 1 April 2013 and 31 March 2014, your Trust had 3 deceased solid organ donors, resulting in 7 patientsreceiving a transplant. 10 organs were donated but one was not transplanted. Further details are provided in the tablesbelow. If you would like further information, please contact your local Specialist Nurse - Organ Donation (SN-OD).

Donors, patients transplanted and organs per donor,1 April 2013 - 31 March 2014 (1 April 2012 - 31 March 2013 for comparison)

Number ofNumber of

patientsAverage number of organs

donated per donorDonor type donors transplanted Trust UK

DBD 1 (2) 5 (5) 6.0 (3.5) 4.0 (3.9) -DCD 2 (2) 2 (3) 2.0 (3.0) 2.6 (2.6) -DBD and DCD 3 (4) 7 (8) 3.3 (3.3) 3.4 (3.4) -

Organs transplanted by type,1 April 2013 - 31 March 2014 (1 April 2012 - 31 March 2013 for comparison)

Number of organs transplanted by typeDonor type Kidney Pancreas Liver Heart Lung

DBD 2 (2) 0 (0) 1 (2) 1 (0) 1 (2) -DCD 2 (2) 0 (1) 0 (0) 2 (0) -DBD and DCD 4 (4) 0 (1) 1 (2) 1 (0) 3 (2) -

Radar charts of key rates, 1 April 2013 to 31 March 2014

DBD

Testing (100%)

Referral (100%)

Approach (100%)SN-OD involved (0%)

Consent (100%)

0

25

50

75

100Testing (100%)

Referral (100%)


Consent (100%)

0

25

50

75

100Testing (100%)

Referral (100%)


Consent (100%)

0

25

50

75

100Testing (100%)

Referral (100%)


Consent (100%)

0

25

50

75

100Testing (100%)

Referral (100%)


Consent (100%)

0

25

50

75

100

DCD

Referral (92%)

Approach (75%)

SN-OD involved (33%)

Consent (50%) 0

25

50

75

100

Referral (92%)

Approach (75%)


Consent (50%) 0

25

50

75

100

Referral (92%)

Approach (75%)


Consent (50%) 0

25

50

75

100

Referral (92%)

Approach (75%)


Consent (50%) 0

25

50

75

100

Referral (92%)

Approach (75%)


Consent (50%) 0

25

50

75

100

• Trust, 2013/14 — UK, 2013/14 - - - Trust, 2012/13*

The blue shaded area represents your Trust's rates for 2013/14. The latest UK rates and your Trust's rates for theequivalent period in the previous year are superimposed for comparison. The fuller the blue shaded area the better. Additionally, the funnel plots in the detailed report can be used to identify the maximum rates currently being achieved byTrusts with similar donor potential.

* The PDA data collection changed on 1 April 2013. Therefore comparisons made between time periods should beinterpreted with caution.

Key numbers and rates

There are seven measures (as indicated by the cells highlighted as red, amber or green below) on the Potential DonorAudit (PDA) which are most likely to affect the conversion of potential donors into actual donors. Between 1 April 2013and 31 March 2014, your Trust met the national target in 4 of these measures. The one potential DBD donor withsuspected neurological death proceeded to donation. Of the 8 eligible DCD donors, 2 proceeded to donation and 6 didnot proceed. Further details are provided below. Caution should be applied when interpreting percentages based onsmall numbers.

DBD DCD2013/14 2012/13³ 2013/14 2012/13³

Trust UK Trust UK Trust UK Trust UK

Patients meeting organ donation referral criteria¹ 1 1,787 2 1,633 13 7,176 23 6,961

Referred to SN-OD 1 1,688 2 1,493 12 5,090 16 4,349Referral rate % G 100% 94% 100% 91% G 92% 71% 70% 62%

Neurological death tested 1 1,422 2 1,269 Testing rate % G 100% 80% 100% 78%

Eligible donors² 1 1,351 2 1,189 8 4,139 10 3,113

Family approached 1 1,258 2 1,100 6 1,989 7 1,818Approach rate % 100% 93% 100% 93% 75% 48% 70% 58%

Family approached and SN-OD involved 0 1,062 0 868 2 1,420 1 1,214% of approaches where SN-OD involved R 0% 84% 0% 79% R 33% 71% 14% 67%

Consent given 1 857 2 744 3 1,071 6 932Consent rate % G 100% 68% 100% 68% R 50% 54% 86% 51%

Expected consents based on ethnic mix 1 1 3 3Expected consent rate based on ethnic mix % 74% 72% 57% 54%

Actual donors from each pathway 1 788 2 676 2 522 2 449% of consented donors that became actual donors 100% 92% 100% 91% 67% 49% 33% 48%

Colour key - comparison with national targets R Red A Amber G Green

¹ DBD - A patient with suspected neurological death¹ DCD - A patient in whom imminent death is anticipated, ie a patient receiving assisted ventilation, a clinical decision to withdraw¹ DCD - treatment has been made and death is anticipated within 4 hours

² DBD - Death confirmed by neurological tests and no absolute contraindications to solid organ donation² DCD - Imminent death anticipated and treatment withdrawn with no absolute contraindications to solid organ donation

³ The PDA data collection changed on 1 April 2013. Therefore comparisons made between time periods should be interpreted with caution.

Further Information

· A detailed report for your Trust accompanies this Executive Summary, which also contains definitions of· terms, abbreviations, table and figure descriptions, targets and tolerances, and details of the main changes made to· the PDA on 1 April 2013.· The latest Activity Report is available at http://www.organdonation.nhs.uk/ukt/statistics/transplant_activity_report/· The latest PDA Annual Report is available at http://www.organdonation.nhs.uk/ukt/statistics/potential_donor_audit/· Please refer any queries or requests for further information to your local Specialist Nurse - Organ Donation (SN-OD).

