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BOARD OF DIRECTORS
Wednesday 22 June 2016 at 09:00 - 12:45 Boardroom, Level 1, Yeovil District Hospital NHS Foundation Trust
AGENDA - PART 1
Presenter Timings Enclosure 1 Welcome and Apologies for Absence Chairman 09:00 Verbal 2 Declarations of Interest Relating to Items on the Agenda All Verbal 3 To Hear a Patient Story and to Receive Feedback on Actions
from the Patient Story from 27 April 2016 The purpose of the patient story is to focus the attention of the Board on patient experiences, the learning from which is used to improve services across the organisation.
HR
Presentation
4 To Approve the Minutes of 25 May 2016 and to Discuss
Matters/Actions Arising Chairman 09:30 Appendix 1
5 To Note the Executive Director Report (Including the TrakCare
Highlight Report and an Update on the STP) Execs 09:35 Appendix 2
6 To Review and Note the Quality and Operational
Performance Report SS / SM
HR 10:05 Appendix 3
BREAK – 10:25
7 To Receive a Presentation on Improving Patient Flow and
Discharge SS and team
10:40 Presentation
8 To Approve the Appraisal and Revalidation Annual Report 2016
MK TS
11:10 Appendix 4
9 To Note the Safer Staffing Report and I Want Great Care Report HR 11:25 Appendix 5 10 11
To Review and Note the Workforce Performance Report To Receive a Verbal Update from the Workforce Committee Held on 20 June 2016 and to Note the Minutes of the Meetings Held on 21 April 2016 and 23 May 2016
TN
MS
11:40 Appendix 6
Appendix 7 And Tabled
12 13
To Review and Note the Financial Performance Report To Receive a Verbal Update from the Last Financial Resilience and Commercial Committee
TN
12:00 Appendix 8
Verbal
14 To Approve the Revised Board Governance Structure JR 12:20 Appendix 9
15 To Receive an Update from the Council of Governors Held on 9 June 2016
PvdH 12:30 Verbal
16 To Approve the Self-Certification Declarations:
• corporate governance statement • AHSCs • training of governors
JR 12:35 Appendix 10
17 Any Other Business and Meeting Close
Chairman 12:45 Verbal
18 Exclusion of the Public 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.
19 Date and Time of Next Meeting
27 July 2016 in the Boardroom, Level 1, Yeovil Hospital
APPENDIX 1 BOARD OF DIRECTORS
22 JUNE 2016 BOARD OF DIRECTORS
DRAFT Minutes of the Board of Directors Meeting held on
Wednesday 25 May 2016 at Yeovil District Hospital
Present: Paul von der Heyde Chairman Maurice Dunster Non-Executive Director Julian Grazebrook Non-Executive Director Jane Henderson Non-Executive Director Mark Saxton Non-Executive Director Jonathan Howes Deputy Chief Executive Paul Mears Chief Executive Tim Newman Chief Finance & Commercial Officer
Helen Ryan Director of Nursing & Clinical Governance Tim Scull Medical Director
In Attendance: Jonathan Higman Director of Strategic Development
Simon Lilley Commercial Director (Observer) Jason Maclellan Chief Information Officer [Item 1-95/16]
Shelagh Meldrum Director of Elective Care Jade Renville Company Secretary Simon Sethi Director of Urgent Care & LTC Apologies: Mandy Seymour-Hanbury Interim Chief Officer for Integrated Care
Ref: No Action 1-
93/16 1
1.1
WELCOME AND APOLOGIES FOR ABSENCE Paul von der Heyde welcomed everyone to the meeting. He explained that the part 1 business meeting had been streamlined to allow more time during the day for seminar sessions on outcomes based commissioning and the STP. Apologies for absence were received as noted above.
1-94/16
2 2.1
DECLARATIONS OF INTEREST Paul von der Heyde reminded the Board that he had listed his declarations of interest at a previous meeting [item 1-2/16 refers]. There were no other declarations of interest relating to items on the agenda.
1-95/16
3 3.1
MINUTES/ACTIONS OF THE PREVIOUS MEETING The minutes of the meeting held on 27 April 2016 were approved as a true and accurate record. In terms of matters arising, Jade Renville confirmed that she had circulated the Better Births; Improving Outcomes of Maternity services in England report [Item 1-51/16 refers] and that Optum would be delivering a seminar session later in the day on outcomes based commissioning [Item 1-70/16 refers].
1-96/16
4 4.1
TRAKCARE HIGHLIGHT REPORT Jason Maclellan gave a verbal update on progress with TrakCare implementation. He explained that the executive team had taken the decision to pause the launch planned for the weekend until the weekend of 11/12 June. This is to enable further validation and testing to take place, particularly in regards to RTT reporting and outpatient administration and booking processes.
2 | P a g e
The Board accepted the reasons for the delay but asked of any risks to the revised go-live date. Jason Maclellan responded that a clear plan for testing and training was in place to maintain focus and momentum over the next two weeks. Jonathan Higman said that clear messaging on the reasons for the delay should be disseminated to staff along with details of the next steps over the next two weeks, which was agreed by Board. The Board also agreed that once go-live had been completed, attention would need to turn to phase 2 and further developing a collaborative partnership with InterSystems.
1-97/16
5 5.1
5.2
5.3
5.4
5.5
EXECUTIVE DIRECTOR REPORT The Board received a verbal report on key activities from the Chief Executive, the key points from which were discussed as follows: Sustainability and Transformation Plan (STP) As discussed at the previous meeting [item 1-53/16 refers], planning is ongoing between providers and commissioners on the development of the Somerset-wide STP. More detailed discussion would take place on this topic as part of the seminar session planned for later in the day. Operational Plan 2016/17 The Board was advised that formal feedback is still awaited on the Trust’s annual plan submitted to NHS Improvement. It was acknowledged that they may make some recommendations with regards the Trust’s proposed budget deficit for 2016/17 which would require consideration by the executive team and the Financial Resilience and Commercial Committee and/or the Board (once received). Tim Newman and Paul Mears confirmed they would keep the Board informed of any correspondence from NHS Improvement. CQC Inspection Following the planned inspection of the Trust’s services by the CQC in March 2016, Paul Mears said that YDH had not yet received its draft report which is now not expected until the end of June 2016 and would then undergo a process of factual accuracy prior to publication at the end July/August 2016 (estimated). Noting the publication of the CQC inspection report for Taunton and Somerset NHS Foundation Trust, the Board congratulated them for obtaining their rating of ‘good’. Junior Doctors Strike Action Following a series of nationwide strikes by junior doctors, the BMA and the Government have re-entered into negotiations and a revised contract has been agreed. The main differences in the revised contract is increased responsibility for the role of the Guardian of Safe Working, changes to the pay calculations for weekend working and reduction to basic salary (in comparison to the contract draft released earlier this year). Trusts have been instructed to continue with the appointment of the Guardian of Safe Working but all other works must halt until the BMA contract referendum outcome at the beginning of July.
1-98/16
6 6.1
6.2
QUALITY, OPERATIONAL AND FINANCIAL PERFORMANCE REPORT The Board reviewed the previously circulated quality and operational performance report, from which the following exceptions were discussed and noted: - Helen Ryan said that YDH was one of only two trusts across the south west with no cases of MRSA in 2015/16, which was positively noted by the Board.
3 | P a g e
6.3
6.4
6.5
6.6
- Despite the ongoing implementation of the recovery plan, YDH did not meet the 92% RTT target in April 2016 (incompletes), primarily due to additional and significant operational pressures and the junior doctor strikes which resulted in the cancellation of elective activity. Validation is ongoing. Linked to this, Simon Sethi spoke of the significant number of delayed discharges which was adversely impacting patient flow through the hospital. While there are a number of internal actions being taken by YDH to improve patient flow, work is ongoing with the health and care system across Somerset to review the external requirements to lessen the operational burden placed on the acute trust sector. It was agreed that Simon Sethi would present a more detailed overview of the plans to improve patient flow at the next meeting of the Board. Jonathan Higman added that this issue is a key area of focus for the STP and the work on outcomes based commissioning. - The Board acknowledged that ED demand continues to increase, a recovery plan for which is in progress. - Simon Sethi said that YDH has strong performance against the cancer standards but that the junior doctor strikes has impacted the 62 day treatment standard (data for which is still being validated). Tim Newman presented the financial performance report (which had been reviewed in detail by the Financial Resilience and Commercial Committee), confirming that year-to-date, YDH was favourable (by £0.06m) to its business as usual budget. The Board noted the risks to the budget in relation to vanguard income and fines for not meeting RTT performance targets under the Trust’s PbR contract with the Somerset CCG.
SS
1-99/16
16 16.1
ANY OTHER BUSINESS There was no further business to discuss.
1-100/ 16
17 17.1
DATE OF NEXT MEETING The next meeting will be held on Wednesday 25 May 2016.
APPENDIX 2 BOARD OF DIRECTORS
22 JUNE 2016
Report to: Board of Directors Subject: Executive Report Date: 22 June 2016 TrakCare Implementation The new TrakCare electronic health record system went live across the Trust over the weekend of 11-13 June. Phase 1 of this project included a new system for the emergency department, maternity and across all wards and outpatient clinics. The go-live was a significant event for the hospital and the implementation of the new system went very well with all wards being live by 11am on the Sunday 13 June 2016. Whilst there will be some minor technical issues to resolve over the coming weeks and a period of transition, overall the implementation has been successful. We would like to thank all of the TrakCare team who have worked very long hours over the past few weeks to prepare for the go-live and in particular Jason McClellan, Tony Smith, Becky Garnett and Nicky Croxon who have been leading the project. The whole team should be congratulated for their efforts and the way in which the go-live was managed and the huge efforts undertaken by Rob Organ and the technical team to migrate the data across which was another significant success. Also all the teams across the hospital have put in significant work to ensure the implementation was as smooth as possible and Sophie Sennet and her team in the Contact Centre should also be thanked for their hard work in preparation and over the go-live weekend making sure that all our outpatient appointments and letters were appropriately transitioned. The whole hospital has responded to the implementation with the usual positivity and the Board would like to thank everyone who has contributed to the success of this first phase of implementation. Sustainability and Transformation Plan (STP) Work continues across Somerset on developing the STP. This work is being led by Matthew Dolman as SRO with senior team members from YDH very involved in the development of the plan. We are also liaising with colleagues at Dorset CCG to ensure appropriate input to their STP in particular the developing thinking around service models for the north of Dorset from where many of our patients originate. Following a series of workshops with senior leaders from all Health and Social Care organisation across Somerset the following areas of priority have been agreed:
1. Prevention 2. Building and sustaining primary care 3. Risk stratification and proactive patient management 4. Addressing urgent care demand, with a focus on developing integrated ‘front door’,
rapid response and hospital at home services 5. Acute service redesign, focussing on new models of delivery for a number of
identified acute services 6. Reducing delayed transfers of care 7. New models of community service delivery 8. Improving efficiency and effectiveness with an initial focus on continuing healthcare,
back office functions and addressing agency workforce utilisation
The Symphony leadership team have become involved in the development work and there is now alignment between the key priorities of the STP and Symphony. Somerset Together (the outcome based commissioning work) is seen as a key enabler to the STP. The 5-year financial challenge for Somerset has been quantified at £313 million. Optum continue with the economic modelling in support of the STP with the aim of quantifying the anticipated benefits of the agreed priorities. The initial outcomes of this work are expected early next week and a verbal update will be provided at the meeting. The next submission to NHS England and NHS Improvement is due on 30 June 2016 and as part of the assurance process a ‘challenge’ event, which will be attended by Matthew Dolman as the STP SRO and members of the Somerset Health and Social Care Leadership Group, is scheduled for 6 July 2016. Opening of the New Special Care Baby Unit (SCBU) After many years of fundraising we recently opened the new SCBU in the Women’s Hospital. This is a significant milestone for YDH and provides a state of the art new unit for vulnerable new born babies and their families. The majority of the funds to build the new unit were raised from charitable sources including staff, patients, families and the local community. We would like to thank everyone who donated money or raised funds for this much needed facility and also thank James Kirton and Sarah Cherry from our fundraising team for their unstinting efforts and hard work to raise the necessary funds to build this unit. They can be very proud of the facility we now have available within the hospital and both staff and patients are very positive about the new environment. Meeting with Oliver Letwin MP The Chairman and Chief Executive met with Oliver Letwin MP recently as a regular meeting with one of our local MPs. We discussed the challenges facing the Trust and the strategy we are implementing to face these challenges and in particular our work on systematised surgery and the Symphony programme. Oliver also visited the Symphony Complex Care Hub to talk to staff about the work they are doing to manage the most complex patients and his feedback was extremely positive.
1
YDH │Quality and Operational Performance Report May 2016
2
CONTENTS
1 Safe
2 Effective
3 Responsive
4 Caring
5 Well-led – Staffing
6 Well-led - Financial Performance
3
Safe [1]
Latest HSMR 12
Months to Nov 15
98.7
April Number of
Deaths
50
Mortality Rates
RAG Status: Significantly better than national average, Within expected range, Significantly higher than national average.
Please note: Due to the termination of the DrFoster Contract, HSMR data will no longer be available from Nov15 onwards.
0
20
40
60
80
100
120
Ma
y-1
2
Jul-
12
Sep
-12
No
v-1
2
Jan
-13
Ma
r-13
Ma
y-1
3
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Ma
r-14
Ma
y-1
4
Jul-
14
Sep
-14
No
v-1
4
Jan
-15
Ma
r-15
Ma
y-1
5
Jul-
15
Sep
-15
No
v-1
5
Hospital Standardised Mortality Ratio (HSMR)
Monthly data 6 month moving average
0
20
40
60
80
100
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
Ap
r-1
5
Jul-
15
Oct
-15
Jan
-16
Ap
r-1
6
Actual number of deaths
Monthly data 6 month moving average
4
Safe [2]
Patient Falls and Pressure Ulcers
Patient Falls
87 (56 in May 15)
Pressure Ulcers
13 (12 in May 15)
0
20
40
60
80
100
120
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
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
Patient falls
Monthly data 6 month moving average
0
5
10
15
20
25
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
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
Pressure ulcers +2
Monthly data 6 month moving average
5
Safe [3]
C.Difficile and MRSA cases
May C.Diff
(Lapses in Care)
0 (1 in May 15)
May MRSA
0 (0 in May 15)
0
1
2
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
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
MRSA
Monthly data 6 month moving average
0
1
2
3
4
5
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
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
Total C Difficile Cases
Monthly data 6 month moving average
Additional Notes
The Trust’s 16/17 Threshold for C.Diff cases is 8.
Total number of cases of C.Diff for 15/16 was 15, of these
4 were due to Lapses in Care.
