trust board meeting in public agenda 11 j… · trust board meeting in public agenda 11 january...

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TRUST BOARD MEETING IN PUBLIC

AGENDA

11 January 2018 at 9.30am – 12.00noon

Terrace Executive Meeting Room, Spice of Life Restaurant, Watford Hospital

Apologies should be conveyed to the Trust Secretary, Jean Hickman on [email protected] or call 01923 436 283

Item ref

Title Objective Previously presented

Lead Paper or verbal

01/55 Opening and welcome

To note N/A Chair Verbal

02/55 Report on a visit to Intermountain and the Institute of Healthcare Improvement, USA

To receive N/A Deputy Chief Executive

Presentation

OPENING

03/55 Apologies for absence


04/55 Conflicts of interest To note N/A Chair Paper

05/55 Minutes of the meeting held on 07 December 2017

For approval

N/A Chair Paper

06/55 Board action log from 07 December 2017 and previous meetings and decision log

To note N/A Chair Paper

07/55 Chair’s report


08/55 Chief Executive’s report To note N/A Chief Executive

Paper

PERFORMANCE

09/55 Integrated performance report – month 8

To note Trust Executive Committee

Chief Operating Officer

Paper

SAFE EFFECTIVE CARE (BAF RISK 1)

10/55 Quality improvement plan update

For information

and assurance

Trust Executive Committee

Chief Nurse

Paper

GOVERNANCE

11/55 Summary report on corporate risk register

For information/assurance


Deputy Chief Executive

Paper

AGENDA

1 of 161Trust Board Meeting in Public-11/01/18

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COMMITTEE REPORTS

12/55 Assurance report from Finance and Investment Committee

For information

and assurance

Finance and Investment Committee

Committee Chair/ Chief Financial

Officer

Paper

13/55 Assurance report from the Patient and Staff Experience Committee

For information

and assurance

Patient and Staff Experience Committee

Committee Chair/Director of

Human Resources

Verbal

14/55 Assurance report from Safety and Compliance Committee

For information

and assurance

Safety and Compliance Committee

Committee Chair/Medical

Director

Paper

15/55 Assurance report from Clinical Outcomes and Effectiveness Committee

For information

and assurance

Clinical Outcomes and Effectiveness Committee

Committee Chair/Chief Nurse

Paper

REPORT TO CORPORATE TRUSTEE

16/55 Assurance report from the Charitable Funds Committee

For information

and assurance

Charitable Funds

Committee


Human Resources

Paper

ANY OTHER BUSINESS

17/55 Any other business previously notified to the Chairman

N/A N/A Chair Verbal

QUESTION TIME

18/55 Questions from Hertfordshire Healthwatch

To receive

N/A

Chair Verbal

19/55 Questions from our patients and members of the public

To receive N/A Chair Verbal

ADMINISTRATION

20/55 Draft agenda for next board meeting

To approve N/A Chair Paper

21/55 Date of the next board meeting in public: 01 February 2018, Terrace Executive Meeting Room, Watford Hospital


AGENDA

2 of 161 Trust Board Meeting in Public-11/01/18

Acronyms and abbreviations

AGENDA


A AAA Abdominal Aortic Aneurysm AAU Acute Admissions Unit A&E Accident and Emergency ABPI Association of the British Pharmaceutical Industry AC Audit Commission ACS Adult Care Services ADM Assistant Divisional Manger AGS Annual Governance Statement AHP Allied Health Professional

B BAF Board Assurance Framework BAMM British Association of Medical Managers BAU Business as usual BC Business Continuity BCP Business Continuity Plan BGAF Board Governance Assurance Framework B&H Bullying and Harassment BISE Business Integrated Standards Executive BMA British Medical Association BME Black and ethnic minorities BSI Bloodstream infection

C CAB/C&B Choose and Book Caldicott Guardian The named officer responsible for delivering and implementing the

Confidentiality and patient information systems CAMHS Child and adolescent mental health services CAS Central Alert System CCG Clinical Commissioning Groups

CCIO Chief Clinical Information Officer CCORT Clinical Care Outreach Team CCU Critical Care Unit CD Clinical Director C.Diff Clostridium Difficile CEO Chief Executive Officer CfH/CFH Connecting for Health CFO Chief Financial Officer CHD Coronary heart disease CIO Chief Information Officer CIP Cost improvement programme CIS Care Information Systems CMO Chief Medical Officer CNO Chief Nursing Officer CNS Clinical Nurse Specialist CNST Clinical Negligence Scheme for Trusts COI Central Office of Information COO Chief Operating Officer COPD Chronic Obstructive Pulmonary Disease COSHH Control of Substances Hazardous to Health CPA Clinical Pathology Accreditation

AGENDA


CPD Continuing Professional Development CPOP Clinical Policy and Operations CFPG Capital Finance Planning Group CPR Cardiopulmonary resuscitation CQC Care Quality Commission CQUIN Commissioning for Quality & Innovation CRS Care Records Service CSE Child sexual exploitation CSSD Central Sterile Service Department CSU Clinical Support Unit CT Computerised Tomography

D DCC Direct Clinical Care DD Divisional Director DGH District General Hospital DGM Divisional General Manager DM Divisional Manager DIPC Director of Infection Prevention and Control DH or DoH Department of Health DNA Did Not Attend DNR Do Not Resuscitate DO Developing our Organisation DoC Duty of Candor DoLS Deprivation of Liberty Safeguards DPH Director of Public Health DQ Data Quality DTA Decision to admit DTOC Delayed Transfers of Care DQ Data Quality

E EA Executive Assistant EADU Emergency Assessment and Discharge Unit ECG Echocardiogram ECIP Emergency Care Improvement Programme ED Emergency Department ED Executive Director EDD Expected Date of Discharge EDS Equality Delivery System EIA Equality Impact Assessment ENHT East & North Herts NHS Trust ENT ear, nose and throat EoE East of England EoL End of Life EPAU Early Pregnancy Assessment Unit EPRR Emergency Preparedness, Resilience and Response ERAS Enhanced Recovery Programme after Surgery ESR Electronic Staff Record EWTD European Working-Time Directive

AGENDA


F FBC Full Blood Count FBC Full Business Case FCE Finished Consultant Episode FFT Friends and Family Test FD Finance Director FGM Female genital mutilation FOI Freedom of Information FRR Financial Risk Rating FSA Food Standards Agency FT Foundation Trust FY Full Year

G GDC General Dental Council GGI Good Governance Institute GMC General Medical Council GP General Practitioner GUM Genito-urinary medicine GOO General other outcome

H H&S Health and Safety HAI Hospital Acquired Infection HAPU Hospital Acquired Pressure Ulcer HCAI Healthcare-Associated Infections HCC Hertfordshire County Council HCT Hertfordshire Community NHS Trust HDA Health Development Agency HDD Historical Due Diligence HDU High Dependency Unit HEE Health Education England HHH Hemel Hempstead Hospital HES Hospital Episode Statistics HIA Health Impact Assessment HITP Hertfordshire Integrated Transport Partnership HON Head of Nursing HPA Health Protection Agency HPFT Hertfordshire Partnership NHS Foundation Trust HR Human Resources HRG Health Related Group HSC Health Service Circular; (House of Commons) Health Select Committee HSC Health Scrutiny Committee, sub-committee of Overview and Scrutiny

Committee, Hertfordshire County Council HSE Health and Safety Executive HSMR Hospital Standardised Mortality Ratio (Rates) HSO Health Service Ombudsman HTM 00 Health Technical Memorandum HUC Herts Urgent Care HVCCG Herts Valley Clinical Commissioning Group

AGENDA


I IBP Integrated Business Plan IC Information Commissioner ICAS Independent Complaints Advocacy Service ICNs Infection Control Nurses ICO Information Commissioners Office ICT Information, Communications and Technology IDT Integrated Discharge Team IVF In Vitro Fertilisation ICU Intensive Care Unit IDVA Independent domestic violence advisors IG Information Governance IMAS Interim Management Service IM&T Information Management and Technology IP Inpatient IPR Integrated Performance Report IRGC Integrated Risk and Governance Committee ISE Integrated Standards Executive IST Intensive Support Team IT Information Technology ITFF Independent trust financial facility ITU Intensive Treatment Unit

J JSNA Joint Strategic Needs Assessment

K KLOE Key Line of Enquiry KPI Key Performance Indicator

L LAs Local authorities LABV Local Asset Backed Vehicle LAT Local Area Team (of NHS England) LCFS Local Counter Fraud Service L&D Learning and Development LDB Local delivery board LGBT Lesbian Gay Bisexual and Transgender LHCAI Local Health Care Associated Infections LHRP Local Health Resilience Partnerships LMC Local Medical Committee LSMS Local Security Management Specialist LSP Local Service Provider LTFM Long Term Financial Model