Source

NHS Blood and Transplant: UK Transplant Registry (UKTR), Potential Donor Audit (PDA) and Referral Record.Issued May 2014 based on data reported at 12 May 2014.

Detailed Full Report

Actual and Potential Organ Donors

1 April 2013 - 31 March 2014

Yeovil District Hospital NHS Foundation Trust

2

Table of Contents1. Donor outcomes1.1 Donors outcomes

2. Key rates on potential for organ donation2.1 Key rates2.2 Key numbers, rates and comparison with national targets

3. Stages where opportunities were lost3.1 Overview of lost opportunities3.2 Neurological death testing3.3 Referral to SN-OD3.4 Contraindications3.5 Family approach3.6 Proportion of approaches involving a SN-OD3.7 Consent3.8 Reasons why solid organ donation did not occur

4. PDA data by hospital and unit4.1 Key numbers and rates by unit where the patient died

AppendicesA.1 Bar charts of key ratesA.2 National rates by unit typeA.3 National rates by Trust/Board levelA.4 DefinitionsA.5 Data descriptionA.6 Table and figure description

Further Information

· Appendix A.4 contains definitions of terms and abbreviations used throughout this report and summarises the main· changes made to the PDA on 1 April 2013.· The latest Organ Donation and Transplantation Activity Report is available at· http://www.organdonation.nhs.uk/ukt/statistics/transplant_activity_report/· The latest PDA Annual Report is available at http://www.organdonation.nhs.uk/ukt/statistics/potential_donor_audit/· Please refer any queries or requests for further information to your local Specialist Nurse - Organ Donation (SN-OD)

Source

NHS Blood and Transplant: UK Transplant Registry (UKTR), Potential Donor Audit (PDA) and Referral Record.Issued May 2014 based on data reported at 12 May 2014.

3

1. Donor OutcomesA summary of the number of donors, patients transplanted, average number of organs

donated per donor and organs donated, obtained from the UK Transplant Registry

1.1 Donor outcomes

Between 1 April 2013 and 31 March 2014, Yeovil District Hospital NHS Foundation Trust had 3 deceased solid organdonors, resulting in 7 patients receiving a transplant. 10 organs were donated but one was not transplanted. Additionalinformation is shown in Tables 1.1.1 and 1.1.2, along with comparison data for 2012/13. If you would like furtherinformation, please contact your local Specialist Nurse - Organ Donation (SN-OD).

Table 1.1.1 Donors, patients transplanted and organs per donor,Table 1.1.1 1 April 2013 - 31 March 2014 (1 April 2012 - 31 March 2013 for comparison)

Number ofNumber of

patientsAverage number of organs

donated per donorDonor type donors transplanted Trust UK

DBD 1 (2) 5 (5) 6.0 (3.5) 4.0 (3.9) -DCD 2 (2) 2 (3) 2.0 (3.0) 2.6 (2.6) -DBD and DCD 3 (4) 7 (8) 3.3 (3.3) 3.4 (3.4) -

Table 1.1.2 Organs transplanted by type,Table 1.1.2 1 April 2013 - 31 March 2014 (1 April 2012 - 31 March 2013 for comparison)

Number of organs transplanted by typeDonor type Kidney Pancreas Liver Heart Lung

DBD 2 (2) 0 (0) 1 (2) 1 (0) 1 (2) -DCD 2 (2) 0 (1) 0 (0) 2 (0) -DBD and DCD 4 (4) 0 (1) 1 (2) 1 (0) 3 (2) -

Data in this section have been obtained from the UK Transplant Registry. Section 2 onwards reports on data obtainedfrom the national Potential Donor Audit (PDA).

4

2. Key Rates on

Potential for Organ DonationA summary of the key rates on the potential for organ donation, obtained from the national

Potential Donor Audit (PDA)

2.1 Key rates

Two radar charts are displayed in Figure 2.1.1 showing specific percentage measures of potential donation activity in2013/14 for Yeovil District Hospital NHS Foundation Trust compared with national data for the UK, and compared with2012/13 activity*. This information is displayed in an alternative format as bar charts in Appendix A.1. The funnel plots inSection 3 can be used to identify the maximum rates currently being achieved by Trusts with similar donor potential.

Figure 2.1.1 Key rates on the potential for organ donation,Figure 2.1.1 1 April 2013 - 31 March 2014 (1 April 2012 - 31 March 2013 for comparison)

DBD

Testing (100%)

Referral (100%)


Consent (100%)

0

25

50

75

100Testing (100%)

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Approach (75%)


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Referral (92%)

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• Trust, 2013/14 — UK, 2013/14 - - - Trust, 2012/13*


5

2.2 Key numbers, rates and comparison with national targets

The percentages shown in Figure 2.1.1 are also shown in Table 2.2.1 along with the number of patients at each stage. Anational comparison and a time period comparison are again provided. A comparison against national DBD and DCDtargets has been applied by highlighting the key rates for your Trust as red, amber or green. See Appendix A.6 for rangesused. Note that caution should be applied when interpreting percentages based on small numbers.

