Balanced Score Card Review of March 2016 Data

Balanced Scorecard

Finance Patient Access

Quality

&

Safety

Human Resource

Management

Patient and Service User

Finance

CUH Finance Report – March 2016

Actual outturn Mar 2016- CUH/MGH Gross pay & non pay budget €89.6m

Actual pay & non pay €91.4m

Actual Deficit €1.8m (2.0%)

Actual outturn Mar 2016- CUH Gross pay & non pay budget €84.6m

Actual pay & non pay €86.3m

Actual Deficit €1.7m (2.0%)

Income outturn Mar 2016- CUH /MGH Income budget €21.0m

Actual Income €20.2m

Actual Deficit €761k (3.6%)

Income outturn Mar 2016- CUH Income budget €20.0m

Actual Income €19.1m

Actual Deficit €919k (4.6%)

CUH Group Summary Budget v Actual Expenditure - Mar 2016

Pay €k Non-Pay €k Total Gross Income €k Net €k

CUH -149 -443 -592 -580 -1,172

SMOH 0 -2 -2 0 -2

CUH-SMOH -149 -445 -595 -580 -1,174

Mallow -13 -23 -36 125 89

Total -163 -468 -631 -454 -1,085

CUH Summary – Budget v Actual Expenditure YTD March 2016

Pay €k Non-Pay €k Total Gross Income €k Net €k

CUH -673 -1,037 -1,710 -919 -2,629

SMOH 0 -5 -5 19 14

CUH-SMOH -673 -1,042 -1,715 -899 -2,615

Mallow -81 -23 -104 138 34

Total -754 -1,065 -1,819 -761 -2,580

CUH Group –Surplus / (Deficit) percentage %

CUH Group –Pay & Non pay Budget Surplus/(Deficit) %

CUH Group –Income Budget Surplus/(Deficit) %

CUH Budget v Actual Pay YTD Mar 2016

2015 Budget €k 2015 Actual €k Variance €k % Variance 2015 Actual €k v 2014 Variance €k

Medical/Dental 16,325 16,725 -400 -2% 16,127 -598

Nursing/Midwifery 22,169 22,218 -49 0% 21,897 -321

Paramedical 8,194 8,289 -95 -1% 7,906 -383

Housekeeping 1,753 1,781 -27 -2% 1,568 -213

Care Assistants 1,735 1,742 -7 0% 1,568 -175

Catering 1,034 1,045 -11 -1% 953 -92

Portering 1,465 1,508 -44 -3% 1,392 -116

Administration 4,611 4,609 2 0% 4,428 -181

Other Staff 792 833 -41 -5% 895 62

Total 58,078 58,751 -673 -1% 56,734 -2,018

CUH Actual Non-pay Expenditure March 2016 v 2015

CUH AGENCY COSTS €k 2014 -16

CUH AGENCY WTE – 2016

CUH Average Nursing & HCA Agency WTE’s per Week 2014 -2016

Patient Income 2014 –2016

Consultant Claims O/s Consultant claims at 31st March 2016

Directorate Value €k Prev

Value €k Current

Diagnostics 8 22

Medicine 3,581 3,445

Surgery 2,169 2,434

Women and Children CUH 355 363

Total-CUH Primary 6,114 6,265

Women & Children CUMH 1,142 1,100

Total-CUH /CUMH Primary

7,256 7,365

Consultants at 14th Apr No of claims Value €k

HARTY, JAMES 132 507,960

O'HALLORAN, D. J. 49 359,745

TAYLOR, COLM 98 285,351

CAHILL, MARY 89 254,177

GUERIN, SHANE 20 191,350

REIDY, DECLAN 24 168,252

O'SULLIVAN, SEAN S. 5 160,901

HENRY, MICHAEL 11 145,700

MCCOURT, MORGAN 41 141,640

O'MAHONY, DENIS 8 135,942

O'CONNOR, MICHAEL 14 133,316

GILLIGAN, OONAGH 87 125,800

O'BROIN, EOIN 43 122,610

FLEMING, PAT 22 114,375

KELLY, PETER 28 111,140

ANDREWS, EMMET J. 31 110,002

MCSWEENEY, NIAMH 28 95,079

O'SHEA, DERVILLE 25 89,488

SWEENEY, BRIAN 68 88,378

ZULQUERNAIN, SYED 40 86,565

PLANT, BARRY 10 85,553

HORGAN, MARY 16 84,422

3,597,746

CUH Debtor days Consultant Claims-Mar 2016