6
Effective [1]
Additional Notes
SSNAP Published figures for Q4Oct-Dec15:
National Average 4hr to Stroke Unit : 59.8%
National Average 90% Stay on Stroke Unit: 84.4%
National Average CT Scan in 1hr: 48.2%
90% Stay on Stroke
Unit
79% (Target: 80%)
Admission Direct
within 4hrs
50% (Target: 90%)
CT Scan in 1hr
52% (Target: 50%)
May 16
Stroke Services
0%
10%
20%
30%
40%
50%
60%
70%
80%
Ap
r-1
3
Jun
-13
Au
g-1
3
Oct
-13
De
c-13
Feb
-14
Ap
r-1
4
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
Achievement 1HrCTScan
High Risk TIA within
24 Hours
78% (Target: 80%)
0%
20%
40%
60%
80%
100%
Ap
r-1
3
Jun
-13
Au
g-1
3
Oct
-13
De
c-13
Feb
-14
Ap
r-1
4
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
4Hr Direct Admission
4Hr Direct Admission Target
7
Effective [2]
Additional Notes
Best Practice achievement in Financial Year 15/16 : 37%
The current measure that is impacting on Best Practice
Performance this year to date is ‘Operated on within 36hrs’ with
performance at 72%.
Best Practice
Achievement
72.0% (Int.Target: 60%)
YTD AvLoS Direct admission:
Trauma ward
13.2 days (vs 17.6 days Other wards)
May 16
Fractured Neck of Femur Services
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Ap
r-14
May
-14
Jun
-14
Jul-
14
Au
g-14
Sep
-14
Oct
-14
No
v-14
Dec
-14
Jan-
15
Feb
-15
Mar
-15
Ap
r-15
May
-15
Jun
-15
Jul-
15
Au
g-15
Sep
-15
Oct
-15
No
v-15
Dec
-15
Jan-
16
Feb
-16
Mar
-16
Ap
r-16
May
-16
Average Length of Stay - #NOF patients
Trauma Ward Admission Other Admissions
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Operated onwithin 36
hours
GeriatricAssessment
within 72hours
Pre-op AMT Post-op AMT FallsAssessment
BoneProtectionMedication
Post-op MDT
Best Practice Achievement Financial Year 2016/17
Overall BPT % Achieving each measure Trauma Ward direct Admissions BPT
8
0
50
100
150
200
250
300
350
400
Completionof
Assessment
PublicFunding
Further nonacute NHS
care
ResidentialHome
NursingHome
Carepackage inown Home
CommunityEquipment
Patient orFamilyChoice
Disputes Housing
Monthly Split of Delayed Discharge Reasons (Bed Days)
03/2016 04/2016 05/2016
Delayed Discharges
May 16
Lost Bed Days
1046 (235 May 15)
In Month Bed Cost
£246,856 (£55,460 May 15)
Additional Notes
In Month Bed Costs are calculated using an average bed cost
of £236 multiplied by the number of lost Bed Days in Month.
Increases in delays in May are primarily due to awaiting Care
Packages in own home.
Effective [3]
0
5
10
15
20
25
30
35
40
45
50
Number of Delayed Transfers of Care
9
DNA - Outpatients
Overall DNA Rate
7.8%
1st Appointment Rate
5.3% FU Appointment Rate
8.0%
Effective [4]
Additional Notes
Published National DNA rates for Q2 15/16 were 8.2%.
(Source NHS Better Care, Better Value Indicators)
The DNA cost is based on the average New appointment
costing £150 and the average FUP appointment costing £75
£60
£70
£80
£90
£100
£110
£120
£130
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
Ap
r-14
Jun
-14
Au
g-14
Oct
-14
Dec
-14
Feb
-15
Ap
r-15
Jun
-15
Au
g-15
Oct
-15
Dec
-15
Feb
-16
Ap
r-16
Tho
usa
nd
s
DNA Cost
RAG Status: Less than 7%, 7-8%, Over 8%.
May 16
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
11.0%
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
Ap
r-14
Jun
-14
Au
g-14
Oct
-14
Dec
-14
Feb
-15
Ap
r-15
Jun
-15
Au
g-15
Oct
-15
Dec
-15
Feb
-16
Ap
r-16
DNA Rate
Overall DNA rate First DNA rate Follow up DNA rate
10
0 1 2 3 4 5 6 7 8 9
Urgent Case took Priority
No Beds Available
Administrative Reasons
Requires Alternative Session/Specialty
Equipment Failure/Unavailable
Insufficent session time / session overrun
Hospital Non Clinical On the Day Cancellations of Elective Operations
- May 16
Cancelled Operations
On the Day Non-
Clinical Reasons
22 (19 – May 15)
Rebooked within 28
Day Target
22
Total Cancelled due
to Lack of Beds
16
May 16
Additional Notes
The figure for Total Cancelled due to Lack of Beds includes
cancellations with more than 1 day notice given.
Note: 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.
Effective [5]
RAG Status: <=15 Cancellations, 16-24 Cancellations, >=25 Cancellations
0 5 10 15 20 25 30 35
Urgent Case took Priority
No Beds Available
Administrative Reasons
Requires Alternative Session/Specialty
Equipment Failure/Unavailable
Hospital Non Clinical On the Day Cancellations of Elective Operations 2016 - 2017 YTD
11
First to Follow up Ratio
New to FU Ratio
1 : 2.2
6 Month Rolling
Average
1 : 2.2
Additional Notes
NHS Better Care, Better Value 15/16 Q2 Ratio: 1 : 2
Effective [6]
1.5
1.7
1.9
2.1
2.3
2.5
2.7
2.9
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
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
New:Follow Ratio
New:Follow Ratio 6 month moving average
May 16
0
1
2
3
4
5
6
7
8
0
500
1000
1500
2000
2500
rate
att
end
an
ces
April 2016 - March 2017 1st to Follow Up Ratio by Speciality
1st Follow Up Rate
12
Responsive [1]
Admitted Stops
76.7% (Target: 90%)
Non-Admitted Stops
92.3% (Target: 95%)
Total Incompletes
91.25% (Target: 92%)
Additional Notes
The trust did not achieve the 92% Total Incompletes
target in the month of May.
The penalties to the Trust are £300 for every incomplete
pathway over the 18 weeks target.
RTT Pathways
80.0%
85.0%
90.0%
95.0%
100.0%
Ma
y-1
3
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Ma
r-14
Ma
y-1
4
Jul-
14
Sep
-14
No
v-1
4
Jan
-15
Ma
r-15
Ma
y-1
5
Jul-
15
Sep
-15
No
v-1
5
Jan
-16
Ma
r-16
Ma
y-1
6
RTT Incomplete Pathways
Monthly data RTT target 6 Month Moving Average
Admitted
Incompletes
78.0% (Target: 92%)
Non-Admitted
Incompletes
95.8% (Target: 92%)
85%
88%
91%
94%
97%
100%
Ma
y-1
3
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Ma
r-14
Ma
y-1
4
Jul-
14
Sep
-14
No
v-1
4
Jan
-15
Ma
r-15
Ma
y-1
5
Jul-
15
Sep
-15
No
v-1
5
Jan
-16
Ma
r-16
Ma
y-1
6
RTT Completed Pathways - Non admitted
Monthly data RTT target 6 Month Moving Average
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
May
-13
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Mar
-14
May
-14
Jul-
14
Sep
-14
No
v-1
4
Jan
-15
Mar
-15
May
-15
Jul-
15
Sep
-15
No
v-1
5
Jan
-16
Mar
-16
May
-16
RTT Completed Pathways - Admitted
Monthly data RTT target 6 Month Moving Average
13
0
100
200
300
400
500
600
>18
wee
ks
>19
wee
ks
>20
wee
ks
>21
wee
ks
>22
wee
ks
>23
wee
ks
>24
wee
ks
>25
We
eks
>26
wee
ks
RTT Incomplete pathways - Aging
Non Admitted Admitted
Responsive [2]
Additional Notes
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.
Admitted Patients over
18 Weeks
551
Non-Admitted Patients
over 18 Weeks
306
Patients over 26
Weeks
312
Patients over 52
Weeks
0
May 16
RTT Incomplete Pathways
01,0002,0003,0004,0005,0006,0007,0008,0009,000
10,00011,000
Ma
y-1
2
Jul-
12
Sep
-12
No
v-1
2
Jan
-13
Ma
r-13
Ma
y-1
3
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Ma
r-14
Ma
y-1
4
Jul-
14
Sep
-14
No
v-1
4
Jan
-15
Ma
r-15
Ma
y-1
5
Jul-
15
Sep
-15
No
v-1
5
Jan
-16
Ma
r-16
Ma
y-1
6
RTT Incomplete Pathways with All Stops
RTT Incomplete Pathways RTT incomplete pathways > 18 weeks
Number of Stops
14
Responsive [3]
Additional Notes
The Trust has successfully achieved the National diagnostics
Target for the first time since Jun 15.
Overall Diagnostic 6
Week Waits %
99.7% (99.6% - May 15)
Imaging 6 Week
Waits %
100% (99.8% - May 15)
Physiological
Measurement Waits %
98.9% (99.1% - May 15)
Endoscopy 6 Week
Waits %
99.0% (98.9% - May 15)
May 16
Diagnostic Waits
0 10
April 16 Diagnostic 6 Week Wait Breaches
EndoscopyBreaches
PhysiologicalMeasurementBreaches
90.0%
92.0%
94.0%
96.0%
98.0%
100.0%
Diagnostic 6 Week Waits %
Diagnostic 6 Week Waits % Target DM01 % - Trajectory
15
0
20
40
60
80
100
120
140
160
Ap
r-1
4M
ay-
14
Jun
-14
Jul-
14
Au
g-1
4Se
p-1
4O
ct-1
4N
ov-
14
De
c-14
Jan
-15
Feb
-15
Ma
r-15
Ap
r-1
5M
ay-
15
Jun
-15
Jul-
15
Au
g-1
5Se
p-1
5O
ct-1
5N
ov-
15
De
c-15
Jan
-16
Feb
-16
Ma
r-16
Ap
r-1
6M
ay-
16
Avg A&E Attendances per Day
Avg A&E attendances per day Avg ambulance arrivals per day
Avg Emergency Admissions Per Day
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
Apr
-12
Jun-
12
Aug
-12
Oct
-12
Dec
-12
Feb-
13
Apr
-13
Jun-
13
Aug
-13
Oct
-13
Dec
-13
Feb-
14
Apr
-14
Jun-
14
Aug
-14
Oct
-14
Dec
-14
Feb-
15
Apr
-15
Jun-
15
Aug
-15
Oct
-15
Dec
-15
Feb-
16
Apr
-16
A&E 4 hour performance - All Attendances
Monthly data 6 month moving average
Responsive [4] ED Attendances
A&E Performance
92.66% (95.82% May 15)
Average A&E
Attendances per day
134.1 (120.4 - May 15)
Average Ambulance
Arrivals per day
42.3 (36.0 – May 15)
Additional Notes
A&E activity over the two month period March and April was up
by 3.7% vs last year (+287 attendances).
YTD attendances (3813) vs last FY YTD (3848).
Average Emergency Admissions excludes Paediatrics and
Maternity.
Average Breaches
per Day
9.8 (5.0 – May 15)
May 16
Average Emergency
Admissions per day
45.2 (42.5 – May 15)
16
Responsive [5]
30 Minute Handovers
98.5% (99.7% May 15)
YTD Fines
£8,400 (£19,000 YTD 15/16)
Ambulance Handovers
£0
£2,000
£4,000
£6,000
£8,000
£10,000
£12,000
£14,000
£16,000
£18,000
0
200
400
600
800
1,000
1,200
1,400
1,600
Ambulance Handovers Per Month
Ambulance Handovers Fines
£4,400 £4,000
£0 £2,000 £4,000 £6,000 £8,000 £10,000 £12,000 £14,000 £16,000 £18,000 £20,000
Ma
y-1
6
Apr-16 May-16RAG Status: >=99%, 98-99%, <98%
17
Responsive [6]
Admission Avoidance
Additional Notes
Inpatient bed pressures have impacted on the use of AEC as
an ambulatory area. It is expected that as this eases the use
of AEC will increase the number of emergency 0 day LoS
patients and we will continue to observe decreases in the
numbers of patients that need to be admitted to wards from
AAU.
May 16
0 LOS % vs LY
33.1% (34.2% - May 15)
% Admitted to Wards
from AAU (CDU)
49.3% (48.8% - May 15)
0
100
200
300
400
500
600
700
800
40.0%
45.0%
50.0%
55.0%
60.0%
65.0%
% of Patients Admitted to Wards from AAU (CDU)
Change in CDU CDU & AEC Admission % Linear (CDU & AEC Admission %)
0
0.2
0.4
0.6
0.8
1
0
100
200
300
400
500
600
Emergency Admissions - Length of Stay
Start of FOPAS Change in CDU 0 Days LOS 1-2 Days LOS
18
Responsive [7]
Elective Admissions
1,763 (1,575 May 15)
Non-Elective Admissions
1,762 (1,701 May 15)
Elective LOS
3.9 Days (+1.9 vs May 15)
Non-Elective LOS
5.1 Days (+0.0 vs May 15)
Additional Notes
Both elective and non-elective admissions are higher than
the same period last year.
Both Length of Stay for Elective and Non-Elective are
comparable to May last year.
May 16
Admissions and LOS
0
500
1,000
1,500
2,000
2,500
Ap
r-1
2Ju
n-1
2A
ug-
12
Oct
-12
Dec
-12
Feb
-13
Ap
r-1
3Ju
n-1
3A
ug-
13
Oct
-13
Dec
-13
Feb
-14
Ap
r-1
4Ju
n-1
4A
ug-
14
Oct
-14
Dec
-14
Feb
-15
Ap
r-1
5Ju
n-1
5A
ug-
15
Oct
-15
Dec
-15
Feb
-16
Ap
r-1
6
Admissions
Total Elective admissions Non Elective admissions
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
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
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
Average Length of Stay (Days)
LOS Elective LOS Non Elective
19
Cancer 2 Week Wait Draft Data
2 Week Suspected
Cancer
95.5% (Target 93%)
2 Week Breast
96.3%
(Target 93%)
Additional Notes
Draft Data for May indicates that the trust has achieved the
2 Week Wait Suspected Cancer and the 2 Week Breast
Cancer Targets.
May 16
Responsive [8]
0
20
40
60
80
100
0
100
200
300
400
500
600
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
4Ju
n-1
4A
ug-
14
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5Ju
n-1
5A
ug-
15
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
no
. ref
erra
ls -
bre
ast
sym
pto
ns
No
. re
ferr
als
-su
spec
ted
ca
nce
r
Number of Referrals Seen
2WW Suspected Cancer 2WW Exhibited Breast Symptoms
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
105.0%
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
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
2 Week Cancer Targets
2WW Suspected Cancer 2WW Breast
20
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
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
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
62 Day Treatment Standard
Achievement % 6 Month Rolling % Target %
Cancer 31 and 62 Day Targets Draft Data
Additional Notes
Draft Data for May indicates that the trust did not achieve the
31 Day Subsequent Surgery Target or the 62 Day standard
Target.
However, further validation is still to take place before the
Quarter End Submission.