AGENDA


M MCA Mental Capacity Act MD Medical Director MDA Medical Device Agency MDT Multi-Disciplinary Team MEWS Modified Early Warning Score MHAC Mental Health Act Commission MHRA Medicines and Healthcare Products Regulatory Agency MIU Minor Injuries Unit MMC Modernising Medical Careers MMR Measles, mumps, rubella MRET Marginal rate emergency tariff MRI Magnetic resonance imaging MRSA Methicillin-resistant Staphylococcus aureus MSSA Methicillin-sensitive Staphylococcus aureus

N NE Never Event NED Non Executive Director NHS National Health Service NHS CFH NHS Connecting for Health NHSE NHS England NHSLA NHS Litigation Authority NHSTDA NHS Trust Development Agency NHSP NHS Professionals NHSP Newborn Hearing Screening Programme NICE National Institute for Health and Clinical Excellence NIHR National Institute for Health Research NMC Nursing and Midwifery Council #NoF Fractured Neck of Femur NPSA National Patient Safety Agency NSF National Service Framework NTDA NHS Trust Development Agency

O OBC Outline Business Case OD Organisational Development OJEU Official Journal of the European Union OLM Oracle Learning Management OMG Operational Management Group ONS Office for National Statistics OOH Out of Hours Service OP Outpatient OSC (local authority) Overview and Scrutiny Committee OT Occupational Therapist/Therapy

AGENDA


P PA Programmed Activities PAC Public Accounts Committee PACS Picture Archiving and Communications System PALS Patient Advice and Liaison Service PAM Premises Assurance Model PAS Patient Administration System PAS 5748 Publicly Available Specification 5748 - provides a framework for the

planning, application and measurement of cleanliness in hospitals PbR Payment by Results PCC Primary Care Centre PCT Primary Care trust PEG Patient Experience Group PFI Private Finance Initiative PHO Public Health Observatory PID Project Initiation Document PLACE Patient Led Assessment of the Care Environment PMO Programme Management Office PMR Provider Management Regime PPI Proton Pump Inhibitors PPI Patient and Public Involvement PR Public Relations PSED Public Sector Equality Duty PSQR Patient Safety, Quality and Risk Committee PTL Patient Tracker List

Q QA Quality Assurance Q&A Questions and Answers QG Quality Governance QGAF Quality Governance Assurance Framework QIA Quality Impact Assessment QIP Quality Improvement Plan QIPP Quality, Improvement, Prevention and Promotion QRP Quality Risk Profile QSG Quality and Safety Group

R R&D Research and Development RA Registration Authority RAG Risk and Governance/Red Amber Green RCA Root Cause Analysis RCN Royal College of Nursing RCP Royal College of Physicians RCS Royal College of Surgeons RES Race Equality Scheme RFH Royal Free Hospitals NHS Foundation Trust RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations RSRC Risk Summit Response Committee RTT Referral to Treatment RTTC Releasing Time to Care

AGENDA


S SACH St Albans City Hospital SCBU Special Care Baby Unit SES Single Equality Scheme SFI Standing Financial Instructions SHMI Standardised Hospital Mortality Index SHO Senior House Officer SI Serious Incident SIC Statement of Internal Control SIRG Serious Incident Review Group SIRI Serious Incident Requiring Investigation SIRO Serious Incident Risk Officer SLA Service Level Agreement SLR Service Line Reporting SLM Service Line Management SMG Strategic Management Group SMS Security Management Service SOC Strategic Outline Case SQ Safety and Quality SPA Supporting Professional Activity SRG System Resilience Group STEIS Strategic Executive Information System ST & M Statutory and Mandatory STP Sustainability and Transformation Programme SUI Serious Untoward Incident (same as Serious Incident, more commonly

used).

T T&D Training and Development TDA Trust Development Authority (also known as NTDA) TEC Trust Executive Committee TLEC Trust Leadership Executive Committee T&O Trauma and Orthopaedic TOP Termination of Pregnancy TOR Terms of Reference TPC Transformation Programme Committee

T TSSU Theatre Sterile Service Unit TUPE Transfer of Undertakings (Protection of Employment) Regulations TVT Tissue Viability Team

U UCC Urgent Care Centre

V VFM Value For Money VTE Venous Thromboembolism

AGENDA


W WACS Women’s and Children’s Services WBC Watford Borough Council WFC Workforce Committee WGH Watford General Hospital WHHT West Hertfordshire Hospitals NHS Trust WHO World Health Organisation WRVS Women’s Royal Voluntary Service WTD Working-time directive WTE Whole Time Equivalent (staffing)

Y YTD Year to date YCYF Your care, your future

AGENDA


the very best care for every patient, every day the very best care for every patient, every day

Boston / Utah Study Tour

October 2017

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Who went? • Mike Van Der Watt – Medical Director

• Freddie Banks – Associate Medical

Director, Strategy

• Andy Barlow – Divisional Director,

Women and Children

• Mary Bhatti – Divisional General

Manager, Women and Children

• Paula King – Head of Nursing,

Surgical Division

• Helen Brown – Deputy Chief

Executive

Who did we meet?

BOSTON

Dr Thomas Lee – Chief Medical Officer Press

Ganey. Internist & Cardiologist at Brigham

Young& Women’s Hospital. Member of editorial

board New England Medical Journal

Institute for Health Improvement leadership

team.

Brigham Young and Women’s Hospital

leadership team

UTAH

Intermountain Healthcare ‘Institute for Healthcare

Research’ and iCentra leadership teams (iCentra

is a fully integrated electronic health record that

Intermountain is developing with Cerner)

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What did we hear about?

• Leadership and change management in healthcare

• Clinician engagement, resilience and ‘burn out’

• Approaches to Quality Improvement (QI) and the IHI

approach

• Improving quality and reducing costs the

Intermountain Healthcare way

• Data for improvement & the opportunities and pitfalls

of electronic health records

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Leadership • Creating the environment in which clinicians can deliver consistently

excellent care for patients.

• Essential ingredients – team work & ‘team of teams’ (Stanley McChrystal),

clinician satisfaction / professional fulfilment, engagement, openness &

transparency, processes aligned to outcomes trying to achieve.

• 3 or more is critical mass for changing attitudes and creating movement

for change. Focus on supporting leaders and encouraging ‘early

adopters’. Peer pressure and competition can drive change effectively.

• No story without data, no data without stories. Create narrative for

change – use videos and in house TED talks and ‘innovation incubator’

awards?

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Burn-out and resilience

• ++ concern re clinician burnout and attrition rates for doctors in training.

• Need to reduce stressors and increase rewards (not money but team work &

recognition in its broadest sense)

• Technology a challenge and an opportunity (EPRs can be burdensome for

clinicians vs opportunities for decision support and artificial intelligence)

• How can we help people to operate ‘at the top of their license’? (e.g scribes

in wards and outpatients

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Transparency

• Sharing real time / live feedback from patients can drive

improvement and provide positive re-inforcement for clinicians

• Phased roll out – first step only clinician can see, only shares

data more widely when happy to

• Light touch ‘appeals’ process for vexatious comments – but

rarely used (and err on side of transparency vs censorship)

• Its not mandatory but a critical mass of clinicians are now

sharing their data openly (BJ&WH / Press Ganey)

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Strategy

• Operational effectiveness = doing things more and more efficiently.

Not enough on its own - need ‘operational effectiveness’ + strategy to

thrive (or even survive)

• Strategy = making choices – what are we trying to do and for whom?

What makes us different?

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Things to think about at WHHT

• Innovation incubator / in-house TED talks / videos

• Storytelling training for leaders?

• Transparency – try again with iWantGreatCare – voluntary basis.

• Increased focus on team work and opportunities to socialise?

• Workforce redesign – pilot scribe on ward round?

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‘framework for clinical excellence’ (IHI and Allan

Frankel)

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Institute for Health Improvement

• Subject matter expertise + improvement science = best recipe for positive

change

• Lots of tools to support quality improvement – clear problem statements

(reduce noise at night or all patients to get 6 hours uninterrupted sleep?!),

driver maps, PDSA cycles etc

• build skills in clinical teams (on line bite sized training)

• Need to collect data – but not obsessively / think carefully about what data

will need.

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• IHI are working with Trust to undertake diagnostic (October)

• Access to on line bite size training (link to innovation incubator?)

• quality strategy will set out our approach ~ ‘the west Herts way’ ()

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Intermountain • Integrated (not-for-profit) healthcare provider based in Utah – 22 hospitals and more than 185

clinics. Also offers health insurance plans.

• Mission – ‘helping people live the healthiest lives possible’ + high quality, affordable care when

needed.