Table 2.2.1 Key numbers, rates and comparison with national targets,Table 2.2.1 1 April 2013 - 31 March 2014 (1 April 2012 - 31 March 2013 for comparison)

DBD DCD2013/14 2012/13³ 2013/14 2012/13³

Trust UK Trust UK Trust UK Trust UK

Patients meeting organ donation referral criteria¹ 1 1,787 2 1,633 13 7,176 23 6,961

Referred to SN-OD 1 1,688 2 1,493 12 5,090 16 4,349Referral rate % G 100% 94% 100% 91% G 92% 71% 70% 62%

Neurological death tested 1 1,422 2 1,269 Testing rate % G 100% 80% 100% 78%

Eligible donors² 1 1,351 2 1,189 8 4,139 10 3,113

Family approached 1 1,258 2 1,100 6 1,989 7 1,818Approach rate % 100% 93% 100% 93% 75% 48% 70% 58%

Family approached and SN-OD involved 0 1,062 0 868 2 1,420 1 1,214% of approaches where SN-OD involved R 0% 84% 0% 79% R 33% 71% 14% 67%

Consent given 1 857 2 744 3 1,071 6 932Consent rate % G 100% 68% 100% 68% R 50% 54% 86% 51%

Expected consents based on ethnic mix 1 1 3 3Expected consent rate based on ethnic mix % 74% 72% 57% 54%

Actual donors from each pathway 1 788 2 676 2 522 2 449% of consented donors that became actual donors 100% 92% 100% 91% 67% 49% 33% 48%

Colour key - comparison with national targets R Red A Amber G Green

¹ DBD - A patient with suspected neurological death¹ DCD - A patient in whom imminent death is anticipated, ie a patient receiving assisted ventilation, a clinical decision to withdraw¹ DCD - treatment has been made and death is anticipated within 4 hours

² DBD - Death confirmed by neurological tests and no absolute contraindications to solid organ donation² DCD - Imminent death anticipated and treatment withdrawn with no absolute contraindications to solid organ donation

³ The PDA data collection changed on 1 April 2013. Therefore comparisons made between time periods should be interpreted with caution.

6

3. Stages Where

Opportunities were LostStages at which potential donors lost the opportunity to become actual donors

3.1 Overview of lost opportunities

The one potential DBD donor with suspected neurological death proceeded to donation. Of the 8 eligible DCD donors, 2proceeded to donation and 6 did not proceed.

Figure 3.1.1 gives an overview of the various stages where opportunities were lost. There are four charts showing DBDand DCD stages separately for Yeovil District Hospital NHS Foundation Trust and the UK, all of which contain acomparison with 2012/13*. The number of potential donors is shown on the vertical axis for each chart and at each 'step'the proportion of potential donors lost at that stage is displayed. Caution should be applied when interpretingpercentages based on small numbers. Further information is available for individual hospitals and units in Tables 4.1.1and 4.1.2 in Section 4.

Figure 3.1.1 Stages at which potential donors lost the opportunity to become actual donors,Figure 3.1.1 1 April 2013 - 31 March 2014 (1 April 2012 - 31 March 2013 for comparison)

Num

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BD

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confirmed

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2013/142012/13* N

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D d

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Neuro.death

confirmed

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Consent Donation

Trust, DCD

2013/142012/13*

27%25%

50% 33%

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BD

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Consent Donation

UK, DBD

2013/142012/13*

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32% 8%

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CD

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Consent Donation

UK, DCD

2013/142012/13*

38%

52%

46%51%


7

3.2 Neurological death testing

A funnel plot of neurological death testing rates is displayed in Figure 3.2.1. The national target for 2013/14 of 80% isalso shown on the funnel plot, for information, but the goal is to ensure that neurological death tests are performedwherever possible. For information about how to interpret the funnel plots, please see Appendix A.6.

Figure 3.2.1 Funnel plot of neurological death testing rates, 1 April 2013 - 31 March 2014

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Table 3.2.1 shows the reasons why neurological death tests were not performed, if applicable, for your Trust.

Table 3.2.1 Reasons given for neurological death tests not being performed,Table 3.2.1 1 April 2013 - 31 March 2014

N %

All patients were tested or there were no patients with suspectedneurological death

- -

If 'other', please contact your local SN-OD for more information, if required.

8

3.3 Referral to Specialist Nurse - Organ Donation (SN-OD)

Funnel plots of DBD and DCD referral rates are displayed in Figure 3.3.1. The 2013/14 national targets of 92% and 65%for DBD and DCD, respectively, are also shown on the funnel plots, for information. Every patient who meets the referralcriteria should be identified and referred to the SN-OD, as per NICE CG135¹ and NHS Blood and Transplant (NHSBT)Best Practice Guidance on timely identification and referral of potential organ donors².

Figure 3.3.1 Funnel plots of referral rates, 1 April 2013 - 31 March 2014

DBD

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Table 3.3.1 shows the reasons why patients were not referred to a SN-OD, if applicable, for your Trust.

Table 3.3.1 Reasons given why patient not referred, 1 April 2013 - 31 March 2014

DBD DCDN % N %

Medical contraindications - - 1 100.0

Total - - 1 100.0

If 'other' or 'medical contraindications', please contact your local SN-OD for more information, if required.

9

Early referral to the SN-OD is important to enable the opportunity for donation to be maximised. Early referral triggersshould be in place to ensure all donors are identified to the SN-OD to allow the family the option of organ donation. Forpatients who were referred, Table 3.3.2 shows the timing of the first contact with the SN-OD by the clinical staff. Allpatients meeting the referral criteria should be referred as early as possible to enable attendance of the SN-OD toassess suitability for donation and ensure that a planned approach for consent to the family is made in line with NICECG135¹ and NHSBT Best Practice Guidance on approaching the families of potential organ donors³.

Table 3.3.2 Timing of first contact with a SN-OD by clinical staff, for patients who were referred,Table 3.3.2 1 April 2013 - 31 March 2014

DBD DCDN % N %

Before sedation stopped - 0.0 2 16.7

Absence of one or more cranial nerve reflexes and GCS of 4 orless not explained by sedation

1 100.0 - 0.0

No sedation or after sedation stopped, decision made to carryout BSD tests, before 1st set of tests

- 0.0 - 0.0

After 1st set and before 2nd set of BSD tests - 0.0 - 0.0

After neurological death confirmation - 0.0 - 0.0

Clinical decision to withdraw life-sustaining treatment has beenmade, before treatment withdrawn

- 0.0 10 83.3

After treatment withdrawn - 0.0 - 0.0

Not reported - 0.0 - 0.0

Total 1 100.0 12 100.0

NB, 0 patients with suspected neurological death also went on to meet the referral criteria for DCDdonation, and are therefore included twice.