31 Day Treatment First
94.4% (Target 96%)
31 Day Treatment
Subsequent Drugs
100.0% (Target 98%)
31 Day Treatment
Subsequent Surgery
100.0% (Target 94%)
62 Day Treatment
Screening
100.0% (Target 90%)
62 Day Treatment
Standard
71.1% (Target 85%)
62 Day Treatment
Upgrades
100.0% (Target 90%)
Responsive [9]
84.0%
86.0%
88.0%
90.0%
92.0%
94.0%
96.0%
98.0%
100.0%
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
Jun
-14
Au
g-1
4
Oct
-14
De
c-14
Feb
-15
Ap
r-1
5
Jun
-15
Au
g-1
5
Oct
-15
De
c-15
Feb
-16
Ap
r-1
6
31 Day Treatment First
Achievement % Target % 6 month rolling %
21
Cancer 62 Day Urgent GP Referral Pathway Draft Data
Additional Notes
Note that shared breaches with other organisations
show as 0.5 on the table above.
Target: 85%.
Responsive [10]
0
1
2
3
4
5
6
7
May-16
Number of 62 Day Patients Seen
Gynaecology Lower GI Lung Breast
Head and Neck Upper GI Brain Haematology
Sarcoma Other
Cancer SiteYTD
15/16
Brain 100% 1 (0)
Breast 95.7% 70 (3) 100% 10 (1) 100% 3 86% 7 (1) 100% 6
Gynaecology 95.8% 24 (1) 0% 0.5 (0.5) 100% 5.5 100% 1.0 0% 1 (1)
Haematology 64.1% 19.5 (7) 0% 1.0 (1) 0
Head and Neck 44.0% 12.5 (7) 0 (0.5) -33% 2 (2) 100% 1 0% 3 (2.5)
Lower GI 63.8% 47 (17) 50.0% 2 (3) 20% 5 (4) 0 60% 5 (2)
Lung 81% 43 (8) 100% 2.5 80% 2.5 (0.5) 67% 1.5 (0.5) 69% 7 (2)
Sarcoma 100% 1.0 (0) 100% 0.5 0
Skin 96.4% 180 (6.5) 85% 13 (2) 95% 19 (1) 88% 21.5 (2.5) 85% 13 (2)
Upper GI 78% 32.5 (7) 100% 3.5 67% 3.0 (1) 0% 1 (1)
Urology 88% 123.5 (14.5) 67% 12 (5) 95% 10.5 (0.5) 91% 5.5 (0.5) 74% 14 (3.5)
Other 100% 2 (0) 0
All 87.2% 555 (71) 82.8% 44 (12) 83.2% 47.5 (8) 84.3% 41.5 (6.5) 71.1% 48.5 (14)
Number of
Referrals
(Breaches)
15/16 YTD
Feb-16 %
Referrals &
(Breaches)
Mar-16 %
Referrals &
(Breaches)
Apr-16 %
Referrals &
(Breaches)
May-16 %
Referrals &
(Breaches)
22
Friends and Family Test Caring [1]
Overall Response
Rate
17.4% (21.8% May 15)
Additional Notes
From April 2015, the Friends and Family Test was extended
to include Outpatients, Daycases and children.
The Trust has engaged with provider Iwantgreatcare to
support the further rollout of the questionnaire to all areas and
to enable near real-time patient feedback to clinical teams.
May 16
73.0% 74.5% 72.6% 71.9% 74.5% 72.2% 77.4% 74.9% 74.0% 69.2% 67.8% 69.2% 70.6% 72.9% 72.0%
21.7% 21.0% 21.6% 23.1% 20.2% 21.5%17.2% 19.8% 21.2%
22.6% 23.9% 21.6% 20.3% 20.5% 21.3%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Sep
-13
Oct
-13
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
De
c-15
Jan
-16
Feb
-16
Ma
r-16
Ap
r-1
6
Ma
y-1
6
Friends and Family Test Inpatient / ED / Maternity Response to 'extremely
likely' and 'likely' to recommend YDH
% Extremely Likely % Likely
814 735 576 462 451 601 705 694 758 890 699 878414 631 656 774 575 890 841 950
34803239 3380
3119 28083202 2990 3190
4071
56455433 5432
53005311 5380
55775025
53904924
5447
0%
5%
10%
15%
20%
25%
0
1000
2000
3000
4000
5000
6000
7000
Oct
-14
No
v-1
4
De
c-14
Jan
-15
Feb
-15
Ma
r-15
Ap
r-1
5
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
De
c-15
Jan
-16
Feb
-16
Ma
r-16
Ap
r-1
6
Ma
y-1
6
Friends and Family Test % of Inpatient / ED / Maternity Responses
No of Respondants No of eligible Patients % of responses
Extremely Likely &
Likely to
Recommend
93.3% (95.0% May 15)
23
Patient Compliments and Complaints Caring [2]
Additional Notes
There were less complaints this May compared to last year
and more compliments.
There were less PALs contacts than the same month last
year.
0 2 4 6 8 10 12
Ward 8A
Emergency Department
Kingston Wing
Ward 6A
Ward 6B
Ward 9B
General YDH Compliments
Highest Departments - Compliments YTD
0
20
40
60
80
100
120
Number of Compliments & Complaints
Complaints Compliments
Compliments
57 (47 May 15)
May 16
Complaints
5 (7 May15)
PALS
102 (119 May 15)
24
Monitor Well Led
Target PeriodFY
15/16Feb-16 Mar-16 Apr-16 May-16
FY
16/17
RTT 18 week RTT Incomplete pathways - All Specialties 92% M 90.4% 92.1% 91.5% 90.7% 91.3% 90.4%
A&E A&E Clinical Quality: Total time of 4 hours in A&E 95% M 93.4% 91.2% 88.1% 92.1% 92.7% 91.4%
Cancer Max waiting time of 2 weeks from urgent suspect cancer GP referral to first outpatient appt 93% Q 93.3% 96.2% 95.7% 96.5% 96.0% 96.0%
Cancer Max waiting time of 2 weeks for symptomatic breast patients (cancer not initially suspected) 93% Q 92.9% 100.0% 97.1% 98.6% 97.4% 97.4%
Cancer Max waiting time of 31 days from diagnosis to first treatment for all cancers 96% Q 98.5% 97.3% 98.4% 98.4% 96.3% 96.3%
Cancer Max waiting time of 31 days for subsequent DRUG treatments for all cancers 98% Q 99.7% 100.0% 100.0% 100.0% 100.0% 100.0%
Cancer Max waiting time of 31 days for subsequent SURGICAL treatments for all cancers 94% Q 96.1% 77.8% 90.0% 85.7% 92.3% 92.3%
Cancer Max waiting time of 62 days from urgent GP referral to first treatment for all cancers 85% Q 87.1% 82.8% 83.2% 84.3% 77.2% 77.2%
Cancer Max waiting time of 62 days from consultant screening service referral for all cancers 90% Q 91.9% 100.0% 100.0% 100.0% 100.0% 100.0%
Safety C.Diff year on year reduction (lapses in care only) 8 pa Q 0 1 0 0 0 0
MONITOR SCORE
Indicators
Yeovil District Hospital NHS Foundation Trust
Senior Medical Staff
Appraisal and Revalidation 2015 – 2016
April 2016
Report to: Trust Board
Purpose of Report: To provide high level information on the Appraisal Process for Senior Medical staff from 1 April 2015 – 31 March 2016, and to provide the Board with assurance that statutory responsibilities are being met to ensure all non-training grade medical staff remain fit to practise Author: Meridith Kane, Responsible Officer Contact Details: [email protected] 01935-384374
1. PURPOSE The purpose of this report is to assure the Board that all non-training grade medical practitioners with a prescribed connection to Yeovil District Hospital NHS Foundation Trust have completed an appraisal according to Trust policy and to inform the Board of exceptions to this. The report is also presented to provide assurance that the statutory functions of the Responsible Officer (Appendix 1) are being appropriately fulfilled; to report on performance in relation to those functions; to highlight current and future risks; and to present action to mitigate potential risks. 2. BACKGROUND Medical revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system. The purpose of medical revalidation is to assure patients and the public that doctors are up to date and fit to practice. Each doctor must have a Responsible Officer who must oversee a range of processes including annual appraisal, and who will at five yearly intervals make a recommendation to the GMC in respect of the doctor’s revalidation. The Responsible Officer is appointed by the Board of the organisation, termed a Designated Body, to which the doctor is linked by a Prescribed Connection. This link is created when a contract of employment, substantive, locum or honorary, is agreed between the doctor and the Designated Body. Designated Bodies have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations and it is expected that provider Boards will oversee compliance by;
• Monitoring the frequency and quality of medical appraisals in their organisations. • Checking that there are effective systems in place for monitoring the conduct and
performance of their doctors. • Confirming that feedback from patients is sought periodically so that their views can inform
the appraisal and revalidation process for their doctors and • Ensuring that appropriate pre-employment background checks (including pre-engagement
for locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.
It should be noted that compliance with these regulations also forms part of the Care Quality Commission’s surveillance model. We are now into the fourth year of the Medical Revalidation process. Revalidation is dependent on practitioners having an annual appraisal and collecting a portfolio of supporting information to evidence that they are up to date with clinical practice and work in partnership with the multidisciplinary team and patients.
3. GOVERNANCE The current Responsible Officer (Dr Meridith Kane, Associate Medical Director) was appointed by the Board on 1st November 2015 in line with statutory requirements. The Responsible Officer and Medical Director (Dr Tim Scull) have both completed accredited Responsible Officer Training. Progress and compliance with regulations are monitored in a variety of ways. Internally the Medical Revalidation Group (MRG) oversees revalidation and appraisal processes. The Medical Director, Responsible Officer, Associate Medical Directors, HR representative and Clinical Governance Representative attend monthly Medical Revalidation Group meetings to discuss local issues pertaining to appraisal and revalidation, and any specific cases of concern. Data on medical appraisals are also submitted to the Trust Management Executive (TME) and to the Trust Board via the key performance indicators (KPIs). Externally, the Trust is subject to the oversight of the NHS England Revalidation Team, and completes an Annual Organisational Audit (Appendix 2) to provide assurance to that body. Additionally, the Trust will be the subject of an NHS England Independent Verification Visit which will assess performance against the national Framework of Quality Assurance for Responsible Officers and Revalidation. This will take place in May 2016. A mandatory requirement, to be included as supporting information for every annual Trust appraisal, is an annual report of serious untoward incidents/complaints raised against an individual. This report is produced for each doctor by the Clinical Governance Department annually in preparation for their annual appraisal meeting. Interim progress on appraisal compliance is monitored by quarterly returns of appraisal figures and revalidation recommendations to NHSE. The Responsible Officer and the Medical Director meet quarterly with the local GMC Employment Liaison Adviser (ELA) to discuss issues pertaining to national and local appraisal and revalidation, including changes to associated regulations and responsibilities, and to review any current GMC proceedings involving doctors with a prescribed connection to the Designated Body (YDH NHS FT). 4. HUMAN RESOURCES The Responsible Officer is supported by the Human Resources Team to maintain an up to date database of the appraisal status of all doctors with whom the organisation has a prescribed connection, to administer the e-portfolio / electronic appraisal system (PReP) and the multisource feedback system (Edgcumbe), and to ensure currency of the GMC Connect list of doctors with whom YDH NHS FT has a prescribed connection. The Responsible Officer meets monthly with the HR Team to review this data. The Human Resources Team administer the processes of pre- and post-employment information collection and sharing between Responsible Officers / Designated Bodies.
Members of the HR Team provide ad hoc advice to support the appraisal and revalidation process to all doctors with a prescribed connection, accessed via [email protected] 5. POLICY GUIDANCE The following policies are in place to support staff: Human Resources Policy Handbook (YDH icloud): Appraisal and Revalidation Policy for Senior Medical Staff (2015) (pg 194) Job Planning (pg 162) Maintaining High Professional Standards (pg 172) Raising Concerns (pg 106) Prevention and Management of Work Related Stress (pg 100) Disciplinary Policy (pg 35) Capability Policy (pg 36)
6. APPRAISERS The Trust has 33 ‘revalidation ready’ trained Appraisers, ensuring that all doctors are able to have either an in-specialty or out-of-specialty appraisal, avoiding reciprocal appraisals within an appraisal year and also ensuring that no more than two consecutive appraisals are undertaken with the same appraiser. Where this is necessary, or required, then a second appraiser must also be present at the appraisal meeting. Appraisal meetings should be undertaken within an appraiser and appraisee’s SPA time. Appraisers should receive 0.25 SPA within their job plans (from total SPA allocation) to undertake the role. Appraisers are supported by CPD meetings held three times a year, led by the Responsible Officer. There is an expectation that all appraisers will try to attend these meetings when clinical commitments allow. Edgcumbe ran a workshop on 8 March 2016 for appraisers and senior clinicians / managers on ‘Tackling Disruption and Dysfunction in Clinical Teams’. The Responsible Officer attends the NHS England South Trust Appraisal Leads forum meetings. An electronic appraiser summary of appraisal activity and appraise feedback is generated from the electronic PReP system and provided to appraisers annually, for reflection and inclusion as supporting information for their own annual appraisal and PDP development. 7. QUALITY ASSURANCE The appraisal process is subject to quality assurance processes to ensure a robust recommendation for Revalidation can be made.