• 30+ years work on ‘reducing variation’ – more than 85 care process models baked in to the way

the organisation operates + an all encompassing ethos about ‘the way we do things here’.

• Clinician freedom paramount – absolutely clinically led

• Only just implementing a full EPR – but early adopters of technology and history of ++ local

systems (e.g. ventilator settings programme).

• Scale and integrated system give additional opportunities, though has taken time to learn how to

do it in multiple locations.

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The basic approach

Review evidence and agree detailed pathway / care process model

Align operational systems to

make it easy to follow

Design measurement system – is the process being

followed?

Track outcomes /

clinical indicators

• Consistent / standardised ‘good’ is better than ‘excellent’ (but variable)

• If no evidence then go with clinical consensus – try / review / adapt

• Focused on high volume activities – e.g. UTIs, deliveries with complications

• Clinical freedom is paramount – they mean it!

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Reducing complications in labour

• If can get the chart re reducing early inductions would like to include

with some notes

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EPR - intermountain / Cerner

• Intermountain – implementing Cerner. Although they had a long history of in-house

software development they came to view that needed to make significant additional

investment and partner with an expert to take to next stage. Felt at limits of what

could achieve without EPR.

• Working with Cerner to fully digitise pathways into the EPR. Demonstrated how

this works with Sepsis pathway as an example. We saw in action in ITU at

Intermountain Medical Centre.

• Cerner will incorporate detailed order sets and prescribing protocols

• Its not just a clinical record but effectively a decision support tool.

• Clinicians can override.

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EPR – Brigham Young and Women’s Hospital

• Recently implemented EPIC (EPR)

• Less focused on supporting clinical care, focus appeared to be more

on data capture and billing

• Reported that having a significant detrimental impact on clinician

satisfaction

• Track time / day of input – clinicians catching up on a Saturday night

(Saturday night used to be date night but not any more!)

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• Enthusiasm for participation in RFL group / CPGs – but need to think

about implementation stage and data capture.

• Need to build / spread knowledge and understanding in clinical body

and empower and support champions.

• We do quite a lot of this already – but are less good at aligning

processes and capturing data to evidence consistent application and

impact on outcomes.

• Is there an opportunity to piggyback RFL ‘GDE’ Cerner roll out and

access funding?

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Last updated : 04 January 2018

Declaration of Board members and attendees conflicts of interest 11 January 2018

Agenda item: 04

Name Role Description of interest Relevant dates

From To

Professor Steve Barnett Trust Chair Chair and Client Partner of SSG Health Ltd

Non-Executive Chairman of Finegreen Associates

Trustee and Director of the Institute of Employment Studies

Wife is CEO of Rotherham NHS Foundation Trust

Visiting Professor University of West London Business School

Honorary Visiting Professor Cranfield University School of Management

Member of the East Midlands Regional Committee for Clinical Excellence Awards

Present Present Present Present Present Present Present

Andy Barlow Divisional Director, Women’s and Children’s Services Barlow Medical Services Ltd Present

John Brougham Non-Executive Director Non-Executive Director and Chair of the Audit Committee of Technetix Ltd

2010

Present

4

Tab 4 C

onflict of interest

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Helen Brown Deputy Chief Executive None

Professor Tracey Carter Chief Nurse and Director of Infection Prevention and

Control None

Paul Cartwright Non-Executive Director Treasurer for St Peter’s Church

Trustee and Chair of Finance and Audit Committee for The Church Lands, St Albans.

Charitable Funds for West Hertfordshire Hospitals NHS Trust

Nov 2015 Nov 2015 Nov 2015

Present Present Present

Virginia Edwards Non-Executive Director Trustee Peace Hospice Care

Global Action Plan; providing support to their programme called Operation TLC

Director Edwards Consulting Ltd

Husband is CEO of Nuffield Trust

Husband is a non-remunerated member of the Strategy Committee of Guys and St. Thomas’s Charitable Trust

Husband is Director of Edwards Consulting Ltd

Charitable Funds for West Hertfordshire Hospitals NHS Trust

2011 2016 2011 2011 2011 2011 2014

Present Present Present Present Present Present Present

Katie Fisher Chief Executive None

Jeremy Livingstone Divisional Director of Surgery , Anaesthetics and

Cancer Jeremy Livingstone Ltd Present

4

Tab 4 C

onflict of interest

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Arla Ogilvie

Divisional Director for Medicine Private practice Present

Jonathan Rennison Non-Executive Director Kings College London

Rising Tides Ltd

The Yellow Chair Ltd

Edgecumbe Consulting

Association of NHS Charities

The Teatpot Trust

Swindon Museum and Art Gallery Trust

BNET (Britain-Nigeria Education Trust)

Centre for Sustainable Working Life, Birkbeck College

Evidence Aid

March 2017 May 2017 August 2012 April 2015 Sept 2015 June 2016 Dec 2016 Oct 2016 April 2017 January 2017

Present Present Present Present Present Present Present Present Present Present

Don Richards Chief Financial Officer Director of 7M Ltd April 2017

Phil Townsend Non-Executive Director None

Sally Tucker Chief Operating Officer None

Dr Mike van der Watt Medical Director

Owner and Director Heart Consultants Ltd

Private Practice

Wife is Director of Hearts Consultants Ltd

Present

4

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onflict of interest

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07 December 2017 at 9:30am - 12.00noon

Terrace Executive meeting room, Watford hospital

Chair Title Attendance

Professor Steve Barnett Chair Yes

Voting members

John Brougham Non-Executive Director Yes

Helen Brown Deputy Chief Executive Yes

Professor Tracey Carter Chief Nurse and Director of Infection Prevention and Control

Yes

Paul Cartwright Non-Executive Director No

Ginny Edwards Non-Executive Director Yes

Katie Fisher Chief Executive No

Jonathan Rennison Non-Executive Director Yes

Don Richards Chief Financial Officer Yes

Phil Townsend Non-Executive Director Yes

Dr Mike van der Watt Medical Director Yes

Non voting members

Dr Andy Barlow Divisional Director, Women’s and Children’s No

Paul da Gama Director of Human Resources Yes

Lisa Emery Chief Information Officer Yes

Mr Jeremy Livingstone Divisional Director, Surgery, Anaesthetics and Cancer

No

Dr Arla Ogilvie Divisional Director, Medicine Yes

Sally Tucker Chief Operating Officer Yes

In attendance

Louise Halfpenny Director of Communications Yes

Jean Hickman Trust Secretary (notes) Yes

Thomas Galliford Consultant Endocrinologist Yes

Gloria Rowland Associate Director of Midwifery and Gynaecology Yes

Sundera Kumara-Moorthy Representative for Healthwatch Yes

1 member of the public N/A

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Tab 5 Minutes of the meeting held on 07 December 2017


of 9

MEETING NOTES

Agenda item

Discussion Lead Dead-line


01.01 The chair opened the meeting and welcomed the board and members of the public.

02/54 Integrated diabetes service

02.01 The chair invited Dr Thomas Galliford to advise the board on progress towards the establishment of an integrated diabetes service. Dr Galliford advised that diabetes was a major health problem in Herts Valley with around 25,000 patients diagnosed with diabetes. He outlined the vision for an integrated diabetes model and the proposed patient journey. The board was advised that the trust would be a lead provider and the model would be based on an outcomes contract approach, which would mean a greater focus by providers on improving outcomes for individual patients and for the diabetes population across Hertfordshire. The board was warned that the hospital infrastructure provided a significant key challenge to the project; however it was assured that the trust was working closely with partners to meet the required short timelines to implement the integrated model.

02.02 Ginny Edwards thanked Dr Galliford for his excellent presentation and asked whether the Health and Wellbeing Board had been actively involved. Dr Galliford advised that prevention was the responsibility of Herts valley clinical commissioning group (HVCCG) and had not been part of the initial specification, however, it was now recognised that this should be included in future discussions.

02.03 Jonathan Rennison asked whether behaviour changes had been considered as part of the new model. The board was informed that patient education was a key element of the integrated approach; this included actions that patients could take to put diabetes into remission, such as advice, exercise, and psychology.

02.04 Phil Townsend said that the presentation had been an excellent measured description of service redesign and enquired whether the learning achieved from this work could be used in other service areas. Dr Galliford responded that integrating care was now the way forward for a wide number of services and, as the diabetes service had been working on this for a long time, the team had spoken to other services and explained the challenges that they may face. He suggested a key factor was to be part of early discussions to ensure that the service was recognised as an integral part of the model. The deputy chief executive reminded the board that the trust was investing in integrated care by developing the programme management office to support this important work. She advised that finance and contracting teams were also closely involved.