¹ NICE, 2011. NICE Clinical Guidelines - CG135 [online]. Available at: <http://publications.nice.org.uk/organ-donation-for-transplantation-improving-donor-identification-and-consent-rates-for-deceased-cg135/recommendations> [accessed 25 September 2013]

² NHS Blood and Transplant, 2012. Timely Identification and Referral of Potential Organ Donors - A Strategy forImplementation of Best Practice [online]. Available at: <http://www.odt.nhs.uk/pdf/timely-identification-and-referral-potential-donors.pdf> [accessed 13 May 2013]

³ NHS Blood and Transplant, 2013. Approaching the Families of Potential Organ Donors – Best Practice Guidance[online]. Available at: <http://www.odt.nhs.uk/pdf/family_approach_best_practice_guide.pdf> [accessed 13 May 2013]

10

3.4 Contraindications

Table 3.4.1 shows the primary absolute medical contraindications to solid organ donation, if applicable, for potential DBDdonors confirmed dead by neurological death tests and potential DCD donors in your Trust.

Table 3.4.1 Primary absolute medical contraindications to solid organ donation,Table 3.4.1 1 April 2013 - 31 March 2014

DBD DCD

Any cancer with evidence of spread outside affected organ (including lymph nodes)within 3 years

- 3

Total - 3

11

3.5 Family approach

Funnel plots of DBD and DCD family approach rates are displayed in Figure 3.5.1. The 2013/14 national targets of93.5% and 58% for DBD and DCD, respectively, are also shown on the plots, for information. All families of eligibledonors should be formally approached for a decision about organ donation.

Figure 3.5.1 Funnel plots of approach rates, 1 April 2013 - 31 March 2014

DBD

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Table 3.5.1 shows the reasons why patients were not formally approached for a decision about organ donation, ifapplicable, for your Trust.

Table 3.5.1 Reasons given why family not formally approached, 1 April 2013 - 31 March 2014

DBD DCDN % N %

Patient's general medical condition - - 2 100.0

Total - - 2 100.0


12

3.6 Proportion of approaches involving a SN-OD

In the UK, in 2013/14, when a SN-OD was not involved in the approach to the family for a decision about organ donation,DBD and DCD consent rates were 58% and 25%, respectively, compared with DBD and DCD consent rates of 70% and65%, respectively, when a SN-OD was involved. NICE CG135¹ and NHSBT Best Practice Guidance on approaching thefamilies of potential organ donors³ reinforces that every approach to those close to the patient should be planned withthe multidisciplinary team (MDT), should involve the SN-OD and should be clearly planned taking into account the knownwishes of the patient. The Organ Donor Register (ODR) should be checked in all cases of potential donation and thisinformation must be discussed with the family as it represents the eligible donor's legal consent to donation.

Funnel plots of DBD and DCD SN-OD involvement rates are displayed in Figure 3.6.1. The 2013/14 national targets of80% and 72% for DBD and DCD, respectively, are also shown, for information. A SN-OD should be actively involved inthe formal approach to the family and an approach plan made and followed.

Figure 3.6.1 Funnel plots of SN-OD involvement rates, 1 April 2013 - 31 March 2014

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13

3.7 Consent

Funnel plots of DBD and DCD consent rates are displayed in Figure 3.7.1. The 2013/14 national targets of 72.5% and55% for DBD and DCD, respectively, are also shown, for information.

Figure 3.7.1 Funnel plot of consent rates, 1 April 2013 - 31 March 2014

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Table 3.7.1 shows the reasons why families did not give consent, if applicable, for your Trust.

Table 3.7.1 Reasons given why family did not give consent, 1 April 2013 - 31 March 2014

DBD DCDN % N %

Patient had stated in the past that they did not wish to be a donor - - 1 33.3Family were not sure whether the patient would have agreed to donation - - 1 33.3Family felt the length of time for donation process was too long - - 1 33.3

Total - - 3 100.0


14

3.8 Reasons why solid organ donation did not occur

Table 3.8.1 shows the reasons why solid organ donation did not occur, if applicable, for your Trust.

Table 3.8.1 Reasons why solid organ donation did not occur, 1 April 2013 - 31 March 2014

DBD DCDN % N %

Prolonged time to asystole - - 1 100.0

Total - - 1 100.0


15

4. PDA data by hospital and unitA summary of key numbers and rates from the PDA by hospital and unit where the patient

died

4.1 Key numbers and rates by unit where the patient died

Tables 4.1.1 and 4.1.2 show the key numbers and rates for patients who met the DBD and/or DCD referral criteria,respectively. Caution should be applied when interpreting percentages based on small numbers. For each of the unitstabulated in Tables 4.1.1 and 4.1.2, the national key rates from the PDA are displayed in Appendix A.2 to aid comparisonwith equivalent units. For example, neurosurgical ICUs can be compared against the average rates achieved nationallyfor neurosurgical ICUs.