The Responsible Officer and dedicated HR support team have access to the electronic portfolio and appraisal system inputs for all senior medical staff. A monthly review of completed appraisals allows the RO to check of the Output Forms, PDP’s and relevant supporting information to ensure that they are of sufficient quality for revalidation purposes. Any inadequate / incomplete datasets are fed back to appraise and appraiser, so that remedial action can be taken, and in order to ensure appraisal outputs are of consistently high quality. From January 2016, specific quality assurance tools will be applied to randomly selected Appraisal Output Forms and Personal Development Plans to ensure consistent high quality. Feedback will be provided to individual appraisers and the audit results will be included in the annual report to the Board. 8. MEDICAL APPRAISAL A completed appraisal is one where the appraisal meeting took place within the Appraisal Year (1 April – 31 March (inc)) with the Appraisal Output Form and PDP agreed and signed off by both appraiser and appraise within 28 days of the appraisal meeting. Number of Doctors with a Prescribed Connection with Yeovil District Hospital NHS Foundation Trust at 31 March 2016 = 176
At 31 March 2016 (cumulative data): Grade Number Completed
Appraisals % Overdue (12-
15 months) Agreed Deferral of Appraisal
Not eligible for appraisal within appraisal year
Consultant 88 79 6 2 3 SAS / Specialty 80 68 3 1 9 Locum 8 1 0 0 7 Total 176 148 9 3 19
Total Number of Doctors with Prescribed Connection at 31 March 2016 = 176 Total Number of Doctors with Prescribed Connection eligible for appraisal 1/4/15 – 31/3/16 = 157 Total Number of Doctors with completed appraisals in period 1/4/15 – 31/3/16 = 148 (94%)
9. AUDIT OF MISSED / INCOMPLETE APPRAISALS In the period 1 April 2015 – 31 March 2016 no appraisals were missed or incomplete due to organisational or appraiser factors 19 appraisals will be missed in the period 1 April 2015 to 31 March 2016 due to the doctor having been in post for < 12 months , the majority new to the NHS (overseas appointments) and / or junior doctor fixed term temporary / locum appointments with no provious experience of the appraisal system. 9 further appraisals were not completed by the due date within the appraisal year. In all cases the doctor concerned was contacted by the Responsible officer and HR support team to ascertain the reason for the failure to undertake a timely appraisal. All doctors were reminded of their responsibility to undertake annual appraisal and required to do so by 31 March 2016. Of these: 6 doctors failed to complete an appraisal within the appraisal year, but have now boked an appraisal meeting with a trained appraiser to take place within 3 months of their appraisal due date. 3 doctors failed to engage in the appraisal process in a timely fashion within the appraisal year, though all are less than 15 months post their planned appraisal date and have been written to by the Responsible Officer requiring a written explanation of their missed appraisal and notification of plans to arrange an appraisal meeting. Responses will be reviewed and actions monitored. There were 3 agreed deferrals of appraisal: 1 appraisal was missed due to unexpected sickness absence (1 SAS doctor) – deferral agreed
1 appraisals were missed due to maternity leave (1 SAS doctor) – deferral agreed 1 appraisal was deferred due to a period of unscheduled compassionate leave. 10. COMPARATIVE DATA (derived from AOA 2014/15 and 2015/16 submission)
11. ACCESS, SECURITY AND CONFIDENTIALITY The electronic portfolio is only accessible to the HR administrative team, Responsible Officer, Medical Director and Associate Medical Directors. Appraisers have access to the portfolios of the individual doctors they are appraising. Senior staff must not include patient identifiable details in their portfolio. All appraisers are aware of the need for confidentiality, but are also aware of when this confidentiality must be broken for the sake of patient safety. There have been no information management breaches. 12. SUPPORTING INFORMATION The Revalidation process requires that appraisal is supported by evidence from six categories of information flows. These are:
• Quality improvement activity • Significant events • Patient feedback • Colleague feedback • Continuous professional development (CPD) • Complaints & compliments
The Trust has a well - established process of multisource feedback (MSF) which is managed by an external agency (Edgcumbe) and fulfils the requirements of the GMC standards. MSF must be undertaken once in a five year Revalidation cycle. Continuous professional development is essential to ensure that practitioners stay up to date and are abreast of advances in current practice. Requirements vary between specialties and individual Royal College requirements. Continuing Professional Development comprises internal CPD (e.g. departmental teaching sessions, team case discussions etc.) and external CPD (e.g. external courses, conferences or clinical peer review). For the purpose of revalidation, an individual must demonstrate that they have undertaken adequate CPD to support their ongoing needs and those of their patients and the organisation.
13. REVALIDATION RECOMMENDATIONS Number of Recommendations 1 April 14 – 31 March 2015 1 April 15 – March 31 2016 Positive Recommendations 47 48 Deferral Requests 14 13 Deferrals subsequently revalidated
13 4
Non-engagement Notifications 0 0 Late Recommendations 0 0 Reasons for missed / late recommendations
n/a n/a
TOTAL 61 61 Recommendations are based on the completion of an annual appraisal with evidence of steady progress on the accumulation of supporting information and the absence of any significant performance concerns. The Responsible Officer has oversight of all the portfolios and makes revalidation recommendations to the GMC via the GMC Connect electronic website. Advice from the GMC Employment Liaison Advisor (ELA) may be requested where a decision is unclear. Deferrals were requested because of insufficient evidence upon which to base a decision. Practitioners were advised of the reasons for this request and, where appropriate, support was put in place to enable them to develop their portfolio. 14. DEFERRALS Total Number of Individual Doctors Multiple
Deferrals Consultants SAS Trust
Appointments Locum
2014-15 4 8 1 0 1 (SAS) 2015-16 5 5 2 0 1 (SAS) Multiple deferrals were made on 2 individuals in the period April 2014 – Jan 2016. In each case the deferrals were made for a minimum period of 3 months, which retrospectively was inadequate to allow any remedial action to be undertaken, necessitating a further deferral. This is a pattern that has been seen regionally and is a reflection of the process being relatively new to Responsible Officers. It is anticipated that any future deferrals will, save in specific and exceptional circumstances, be for a minimum of 6 – 12 months.
15. RECRUITMENT Trust Human Resources policies mandate that all necessary pre and post recruitment checks are completed in full and any required action is undertaken, including delaying start dates or withdrawing offers of employment, where the responses to these checks are not satisfactory. This applies to both permanent staff, fixed term and those appointed on a locum basis. For those doctors appointed through a locum agency, the agency is their Designated Body and is responsible for the majority of these checks, but assurance is sought that there are no issues prior to completion of the booking. For all doctors with whom YDH NHS FT has a prescribed connection, the following additional information is required:
• Name of previous Responsible Officer • Dates and Outcome Data for last 5 appraisals (if available) • Dates and Outcome of any multi-source feedback exercises undertaken in the preceding
5 years • Details of any performance issues in previous employment
16. MONITORING PERFORMANCE, RESPONDING TO CONCERNS AND REMEDIATION Performance issues are identified through the clinical governance processes embedded within the Trust. There is a robust system of incident reporting, and complaints and litigation management. The Trust fosters an open and honest approach, as detailed in the Raising Concerns HR policy. The organisation is committed to maintaining the safety of its patients and staff by swift and effective action when a performance concern is raised. If performance concerns are raised, progress is monitored by the Medical Revalidation Group, Medical Director, Associate Medical Directors and Responsible Officer, acting in conjunction with the relevant Clinical Director, and supported by the Human Resources team. The Medical Director, Responsible Officer and AMD’s meet weekly and the MRG meets monthly. To ensure the effective resolution of concerns, the Responsible Officer and Medical Director also work closely with external agencies (NCAS, GMC, other Designated Bodies) and with educational leads (Director of Medical Education, Postgraduate Dean) if trainees are involved. In each of 2014-15 and 2015-2016 one consultant became the subject of a GMC investigation, the outcomes of which both remain outstanding at 31 Jan 2016. The revalidation date of one of the consultant’s under investigation is ‘on hold’ pending an outcome decision. An SAS doctor was also investigated by the GMC in 2014-2015, and the case is now closed without undertakings or conditions imposed.
2 other cases involving doctors who no longer have a prescribed connection with YDH NHS FT continue to have GMC involvement, with regular updates provided by the GMC ELA. The Responsible Officer has undertaken RST / NCAS approved Case Investigation training, and the Medical Director has undertaken RST/NCAS approved Case Manager training. In 2015, YDH NHS FT hosted NCAS to deliver further Case Investigator Training to 20 senior medical, business manager and Human Resources staff. 17. RISKS AND ISSUES The role of the Responsible Officer is not insubstantial, and is associated with significant statutory responsibilities in law. At present the Responsible Officer for YDH NHS FT undertakes this role, and that of Trust Appraisal Lead, in an unremunerated capacity, not specified within their job plan. Organisations are responsible for providing resources to support RO’s in their role (Appendices 1 and 3); the vast majority of Designated Bodies have dedicated admin / HR support for appraisal and revalidation processes, and a Deputy Responsible Officer / Trust Appraisal Lead appointed to support the RO in discharging their duties.. 18. DESIGNATED BODY STATEMENT OF COMPLIANCE (2015) A statement of compliance with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2014) was submitted to NHS England by the Board of Yeovil District Hospital NHS Foundation Trust in October 2015 and February 2016 (Appendix 4). 19. IMPROVEMENT PLAN 2016 Objective Monitoring Actions Resources Responsibility Time
Frame Maintain the quality of medical appraisals
Quality Assure all appraisal output forms and PDP’s
• Apply QA tool to all appraisal output forms prospectively
• Audit results • Feedback to individual
appraisers • Support Appraiser CPD
Sufficient dedicated HR/Admin support time
RJ / LK/MK From April 2016
Adequate Resource to support Responsible Officer to discharge statutory duties
Successful process
• Recommendation to the Board
• Recruit Trust Appraisal Lead
• Increase dedicated HR / admin support time
Funding MK From April 2016
Ensure adequacy of pre and post employment checks and information
Audit results • Audit of HR process Sufficient dedicated HR / admin support time
RJ/LK April 2016 – March 2017
exchange Maintain appropriate number of quality assured trained appraisers in clinical areas
MRG Review • QA appraisal outputs & feedback to appraisers
• Support Appraiser CPD • Appraisers to do 3-8
appraisers annually • Appraiser status to be
recognised in job plans • Train appraisers
• Funding • Training course
availability • Recruitment
MRG From April 2016
20. INDEPENDENT VERIFICATION VISIT Yeovil District Hospital NHS Foundation Trust will be subject to an Independent Verification Visit, led by NHS England on 15 June 2016. 21. RECOMMENDATIONS
1. The Board is asked to accept this report (noting that it will be shared with the Higher Level Responsible Officer).
2. It is recommended to the Board that additional dedicated support for the Responsible Officer to discharge the statutory duties pertaining to appraisal and revalidation at Yeovil District Hospital is resourced as a priority. In particular, it is recommended that resource (1PA consultant time) be provided to facilitate the appointment of a Trust Appraisal Lead to support the Responsible Officer and additional resource be made available to allow adequate HR support be provided, as per estimated time requirements already submitted, to the administration and quality assurance of the appraisal and revalidation systems and processes. Consideration should also be given to remuneration for the Responsible Officer role.
APPENDICES Appendix 1: The Medical Profession (Responsible Officers) Regulations 2010 Appendix 2: Medical Revalidation Annual Organisational Audit Comparator Report 2014/15 Appendix 3: Effective governance to support medical revalidation: A handbook for boards and governing bodies Appendix 4: Designated Body Statement of Compliance 2015 Appendix 5: Annual Organisational Audit 2016
OFFICIAL
A Framework of Quality Assurance for Responsible Officers and Revalidation Annex E - Statement of Compliance
OFFICIAL
2
Statement of Compliance Version number: 2.0 First published: 4 April 2014 Updated: 22 June 2015 Prepared by: Gary Cooper, Project Manager for Quality Assurance, NHS England Classification: OFFICIAL Publications Gateway Reference: 03432
NB: The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes.
OFFICIAL
3
Designated Body Statement of Compliance
The board of Yeovil District Hospital NHS Foundation Trust can confirm that • an AOA has been submitted, • the organisation is compliant with The Medical Profession (Responsible
Officers) Regulations 2010 (as amended in 2013) • and can confirm that:
1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer;
YES – Dr Meridith Kane
2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained;
YES
3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners;
YES
4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers1 or equivalent);
YES
5. All licensed medical practitioners2 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken;
YES
6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners1 (which includes, but is not limited to, monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues) and ensuring that information about these matters is provided for doctors to include at their appraisal;
YES
7. There is a process established for responding to concerns about any licensed medical practitioners1 fitness to practise;
YES
8. There is a process for obtaining and sharing information of note about any licensed medical practitioner’s fitness to practise between this organisation’s
1 http://www.england.nhs.uk/revalidation/ro/app-syst/ 2 Doctors with a prescribed connection to the designated body on the date of reporting.
OFFICIAL
4
responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where the licensed medical practitioner works;3
YES
9. The appropriate pre-employment background checks (including pre-engagement for locums) are carried out to ensure that all licenced medical practitioners4 have qualifications and experience appropriate to the work performed;
YES
10. A development plan is in place that ensures continual improvement and addresses any identified weaknesses or gaps in compliance.
YES
Signed on behalf of the designated body [(Chief executive or chairman (or executive if no board exists)]
Official name of designated body: YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST Name: _ _ _ _ _ _ _ _ _ _ _ Signed: _ _ _ _ _ _ _ _ _ _ Role: _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ _ _ _
3 The Medical Profession (Responsible Officers) Regulations 2011, regulation 11: http://www.legislation.gov.uk/ukdsi/2010/9780111500286/contents
mg/lth June 2016
Board of Directors Meeting June 2016
Director of Nursing Report
Monthly Report of Nurse/Midwifery Staffing Levels
1 May 2016 - 31 May 2016 EXECUTIVE SUMMARY The NHS National Quality Board published a new guidance in November 2013 to support providers and commissioners to make the right decisions about nursing, midwifery and care staffing capacity and capability “How to ensure the right people with the right skills are in the right place at the right time”: A Guide to Nursing, Midwifery and Care Staff Capacity and Capability. There are nine key expectations that apply to the Trust: 1. Boards take full responsibility for the quality of care provided. 2. Processes are to be in place to enable staffing establishments to be met on a shift by
shift basis. 3. Evidence based tools to be used. 4. Clinical and managerial leaders foster a culture of professionalism and responsiveness
where staff feel able to raise concerns. 5. Multi-professional approach is taken when setting staffing establishments. 6. Sufficient time to undertake care and duties in practice. 7. Boards receive monthly updates on workforce information and staffing capacity and
capability and is discussed at public Board meetings every six months. 8. Clearly display information about the nursing and care staff present on each ward,
clinical setting or service on each shift. 9. Provider to take an active role in securing staff in line with their workforce requirements. PURPOSE The purpose of this report is to provide the Board of Directors with monthly information regarding the nursing and midwifery registered and unregistered staffing levels on a shift by shift basis of the planned and actual nurse staffing levels across the organisation and across inpatient areas of the Trust as per the guidance received from NHS England and the Care Quality Commission. METHODOLOGY AND SCOPE FOR REVIEW This report focusses on all adult inpatient areas including Critical Care, inpatient maternity wards and inpatient paediatric wards. With the Trust working towards the 1:8 ratio as recommended in the National Safe Staffing Alliance for relevant adult wards. For the purpose of this report non inpatient areas such as the operating theatres, day theatre, endoscopy and emergency department are currently excluded. KEY POINTS National Unify Return Recruitment Current vacancy position - Registered Nurses Bank Recruitment Bank and Agency usage
mg/lth June 2016
Unfilled Shifts Monitor nursing agency rules Unify Return (now including care hours per day data)
Day Night Day Night Care Hours Per Patient Day (CHPPD)
War
d na
me
Registered midwives/nurses Care Staff Registered
midwives/nurses Care Staff
Ave
rage
fill
rate
- re
gist
ered
nu
rses
/mid
wiv
es (
%)
Ave
rage
fill
rate
- ca
re s
taff
(%)
Ave
rage
fill
rate
- re
gist
ered
nu
rses
/mid
wiv
es (
%)
Ave
rage
fill
rate
- ca
re s
taff
(%)
Cum
ulat
ive
coun
t ove
r the
mon
th
of p
atie
nts
at 2
3:59
eac
h da
y
Reg
iste
red
mid
wiv
es/ n
urse
s
Car
e St
aff
Ove
rall
Tota
l mon
thly
pl
anne
d st
aff h
ours
Tota
l mon
thly
ac
tual
sta
ff ho
urs
Tota
l mon
thly
pl
anne
d st
aff h
ours
Tota
l mon
thly
ac
tual
sta
ff ho
urs
Tota
l mon
thly
pl
anne
d st
aff h
ours
Tota
l mon
thly
ac
tual
sta
ff ho
urs
Tota
l mon
thly
pl
anne
d st
aff h
ours
Tota
l mon
thly
ac
tual
sta
ff ho
urs
Jas 1052 1057.5 701 730.5 713 713 713 713 100.5% 104.2% 100.0% 100.0% 643 2.8 2.2 5.0
KW 713 713 669.5 663 713 713 365.5 365.5 100.0% 99.0% 100.0% 100.0% 325 4.4 3.2 7.6
6A 1057 1131 1374.5 1453.5 713 713 589 566 107.0% 105.7% 100.0% 96.1% 590 3.1 3.4 6.5
6B 1046.5 1058.5 1496 1520 713 724.5 713 724.5 101.1% 101.6% 101.6% 101.6% 1071 1.7 2.1 3.8
7A 1287.5 1293 991 991 713 713 713 713 100.4% 100.0% 100.0% 100.0% 893 2.2 1.9 4.2
7B 1420.5 1427 1600 1623 1069.5 1081 713 713 100.5% 101.4% 101.1% 100.0% 1113 2.3 2.1 4.4
EAU 1426 1439 1057.5 1052 1069.5 1069.5 713 713 100.9% 99.5% 100.0% 100.0% 626 4.0 2.8 6.8
8A 1041 1041 1295.5 1311 713 713 713 713 100.0% 101.2% 100.0% 100.0% 908 1.9 2.2 4.2
8B 1283.5 1294.5 1283.5 1296.5 713 713 713 713 100.9% 101.0% 100.0% 100.0% 743 2.7 2.7 5.4
9A 1409.5 1416 899 915.5 713 713 713 724.5 100.5% 101.8% 100.0% 101.6% 913 2.3 1.8 4.1
9B 1057.5 1069.5 1187 1211 701.5 713 713 713 101.1% 102.0% 101.6% 100.0% 934 1.9 2.1 4.0
10 1045.5 1045.5 332.5 327 1012 1012 0 34.5 100.0% 98.3% 100.0% - 272 7.6 1.3 8.9
ICU 2042.5 2042.5 143.5 143.5 2104.5 2104.5 0 0 100.0% 100.0% 100.0% - 253 16.4 0.6 17.0
CCU 1395 1407 0 0 883.5 883.5 0 0 100.9% - 100.0% - 208 11.0 0.0 11.0
Freya 2671.5 2559 868 755.5 1953 1879.5 325.5 252 95.8% 87.0% 96.2% 77.4% 295 15.0 3.4 18.5
SCBU 930 930 465 452 465 465 294.5 294.5 100.0% 97.2% 100.0% 100.0% 114 12.2 6.5 18.8
Recruitment The ongoing recruitment drive continues to try and maintain our current vacancy position. Clinical areas with significant vacancies are Theatres, ICU and ED. India There are currently three nurses who have now passed their IELTS and are now studying for their CBT. Philippines We continue to Skype interview those that have passed their IELTS and offer positions if successful at interview. They are then required to pass their CBT. Non EU UK Recruitment There is a cohort of eight nurses planned to start June 2016. These individuals will require IELTS, CBT and OSCE. Prior to achieving their IELTS and CBT they will be employed as Band 2s and receive English tuition through the Academy.