02.05 The divisional director for medicine thanked Dr Galliford for his hard work in leading this complex work and noted that it was crucial for future redesign work to be appropriately resourced in order to provide adequate support to allow clinicians to lead this work. The chief information officer concurred with this view and noted the importance of investing time and effort in IT to ensure the success of integrated service model approaches.

02.06 The chair thanked Dr Galliford for attending the board meeting and for his excellent leadership in this important area.

02.07 Resolution: The board received the presentation.

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Agenda item


OPENING


03.01 Apologies were received from Paul Cartwright, the chief executive, the divisional director of women’s and children’s division and the divisional director of surgery, anaesthetics and cancer.

04/54 Conflicts of interest

04.01 No further conflicts of interest were reported than those circulated previous to the meeting.

05/54 Minutes of the meeting held on 02 November 2017

05.01 09.15. This point should read ‘The chief nurse confirmed that patients who meet the clinical need of the hyper acute stroke unit was not an area where mixed sex breaches were part of contractual sanctions’.

05.02 10.02. It was reported that the quality strategy would be launched in April 18 and the quality improvement plan will complete at the end of March 18.

05.03 Subject to the above changes, the minutes were agreed to be a true record of the meeting.

06/54 Board action log from 02 November 2017 and previous meetings and decision log

06.01 All actions were either completed or on track to be completed within the timeline.


07.01 The chair presented his report and highlighted that the Chancellor of the Exchequer had announced in his autumn budget that the NHS would receive £1.6bn of extra revenue in 2018/19.

07.02 It was reported that Professor Stephen Powis had been appointed as the national medical director and Ian Dalton had taken over as chief executive of NHS improvement (NHSI). The chair advised that he would be inviting Ian Dalton to visit the trust when he had started in his new post.

07.03 Phil Townsend asked for clarification on the trust’s x-ray reporting process, following the launch of a national review by the care quality commission (CQC) after it had found that more than 20,000 x-rays had not been reviewed at an appropriate senior staffing level. The board was assured that the trust had undertaken an internal investigation and had taken immediate steps to ensure that appropriate reporting processes were in place. It was noted that the safety and compliance committee would receive a paper to provide assurance on the process.

07.04 The chair updated the board on stakeholder engagement around the development of a strategic outline case (SOC) for Hemel Hempstead hospital. This included the establishment of a Dacorum and Hemel Hempstead hospital project group and a consultation planned for the spring 2018 which will be led by HVCCG.

07.05 A number of groups and businesses were thanked by the board for their kind donations to the trust since the previous meeting. This included Hygiene Finishers and Tri Electrics for the donations of Christmas trees and decorations and the chair advised that he would be switching on the Christmas lights across the trust from 07 December 2017.

07.06 The board applauded the outstanding work and achievements of individual staff and teams highlighted in the chair’s report.

07.07 Resolution: The board received the report for assurance.

08/54 Chief executive’s report

08.01 In the absence of the chief executive, the deputy chief executive advised the board that the hospitals continued to be extremely busy and

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Agenda item


she thanked staff for their tremendous commitment and hard work in providing care to patients.

08.02 The deputy chief executive reported that the trust had approved the commencement of works to move to a full electronic medical records storage system. She reminded the board that better use of data and technology in the NHS had the power to deliver improved services, reduce the administrative burden for care professionals and reduce costs.

08.03 It was noted that the staff flu vaccination programme was ongoing despite the extremely challenging target. Similarly, staff continued to be encouraged to complete the national staff survey,

08.04 Resolution: The board received the report for assurance.

PERFORMANCE

09/54 Integrated performance report- month 7

09.01 The chief operating officer introduced the integrated performance report (IPR) and highlighted areas of particular note.

09.02 John Brougham enquired why the data regarding 62 day screening was provisional in every IPR. The chief information officer responded that there were a number of tertiary elements in this particular pathway which were required to be collated before the data could be validated and confirmed and assured the board that performance was being closely tracked.

09.03 John Brougham noted a reduction in referral to treatment (RTT) performance and asked what action was being taken to improve this. It was reported that issues with theatre ventilation had been a key source in the decrease in performance and the board was assured that the trust was working on how it could better utilise the St Albans site to improve operational performance. The chief financial officer also noted that a surge into Flaunden ward had impacted on RTT performance.

09.04 Phil Townsend brought the ward scorecard to the board’s attention and congratulated the chief nurse and the wider nursing teams on the actions that were having an impact on safety performance. The chief nurse commented that frontline staff were working hard to provide the best possible safe, patient care.

09.05 The board noted a steep decline in safer staffing performance and the chief nurse advised that this was due largely to the need to move substantive staff to appropriately support surge areas and manage emergency pressures. She advised that the trust had put out 500 more shifts in October 2017 than in the previous month due to the number of vacancies, supporting the enhanced care team and managing surge areas.

09.06 The chief financial officer presented an overview of the financial position and noted that this did not include the outcome of a mediation meeting. He advised that the report reflected a new, provisionally accepted, revised financial forecast of £35m deficit and noted that the trust would be discussing the actions required to meet the new trajectory with NHSI. The board was advised that the current year to date deficit of £27.57m was £12.72m adverse to plan at month 7. All areas were adverse to the plan, with £4.5m due to unachieved cost improvements and £3.25m due to NHS revenue. The chief financial officer reported that pay costs were worse than the previous month due to a demand for more one to one nursing and assured the board that the trust was working with divisions to improve this area.

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09.07 It was reported that income year to date was £3.3m below plan with non-elective income better than forecast due to unexpected use of the St Albans site. The chief financial officer advised that agency costs were good when compared to the same period the previous year which meant that the trust was heading towards its internal target, however he strongly recognised the need to drive agency costs down further.

09.08 The chair enquired whether, due to the late confirmation of capital expenditure, the trust would be able to transfer the funding over to 2018/19. The chief financial officer advised that although this had not been confirmed, it was expected that some of the funding would be able to be transferred over.

09.09 As chair of the finance and investment committee, John Brougham acknowledged the focused commitment of the trust to meet the financial control total; however he reminded the board of the significant challenge it posed.

09.10 Resolution: The board noted the IPR for assurance.

10/54 Winter readiness briefing

10.01 The chair informed the board that NHSI had instructed every NHS trust to receive a briefing and a resolution on how it planned to fully implement the actions detailed in a letter by the national urgent and emergency director.

10.02 The chief operating officer advised that, similar to other NHS trusts in Hertfordshire, the trust was experiencing a significant early level of increased attendances. However, she assured the board that the trust was in a good position regarding preparedness for winter.

10.03 It was reported that a number of the actions requested by NHSI were system wide and the trust was working closely with its partners to achieve these. It was noted that there were four areas which the trust had sole influence over; expanding the flu vaccination programme; reducing delayed transfers of care to provide additional hospital bed capacity; increasing the emergency care workforce and clinical oversight and risk. The board discussed the actions being taken and was advised that winter preparedness was a key part of discussions at performance monitoring meetings with NHSI.

10.04 Phil Townsend was keen to understand whether the trust took similar actions to monitor the readiness of the physical hospital infrastructure. The deputy chief executive responded that the trust had a comprehensive planned maintenance programme. This had identified a risk around the trust’s hot water system which would require urgent capital funding. She assured the board that the planned maintenance programme was monitored by the safety and compliance committee.

10.05 Resolution: The board was assured that all guidance issued by NHSI had been met and actions fully implemented.


11.01 The chief nurse presented a report on the quality improvement plan (QIP) and assured the board that the plan was monitored by the strategy delivery board (SDB). She advised that two change request forms had been approved by SDB relating to end of life care and patient feedback. It had been agreed that ongoing ICT and information projects would be removed from the QIP as they were included in the Make IT Happen programme and the ICT governance structure.

11.02 The chief nurse advised that any further actions from the most recent CQC inspection report, which was expected to be published in January 2018, would be added to the QIP and continued to be tracked through

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until the end of March 2018.

11.03 The non-executive directors recognised the significant improvement that had been made to the content of the regular QIP report.

11.04 Resolution: The board received the report for information and assurance.

12/54 Annual maternity establishment review

12.01 The chair welcomed the associate director of midwifery and gynaecology to the meeting and congratulated her on the maternity service winning a national workforce award for its successful drive to recruit and retain midwives and for turning around its CQC rating from ‘inadequate to ‘good’.

12.02 The associate director of midwifery and gynaecology presented an overview of the outcome of the national annual establishment review. She advised that the review which had focused on all births from October to December 2016 had concluded that the overall ratio for births was 26 births to 1 whole time equivalent (WTE) midwife. The board was informed that the service had been able to absorb the additional staffing requirements by introducing innovative ways of working and new roles. The associate director concluded her presentation by advising the board that the trust executive committee had approved a recommended principle to over-recruit band 6 midwives to reduce the reliance on agency staff, which was expected to result in a safer and more cost-effective service. It was noted that a business case was being developed to support this approach and the director of workforce assured the board that this would not represent an increase in the substantive establishment.