Table 4.1.1 Patients who met the DBD referral criteria - key numbers and rates,Table 4.1.1 1 April 2013 - 31 March 2014 (1 April 2012 - 31 March 2013* for comparison)

Unit wherepatient died

Patientswhere

neurologicaldeath wassuspected

Patientsthat were

tested

Neurologicaldeath testing

rate (%)

Patientswhere

neurologicaldeath wassuspectedthat were

referred toSN-OD

DBDreferralrate (%)

Patientsconfirmeddead by

neurologicaltesting

Eligible DBDdonors(Death

confirmed byneurologicaltests and no

absolutecontra-

indications)

Eligible DBDdonors

whose familywere

approached

DBDapproachrate (%)

Familiesconsenting

donation

DBDconsentrate (%)

ActualDBD and

DCDdonors

fromeligible

DBDdonors

DBD SN-ODinvolvement

rate (%)

1 April 2013 to 31 March 2014

Yeovil, Yeovil District HospitalGen. ICU/HDU 1 1 100 1 100 1 1 1 100 1 100 1 0

1 April 2012 to 31 March 2013*

Yeovil, Yeovil District HospitalA&E 0 0 - 0 - 0 0 0 - 0 - 0 -Gen. ICU/HDU 2 2 100 2 100 2 2 2 100 2 100 2 0


16

Table 4.1.2 Patients who met the DCD referral criteria - key numbers and rates,Table 4.1.2 1 April 2013 - 31 March 2014 (1 April 2012 - 31 March 2013* for comparison)

Unit wherepatient died

Patients forwhom

imminentdeath wasanticipated

Patients forwhom

imminentdeath wasanticipatedthat were

referred toSN-OD

DCD referralrate (%)

Patients forwhom

treatmentwas

withdrawn

Eligible DCDdonors

(Imminentdeath

anticipatedand treatment

withdrawnwith no

absolutecontra-

indications)

Eligible DCDdonors whose

family wereapproached

DCDapproachrate (%)

Familiesconsenting

donationDCD consent

rate (%)

Actual DCDdonors fromeligible DCD

donors

DCD SN-ODinvolvement

rate (%)

1 April 2013 to 31 March 2014

Yeovil, Yeovil District HospitalGen. ICU/HDU 13 12 92 11 8 6 75 3 50 2 33

1 April 2012 to 31 March 2013*

Yeovil, Yeovil District HospitalA&E 1 1 100 1 1 1 100 1 100 1 0Gen. ICU/HDU 22 15 68 20 9 6 67 5 83 1 17

Tables 4.1.1 and 4.1.2 show the unit where the patient died. However, it is acknowledged that there are some occasionswhere a patient is referred in an Emergency Department but moves to a critical care unit. In total, for Yeovil DistrictHospital NHS Foundation Trust in 2013/14 there were 3 such patients.

17

Appendices

Appendix A.1 Bar charts of key rates

Figure A.1.1 shows the same information as the radar charts in Section 2 but in an alternative format. The bars show thelatest rates for your Trust. Purple lines have been superimposed to provide a comparison with the UK and turquoisedashed lines show the rates achieved by your Trust in the equivalent period last year. The funnel plots in Section 3 canbe used to identify the maximum rates currently being achieved by Trusts with similar donor potential.

Figure A.1.1 DBD and DCD key rates

DBD

Rat

e (%

)

0

10

20

30

40

50

60

70

80

90

100

BSD testing

Referral Approach SN-OD inv.

Consent

100 100 100 0 100

DCD

Rat

e (%

)

0

10

20

30

40

50

60

70

80

90

100

Referral Approach SN-OD inv.

Consent

92 75 33 50

— Trust, 2013/14 — UK, 2013/14 - - - Trust, 2012/13*


18

Appendix A.2 National rates by unit type

For each of the units tabulated in Tables 4.1.1 and 4.1.2, the national key rates from the PDA are displayed in TablesA.2.1 and A.2.2 to aid comparison with equivalent units.

Table A.2.1 National DBD key numbers and rates by unit where the patient died, 1 April 2013 - 31 March 2014

Unit where the patient died

Patientswhere


Patientsthat were

tested


rate (%)

Patientswhere

neurologicaldeath wassuspectedthat werereferred to

SN-OD

DBDreferral

rate (%)


neurologicaltesting


confirmedby

neurologicaltests and no

absolutecontra-

indications)

EligibleDBD donors

whosefamily wereapproached

DBDapproachrate (%)

Familiesconsenting

donation

DBDconsentrate (%)

ActualDBD and

DCDdonors

fromeligible

DBDdonors

DBDSN-OD

involvementrate (%)

General ICU¹ 1026 834 81 982 96 816 792 741 94 524 71 471 84

Neurosurgical ICU 296 274 93 291 98 270 259 238 92 156 66 149 90

General/Neuro ICU 205 167 81 201 98 166 161 156 97 97 62 93 78

Cardiothoracic ICU 42 25 60 34 81 24 24 21 88 13 62 13 71

Paediatric ICU² 81 43 53 69 85 41 41 33 80 22 67 20 76

Specialist ICU³ 65 61 94 65 100 60 59 55 93 33 60 30 98

Accident and emergency 66 13 20 40 61 12 12 11 92 9 82 9 64

Table A.2.2 National DCD key numbers and rates by unit where the patient died, 1 April 2013 - 31 March 2014

Unit where the patient died

Patients forwhom


Patients forwhom

imminentdeath wasanticipatedthat werereferred to

SN-ODDCD referral

rate (%)

Patients forwhom

treatmentwas

withdrawn

Eligible DCDdonors

(Imminentdeath

anticipatedand

treatmentwithdrawn

with noabsolutecontra-

indications)

Eligible DCDdonors

whose familywere

approached

DCDapproach rate

(%)

Familiesconsenting

donationDCD consent

rate (%)

Actual DCDdonors fromeligible DCD

donors


rate (%)

General ICU¹ 5256 3686 70 4857 2873 1289 45 711 55 334 72

Neurosurgical ICU 412 389 94 389 304 241 79 147 61 79 84

General/Neuro ICU 553 471 85 520 331 198 60 114 58 55 68

Cardiothoracic ICU 243 138 57 214 140 61 44 34 56 18 67

Paediatric ICU² 200 109 55 183 130 55 42 21 38 13 58

Specialist ICU³ 83 66 80 75 53 31 58 16 52 9 90

Accident and emergency 403 209 52 368 285 103 36 21 20 10 45

¹ includes General ICU, HDU, General ICU/HDU/Coronary Care Unit, General ICU/HDU.² includes Paediatric ICU, Neonatal ICU.³ includes Specialist ICU, Multiple Injuries Unit.