Patient Access

INMO Trolley Report Annual data for 2015 and comparative data for 2014

Weekly INMO Trolley Report Week ending 15th April

ED New Presentations Jan – Mar 2016

ED Admissions Jan – Mar 2016

ED – 6hr & 9hr Target – All Patients (Quarter 4 2015 Jan – Mar 2016)

Monthly Distribution of Ambulance Presentations (Jan – Mar 2016)

CUH Monthly Performance 20min Target

Delayed Discharges Jan- April 12th 2016

0

5

10

15

20

25

5th Jan 12th jan

19th Jan

26th Jan

2nd Feb 9th Feb 16th Feb

23rd Feb

1st Mar 8th Mar 15th Mar

22nd Mar

29th March

5th April

12th Apr

13

15 14

20

13

21

18

17

18

22 21

23

16

23 23

Outpatient Waiting Lists

27

2041 Urgent and Routine Patients who need to be seen in relation to the 15 month deadline by

month end (April) 2016 Count of Patients %

No of Patients with an Appointment before or on End of Month 251 12.30%

Number of Patients with an Appointment Post End of Month 62 3.04%

Number of Patients with No Appointment 1728 84.66%

Patients to be seen by 15 Month Timeline (end of current month April 2016)

Total Medical Patients to be seen by 15 Month Target

End of April 2016

Total Patient Count - 236

29

Total Surgical Patients to be seen by 15 Month Timeline End of April 2016

30

Women and Children Patients to be seen by 15 Month Timeline End of April 2016

Patients Currently Waiting Longer Than 12 Months

as of 06/04/2016 Waiting List

New and Return DNA Rate in CUH

32

Scope Waiting List

Scopes Urgent – February 2016 G

Scopes Routine - February 2016 R

INPATIENT WAITING LIST

Total Inpatient & Day case Waiting List (14th April 2016)

Count

of id Wait category

hospital name wl type ACTIVE PREADM

IT SUSPENSI

ON Grand Total

Cork University Hospital Adult 1729 366 47 2142

Child 71 37 3 111

GI Scope 139 167 16 322

Cork University Hospital Total 1939 570 66 2575

Grand Total 1939 570 66 2575

18 month Breaches as of 14th April 2016 (63)

15 month Breaches as of 14th April 2016 (139)

0

10

20

30

40

50

60

70

Cadriology Cardio thoracic

General Surgery

Urological Surgery

Plastic Surgery Vascular Surgery

Respiratory Gynaecology Orthopaedics

3

8

37

9 8

3 3

67

1

Quality & Safety

Surgical ALOS – February 2016

R

Medical ALOS – February 2016 R

Day Case Rate – Elective Cholecystectomy February 2016

R

NEWS Implementation – Feb 20116

G

IMEWS Implementation – Feb 2016

G

Risk Management – April KPI data

• Serious Reportable Events reported - 0

• Medication Safety Incidents reported -3

• Complaints – 16 complaints raised in January on average 3.6% closed within 30 day timeframe

• New claims notified to hospital - 1

• Risk(s) escalated in December -

Cancer KPI – Breast-Lung-Prostate January – March 2016

CIT Referrals – 5th April 2016

10

12

2

1

2 2

1

0

2

4

6

8

10

12

14

INR POC INR HOPAT s/c inohep W/Care Port flush IV abs

Risk Management - March KPI data

• Serious Reportable Events reported - 0

• Medication Safety Incidents reported 3

• Complaints – 16 complaints raised in February on average 3.6% closed within 30 day timeframe