12.03 Phil Townsend enquired whether there was an increased risk to changing the staffing ratio. The associate director confirmed that there was a risk, however she agreed that 1WTE to 26 births was the correct number in order to keep patients safe. It was noted that this would be closely monitored by the patient and staff experience committee.

12.04 The divisional director of medicine congratulated the maternity unit on its excellent work and asked whether this could be replicated in other service areas. The chief nurse confirmed that re-profiling of the workforce was underway in a number of areas which involved reviewing senior decision makers and the skill-mix required.

12.05 The chief financial officer commented that the women’s service had shown a marked increase in clinical and financial performance which was as a result of the hard work, resilience and expertise of the associate director of midwifery and gynaecology.

12.06 The chair reminded the board that the associate director of midwifery and gynaecology services would be leaving the trust at the end of December 2017 to take up a senior post at Guy’s and St Thomas’ NHS Hospital Trust. The board thanked her for her excellent work and wished her well in her future role.

12.07 Resolution: The board received the presentation for information and assurance.

13/54 Strategy update – month 8

13.01 The board received a strategy update from the deputy chief executive. She advised that NHSI had confirmed that the SOC for the redevelopment of acute services was progressing through its governance process and although the trust was unlikely to receive any feedback before Christmas, NHSI had indicated that the trust was considered a priority.

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13.02 The deputy chief executive advised the board that it would receive a paper in the private session on proposals for the SOC for Hemel Hempstead hospital. The original target timeline for completion was March 2018; however the board was advised that this was now likely to be April 2018 following discussion with HVCCG.

13.03 The chief financial officer pointed out that a car parking SOC had been submitted to NHSI for review and approval and reminded the board that the lease ran out in September 2018 when Kier and Watford borough council planned to start redeveloping the land. This land was required for staff car parking; therefore the trust was negotiating a year extension to the current lease. The chair expressed his concern at a recent article in the Watford Observer that the football club planned to extend its ground and asked if this would compromise the trust’s plans. The deputy chief executive advised that the Watford riverwell partnership had contacted the football club and been assured that it had no plans to extend.

13.04 The board was advised that good progress was being made with the Royal Free London partnership and a board development session would be held in March 2018 to explore this further.

13.05 The board discussed the implications of integrated care and pathway redesign. The deputy chief executive warned the board that this could cause some disruption to services, in particular the ear, nose and throat and ophthalmology pathways, which were just beginning the process. She noted that HVCCG was continuing to push through the provider collaborative approach and, if the contractual terms were not agreed, it was likely to be put through a competitive route. The chief financial officer assured the board that the trust was working with HVCCG to obtain confirmation on contractual terms before it would move forward.

13.06 Ginny Edwards reminded the board of the importance of ensuring the health and wellbeing of staff when discussing changes in services, such as continuing to offer fast track physiotherapy.

13.07 Resolution: The board received the paper for information and assurance.

14/54 Assurance report from the Finance and Investment Committee

14.01 John Brougham presented an assurance report on the work of the finance and investment committee. He advised that the committee recommended that the board ratify an £8m NHS revenue support loan to cover funding requirements in November 2017. It was reported that the board would receive an update on the plans and risks to the trust achieving its £35m financial deficit forecast and a briefing on a refreshed digital IT strategy.

14.02 John Brougham noted that the committee had reviewed the planned approach and timetable to produce the trust’s operational and financial plans for 2018/19 and advised the board that this included a significant set of challenges and that the final plan would be presented to the board for approval in May 2018.


15/54 Assurance report from Patient and Staff Experience Committee

15.01 The board received an assurance report from Ginny Edwards on the work of the patient and staff experience committee. She advised that the committee had reviewed the workforce key performance indicators and considered the assurances received. The workforce risks in the board assurance framework had been reviewed and the committee had

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examined band 5 vacancies.


16/54 Assurance report from the Clinical Outcomes and Effectiveness Committee

16.01 1. Jonathan Rennison gave brief verbal assurance update on the work of the clinical outcomes and effectiveness committee. He advised that the committee had reviewed seven items for assurance, including two ‘getting it right first time’ reports, a NCEPOD report on non-invasive ventilation, the risk register and the BAF risks (recommending for one target to be amended to reflect changes in the learning from deaths action plan). He advised that the committee had received assurance from an infection prevention and control bi-annual report and had noted that the quality of the report had improved significantly. The targets in the quality account had also been reviewed and largely been found to be performing well.


17/54 Corporate governance meeting schedule

17.01 Resolution: Subject to some minor updates, the board approved the 2018/19 corporate governance meeting schedule.

CORPORATE TRUSTEE

18/54 Assurance report from the Charitable Funds Committee

18.01 The corporate trustee received a verbal assurance report on the work of the charitable funds committee from Jonathan Rennison. It was noted that the committee had discussed and recommended that the corporate trustee approve the commissioning of a governance consultant to review the charity’s current arrangements and make recommendations on how to move the charity forward. The committee had also considered whether to commission a consultant to undertake specific aspects of the charity’s work following the head of charity leaving; however it had been agreed that this would be discussed further at the next meeting. Jonathan Rennison reported that discussions were ongoing with the Royal Free London NHS Foundation Hospital Trust on buddying and support options.

18.02 Following an options appraisal to commission some external support to undertake a review of the charity’s current structure and future management options, the corporate trustee was recommended to approve Kingston Smith.

18.03 Resolution: The corporate trustee noted the update and approved a recommendation to appoint Kingston Smith to undertake a review.

19/54 Any other business

19.01 The chair announced the re-appointment of Ginny Edwards, John Brougham and Jonathan Rennison as non-executive directors as from January 2018. He reminded the board that Phil Townsend and Paul Cartwright had previously been re-appointed. These reappointments would provide welcome continuity for the trust.


20.01 Q1. Why are the minutes of the latest patient experience group meeting not included in the patient and staff experience committee report? A discussion around complaints had taken place which required immediate action. A1. The chief nurse responded that the minutes would be received by the patient and staff experience committee at its meeting in January

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2018. She further advised that the trust was aware of the themes highlighted from patient feedback and these were monitored closely by the safety and compliance committee and the clinical outcomes and effectiveness committee through the integrated performance report.

20.02 Q2. Following a move to new urgent treatment centres, did the board think that this would have an impact on the experience of patients using the emergency department at Watford. A2. The chief operating officer replied that urgent treatment centres were new and therefore the impact was not yet known, however it was hoped that patients would choose to access this service and divert activity away from the emergency department. She noted that HVCCG was closely monitoring the new model.

21/54 Questions from the public

21.01 No questions were raised by the public.


22.01 The draft agenda was approved.

23/54 Date of the next board meeting

23.01 The next board meeting would be held on 11 January 2018 in the Terrace executive meeting room, Watford hospital.

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Agenda item 06a/55

Action log Part 1 – 11 January 2018

Ref No.

Action from agenda item

Action Lead for completing the

action

Date to be completed

Update

1 09.12/53 The forecast I&E performance to be added to the IPR finance graph. DR/LE 01/18 Action completed. The forecast is added to the graph in the report.

6

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oard action log from 07 D

ecember 2017 and previous m

eetings and decision log

41 of 161T

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Agenda item: 06b/55

Board

meeting/decision date

Decision reference

(from minutes)

Item presented to Board for action Comments/outcome

07/04/2016 16/36The Board received corporate aims and objectives for 2016/17 Approved, subject to inclusion of

comments from Board

07/04/2016 17/36The Board received a refreshed Board Assurance Framework for 2016/17 Approved

05/05/2016 17/37

The Board received the updated terms of reference and work plans for 2016/17 for the

Audit, Remuneration, Workforce, Finance and Performance, Charitable Funds and

Integrated Risk and Governance Committees

Approved

07/07/2016 .09/39 The quality account 2015/16 Approved

07/07/2016 16/39Funding for external advisory support to develop a strategy outline case (SOC) for the

configuration of acute hospital service

Approved

07/07/2016 17/39 Infection prevention and control annual report 2015/16 Approved for publication

07/07/2016 18/39 The end of life care strategy Approved

07/07/2016 19/39The Board received the updated terms of reference and work plans for the Safety and

Quality Committee and the Trust Board

Approved

07/07/2016 21/39 Updated Board Assurance Framework Approved

01/09/2016 21/40Charitable Funds annual report and annual accounts 2015/16 , £12,000 of funds of funds

to support a holistic service for patients and their carers

Approved

01/09/2016 23/40 Terms of reference for the Trust Executive Committee Approved

07/10/2016 07/41Recommendation to increase the number of scheduled Board meetings to eleven per

annum.