Further national comparisons can be made by viewing the PDA section of the Organ Donation and TransplantationActivity Report and the PDA Annual Report, both of which are available on the ODT website. See links on Page 2.

19

Appendix A.3 National rates by Trust/Board level

Yeovil District Hospital NHS Foundation Trust has been categorised as a level 3 Trust/Board. Tables A.3.1 and A.3.2show the national DBD and DCD key numbers and rates for the UK by Trust/Board level, to aid comparison withequivalent Trusts/Boards. Note that caution should be applied when interpreting percentages based on small numbers.

Table A.3.1 National DBD key numbers and rates by Trust/Board level, 1 April 2013 - 31 March 2014

Patientswhere


Patientsthatwere

tested


rate (%)

Patientswhere

neurologicaldeath wassuspectedthat were

referred toSN-OD

DBDreferralrate (%)


neurologicaltesting


confirmed byneurologicaltests and no

absolutecontra-

indications)

Eligible DBDdonors

whose familywere

approached

DBDapproachrate (%)

Familiesconsenting

donation

DBDconsentrate (%)

ActualDBDandDCD

donorsfrom

eligibleDBD

donors

DBD SN-ODinvolvement

rate (%)

Your Trust 1 1 100 1 100 1 1 1 100 1 100 1 0

Level 1 ('Club 32')* 984 797 81 937 95 783 754 690 92 452 66 421 84

Level 2 414 324 78 387 93 314 307 291 95 202 69 181 85

Level 3 389 301 77 364 94 296 290 277 96 203 73 186 85

Table A.3.2 National DCD key numbers and rates by Trust/Board level, 1 April 2013 - 31 March 2014

Patients forwhom


Patients forwhom

imminentdeath wasanticipatedthat were

referred toSN-OD

DCDreferral rate

(%)

Patients forwhom

treatmentwas

withdrawn

Eligible DCDdonors

(Imminentdeath

anticipatedand treatment

withdrawnwith no

absolutecontra-

indications)

Eligible DCDdonors whose

family wereapproached

DCDapproachrate (%)

Familiesconsenting

donation

DCDconsentrate (%)

Actual DCDdonors from

eligibleDCD

donors


rate (%)

Your Trust 13 12 92 11 8 6 75 3 50 2 33

Level 1 ('Club 32')* 2898 2162 75 2690 1740 949 55 521 55 262 72

Level 2 2324 1636 70 2136 1303 560 43 306 55 140 74

Level 3 1954 1292 66 1806 1096 480 44 244 51 120 67

* Level 1 ('Club 32') Trust/Boards are defined as those Trusts/Boards having donation potential^ of 50 or more in theprevious financial year, and/or having a major trauma centre and/or having a neurosurgery unit. The remainingTrusts/Boards are categorised as level 2 if there was donation potential of 20 or more in the previous financial year. Allother Trusts/Boards are categorised as level 3.

^ Potential DBD donors plus eligible DCD donors.

20

Appendix A.4 Definitions

POTENTIAL DONOR AUDIT / REFERRAL RECORD

Data excluded Patients who did not die on a critical care unit or an emergency department andpatients aged over 80 years are excluded.

Donors after brain death (DBD)

Suspected Neurological Death A patient who meets all of the following criteria: Apnoea, coma from known aetiologyand unresponsive, ventilated, fixed pupils.

Potential DBD donor A patient who meets all four criteria for neurological death testing (ie suspectedneurological death, as defined above)

DBD referral criteria A patient with suspected neurological death

Discussed with SpecialistNurse – Organ Donation

A patient with suspected neurological death discussed with the SpecialistNurse – Organ Donation (SN-OD)

Neurological death tested Neurological death tests were performed

Eligible DBD donor A patient confirmed dead by neurological death tests, with no absolute medicalcontraindications to solid organ donation

Absolute contraindications An absolute contraindication is defined as any of:a) Age > 85 yearsb) Any cancer with evidence of spread outside affected organ (including lymph nodes)within 3 yearsc) Melanoma (except completely excised Stage 1 cancers)d) Choriocarcinomae) Active haematological malignancy (myeloma, lymphoma, leukaemia)f) Definite, probable or possible cases of human TSE, including CJD and vCJDh) Individuals whose blood relatives have had familial CJDi) Other neurodegenerative diseases associated with infectious agentsj) TB: active and untreatedk) HIV disease (but not HIV infection)l) No transplantable organ in accordance with organ specific contraindications

Family approached forconsent / authorisation

Family of eligible DBD asked to make a decision on donation

Family consented / authorised Family consented to / authorised donation

Actual donors: DBD Neurological death confirmed patients who became actual DBD as reported throughthe PDA

Actual donors: DCD Neurological death confirmed patients who became actual DCD as reported throughthe PDA

Neurological death testing rate Percentage of patients for whom neurological death was suspected who were tested

Referral rate Percentage of patients for whom neurological death was suspected who werediscussed with the SN-OD

Approach rate Percentage of eligible DBD families approached for consent /authorisation fordonation

Consent / authorisation rate Percentage of families approached about donation that consented to / authoriseddonation

Expected consent / authorisation rate The expected consent / authorisation rate given the ethnicity case mix (white or BAME(black, asian and minority ethnic)), based on those patients whose family wereapproached for consent /authorisation and patient ethnicity was known

SN-OD involvement rate Percentage of family approaches where a SN-OD was involved

SN-OD consent / authorisation rate Percentage of families approached about donation by a SN-OD that consentedto / authorised donation