mg/lth June 2016
Recruitment We continue to review CVs from EU applicants although this has now reduced considerably with the introduction of IELTS. The fortnightly rolling interviews continue and these candidates are added to the schedule. The following table indicates our current recruitment position with regards to registered nurses and going forward as of 1 June 2016; (‘-’ indicates the vacancy factor). Band 5 Registered Nurse Vacancies - 1 June 2016
Ward Vacancy July 2016 Anticipated
Starters
Ward 10 -0.49 Ward 9B -0.5 Ward 9A -0.32 Ward 8B -1.76 2 ACCU -1.95 Ward 8A -0.9 1 EAU -0.98 Ward 7A 0.21 1 MFFD -1.5 2 Trauma and Orthopaedics 1.6 ICU -5.62 5 (3 internal) Kingston Wing -1.76 1 Elective -2.57 2 Jasmine -3.21 2 ED -8.38 3 (1 internal) Main Theatre -6.6 Day Theatre -4.72 SCBU -0.3 TOTAL 42.95 19 Bank Recruitment A cohort of unregistered nurses commences June 2016 with a second cohort planned for September 2016. There is a rolling advertisement for registered nurses with suitable applicants being added to the fortnightly rolling interviews.
mg/lth June 2016
Bank and Agency Usage The following table indicates the number of bank / agency used during May 2016:
Ward 6A
6B
7A
7B
8A
8B
9A
9B
10
AC
CU
EAU
ED
ICU
JASM
INE
KW
MA
TER
NIT
Y
SCB
U
TOTA
L
Registered Bank
6 12 10 22 16 24 11 4 9 1 12 60 5 32 5 34 14 277
Unregistered Bank
12 23 29 41 17 19 11 17 11 0 13 11 0 40 13 3 7 267
Total Bank
18 35 39 63 33 43 22 21 20 1 25 71 5 72 18 37 21 544
Registered Agency
11 29 6 29 11 31 20 11 15 8 29 80 43 21 22 0 0 366
Unregistered Agency
6 32 20 22 19 27 12 22 2 0 20 6 0 5 13 0 0 206
Total Agency
17 61 26 51 30 58 32 33 17 8 0 86 43 26 35 0 0 523
TOTAL Bank & Agency
35 96 65 114 63 101 54 54 37 9 25 157 48 98 53 37 21 1067
The following table indicates the changes in booking from April - May 2016:
April May Increase Decrease Registered Bank 214 277 63 Unregistered Bank 189 267 78 Registered Agency 515 366 149 Unregistered Agency 397 206 191 TOTAL 1315 1116 141 340 Escalation areas continue to be required and therefore staffed during May 2016 however there has been an increase in bank usage and reduction in agency. Unfilled Shifts
10
9A
9B
8A
8B
7A
7B
EAU
6A
6B
ED
CC
U
ICU
KW
JW
Mat
erni
ty
SCB
U
Tota
l
Using
Professional Judgement
Registered 11 4 2 5 3
2
3 3 6 114 3
156
Unregistered 6
1
3
2
2
12
3
5 1
35
Nurses Not Available
Registered 1
1
1
1
1
5
Unregistered 1
1
1
1
4
TOTAL 19 5 2 6 7 4 3 16 3 9 116 6 4 200 RECOMMENDATIONS The Board of Directors is asked to note the information contained in this summary report and the actions currently in place.
Yeovil District Hospital NHSFoundation Trust
Date
01 May - 31 May
Your average score for all questions this period
1 2 3 4 5 4.71Reviews this period
1429Your recommend scores
5 Star Score
4.67% Likely to recommend
93.2%% Unlikely to recommend
2.0%This period Last 6 months Questions
Nam
e
Resp
onse
s
Scor
e
Scor
e
Tren
d
Reco
mm
end
Dig
nity
/Res
pect
Invo
lvem
ent
Info
rmat
ion
Clea
nlin
ess
Staf
f
ACCU1 78.6%(22) 4.89 4.82
Ambulatory Emergency CareFollow up Clinic1 -- (47) 4.94 4.87
Antenatal Clinic1 -- (0) - -
Antenatal Outpatients1 -- (0) - -
Cardiac Rehab1 -- (40) 4.88 4.88
Clinical InvestigationsDepartment (CID)1
--(226) 4.71 4.70
Day Surgery Unit (DSU)1 -- (18) 4.92 4.95
Dermatology1 -- (20) 4.88 4.88
Discharge Lounge1 -- (13) 4.37 4.60
EPAC - Early PregnancyAssessment Clinic1 -- (0) - 4.86
Emergency Admissions Unit1 23.3%(30) 4.79 4.70
Emergency Department1 -- (54) 4.63 4.54
Emergency Department -Children1 -- (88) 4.69 4.73
Endoscopy Unit1 -- (23) 4.93 4.96
FOPAS (Frail Older PersonsAssessment Service)1 -- (66) 4.78 4.84
Freya Ward (Postnatal)1 58.2%(53) 4.72 4.71
Gastroenterology1 -- (7) 4.85 4.78
This period Last 6 months QuestionsN
ame
Resp
onse
s
Scor
e
Scor
e
Tren
d
Reco
mm
end
Dig
nity
/Res
pect
Invo
lvem
ent
Info
rmat
ion
Clea
nlin
ess
Staf
f
Gynaecology Assessment Unit(GAU)1 -- (0) - 4.83
ICU (Intensive Care Unit)1 100.0% (11) 4.83 4.79
Jasmine Gynae Ward1 13.4%(16) 4.48 4.56
Kingston Wing1 89.4%(59) 4.71 4.77
Labour Ward (Birthing)1 -- (0) - 4.90
MacMillan Unit - Outpatients1 -- (8) 5.00 4.91
Ophthalmology1 -- (0) - -
Orthopaedic OutpatientsDepartment1 -- (36) 4.76 4.85
Paediatric Outpatients1 -- (0) - -
Physiotherapy1 -- (68) 4.87 4.84
Queensway Day Hospital1 -- (19) 4.76 4.80
Queensway Day Hospital -Other Services1 -- (22) 4.98 4.92
Stoma Care Clinic1 -- (6) 4.81 4.77
Urology1 -- (8) 4.90 4.89
Ward 10 (Children & YoungPerson's Unit)1
39.8%(49) 4.78 4.73
Ward 10 (Young Adults)1 100.0% (24) 4.72 4.44
Ward 6A 1 46.3%(95) 4.67 4.71
Ward 6B 1 94.7%(89) 4.55 4.46
Ward 7A1 34.2%(39) 4.53 4.53
Ward 7B 1 45.5%(30) 4.65 4.61
Ward 8A1 44.6%(33) 4.43 4.45
Ward 8B 1 33.3%(20) 4.59 4.67
Ward 9A1 98.1%(52) 4.46 4.51
Ward 9B1 52.5%(32) 4.40 4.47
YDH Sleep Clinic at SouthPetherton1 -- (6) 4.44 4.87
Yeatman Hospital - DaySurgery Unit3 -- (0) - 4.88
Reviews by patient's age
0-20 21-30 31-40 41-50 51-60 61-70 71-80 81+
160 114 104 102 135 242 263 273
FemaleMale
Reviews by patient's ethnicity
White Mixed Asian Black Other
1283 8 8 0 5
Reviews by patient's conditionsD
eaf
Blin
d
Phys
ical
Men
tal
Illne
ss
Lear
ning
Non
e
142 56 221 67 419 30 577
Reviews by reviewer type
Patient Carer Parent Family
1109 42 0 191
Demographics completion rate
Question Blanks % Completed
Age 45 96.87
Gender 55 96.18
Ethnicity 123 91.38
Long-term Conditions 252 82.34
Reviewer type 46 96.69
Top three services (with 5 reviews ormore)
MacMillan Unit - Outpatients 5.00
Queensway Day Hospital - OtherServices
4.98
Ambulatory Emergency Care Follow upClinic
4.94
Bottom three services (with 5 reviewsor more)
Ward 8A 4.43
Ward 9B 4.40
Discharge Lounge 4.37
Key Location
1 Yeovil District Hospital
2 Community Services - Yeovil District Hospital NHS FoundationTrust
3 Yeatman Hospital
1
YDH │Workforce Performance Report Well Led - Staffing May 2016
2
Well Led [1]
Additional Notes
Total FTE has increased by 237 FTE compared to May 2015.
Action plan to reduce temporary workforce costs beginning to
have an effect.
Increase in contracted people due to escalation areas, safer
staffing, modular ward, Cooksons Court, Symphony, TUPE of
IT, TrakCare, commercial team, HR, and appointment of
additional SHOs to support medical rotas.
Total FTE
2,168 (May 15 – 1,931)
May 16
Contracted & Temporary FTE
Contracted includes permanent and fixed term employees
Temporary includes bank, agency and contractors
3
Well Led [2]
Additional Notes
Contracted FTE has increased by 215 FTE compared to May
2015.
A review of the non-clinical workforce is taking place to ensure
our establishment is at the correct level.
Contracted FTE
1,968
(May 15 – 1,753)
May 16
Contracted FTE
Contracted includes permanent and fixed term employees
4
Well Led [3]
Additional Notes
Temporary FTE has increased by 22 FTE compared to May
2015.
Significant effort are being made to reduce our use of a
temporary workforce. Plan approved by NHS Improvement.
Total FTE
200
(May 15 – 178)
May 2016
Temporary FTE
Temporary includes bank, agency and contractors
5
Well Led [4]
Workforce Comparison
Skills GroupsContracted
FTE
Temporary
FTETotal FTE
Temporary
%
Contracted
FTE
Temporary
FTETotal FTE
Temporary
%
Total FTE
Difference
Trakcare 6 8 14 55% 11 14 25 55% 11
Symphony 5 2 7 30% 28 2 30 6% 23
Additional Clinical Services 42 5 46 10% 54 1 56 2% 9
Additional Prof Scientific & Technical 46 2 48 4% 47 2 48 3% 1
Admin & Clerical 373 21 394 5% 413 9 422 2% 28
Allied Health Professionals 90 1 91 2% 95 10 105 10% 14
Ancillary 155 24 179 14% 165 35 200 18% 21
Estates 21 - 21 0% 23 6 29 20% 8
HCA's 236 57 293 20% 247 30 277 11% 16-
Medical & Dental 209 13 221 6% 235 24 259 9% 38
Nursing & Midwifery Reg 497 44 542 8% 558 66 624 11% 82
Senior Managers 75 1 76 1% 93 1 94 1% 19
Total 1,753 178 1,931 9% 1,968 200 2,168 9% 237
May-16May-15
6
Additional Notes
Figures based on previous 12 months.
Excludes bank people and doctors in training.
A review of HCA leavers is currently taking place to better
understand reasons. All HCAs are asked for their reasons for
leaving and offered a ‘stay interview’.
Well Led [5]
15.9% (May 15 – 15.2%)
May 16
Labour Turnover
7
Well Led [6]
Additional Notes
Figures based on the previous 12 months.
New exit interview process is giving us better data as to
why our people are leaving.
May 2016 Leavers
Number of Leavers
29
(May 15 – 25)
0 20 40 60 80 100
Other/Not Known
Relocation
Work Life Balance
To undertake further…
Promotion
Lack of Opportunities
Health
Incompatible Working…
Child Dependants
Better Reward Package
Adult Dependants
Rolling Year Leavers - Resignations
0 50 100 150 200 250
Resignation
End of Fixed…
Retirement
Redundancy
Dismissal
Death in service
Transfer
Pregnancy
Rolling Year Leavers by Reason
8
Well Led [7]
Vacancies being recruited to
May 2016
Additional Notes
Medical & Dental includes consultants in Anaesthetics, Elderly Care, Breast Radiology, Paediatrics, Oncology,
Ophthalmology and speciality doctors in Anaesthetics, Respiratory, Obs & Gynae and Ophthalmology.