Approved

07/10/2016 14/41 Recommended changes to the BAF 2016/17. Approved

03/11/2016 12/42 Patient experience and carer strategy Approved

03/11/2016 13/42 Statutory annual public sector equality duty report 2015 Approved

03/11/2016 18/42 The gifts, hospitality and sponsorship policy Approved

03/11/201619/42a

Recommendation to reduce the frequency of Integrated Risk and Governance

Committee meetings

Approved

03/11/2016 19/42c Update to terms of reference for the Board Approved

03/11/2016 19/42b Draft Board and Committee meeting schedule 2017/18 Approved

01/12/2016 10/43 Nursing, midwifery and allied health professions strategy Approved

BOARD AND CORPORATE TRUSTEE

DECISION LOG PART 1

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12/01/2017 15.2/44 counter fraud policy Approved

02/02/2017

02.13/45

Recommendation that the Watford site continue to be the location for emergency and

specialised care and the St Albans site continue to be the location for planned care as

recommeded in the SOC

Approved

02/02/201712.01/45

An interim revenue support loan of £2.3m to cover February 2017 revenue cash

requirements

Approved

02/02/201712.01/45

The transfer of 0.29 hectares (0.72 of an acre), to Watford Borough Council in line with

the Trust's obligations under the Health Campus agreement

Approved

06/03/2017 13.07/46 A graded approach to workforce metrics for future reporting. Approved

06/03/201715.02/46

An interim loan of £4m to cover cash flow requirements in February and March 2017

Approved

Approved

06/03/2017 15.02/46 The conversion of an IRWCF loan of £26.8m to an ISLF loan. Approved

06/03/2017 17.02/46Recommendation to delegate responsibility to the Audit Committee to sign off the Annual

Accounts, Annual Report and Annual Governance Statement.Approved

06/03/2017 18.02/46 The 2017/18 Board and Committee structure and meeting schedule Approved

06/04/2017 11.04/47 Hospital Pharmacy Transformation PlanApproved as direction of travel for

pharmacy service.

06/04/2017 14.02/47 Aims, objectives and principle risks. Approved

06/04/2017 16.02/47 Interim capital support facility agreement £7.5m Rattified

06/04/2017 16.02/47 Deficit control totals for 2017/18 of £15.4m Approved

04/05/2017 15.02/48 An interim revenue support loan of £1.964k Approved

04/05/2017 20a.03/48 West Herts charity strategy Approved

04/05/2017 20b.02/48 Discretionary resources policy Approved

01/06/2017 14.04/49 Outline business case for theatre reconfiguration Approved option E

01/06/2017 15.03/49 Proposed monitoring arrangements for aims and objectives Approved the approach

01/06/2017 17.01/49 NHS self-certification 2017/18 Approved condition G6 (3)

01/06/2017 18.02/49 Assurance report from Finance and Investment CommitteeRatified the terms and conditions of a

£42m interim revenue support loan

06/07/2017 16.04/50 The terms of reference and work plans for the board and committees Approved

06/07/2017 18.02/50The board approved the annual accounts, annual report, governance statement and

quality account 2016/17. Approved

06/07/2017 22.05/50The corporate trustee approved the recommended way forward to the future

management of the charity Approved

07/09/2017 10.02/51The board aproved the NHS England emergency preparedness, resilience and response

annual assurance. Approved

07/09/2017 13.02/51The board approved the infection prevention and control annual report 2016/17 for

publication on the Trust website Approved

05/10/2017 13.03/52 Assurance report from Finance and Investment CommitteeRatified a £1.4 interim revenue support

loan

6

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05/10/2017 13.03/52 Assurance report from Finance and Investment Committee

Approved £1m capital expenditure

funding for the redevelopment of the

A&E department

02/11/2017 13.03/53 The Board approved the Hertfordshire health concordat Approved

02/11/2017 15.04/53 Board assurance framework Approved

07/12/2017 17.01/54 Corporate governance meeting schedule

subject to some minor updates, the

board approved the 2018/19 corporate

governance meeting schedule.

07/12/2017 18.03/54 Assurance report from the Charitable Funds Committee - The corporate trustee approved a

recommendation to appoint Kingston

Smith to undertake a review.

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Trust Board Meeting 11 January 2018

Title of the paper Chair’s report

Agenda item 07/55

Lead Executive Professor Steve Barnett, Chair

Author Jean Hickman, Trust Secretary

Executive summary (including resource implications)

The aim of this paper is to provide an update on items of national and local interest/relevance to the Board.

Where the report has been previously discussed, i.e. Committee/Group

N/A

Action required:

The Board is asked to receive the report for assurance.

Link to Board Assurance Framework (BAF)

[Please indicate which Principal Risk this paper relates to by double clicking on the corresponding box]

PR1 Failure to provide safe, effective, high quality care

PR2 Failure to recruit to full establishments, retain and engage workforce

PR3 Current estate and infrastructure compromises the ability to deliver safe, responsive and efficient patient care

PR4a

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance

PR5a

Inability to deliver and maintain performance standards for Emergency Care

PR5b

Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)

PR7a

Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes

PR7b

Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure

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Tab 7 Chairs report


PR8 Failure to engage effectively with our patients, their families, local residents and partner organisations compromises the organisation’s strategic position and reputation.

PR9 Failure to deliver a long term strategy for the delivery of high quality, sustainable care

PR10

System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)

Trust objectives [Double click on the box to mark as appropriate]

To deliver the best quality care for our patients

To be a great place to work and learn

To improve our finances

To develop a strategy for the future

Benefits to patients/staff from this project/initiatives

Risks attached to this project/initiatives and how these will be managed

7

Tab 7 Chairs report


Agenda Item: 07/55

Trust Board Meeting – 11 January 2018 Chair’s report Presented by: Professor Steve Barnett, Chair 1. Purpose

1.1. The aim of this paper is to provide an update on items of national and local

interest/relevance to the Board.

2. NATIONAL NEWS AND DEVELOPMENTS

System-wide workforce strategy

2.1. Health Education England (HEE) has published Facing the Facts, Shaping the Future: a system-wide draft workforce strategy for consultation. This strategy has been led and developed by HEE with other national system leader partners, including NHS England (NHSE), NHS Improvement (NHSI), Public Health England (PHE) and other organisations.

2.2. The draft strategy is intended as the start of a wide-ranging conversation about what NHS staff, and the people the NHS serves, need now and in the future. It will be consulted upon widely over the coming months and a final report will be produced to coincide with the NHS 70th birthday in 2019.

NHS Charities

2.3. Amanda Witherall, the Chief Executive of NHS Charities, has announced her intention to

retire from the role at the end of May 2018. Amanda has been the CEO of the Association from 2009, shortly after its inception, and has successfully built its competence and effectiveness and developed a wide network of contacts within NHS Charities, the wider charity sector, the Department of Health, the NHS and the Charity Commission and many others.

Organ and tissue donation

2.4. The Department of Health has launched a consultation about organ and tissue donation. The government wants to know what people think about proposed changes in which people are considered willing to be an organ donor after their death, unless they have ‘opted out’.

2.5. The defining issues of the new system are:

how much say families have in their deceased relative’s decision to donate their organs

when exemptions to ‘opt-out’ would be needed, and what safeguards would be necessary

how a new system might affect certain groups depending on age, disability, race or faith

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Tab 7 Chairs report


Gender pay gap

2.6. Following government consultation, it became mandatory on 31 March 2017 for public sector organisations with over 250 employees to report annually on their gender pay gap (GPG).

2.7. Electronic staff record are developing a tool that will help organisations calculate their GPG data, the tool will be available before 30 March 2018, the final date for the first publication of the data.

3. LOCAL NEWS AND DEVELOPMENTS

Care Quality Commission inspection

3.1. Following an inspection in August 2017, the Trust has received a draft report from the

Care Quality Commission (CQC). The report was reviewed for factual accuracy within the appropriate timescale and the CQC is currently considering the response and is expected to issue a final report in early 2018.

Leadership changes at Herts Valleys Clinical Commissioning Group

3.2. Herts Valley Clinical Commissioning Group (HVCCG) has appointed its Director of Nursing and Quality, Diane Curbishley, to the role of Deputy Chief Executive. Diane will continue with her leadership of the nursing and quality directorate, with the deputy role adding to her responsibilities.

3.3. This is the first time HVCCG has formally had a Deputy Chief Executive in its leadership structure and this will offer broader leadership across all the Herts Valleys teams and in representing the organisation in a range of situations, such as the STP and meetings with regulators.

Christmas!