21

Donors after circulatory death (DCD)

Imminent death anticipated A patient, not confirmed dead using neurological criteria, receiving assisted ventilation,a clinical decision to withdraw treatment has been made and death is anticipatedwithin 4 hours

DCD referral criteria A patient in whom imminent death is anticipated (as defined above)

Discussed with SpecialistNurse – Organ Donation

Patients for whom imminent death was anticipated who were discussed with theSN-OD

Potential DCD donor A patient who had treatment withdrawn and death was anticipated within four hours

Eligible DCD donor A patient who had treatment withdrawn and death was anticipated within four hours,with no absolute medical contraindications to solid organ donation

Absolute contraindications An absolute contraindication is defined as any of:a) Age > 85 yearsb) Any cancer with evidence of spread outside affected organ (including lymph nodes)within 3 yearsc) Melanoma (except completely excised Stage 1 cancers)d) Choriocarcinomae) Active haematological malignancy (myeloma, lymphoma, leukaemia)f) Definite, probable or possible cases of human TSE, including CJD and vCJDh) Individuals whose blood relatives have had familial CJDi) Other neurodegenerative diseases associated with infectious agentsj) TB: active and untreatedk) HIV disease (but not HIV infection)l) No transplantable organ in accordance with organ specific contraindications

Family approached forconsent / authorisation

Family of eligible DCD asked to make a decision on donation

Family consented / authorised Family consented to / authorised donation

Actual DCD DCD patients who became actual DCD as reported through the PDA

Referral rate Percentage of patients for whom imminent death was anticipated who were discussedwith the SN-OD

Approach rate Percentage of eligible DCD families approached for consent /authorisation fordonation

Consent / authorisation rate Percentage of families approached about donation that consented to / authoriseddonation

Expected consent / authorisation rate The expected consent / authorisation rate given the ethnicity case mix (white or BAME(black, asian and minority ethnic)), based on those patients whose family wereapproached for consent /authorisation and patient ethnicity was known

SN-OD involvement rate Percentage of family approaches where a SN-OD was involved

SN-OD consent / authorisation rate Percentage of families approached about donation by a SN-OD that consentedto / authorised donation

UK Transplant Registry (UKTR)

Donor type Type of donor: Donation after brain death (DBD) or donation after circulatory death(DCD)

Number of actual donors Total number of donors reported to the UKTR

Number of patients transplanted Total number of patients transplanted from these donors

Organs per donor Number of organs donated divided by number of donors. The maximum number ofsolid organs that can be donated are 7 for a DBD and 6 for a DCD.

Number of organs transplanted Total number of organs transplanted by organ type

On 1 April 2013 significant changes were made to the PDA. The main changes that should be borne in mind, especiallywhen making comparisons across time periods, are as follows:

· Upper age limit increased from 75 to 80 years.· Cardiothoracic ICUs included.· Changes to imminent death definition to be clear that death was anticipated within four hours.· Contraindications brought in line with current practice.· Terminology changes, eg 'potential donor' changed to 'eligible donor', for consistency with World Health

Organisation definitions.

22

Appendix A.5 Data description

This report provides a summary of data relating to potential and actual organ donors as recorded by NHS Blood andTransplant via the Potential Donor Audit (PDA), the accompanying Referral Record and the UK Transplant Registry forYeovil District Hospital NHS Foundation Trust. The report covers the time period 1 April 2013 to 31 March 2014 and datafrom 1 April 2012 to 31 March 2013 are also provided in certain sections for comparison purposes.

This report is provided for information and to facilitate case based discussion about organ donation by the DonationCommittee and your Trust.

As part of the PDA, patients aged over 80 years of age and those who did not die on a critical care unit or an emergencydepartment are not audited nationally and are therefore excluded from the majority of this report. In addition, someinformation from this time period may be outstanding due to late reporting and difficulties obtaining patient notes.Donations not captured by the PDA will still be included in the data supplied from the accompanying Referral Record orfrom the UK Transplant Registry, as appropriate.

Some percentages in this report were calculated using small numbers and should therefore be interpreted with caution.

Please refer any queries or requests for further information to your local Specialist Nurse - Organ Donation(SN-OD)

23

Appendix A.6 Table and figure description

Each table and figure displayed throughout the report is described below to aid interpretation.

1.1 Donor outcomesTable 1.1.1 The number of actual donors, the resulting number of patients transplanted and the average number of

organs donated per donor have been obtained from the UK Transplant Registry for your Trust/Board.Results have been displayed separately for donors after brain death (DBD) and donors after circulatorydeath (DCD).

Table 1.1.2 The number of organs transplanted by type from donors at your Trust/Board has been obtained from the UKTransplant Registry. Further information can be obtained from your local Specialist Nurse – Organ Donation(SN-OD), specifically regarding organs that were not transplanted. Results have been displayed separatelyfor DBD and DCD.

2.1 Key ratesFigure 2.1.1 Radar charts are displayed showing specific percentage measures of potential donation activity for your

Trust/Board compared with national data for the UK, and compared with an equivalent time period from theprevious financial year, using data from the Potential Donor Audit (PDA). The DBD charts show thepercentage of patients tested for neurological death, and all four charts also show the referral rates,approach rates, proportion of approaches involving a SN-OD and observed consent/authorisation rates.Appendix A.4 gives a fuller explanation of terms used.The blue shaded area represents your Trust/Board, and the national rates are superimposed as a solidpurple line for comparison. The equivalent period from the previous year is superimposed as a dashedturquoise line. The fuller the blue shaded area the better. Note that 0% and ‘not applicable (N/A)’ ratesappear the same. The rates have therefore been displayed on the spokes of the radar charts.Note that caution should be applied when interpreting percentages based on small numbers and whencomparing time periods.