• New claims notified to hospital - 1

• Risk(s) escalated to CUH Risk Register - March - 0

Quality and Safety

Serious Reportable Events

Audit of Serious Reportable Events completed – report awaited

Housekeeping Services Project Group

Post of Health Care Assistant advertised

Post of Health Care Assistant Facilitator signed off

Quality Improvement Programme for Outpatient services

Commence development of CUH Quality Strategy

NAS/Cork Hospital Interface Group

Development of South West Dispatch/Operational Paramedical Personnel Guideline

Human Resource Management

Sick Leave – March 2015

4.01 3.79

3.74

3.16 3.07

3.86 3.75 3.91 3.72 3.81 4.084.324.65 4.59 4.53

0

2

4

6

Jan Feb Mar April May June July August Sept Oct Nov Dec

%

CUH – Total % Sick Leave 2015 v 2016

2015% 2016% % Target

29.95

31.7 29.5

19.03

28.37

28 27.39

34.06

32.07

37.99

28.8924.99

36.59

34.31

0

10

20

30

40

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

WTE’s

CUH Long Term Sick Leave – WTE’s

Medically V’s Self Certified Sick Leave – March 2016

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

H'keep

ing

Po

rtering

Caterin

g

HSSD

Security

HC

A'S

Nu

rsing

Ad

min

Direc

Param

ed

Ad

min

Co

nsu

ltants

NC

HD

'S

9.895.93 5.39

18.27 17.3920.87 20.3 18.81

10.23 9.74

0 2.91

90.11

94

.07

94

.61

81

.73

82.61

79.13

79.7

81

.19

89

.77

90

.26

100

97.09

Self Certified Hrs Med Certified Hrs

% Hours Sick Leave per Dept (Paramedical) – March 2016

Speech & Lang,

2.57%

Resp Tech,

0.00%

Dark Room

Tech's, 23.23%

Biochem, 0.78%

Radiography,

8.80%

Biomed Eng,

1.94%

Radiation

Oncology,

11.58%Podiatry, 0.00%

Physiotherapy,

4.50%

Non Invasive

Cardiology,

2.25%

Dietetics,

2.45% Histopathology,

6.03%

Haematology,

2.02%

Blood

Transfusion,

1.81%

Microbiology,

13.36%

Neurophys,

2.05%

Occ. Therapy,

0.00%

Perfusionist,

0.00%

Physics, 6.27%Phlebotomy,

3.53%

March 2016

There was no return from Pharmacy and Social Work for March 2016

EWTD Compliance – Quarter 4 2015 & Jan - March 2016

Capital Projects Project Status

Paediatric Unit Phase 1 - build programme to be completed by

November 2016

Phase 2 – funding received to progress to Design stage

Radiation Oncology Unit

Planning permission granted

Contractor appointed for enabling work

Funding received for Bracktherapy Equipment

Education and Training Centre Statement of Need being developed

Blood Sciences Project

Design Team appointed Funding for interim

infrastructural works approved

Purchase of OLA approved

Oncology Service

Expansion of Day Unit – plan signed off –

submitted for Philanthropic funding (ACT)

Refurbishment of Ward 2D – capital funding in

place

Medical Oncology Centre – developing Statement

of Need

Ophthalmology Transfer – Phase 2

Project group in place

Application for planning permission submitted

Helipad

Interim helipad in place – contractor to be appointed in

March 2016

Replacement Autoclaves & RO Project Commenced

Key Issues

• Retention of 30 inpatient beds (Transitional Care Unit)

• Dependency on patient income

• Clarification of 2016 Budget

• Undergraduate Training costs - €6.5m per annum

• Management of Unscheduled Care

• Implementation of Change Programme Initiatives