3.4. Thank you to everyone who helped to cheer up the patients and staff over the Christmas and New Year period, including:

All those who came to see the Christmas tree lights switch-on across the trust

Pupils from St Joan of Arc secondary school, Rickmansworth who visited wards to sing to patients

The team on the intensive care unit for arranging carols and Christmas songs.

Members of Watford Football Club’s first-team squad who visited Starfish Ward and the Children's Emergency Ward and presented gifts to patients

Hamlet Commercial Ltd for donating 50 teddy bears to Starfish ward Recognising and celebrating our staff

3.5. Well done to the following staff and teams for their outstanding work since the last board

meeting:

Dr Pokrajac, for leading the Diabetes UK Clinical Champions programme which won a Practice Gold award from the European Foundation for Management Development

Alex Newland-Smith, chief respiratory physiologist, who won staff member of the month. Alex was nominated as he has been an integral part in the development of the physiology service and helped to develop an exercise testing service to improve the service for patients with unexplained breathlessness

Lucinda Wilkinson was highly commended at a recent award ceremony for her success in coming second in her class on the annual procurement development programme 2017

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Tab 7 Chairs report


Heidi Buckell, quality governance administrator, who won staff member of the month. Heidi was nominated for her participation in the Trust’s equality and diversity workforce group and as a tireless champion for improving the experiences of people with disability for both staff and patients

Dian Chambers, bowel cancer screening nurse, who won staff member of the month. Dian was nominated for the kind and sensitive care that she gave a patient who had been diagnosed with cancer.

NExT Director scheme

3.6. The Board has agreed to be part of NHS Improvement’s NExT Director scheme. This is a shadowing scheme for people who might be interested in becoming a NED at some point in the future.

3.7. Natalie Edwards has been assigned to the Trust and officially started in January 2018. Natalie has a structured induction plan in place and the Chair has been assigned as her mentor and Paul da Gama, Director of Human Resources, will be her buddy. Paperless board meetings

3.8. The Trust has adopted a board portal system which has eliminated the need for Board papers to be printed and distributed. This new system will strengthen governance arrangements, improve the effectiveness of the management of Board meetings and realise cost savings.

4. KEY MEETINGS

Attended quarterly review meeting with NHS Improvement

Switched the Christmas lights on at Watford, St Albans and Hemel Hempstead Hospitals

Met with Manny Lewis, MD of Watford Borough Council

Met with the Michael Green Foundation (Diabetes Charity)

Met with Heather Lawrence, Chair of the London Ambulance Service

Toured services in Watford hospital specifically; A&E, orthopaedic and elderly ward with Patient representative Wendy Wilson

Visited ED, CDU, Outpatients, PMOK wards and Cath’ Labs 5. RECOMMENDATION

5.1. The Board is asked to receive the report for assurance. Professor Steve Barnett Chair January 2018

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of 8

Trust Board Meeting

11 January 2018

Title of the paper Chief Executive’s report

Agenda item 08/55

Lead Executive Katie Fisher, Chief Executive Officer

Author Jean Hickman, Trust Secretary


The aim of this paper is to provide an overview of the work and key decisions taken by the trust executive committee since the previous board meeting.


N/A

Action required: The Board is asked to receive the report for assurance that the trust executive is effectively managing the business of the trust.

Risk to Board Assurance Framework (BAF)

[Please indicate which Principal Risk this paper relates to by double clicking on the corresponding box]




PR4a

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance

PR5a

Inability to deliver and maintain performance standards for Emergency Care

PR5b

Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)

8

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of 8

PR7a

Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes

PR7b

Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure



PR10

System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)

Trust objectives [Double click on the box to mark as appropriate]

To deliver the best quality care for our patients

To be a great place to work and learn

To improve our finances

To develop a strategy for the future

Benefits to patients/staff from this project/initiatives

Risks attached to this project/initiatives and how these will be managed

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Agenda Item: 08/55

Trust Board Meeting – 11 January 2018 Chief Executive’s report Presented by: Katie Fisher, Chief Executive 1. PURPOSE

1.1. The aim of this paper is to provide an overview of the work and key decisions taken by

the Trust Executive Committee since the previous board meeting.

2. LOCAL NEWS AND DEVELOPMENTS

Winter pressures 2.1. The Trust continues to be very busy with a high demand for services, especially A&E at

Watford. Staff have worked incredibly hard throughout the Christmas and New Year period to continue to provide care for all patients.

2.2. The Trust has been required to submit a daily situation report to NHS Improvement (NHSI) to indicate any pressures on services such as impact on A&E, overall performance and bed pressures. This additional reporting will continue throughout the winter months.

2.3. The snowfall in December 2017 created further challenges to the Trust, however the determination of staff to get to work was extremely impressive, some staff coming in early and making extra arrangements to ensure that all patients received the care they needed.

2.4. In January 2018, the National Emergency Pressures Panel (NEPP) issued further

recommendations that it believed would support frontline staff to activate a new NHS winter pressures protocol. These included the deferral of all non-urgent inpatient elective care to free up capacity for the sickest patients.

2.5. NEPP reiterated that cancer operations and time-critical procedures needed to prevent

rapid deterioration in a patient’s condition should go ahead as planned and over and above this, day-case procedures and routine follow-up and outpatient appointments should be deferred or dealt with in different ways, e.g. telephone consultation, where this will release clinical time for non-elective care.

2.6. The clinical time released from the above actions should be re-prioritised to implement

consultant triaging of emergency patients, ensure consultant availability for phone advice to GPs, maximise the usage of ambulatory care and hot clinics, staff additional inpatient beds and provide additional input into rehabilitation and discharge.

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Urgent treatment centre, Hemel Hempstead 2.7. The urgent treatment centre (UTC) in Hemel Hempstead, which went live on 1

December 2017, is offering new benefits to patients in addition to all the services previously available in the urgent care centre. Initially, the UTC will open from 8am to 10pm, the same interim hours that the urgent care centre had been operating. HVCCG will launch a consultation by the end of January 2018 to inform a long-term decision on opening hours.

2.8. UTCs are GP-led and are equipped to diagnose and deal with many of the most common ailments for which people currently attend A&E. They are designed to ease pressure on hospitals, leaving them free to treat the most serious cases.

2.9. The following services are now available:

Some booked appointments through NHS 111

On-site tests for sepsis and deep vein thrombosis

Access to patient records for clinicians working in the UTC

2.10. Herts valleys clinical commissioning group (HVCCG) is leading on the development of UTCs in west Hertfordshire as part of a new urgent care strategy. UTCs are being introduced nationally to provide a standardised service that is clearer for patients and professionals. This will help make sure that people get the most appropriate care for their needs in the right place at the right time. Patients with non-life threatening issues will be encouraged to call the NHS non-emergency 111 number to be directed to the right care for their needs.

2.11. The trust is working with HVCCG, as well as with Herts urgent care to mobilise the new

UTC and to ensure that the service meets core NHS England requirements. The mobilisation has included ensuring that the necessary training, assurance and processes are in place. Our staff have also fed into the development of shared protocols that will indicate the type of treatment which should be referred to the UTC as opposed to A&E to ensure that there is a cohesive approach to urgent care going forward. Low priority/threshold treatment

2.12. From 01 January 2018, primary care clinicians and community specialists will only be able to refer HVCCG patients to secondary care where they can determine that the patient meets the relevant criteria as indicated in HVCCG’s policy for low priority/threshold treatment.

2.13. Low priority conditions are classified as:

Hysterectomy • Cataracts • Total hip replacement • Total knee replacement • Knee arthroscopy • Minor skin surgery • Hernias • Varicose veins • Video capsule endoscopy • ENT- tonsillectomy, adenoidectomy, adenoid/tonsillectomy (children and adults) • ENT- grommets (children only) • Hand surgery - carpal tunnel, trigger finger, ganglion, fasciectomy • Back injections - facet joint, epidural, radio frequency denervation

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• Tier 3 and 4 weight management 2.14. The trust has established a set of controls to ensure the prior approval request process

is appropriately managed.

Norovirus 2.15. Due to an outbreak of norovirus in December 2017, two wards were closed to

admissions at Watford. Enhanced infection prevention and control measures were put in place and the situation was managed in line with the Trust’s usual procedures and protocols.

2.16. During this time, staff were reminded of the importance of vigilance throughout the hospitals of increased incidents of diarrhoea and vomiting within the community.

Paper switch off programme

2.17. The NHS standard contract for 2018/19 will no longer pay providers for consultant led care unless the referral to the first outpatient appointments is made through the NHS electronic referral system e-RS.