Trakcare 11 0 0%
Symphony 28 15 56%
Additional Clinical Services 54 1 1%
Additional Prof Sci & Tech 47 2 4%
Admin & Clerical 413 9 2%
Allied Health Professionals 95 3 3%
Ancillary 165 0 0%
Estates 23 1 4%
Medical & Dental 235 15 6%
Nursing & Midwifery Reg 558 52 9%
HCA's 93 2 2%
Senior Managers 247 0 0%
Total 1968 85 4%
Vacancies FTESkills Group Contracted FTE %
Contracted includes permanent and fixed term employees
9
Well Led [8]
Employee Relations
Registered Nurse Pins Awaited
Additional Notes
The outstanding Pins are due to the NMC’s backlog.
The NMC advise that they aim to assess applications
between 40 and 70 working days.
Performance Dismissal 4 12 7
Sickness Dismissal 10 5 3
Protected discusssion leading to termination 10 6 0
Redundancy 12 2 0
MARS 19 1 0
Total 55 26 10
Grievances 8 1 1
2014-15 2016-17 YTDDismissals and Grievances 2015 -16
Nov-15 2 13%
Jan-16 2 22%
Mar-16 3 43%
May-16 4 50%
%Month Joined Pins Outstanding
10
Well Led [9]
Additional Notes
Sickness is reported one month in arrears.
HR are focusing on ward sickness, nursing and HCA.
HR attending the sisters meeting to discuss sickness and
improved use of E-Rostering data to manage this.
Percentage
3.3% (Apr 15 – 2.4%)
April 16
Sickness
0% 1% 2% 3% 4% 5% 6% 7% 8%
Senior Managers
Nursing & Midwifery Reg
Medical & Dental
HCA's
Estates
Ancillary
Allied Health Professionals
Admin & Clerical
Additional Prof Scientific &…
Additional Clinical Services
Sickness Absence by Skills Group
Feb-16 Mar-16 Apr-16
11
Well Led [10]
Additional Notes
The percentage of staff up to date with their Mandatory
Training has reduced to 90% in May, against a target of 90%.
Compliance
Percentage
90%
(May 15– 86%)
May 16
Mandatory Training
.
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Mar
-14
May
-14
Jul-
14
Sep
-14
No
v-1
4
Jan
-15
Mar
-15
May
-15
Jul-
15
Sep
-15
No
v-1
5
Jan
-16
Mar
-16
May
-16
Mandatory Training Compliance vs Target
Total for YDH Target
0% 20% 40% 60% 80% 100%
Senior Managers
Nursing & Midwifery Reg
Medical & Dental
HCA's
Estates
Ancillary
Allied Health Professionals
Admin & Clerical
Additional Prof Scientific…
Additional Clinical Services
Mandatory Training by Skills Group - % Compliant
Mar-16 Apr-16 May-16
12
Well Led [11]
Additional Notes
The percentage of staff remaining in date for their Annual
Appraisal has reduced to 84% against target of 90%.
Compliance
Percentage
84%
(May 15 – 78%)
May 16
Appraisals
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Mar
-14
May
-14
Jul-
14
Sep
-14
No
v-1
4
Jan
-15
Mar
-15
May
-15
Jul-
15
Sep
-15
No
v-1
5
Jan
-16
Mar
-16
May
-16
Appraisal Compliance vs Target
Total for YDH Target
0% 20% 40% 60% 80% 100%
Senior Managers
Nursing & Midwifery Reg
Medical & Dental
HCA's
Estates
Ancillary
Allied Health Professionals
Admin & Clerical
Additional Prof Scientific…
Additional Clinical Services
Annual Appraisal by Skills Group - % Compliant
Mar-16 Apr-16 May-16
13
Well Led [12]
Workforce Assurance
Workforce
Contracted FTE 2186 54 48 421 96 165 23 238 566 106 251 1968 1753
Turnover
Turnover 10% - 15% 17% 0% 16% 17% 13% 0% 14% 15% 11% 22% 16% 15%
Sickness Absence
Sickness Absence (Apr-16) 3.0% 0.7% 0.7% 3.2% 0.9% 3.8% 0.0% 0.6% 4.5% 1.5% 6.3% 3.3% 2.9%
Sickness Absence (Rolling Yr) 3.0% 2.2% 3.6% 2.5% 1.3% 4.9% 1.4% 0.6% 3.5% 1.9% 5.4% 3.0% 3.4%
Performance Compliance
Mandatory Training 90% 89% 89% 93% 89% 85% 93% 88% 92% 89% 88% 90% 86%
Appraisal 90% 80% 93% 83% 87% 90% 100% 89% 82% 85% 75% 84% 78%
* Excludes Jnr M & D
Trustwide
Senior
ManagersHCA'sMay-16 Target
Nursing &
Midwifery May-16 May-15
Additional
Clinical
Services
Add'l Prof
Scientific &
Technical
Admin &
Clerical
Allied
Health
Professional
Medical
& DentalAncillary Estates
14
Well Led [13]
Workforce Assurance
Nursing
Trauma & Orthopaedics 20 35 103% 30% 5.2% 81% 93% 86% 0 0 0
Elective Ward 12 27 101% 11% 4.9% 93% 87% 96% 4 0 0
Surgery Ward 18 31 100% 34% 3.0% 94% 90% 97% 4 0 0
Kingston Wing 10 29 100% 17% 4.2% 96% 90% 97% 0 0 0
ICU 40 41 101% 24% 5.3% 75% 96% 100% 1 0 0
Gynae & Female Surgery Ward 11 11 101% 22% 4.9% 74% 86% 94% 0 0 0
Midwifery 58 76 101% 13% 7.3% 85% 92% 96% 1 0 0
Emergency Admisssions Unit 19 35 101% 17% 1.9% 86% 89% 97% 2 0 0
Ward 8A - Medicine 12 28 100% 35% 7.6% 75% 96% 94% 2 0 0
Stroke & Elderly Care 14 32 100% 17% 3.1% 74% 95% 80% 2 0 0
Medically Fit for Discharge 16 20 99% 0% 0.8% 100% 92% 93% 1 0 0
Ward 9A - Medicine 20 32 101% 30% 7.3% 75% 92% 88% 4 0 0
Ward 9B - Medicine 15 30 101% 32% 5.7% 67% 93% 84% 2 0 0
Ward 10 15 19 101% 5% 9.7% 80% 97% 95% 1 0 0
CCU 16 16 100% 19% 4.2% 93% 88% 100% 0 0 0
SCBU 10 15 94% 9% 4.9% 83% 93% N/A 0 0 0
*
Elec
tive
Car
e
Turnover % Sickness
Absence %
Urg
ent
Car
e
May-16Average Fill
Rate %GrievancesFFT *
Mandatory
Training %
All Staff
Extremely Likely and Likely to recommend
Contracted
FTE
Contracted
FTE Appraisal % Pals Complaints
15
Well Led [14]
Key Developments in Month Project Search – YDH has been nominated for a Learning Disability & Autism Award for our work with Project
Search. The ceremony to take place on 14th July in Birmingham with over 600 guests
Emotion Coaching – launched a programmed to help our people cope with stress and build up their resilience. 1st
cohort of 14 people attended programme and feedback very positive. More programs to be run in June and July
Better Place to Work (BP2W) – we have now received input/support from a number of directors to start the BP2W
process in the following departments: theatres, ED, pediatrics, gynecology/outpatients, maternity. The roll-out has
to be discussed and agreed with the department heads
Workforce plans – new simple but robust system developed to ensure we have robust workforce and succession
plans in place. Being piloted on Wards 1st
Schwartz rounds – to be launched within YDH on 30 June. They are a multidisciplinary forum designed for staff to
come together once a month to discuss and reflect on the emotional and social challenges associated with working
in healthcare. Rounds provide a confidential space to reflect on and share experiences
Temporary staffing – making good progress with bank and agencies to reduce the number of breaches reported to
NHSI each month
Junior doctors contract – new rotas drafted for every area. One of the few trusts in the South West to have done
this
WORKFORCE COMMITTEE
Minutes of the Workforce Committee held on 21 April 2016 at Yeovil District Hospital
Present: Mark Saxton [Chair] Non-Executive Director Mark Appleby Associate Director of HR and Organisational Development (OD) Maurice Dunster Non-Executive Director Tim Newman Chief Finance & Commercial Officer Attendance: Tracy Jones Head of HR Debbie Matthewson Head of Education and Development Ali Morris Head of OD & Recruitment Jade Renville Company Secretary
Action 1
1.1
WELCOME & APOLOGIES Mark Saxton welcomed everyone to the Workforce Committee. There were no apologies for absence from members of the Committee but there were apologies for absence from the following regular attendees/observers: Sue Oliver - Head of HR (Symphony), Yvonne Thorne - Staff Governor Observer and Sue Bulley – Public Governor.
2 2.1
DECLARATIONS OF INTEREST There were no declarations of interest relating to items on the agenda.
3 3.1
3.2
3.3
3.4
MINUTES OF THE PREVIOUS MEETING AND MATTERS ARISING The minutes of the meeting held on 23 March 2016 were approved as a true and correct record. All matters arising would be covered as part of the agenda. In terms of the actions arising from the last meeting: 4.4 – 4.5 - Plans to encourage greater uptake of the bank would be discussed later in the meeting [item 5 refers]. 5.2 - The workforce performance report had been updated to reflect the comments from the last meeting. 6.5 – Mark Saxton thanked Mark Appleby for the communications that was issued Trustwide about the staff survey which reflected the comments that were made by the Workforce Committee. There was discussion about the way in which the staff survey results reviewed at the last meeting should be presented to the Board. It was agreed that Mark Appleby would be invited to the Board to lead the presentation, supported by Tim Newman, Maurice Dunster and Mark Saxton. It would focus on: the 5 highest and lowest ranking responses, the key areas of strength and points for improvement and the 3 main foci of the corporate response plan. Reflecting on discussions at the previous meeting, the Workforce Committee spoke positively of the overall improvement in the results but acknowledged that more is to be done to ensure YDH is viewed as one of the best hospitals in the country in which to work.
JR/MA
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3.5
3.6
3.7
3.8
There was discussion about one element of the staff survey where staff had communicated that they felt there were limited opportunities for promotion. This is often the case in smaller organisations but Mark Appleby and Ali Morris said that YDH is working hard to promote talent within the organisation through initiatives such as the employee value proposition and career coaching. Ali Morris said she wouldn’t want to limit managers to recruiting only internally as this may delay the overall process of filling vacancies. For staff wanting progression, sabbatical opportunities to work on specific projects is under consideration. Tim Newman added that he would like to understand if there is a particular staff group affected by this statement and the position in other trusts. As raised by Maurice Dunster, the staff survey response plan should acknowledge that YDH is already implementing its recently updated People Plan which has the requisite strategic approach rather than being transactional in nature. Tim Newman also said that Mark Appleby should involve his team when developing plans such as the staff survey response. In terms of the ongoing elements captured on the action sheet: 4.9 (20.1.16) - Tracy Jones said she would give an update on the new leavers process later in the meeting, building on discussion at previous meetings. 7.2 (19.2.16) – Sue Oliver to give an update on the organisational development plan for Symphony Healthcare Services at the next meeting.
4 4.1
WORKFORCE PERFORMANCE REPORT Mark Appleby presented the workforce performance report, advising that the amendments requested at the last meeting had been reflected within the revised report [item 5.2 refers]. Referring to the contracted and temporary FTEs employed by YDH, Mark Appleby confirmed the overall number had increased by 211 compared to March 2015. Maurice Dunster and Mark Saxton asked for the reasons for the increase. They were advised that 130 are clinical roles and of the non-clinical positions, much of the increase is for the delivery of the Trust’s strategic programmes (Symphony and TrakCare) as well as putting in place an in-house IT service (which had previously been outsourced). Other than these, it was confirmed that there are no significant outliers in terms of departments or teams that have seen particular growth. Tim Newman confirmed the admin and clerical roles are constantly scrutinised by directors to ensure that they are appropriate and to consider if there are any savings to be made. The Committee agreed that increasing the clinical workforce was a positive investment. There is an ongoing, focused recruitment campaign for nursing and medical staff. Alongside recruitment, Mark Saxton said it would be important to try and reduce the number of leavers, which links to discussion at previous meetings about improving the process for managing leavers and encouraging them to stay, where possible [item 5.4 of 21.3.16 refers]. In terms of cost pressure, nursing, followed by HCAs, contribute to the greatest area of overspend (which are already an area of focus for recruitment), followed by ancillary, on which Tracy Jones is working with the relevant teams.
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4.2
4.3
Mark Appleby briefly summarised the remaining sections of the workforce report. There was particular discussion about sickness absence, which was improving. Tracy Jones added that managing sickness absence is easier for those staff on e-roster as the system provides more detailed, up-to-date information. Mark Saxton asked how many wards are using the system and Tracy Jones confirmed the roll-out had been fully implemented with the wards and other staff groups are now being considered (such as pharmacy and porters). There was also discussion about ensuring managers feel supported to deal with sickness absence in their departments, particularly when it is long-term. It was agreed that focussed support should be provided to those areas where the levels are higher, such as nursing and HCAs. In terms of ongoing developments, the areas highlighted were the new Trac Recruitment System, which had gone live, was liked by managers and which would improve efficiency in recruitment. Ali Morris also highlighted workforce planning as a significant piece of work which would require the support of the Board, on which there would be discussion at a future meeting of the Workforce Committee.
5 5.1
5.2
PERFORMANCE AGAINST THE MONITOR AGENCY CAP Tracy Jones presented the monthly update on performance against the Monitor agency cap. She explained that the charts had now been included within the workforce performance report rather than her presentation. She provided an overview of the actions being taken by YDH to reduce agency nurse utilisation. Maurice Dunster asked for an update on the outcome of the workforce diagnostic undertaken by Monitor (now overseen by NHS Improvement). Mark Saxton asked if YDH is still considered as an outlier in terms of its utilisation and spend. Tracy Jones confirmed that following the review by Monitor, they are satisfied with the actions being taken by YDH to reduce reliance on agency utilisation. They concurred with the Trust’s aim to encourage greater uptake to the bank (along with weekly pay) as a key enabler to reducing agency spend. Tracy Jones said that along with other trusts in the country the reduction in the cap had made meeting the targets more challenging. However, the staffing manager is now making some “quick-wins” and negotiations have been successful with some agencies. The overall trend in bookings for agency nurses is reducing. The Workforce Committee discussed the marketing campaign to increase uptake to the bank including clarifying the rates of pay, implementing weekly pay and working with other NHS trusts locally to consider having shared back-offices processes such as standardised induction and training to make it easier for bank staff to work across NHS trusts in the region. Mark Saxton commented on the positive work being done to reduce agency utilisation but noted that ongoing focus is required to reduce spend on agency nurses without compromising patient safety and/or the quality of care. Part of this may involve stronger negotiations with the agencies that are used by YDH, decisions about which should involve the Helen Ryan as the Director of Nursing and Clinical Governance. It was agreed that Helen Ryan would be invited to attend the next meeting to discuss nurse staffing and agency utilisation in recognition that she is a key influencer and decision maker in these discussions.