2.2 Key numbers, rates and comparison with national targetsTable 2.2.1 A summary of DBD and DCD data and key rates have been obtained from the PDA. A national comparison

and a time period comparison are provided. Note that caution should be applied when interpretingpercentages based on small numbers and comparing time periods. Appendix A.4 gives a fuller explanation ofterms used.A comparison against national targets has been displayed by highlighting the key rates as red, amber orgreen. Tolerances for national targets:Green: >=98% of targetAmber: >=95% to <98% of targetRed: <95% of targetTargets specific to the financial year have been used and are displayed throughout Section 3.

3.1 Overview of lost opportunitiesFigure 3.1.1 The stages at which potential donors lose the opportunity to become actual donors have been obtained from

the PDA. There are four charts showing the DBD and DCD stages separately for your Trust/Board and theUK, all of which contain a comparison against an equivalent period from the previous financial year.The number of potential donors is shown on the vertical axis for each chart and at each ‘step’ the proportionof potential donors lost at that stage is displayed. Caution should be applied when interpreting percentagesbased on small numbers and comparing time periods.

3.2 Neurological death testingFigure 3.2.1 A funnel plot of the neurological death testing rate is displayed using data obtained from the PDA. Each

Trust/Board is represented on the plot as a blue dot, although one dot may represent more than oneTrust/Board. The national target is shown on the plot as a pink horizontal dotted line. The national rate isshown on the plot as a black horizontal dashed line, together with 95% and 99.8% confidence limits for thisrate. These limits form a ‘funnel’, with the 95% limits shown as a solid line and the 99.8% limits shown as adashed line. Graphs obtained in this way are known as funnel plots.If a Trust/Board lies within the 95% limits, then that Trust/Board has a rate that is statistically consistent withthe national rate. If a Trust/Board lies outside the 95% confidence limits, this serves as an alert that theTrust/Board may have a rate that is significantly different from the national rate. When a Trust/Board liesabove the green upper 99.8% limit, this indicates a rate that is significantly higher than the national rate,while a Trust/Board that lies below the red lower limit has a rate that is significantly lower than the nationalrate. It is important to note that differences in patient mix have not been accounted for in these plots.Your Trust/Board is shown on the plot as the large orange cross. If there is no large orange cross on theplot, your Trust/Board did not report any patients of the type presented.The funnel plots can also be used to identify the maximum rates currently being achieved by Trusts/Boardswith similar donor potential.

Table 3.2.1 The reasons given for neurological death tests not being performed have been obtained from the PDA, ifapplicable.

24

3.3 Referral to Specialist Nurse - Organ DonationFigure 3.3.1 Funnel plots of DBD and DCD referral rates are displayed using data obtained from the PDA. See

description for Figure 3.2.1 above.Table 3.3.1 The reasons for not referring the patient to the SN-OD have been obtained from the PDA, if applicable.Table 3.3.2 For patients who were referred, the timings of the first contact with the SN-OD by clinical staff have been

obtained from the PDA.

3.4 ContraindicationsTable 3.4.1 The primary absolute medical contraindications to solid organ donation have been obtained from the PDA, if

applicable.

3.5 Family approachFigure 3.5.1 Funnel plots of DBD and DCD approach rates are displayed using data obtained from the PDA. See

description for Figure 3.2.1 above.Table 3.5.1 The reasons why families were not formally approached for a decision about solid organ donation have been

obtained from the PDA, if applicable.

3.6 Proportion of approaches involving a SN-ODFigure 3.6.1 Funnel plots of DBD and DCD SN-OD involvement rates are displayed using data obtained from the PDA.

See description for Figure 3.2.1 above.

3.7 ConsentFigure 3.7.1 Funnel plots of DBD and DCD consent/authorisation rates are displayed using data obtained from the PDA.

See description for Figure 3.2.1 above.Table 3.7.1 The reasons why families did not give consent/authorisation for solid organ donation have been obtained

from the PDA, if applicable.

3.8 Reasons why solid organ donation did not occurTable 3.8.1 The reasons why solid organ donation did not occur have been obtained from the PDA, if applicable.

4.1 Key numbers and rates by unit where the patient diedTable 4.1.1 DBD key numbers and rates by unit where the patient died have been obtained from the PDA. Data for the

current time period are included, along with an equivalent comparison period from the previous year.If the hospitals/units are not equivalent for the two time periods, this is due to hospital/unit changes, and/orthere were no patients for whom neurological death was suspected or imminent death was anticipated in oneof the time periods.Caution should be applied when interpreting percentages based on small numbers and comparing timeperiods.

Table 4.1.2 DCD key numbers and rates by unit where the patient died have been obtained from the PDA. Seedescription for Table 4.1.1 above.

Appendix A.1 Bar charts of key ratesFigure A.1.1 Bar charts have been used to display the DBD and DCD key rates from the PDA. This is an alternative way

of displaying the information in Figure 2.1.1.The percentages for your Trust/Board in the latest time period are displayed on each bar. Note that cautionshould be applied when interpreting percentages based on small numbers and comparing time periods.

Appendix A.2 National rates by unit typeTable A.2.1 For each of the units in Table 4.1.1, the national DBD key rates from the PDA are displayed to aid

comparison with equivalent units. Units have been grouped to aid a more meaningful comparison.Table A.2.2 For each of the units in Table 4.1.2, the national DCD key rates from the PDA are displayed to aid

comparison with equivalent units. Units have been grouped to aid a more meaningful comparison.

Appendix A.3 National rates by Trust/Board levelTable A.3.1 National rates for level 1, 2 and 3 Trusts/Boards are displayed to aid comparison with equivalent

Trusts/Boards. Caution should be applied when interpreting percentages based on small numbers.

agenda - part 1...gynaecologists report will be shared with the cqc. although ydh has not yet...

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