HR/JR
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6 6.1
6.2
6.3
DEEP DIVE – TRAINING Debbie Matthewson tabled a presentation on the Academy 3 Year Plan, including the successes so far and the ongoing developments. She spoke of the improvements to the appearance of the Academy and explained that her team had now adopted uniform. She added that staff across the Trust give positive feedback about the Academy and find it a good place to work. In terms of mandatory training, Debbie Matthewson confirmed that the Trust is now consistently meeting its target of 90% although she acknowledged that the operational pressures and levels of sickness have had an impact. She said that training is now being delivered at the UCY campus on Preston Road, Yeovil, which has received positive comments from staff although the subject matter trainers had found it more difficult and time consuming to travel offsite. She added that this had highlighted an ongoing question about whether the subject experts are the best trainers and she said there may be an opportunity for the Academy team or vocational trainers to take on some of this training. Debbie Matthewson said that the Academy would soon be implementing e-learning for mandatory training starting with a license for 800 staff and complimented by face-to-face sessions. She confirmed that depending on the success of the project, more licenses could be purchased in future as required. There was discussion about the management and leadership classes with are offered to staff. The “introduction to leadership” is a five day, self-booking course which 43 people have completed in the last 18 months. Debbie Matthewson explained that this is aimed at staff wanting to move into a leadership roles. The “management development programme” had also received positive feedback and 30 people will have completed the course by October 2016. Mark Saxton asked whether these courses are targeted and positioned in the right way and whether the “introduction to leadership” would be better titled “introduction to management”, highlighting the different skill sets involved. He also questioned whether it would be more appropriate for managers to highlight the best people for this course rather than it being open to self-selection. Ali Morris responded that the management development programme is for staff that are highlighted by their managers. She added that the courses do set out the differences between management and leadership. Debbie Matthewson expressed her support for staff wanting to develop and progress to be allowed to self-select onto the “introduction to leadership” course. Debbie Matthewson spoke positively of the leadership development programme aimed senior staff across the organisation. She said that the course (which is on its penultimate session) had been well received and was helping to break barriers between the clinical and non-clinical participants. Learning from the programme (including ideas to improve operational delivery) was already being put into practice. Jade Renville suggested that there should be a mechanism in place to review the output from the course. Ali Morris confirmed that she would give a more detailed presentation about the programmes and their outcomes later in the summer.
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6.4
6.5
6.6
6.7
Debbie Matthewson advised that needs based, tailored support is in place for individuals and departments, such as for CPD and revalidation. She said that the onsite library offers a good service. There was discussion about the role of the Academy in helping with the integration of nurses recruited from overseas, particularly with their language skills. Mark Saxton said that the wards also had a role to play in helping them to fully integrate within the department. Finally, Debbie Matthewson outlined the positive response to the Trust’s apprenticeship programme which had grown over the last few years, although in future the financial model would need to be reviewed in response to new national guidance. She spoke of opportunities to maximise potential within the organisation through talent mapping. There was discussion about this being a mechanism for staff to feel valued and to consider opportunities for progression. In terms of the work programme associated with equality and inclusion, Debbie Matthewson said it could be challenging to get uptake for the various initiatives such as drop-ins but focus would be maintained with specific training for managers, focus groups and a dedicated email address for staff to raise concerns about equality and inclusion. Mark Saxton asked about progress on proposals with Yeovil College on the development of an onsite career college, which Debbie Matthewson said is still under consideration with them and with the Local Education Partnership (LEP), particularly around the funding options. Mark Saxton thanked Debbie Matthewson for her presentation and complimented the professional approach of the Trust’s training programme under her leadership which is aligned to the needs of staff. He summarised the areas for future focus including the “introduction to leadership” programme, the financial model for apprentices and the development of the career college proposals.
7 7.1
ACTIONS ARISING FROM THE PEOPLE PLAN The actions arising from the People Plan were noted.
8 8.1
ANY OTHER BUSINESS There was no further business to discuss.
9 9.1
DATE OF THE NEXT MEETING 23 May 2016, 15:30 – 17:30, Boardroom, Level 1, YDH.
YDH │Financial Performance Month 2 – May 2016
Executive Summary (Whole trust) In month position is £2.2m deficit, this is £37k adverse to budget. The year to date position is £4.3m deficit, £20k favourable to budget.
£4.3m YTD
deficit
£0.02m YTD
favourable vs
budget
£2.2m in
month
deficit
Financial Summary In Month Year to Date
£000's Actual Variance to
Budget Actual
Variance to Budget
BAU (1,960) 172 (4,076) 229
Transformation (209) (209) (209) (209)
Total (2,169) (37) (4,285) 20
Executive Summary (Business as usual – BAU) In month position is £2.0m deficit, which is £172k favourable to budget. The year to date position is £4.1m deficit, £229k favourable to budget.
Su
rplu
s /
(D
efi
cit
) £
m
(2.50)
(2.00)
(1.50)
(1.00)
(0.50)
0.00
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Actual 16/17 Budget 16/17 Actual 15/16
£4.1m YTD
deficit
£0.2m YTD
favourable vs
budget
£2.0m in
month
deficit
Trend in month surplus / deficit
Executive Summary (BAU) In month May 2016 BAU favourable variance to budget £172k.
(7)
(300)
409
2
5 64
(2,133)
(1,960)
(2,250)
(2,000)
(1,750)
(1,500)
Underspend
Overspend
Su
rplu
s /
(D
efi
cit
) £
’00
0
1.1 | Income Summary In month £410k favourable and YTD £117k favourable to plan
Somerset CCG income detail
1 2 3 4 5
In Month In Month YTD
Actuals Variance Variance
R&D Income 141 (3) 16
Education & Training 341 (5) (14)
Trakcare 104 (50) (50)
Pharmacy & Maintenance Contracts 243 30 33
Catering 59 (2) 12
Car Parking 46 2 2
Other (incl. Cookson Court Beds) 346 59 61
Total 1,278 32 62
Non Clinical Income Source
In month In month YTD
Actuals Variance Variance
Somerset CCG 6,952 409 207
Dorset CCG 1,192 0 5
Specialist Commission Grp 234 (68) (78)
Public Health Clinical Income 71 4 (19)
CDF and Spec Comm drugs 884 306 125
Private Patients 170 (32) (48)
Other (incl. NCAs, RTAs (215) (240) (137)
Total 9,289 379 55
Clinical Income Source
13,400
Underperformance
Overperformance
13,300
(-8)
13,200
13,100 (11)
13,000 Som
erse
t CCG
Inco
me
(£00
0s) Y
tD M
onth
2
13334
13,127
83
121
(64)86
Budgeted value
Daycases
Elective
Admiss
ions
Outpatie
nts
Non Elective
Admiss
ions
Other a
ctivity
Drugs a
nd
devices
Actual v
alue
Som
erse
t CCG
Inco
me
(£00
0s) Y
tD M
onth
2
1.1 | Income Summary Somerset PBR detail
1 2 3 4 5
13,400
Underperformance
Overperformance
13,300
Other activity
Other13,200
Other
13,100
13,000
So
me
rse
t C
CG
In
co
me
(£
00
0s)
Ye
ar
to D
ate
Mo
nth
2
ENT
Dayca
ses
Elec
tive
Admiss
ions
Non
Elective
Admiss
ions
Out
patie
nts
Other
Surgery
Orthopaedic
General
Medicine
Ophthalm'y
13,127
Ophthalm'yPlastics
General
Medicine
13334
A&E/AEC Trauma
General
Medicine /
COE/FOPAS
Other
Marginal
rate
discountDrugs and
devices
Budg
eted
value
Oth
er activity
Drugs
and
device
s
Actua
l value
So
me
rse
t C
CG
In
co
me
(£
00
0s)
Ye
ar
to D
ate
Mo
nth
2
Dayca
ses
Elec
tive
Admiss
ions
Non
Elective
Admiss
ions
Out
patie
nts
(24)
(78)
61
16
(9)
(100)
(50)
0
50
100
2.1 | Pay expenditure & temporary staffing Pay in month is £7k overspent and YTD is £96k underspent.
1 2 3 4 5
4,000
5,000
6,000
7,000
8,000
9,000
Agency Bank & Locum Substantive
£’0
00
Variance to Budget
in Month
£7k Adv
Notes
• Nursing pay is £24k overspent due to staffing escalation beds £40k. These were partly
offset by underspends due to skill mix and unspent developments.
• Medical staff are overspent due to vacancies, additional sessions and discharge ‘hit
squads’.
• Estates, Admin & Clerical are mainly underspent due to vacancies
• Ancillary £9k overspent due to car parking attendants, portering and escalation.
£’0
00
2.1 | Pay expenditure & temporary staffing (Whole trust) Agency staff spend YTD (BAU and transformation) is £1,563k against the plan of £1,254k, the annual ceiling is £6,498k
1 2 3 4 5 £
’00
0
Notes
• Annual budget and NHS Improvement ceiling are phased with
reducing spends in the latter months as we plan to fill vacancies.
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12
Agency spend
Actuals Annual Budget NHSI Ceiling
Staff group M1 M2
Medical 283 337
Nursing 339 307
Other 151 146
Total 772 791
2.1 | Pay expenditure & temporary staffing (BAU) Nursing Staff (Registered and Unregistered) - £24k overspent in month
100
150
200
250
300
350
400
1,600
1,800
2,000
2,200
2,400
2,600
2,800
3,000
Oc
cu
pie
d B
ed
Da
ys
Agency Bank Substantive Prior Month Budget Average Occupied Bed Days(exc Cookson Court)
Notes
• Substantive costs remained static in month.
• Agency costs reduced by £42k in month, although still above the
budget for agency by £148k.
• Bank costs reduced in month, whilst the number of bank shifts
increased, the payments made for hot shifts reduced.
£’0
00
1 2 3 4 5
Area £000s
Adult IP Wards 135
ED 39
Specialist Wards 53
Theatres 78
Other 1
Grand Total 307
Nursing Agency Spend - May 2016 Actual
Reason for Variance In Month
Variance
£’000
YTD
Variance
£’000
Comments
Escalation (40) (111) Agency cost of staffing inpatient beds within day theatre.
Open as an inpatient area for 16 days in May.
Absence (wards only) (15) (58) Agency cost of covering absence over and above the 4%
planned for within budget.
Supernumerary Within allocated risk budget
Specialing Within allocated risk budget
Developments 13 28 Capacity developments not yet started
Other 19 58 Includes skill mix saving on the planned development for
increased registered staff on night shifts.
Total (24) (84)
2.1 | Pay expenditure & temporary staffing Nursing Staff (Registered and Unregistered) – Analysis of in month and YTD variance
1 2 3 4 5
2.1 | Pay expenditure & temporary staffing Medical Staff Analysis (BAU) - £78k overspent in month, £25k overspent YTD. Agency spend in month £322k, YTD £576k.
1000
1200
1400
1600
1800
2000
2200
2400
2600
Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Regular payroll Additional payroll Agency Budget Budget 2016/17 excl risk budget
£’0
00
1 2 3 4 5
Agency Spend by department
In monthYear to
dateIn month
Year to
date
Radiology Consultant 91 151 28% 26%
Care of the Elderly Consultant 49 54 15% 9%
Diabetes Consultant & MG 13 37 4% 6%
ED Consultant 33 54 10% 9%
Child Health 14 21 4% 4%
Respiratory 34 69 11% 12%
Expenditure (£'000s) % of expenditureIn month
Year to
dateIn month
Year to
date
Dermatology 31 52 10% 9%
General Surgery MG 23 57 7% 10%
Ophthalmology 10 18 3% 3%
Other Elective Care 5 13 2% 2%
Other Urgent Care 19 49 6% 9%
Other Corporate 0 1 0% 0%
Totals 322 576
2.1 | Pay expenditure & temporary staffing Medical Staff – Analysis of in month and YTD variance
1 2 3 4 5
£ £
In Month YTD
Variance Variance
Fav/(Adv) Fav/(Adv)
BAU Medical Staff
Position (79) (25)
Analysis of Variance
Elective Care Surgical (19) (24)
ENT (additional sessions, possible reduction in bought in
services) , Ophthalmology and OMF (offset by bought in
service underspend)
Elective Care Anaesthetics 4 26Vacancies partially offset by additonal payments for backfill
of sessions
Elective Care Other (3) (3)
Urgent Care Risk budget (18) 11 Timing of usage of risk budgets
Urgent Care Internal Medicine (6) (27) Additional junior cover on wards
Urgent Care Long Term Conditions (17) (17)Additional junior cover on wards & weekend Discharge 'hit
squads'
Urgent Care Emergency Medicine (18) (9)ED consultant rota cover for sickness absence, EAU
additional cover on wards
Urgent Care Other 3 16Pathology offset with underachieved income and vacancy in
Cancer
Corporate Maternity Pay (4) (8)
Corporate R&D (4) (9) Offset with income
Corporate Academy (4) (6) F2 locum to cover GP rotation sickness abesence
Corporate Other (3) (2)
Central Budgets Developments 11 33 Capacity growth budgets not yet being utilised
Central Budgets Other (1) (6)
Total (79) (25)
Comments
2.2 | Non pay expenditure – Medical Consumables (BAU) Overspent by £229k in month and underspent by £5k YTD.
750
950
1,150
1,350
1,550
1,750
1,950
2,150
2,350
2,550
2,750
High Cost Consumables Consumable M&SE Drugs
Consumable M&SE – Medical & Surgical Equipment
High Cost Consumables – Includes high cost prostheses
£’0
00
1 2 3 4 5
Business Unit Drugs
Medical
Consumables
Actual
£000’s
Variance
£000’s
Actual
£000’s
Variance
£000’s
Cancer Services (367) 78 (5) 1
Child Health (27) 8 (28) (15)
Emergency Medicine (23) (3) (23) 3
Gen Surgery & Spec Serv (156) (29) (70) 1
Integrated Care 0 0 (6) (4)
Internal Medicine 0 0 (64) 14
Long Term Conditions (715) (352) 4 6
Obs & Gynae (11) (2) (28) 6
Orthopaedics 0 0 (154) 10
Pathology 0 0 (339) (15)
Pharmacy (153) 2 (3) 10
Private Patients (2) 1 (24) 7
Radiology (10) 5 (25) (4)
Theatres & Critical Care (48) (6) (82) (8)
Other (12) (2) 24 57
Total (1,524) (300) (823) 71
Notes
Drugs
• Long term conditions includes high cost drugs which is offset by
additional income.
Medical Consumables
• Child Health £15k overspend due to paediatric diabetes pumps
• Pathology £15k overspent on blood products
• Other includes £57k of activity related contingency not required in
month
2.2 | Other non pay (BAU) Overspent by £66k in month and £130k YTD.
750
950
1,150
1,350
1,550
1,750
1,950
2,150
2,350
2,550
Other Non Pay Actual Other Non Pay Budget
£’0
00
1 2 3 4 5
Other Non Pay Category
In Month In Month
Actual Variance
£'000 £’000
Catering (79) (4)
Cleaning, Linen, Laundry
& Uniforms (106) (30)
Delivery Charges (27) (1)
Equipment, Leases &
Maintenance (90) 5
Insurances (247) (0)
Medical Equipment (95) 5
Office Expenses (28) 17
Other (189) (64)
Patient & Staff Travel (78) (5)
Patient Appliances (50) 11
Postage, Phones & Calls (38) (9)
Printing & Photocopiers (44) (12)
Professional &
Consultancy Fees (69) (25)
Property, Rates & Utilities (247) (22)
Recharges - NHS (235) 3
Recruitment &
Redundancy (41) 24
Rent (197) 3
Software (210) 45
Training (45) (8)
Total (2,114) (66)
Notes
• Cleaning, Linen, Laundry – overspent due to increased activity and deep
cleans
• Other – Includes £103k for orthopaedic activity outsourced to an
independent provider offset by contingency not required in month
• Printing and Photocopiers – Increased spend relates to Xerox usage
currently being investigated
• Professional and Consultancy - £19k for estates feasibility studies
• Property, Rates and Utilities - £9k termination fee for managed car park
service and minor works
• Recruitment and Redundancy – timing of recruitment and associated
costs
• Software - £50k timing benefit due to delayed implementation of trakcare
(offset by reduced income)
2.3 | CIP Achievement In month - £528k achieved against plan of £397k. FYE - £851k achieved against plan of £5,173k
0
1,000
2,000
3,000
4,000
5,000
6,000
FYE achieved Plan total
£'0
00
s
FYE CIP achieved
1 2 3 4 5
0
1,000
2,000
3,000
4,000
5,000
6,000
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
£'0
00
s
Current Year CIP achieved - Cumulative
CIP Recurrent CIP Non Recurrent CIP Plan 2016/17
In Month Year to Date
Project Actual
Recurrent Actual Non Recurrent
Total Achieved Plan Variance
Actual Recurrent
Actual Non Recurrent
Total Achieved Plan Variance
Hospital Effectiveness 165 0 165 83 82 165 0 165 167 (2) Nursing Reduction 66 0 66 90 (24) 97 0 97 181 (84) Ophthalmology 10 0 10 10 0 19 0 19 19 0 Pathology 6 0 6 6 0 13 0 13 13 0 Pharmacy 0 0 0 17 (17) 0 0 0 33 (33) Procurement 2 0 2 1 1 3 0 3 3 0 Revenue generation 240 0 240 191 49 382 0 382 382 0 Symphony Bed Savings 0 0 0 0 0 0 0 0 0 0 Vacancy Factor 0 39 39 25 14 0 77 77 50 27
Risk 0 0 0 (26) 26 0 0 0 (53) 53
Total 489 39 528 397 131 678 77 755 794 (39)
2.4 | Transformation Budget Details of transformation budget items Vanguard income for YDH 2016/17 expected to be £3.5m.
1 2 3 4 5
Transformation Budget Summary YTD -May 16
Actual Variance to Budget
Annual Budget Description
Transformation Income 494 (616) 7,637 Income to cover costs - 12 months at this rate would exceed indicative allocation.
Enhanced Primary Care (199) 160 (2,155) Costs for health coach salary reimbursement and support packages to EPC practices.
Project Teams & External Support (83) (4) (475)
New Models - Primary Care Management (62) 111 (1,036)
Hub Management (42) (6) (213)
PMO Team (101) 18 (713)
Symphony Hub (27) 127 (1,906)
FOPAS (188) 1 (1,139) Costs for the FOPAS weekday service and for extended hours on evenings and weekends.
Transformation Total (209) (209) 0
3.1 | Capital 2016/17 Spend in Month is £450k, £724k YTD, year to date underspend of £241k
0
200
400
600
800
1000
1200
1400
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Actual
Plan
Forecast
Notes
• General site capex underspend is due to works within
Radiology and Macmillan, now scheduled later in the
year.
• Medical equipment year to date underspend of £58k is
due the a slippage of works and not an underspend.
• Trakcare year to date underspend of £97k is due to
un-filled positions within the team and the go live date
delay.
£’0
00
Capital Expenditure In Month Year to Date
Actual Variance Actual Variance
Operational Capital
Total General Site Capex 251 12 371 46
Medical Equipment 19 (11) 20 58
Radiology 0 0 0 0
IT Upgrade/ Development 0 30 0 30
Strategic Developments 0 0 0
Major Developments 0 0 0 0
IT - Trakcare 179 32 326 97
Donated Schemes in Year 0 8 7 9
Total 450 72 724 241
1 2 3 4 5
4000
400 0
9600
5828
0
3172 4053
181 295 1808 1,997 2,027
2,979 1,892
1,284 2,351 1,983
3,172
0
2,000
4,000
6,000
8,000
10,000
Actual Cash Actual / Planned Cash Support Planned cash Revised forecast
4.1 | Cash Outflow in month was £0.3m, cash balance at 31st May; £2.6m
£’0
00
Notes
• At end of May 2016 cash balance was £2.6m which is £1.7m adverse to plan. The variance is
mainly timing differences on payments and Somerset CCG income.
• An interim loan of £10.631m has been put in place by DoH to ensure the Trust has cash for the
start of the new financial year. NHS Improvement have since advised that the process for
issuing 2016/17 loans is still being worked out.
Total planned cash support for 2016/17 of
£25.7m to cover revenue and capital.
1 2 3 4 5
5 | Appendices
5.1 Balance Sheet
5.2 Statement of Comprehensive Income
5.3 Service Line Reporting
1 2 3 4 5
5.1 | Balance Sheet 1 2 3 4 5 Apr 16 May 16 Mvt In Mth May 15 Mvt In Yr
Non Current Assets 58,417 58,552 135 51,720 6,832
Current Assets
Stock 2,159 2,143 (16) 2,012 131
NHS Trade Debtors 2,489 1,725 (764) 1,298 427
Non NHS Trade Debtors 1,217 1,264 47 859 405
Accrued Income 2,137 3,260 1,123 1,211 2,049
Prepaid Contracts 965 1,594 629 1,587 7
Cash in Hand and at Bank 3,000 2,645 (355) 6,266 (3,621)
Total Current assets 11,967 12,631 664 13,233 (602)
Current Liabilities
Trade Creditors (1,090) (3,248) (2,158) (2,349) (899)
Other Creditors (2,878) (3,827) (949) (2,853) (974)
PDC Dividend Creditor (98) (187) (89) (209) 22
Capital Creditor (1,321) (1,236) 85 (810) (426)
Accruals (9,836) (9,011) 825 (6,838) (2,173)
Borrowings <1yr (126) (126) 0 (130) 4
Deferred Income (1,049) (1,542) (493) (7,432) 5,890
Current Liabilities (16,398) (19,177) (2,779) (20,621) 1,444
Net Current Assets (4,431) (6,546) (2,115) (7,388) 842
Total Assets less Current Liabilities 53,986 52,006 (1,980) 44,332 7,674
Trade and other Payables >1yr 0 0 0 (11) 11
Borrowings> 1yr (28,545) (28,715) (170) (1,626) (27,089)
Provisions >1yr (979) (999) (20) (1,047) 48
Net Assets employed 24,462 22,292 (2,170) 41,648 (19,356)
Financed by:
I&E Reserve Current year (2,116) (4,286) (2,170) (3,535) (751)
Public Dividend Capital 41,823 41,823 0 41,823 0
I&E Reserve Previous year (23,223) (23,223) 0 (4,638) (18,585)
Revaluation Reserve 7,978 7,978 0 7,998 (20)
Total Financed 24,462 22,292 (2,170) 41,648 (19,356)
5.2 | Summary Statement of Comprehensive Income For whole trust including business as usual operations and transformation.
1 2 3 4 5
Financial Summary
£000's Mar-16 Apr-16 Actual
Variance to
Budget % var Actual
Variance
to
Budget % var
Annual
Budget
2016/17
Income
Clinical Income 10,822 8,818 9,263 29 (0.3%) 18,081 (482) 2.7% 116,808
Non NHS Clinical Income 462 225 200 (31) 15.4% 426 (23) 5.3% 2,769
Other Income 1,488 1,274 1,312 65 (5.0%) 2,586 95 (3.7%) 15,157
Total Income 12,772 10,317 10,775 63 (0.6%) 21,092 (410) 1.9% 134,735
Pay
Registered Nursing (2,248) (2,255) (2,254) 39 1.7% (4,509) 100 2.2% (27,763)
Unregistered Nursing (559) (639) (585) (50) (8.5%) (1,224) (147) (12.0%) (6,309)
Medical Staff (2,376) (2,344) (2,487) (92) (3.7%) (4,831) (40) (0.8%) (28,871)
Estates, Admin & Clerical (1,545) (1,502) (1,506) 133 8.8% (3,008) 269 8.9% (19,704)
Pay - Scientific, Therapeutic & Technical (790) (766) (790) 109 13.8% (1,556) 244 15.7% (10,800)
Pay - Ancillary (404) (407) (392) (9) (2.3%) (799) (33) (4.1%) (4,580)
Total Pay Expenditure (7,923) (7,913) (8,014) 130 1.6% (15,927) 393 2.5% (98,027)
Non Pay
Drugs (1,146) (1,109) (1,524) (300) (19.7%) (2,633) (154) (5.9%) (16,804)
Consumable M&SE (945) (683) (628) 48 7.7% (1,311) 73 5.6% (8,473)
High Cost M&SE (254) (155) (196) 22 11.4% (351) 86 24.5% (2,622)
Other (3,562) (2,187) (2,182) (64) (2.9%) (4,369) (108) (2.5%) (25,755)
Total Non Pay Expenditure (5,907) (4,134) (4,530) (294) (6.5%) (8,664) (104) (1.2%) (53,654)
EBITDA (1,058) (1,730) (1,769) (100) (5.7%) (3,499) (121) (3.5%) (16,947)
Other Technical (711) (386) (400) 64 15.9% (786) 141 18.0% (5,562)
Surplus / (Deficit) (1,769) (2,116) (2,169) (37) (4,285) 20 (22,509)
Prior Months Actuals In Month - May 16 Year to Date
5.3 | Service Line Reporting Urgent Care SLR YTD contribution by specialty
Notes
• The above shows Medicine as making the most significant contribution (Income less specialty-specific costs). However, as a
percentage of its total revenue this contribution is only 3%.
• Urgent Care is making an overall loss of £2.2m. This is significantly lower than the SLR plan which showed a loss
of £2.7m.
• This is mainly due to over-performance of income of £386k, virtually all of which was admissions.
1 2 3 4 5
5.3 | Service Line Reporting Elective Care SLR YTD contribution by specialty
Notes
• Overall, Elective Care is making a £1.8m loss. This is £93k more than the SLR planned loss of £1.7k.
• Year to date income in this directorate is £322k under plan, but it is important to note that the in month variance is
£261k positive, mainly due to a reduction in cancelled operations and increased outpatient activity
1 2 3 4 5
Appendix: 9 REPORT TO: Board of Directors REPORT BY: Jade Renville, Company Secretary PRESENTED BY: Jade Renville, Company Secretary
Jonathan Higman, Director of Strategic Development TITLE: Revised Board Governance Structure DATE: 22 June 2016 What is this item about and what is the Board asked to do? The Board is asked to approve revisions to the Board governance structure to take account of the establishment of the Hospital Transformation Programme Board which will report to the Financial Resilience and Commercial Committee. Are there legal, financial, procedural, workforce implications and/or legislative requirements? The proposals adhere to the Trust’s constitutional documents. Is this paper clear for release under the Freedom of Information Act 2000? Yes What are the next steps/future actions? To continue developing the programme of work for the PMO. The Terms of Reference for the Hospital Transformation Programme Board will need to be approved by the Financial Resilience and Commercial Committee. Links to the Trust’s strategic objectives and/or priorities: The Hospital Transformation Programme Board will be a key enabler to delivery of the Trust’s strategic objectives. Links to the Board Assurance Framework/Corporate Risk Register (if applicable): A key aim of the Hospital Transformation Programme Board will be to help mitigate any risks to delivery of the Trust’s strategic objectives as set out in the Board Assurance Framework. Reference to CQC domains: Well-led Report history: The governance structure was previously approved in November 2015 to take account of the establishment of the Workforce Committee
(DRAFT for Board Approval on 22 June 2016) Board Governance Structure
Governance Committee
Equality &
Inclusion
Patient Safety
Patient Experience
Audit Committee
Hospital Management Team (HMT)*
Board of Directors
Information Governance & Caldicott
Emergency Planning
& Bus Continuity
Clinical Outcomes Committee
Data Quality Nutrition, Patient Voice
Remuneration Committee
Elective Care Strategic Business Unit (SBU)
Financial Resilience and
Commercial Committee
Executive Directors*
Board of Trustees
Urgent Care Strategic Business Unit (SBU)
Infection, Prevention & Control, Safeguarding, Medical Devices, Safer Medicines Mgt, Harm Free Groups (falls, pressure ulcers, recognition and rescue), Maternity Risk Mgt, Obstetric Interventions
Fire, Health & Safety & Security
Board Assurance Committees Board and Committees of the Board Operational Groups and Strategic Business Units
Quality Oversight Sub-Committees Working Groups
-See SBU meetings matrix -CBU Rolling Governance - Peer Review
Resuscitation, Patient Blood Mgt, Drugs and Therapeutics, Point of Care Testing
Note*: Terms of Reference set out what should be reported to HMT / Executive Directors and the relationship between them
Operational updates provided to the Board via CEO Report and Operational Report
Workforce Committee
[Established
21.10.15]
Quality Committee
End of Life Care
Hospital Transformation
Programme Board
APPENDIX 10 BOARD OF DIRECTORS
22 JUNE 2016 Report to: Board of Directors
Report from: Jade Renville, Company Secretary Subject: NHS Improvement Self-Certifications (Corporate Governance, AHSC,
Training of Governors)
Date: 22 June 2016
Introduction As part of the annual planning process, YDH is required to submit a number of self-certifications to NHS Improvement as set out below: 1. Systems for compliance with licence conditions - in accordance with general condition 6
of the NHS provider licence
2. Availability of resources and accompanying statement - in accordance the continuity of service condition 7 of the NHS provider licence
3. Corporate governance statement - in accordance with the risk assessment framework
4. Certification on AHSCs and governance – in accordance with the risk assessment
framework
5. Certification on training of governors – in accordance with s151(5) of the Health and Social Care Act
Recommendation Declarations 1&2 have been approved and submitted. Declarations 3, 4 and 5 are set out below. To enable submission to NHS Improvement by 30 June 2015, the Board is required to respond "confirmed" or "not confirmed" to the following statements, noting any risks and/or mitigating actions for each one: 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. (2)The Board has regard to such guidance on good corporate governance as may be issued by NHS Improvement from time to time (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.
(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. (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. (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. Certification on AHSCs and Governance 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. 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.