2.18. The NHS has launched the ‘paper switch off’ programme to support health organisations and to ensure trusts are ready for the change. Operationally, the programme will:

reduce the time from referral to treatment

reduce inappropriate referrals

provide better tracking of referrals

reduce patient and clinician enquiries

reduce lost referrals 2.19. The trust is making good progress and many services are already above the required

80%. However, work is ongoing to ensure that all services and all GP referrers are managed electronically in line with the programme timetable.

Flu vaccination programme

2.20. The NHS is expected to face severe pressure this winter with an increase in demand for services related to flu, norovirus and respiratory conditions. Experts are warning that this year's flu strain is "potentially the worst seen in two decades.

2.21. The trust has reacted to this warning of increased incidence of flu by:

Strongly encouraging staff who have not had the vaccination to reconsider, including sending individual letters

Establishing an emergency resilience stock of face masks and reminding staff of the importance of undertaking a fit mask testing

Ensuring that ward/departmental emergency planning procedures are up to date and all staff are aware of what to do in the event of a flu outbreak.

Emergency preparedness

2.22. The trust was assessed in October 2017 by NHS England against the NHS Core

Standards for emergency preparedness and was found to be fully compliant, with a clear sense of commitment and ownership across the organisation.

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2.23. In particular the trust was complimented on leading a successful multi-agency live

exercise involving a terrorist incident in Watford, which was described as an excellent example of the type of exercise that improves multi-agency coordination and increases the level of preparedness within the NHS. The Panel was also impressed with the trust’s engagement with the London NHS Emergency planning network, including participation in exercises.

2.24. New legislation requires the trust to have provision of emergency planning and business

continuity training for its staff and sub-contractors. The trust has agreed to upgrade its training package to core status using existing locally adapted Public Health England e-learning package.

2.25. The importance of offering regular table top exercises to senior leaders has also been recognised and will be incorporated into a development programme.

Development of a quality commitment

2.26. In 2017, the trust commissioned Gate One to support it in the development of a new quality commitment. Following an extensive engagement programme with staff, the quality commitment document is nearing completion. The next phase is for the trust to work with Gate One on the planning and mobilisation of the commitment in preparation for it to be presented to the Board in March 2018.

Fax decommissioning project

2.27. Fax machines are being discontinued across the trust in order to improve information security. Work is progressing well and a webpage has been set up to offer staff information and guidance on how to support this project.

3. COMMUNICATIONS REPORT

Media 3.1. The trust received coverage on a variety of topics during November 2017, notably the

coverage that surrounded the plans for Hemel Hempstead’s urgent care centre to become an urgent treatment centre from 01 December 2017. BBC Three Counties Radio covered the plans and local GP Richard Pile, who is a Board member at HVCCG and the clinical lead for urgent care, explained that the move to urgent treatment centres is a national change and is not a cut or reduction.

3.2. Other articles in the media during November 2017 included:

The Gazette and Express reported that the maternity unit at Watford General Hospital won a Health Service Journal (HSJ) award. The unit won the national workforce award for its drive to recruit and retain midwives by improving career development opportunities. Katie Fisher said she was “beyond proud”

The Watford Observer included a letter from Joe McCullough from North Watford in which he praised his recent treatment in A&E and AAU. He says: “After hearing some very negative stories about the hospital I can only say I have never been treated so well by the kindest of staff and cannot praise them highly enough.”

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The Watford Observer reported that a woman who lost her husband due to a complication from diabetes doesn't want anyone to "die of ignorance". Joanne Green and her daughter were devastated when Michael died from a "silent heart attack", a common but overlooked complication of Type 2 Diabetes. In his memory, she launched the Michael Green Diabetes Foundation to raise money to help find a cure. Since then they have raised over £70,000 and helped to open the Michael Green Dietetic Educational Kitchen at Watford General, as well as funding two specialist dieticians. Chairman of the Trust, thanked the foundation and praised their continuing support.

3.3. Communications data

Website

Month’s Figures 17/18

Month’s Figures 16/17

Total Quarter

1

Total Quarter 2

Running Quarter

3

Running total 17/18

Total 16/17

Total Page Views

469,444 473,535 1,364,707

1,414,842 953,859

3,733,408 4,901,513

Number of unique visitors

40,344 41,530 106,195 107,937 78,306 292,438 370,658

Top five pages visited on internet site (excluding home page and vacancy pages):

1. Watford, wards and departments 2. Travel information and parking 3. Our services: pathology 4. About: contact 5. Our services

Internal Communications

November 17/18

Total Quarter 1

Total Quarter 2

Running Quarter 3

Running total 17/18

Number of e-newsletters (e-update)

9 15 26 17 58

Number of CEO briefings 6 12 19 12 43

Number of Herts & minds newsletters

1 1 1 1 3

October 2017 Positive coverage Neutral coverage Negative coverage

National coverage 0 0 0

Coverage (Watford) 1 1 0

Coverage (Dacorum) 1 1 1

Coverage (St Albans) 0 0 0

Other local 2 1 0

Letters coverage 2 3 4

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Freedom of Information

November 17/18

Total Quarter 1

Total Quarter

2

Running Quarter

3

Running total 17/18

Total 16/17

Number of FoIs received 50 153 169 104 426 662

Compliance within 20 day deadline

88.7% 95.0% 88.6 88.8% 87% 94.3%

No of FoIs received from media outlets

3 24 24 5 53 100

Social Media

Twitter

Followers Posts Likes Retweets

November 2017 5941 124 321 183

The Trust’s most popular Tweet was “Let’s hear it for our maternity team led by Gloria Rowland who have done us all proud by winning the @HSJ_Awards for Best Workforce sponsored by @nhsemployers. Fantastic work! A job well done!” with 37 likes and 6 retweets.

Facebook

Followers Posts Likes Reach Shares Comments

November 2017

1319 44 863 29,346 218 75

4. RECOMMENDATION

4.1. The Board is asked to receive the report for assurance that the trust executive is

effectively managing the business of the trust. Katie Fisher Chief Executive

January 2018

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the very best care for every patient, every day

Results of our

Care Quality

Commission

inspection

Published January 2018

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Our vision

Our aims are:

• To deliver the best quality care for our patients

• To be a great place to work and learn

• To improve our financial sustainability

• To develop a strategy for the future

Our values:

• Commitment, Care, Quality

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Watford General Hospital

• Inpatient emergency and intensive care

• Elective care for higher risk patients

• Outpatient and diagnostic services

• 600 beds and 9 theatres

• Women's and children's services

Hemel Hempstead Hospital

• UTC open seven days a week, 8am-10pm

• Diagnostic services, incl. MRI and pathology

• Outpatient services

• Endoscopy and bowel cancer screening services

• Herts Community Trust operates intermediate care

beds on site

St Albans City Hospital

• Elective care (inpatient low risk and day case)

• Outpatient and diagnostic services

• 40 beds and 6 theatres

• Minor Injuries Unit open 7 days a week, 9am-8pm,

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About us… Our local hospitals at Watford, Hemel Hempstead and

St Albans cover a catchment area of

over 500,000 people

140,000 emergency patients treated

460,000 outpatient attendances

47,000 planned operations

5,000 babies delivered

with 4,800

staff and 340

volunteers

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The inspection

• The Care Quality Commission (CQC) assesses five aspects of a site or

service – safe, caring, responsive, effective and well led – and awards them

ratings: inadequate, requires improvement, good or outstanding

• Each hospital is given an overall rating and the trust is given an overall rating

• In 2015 we were rated ‘inadequate’ overall and went into special measures

• In 2016 we were rated ‘requires improvement’ overall and remained in special

measures.

• Our latest inspection took place 31 August to 1 September 2017. The CQC

inspectors visited all three West Herts hospitals and also made unannounced

visits to all three sites on 12 September

• They interviewed frontline staff and the leadership team, spoke to patients

and relatives and took soundings from key stakeholders. They reviewed

nearly 1,000 documents: policies, data and additional information in relation

to specific questions

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The headlines

West Hertfordshire Hospitals NHS Trust is out of special measures!

• We have demonstrated sustained improvements across the board

• We were rated as ‘requires improvement’ for safe, effective, responsive and well led and we were rated ‘good’ for caring

• Our overall rating remains ‘requires improvement’ but we have achieved a significant increase in the number of services rated as ‘good’

• Eight services were rated ‘good’ (compared to five in 2016)

• Four services were rated as ‘requires improvement’ (five in 2016); one was rated as ‘inadequate’ (two in 2016, although one is no longer run by us)

• 45 individual quality ratings of ‘good’ compared to 32 in 2015

• Only three individual ratings of ‘inadequate’ compared to eight in 2016

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What the inspectors observed

• All staff treat patients in a respectful and considerate manner

• A positive culture, focused on improving patient outcomes and experience

• Patients and relatives are included decisions about their treatment and care

• Staff are proud to work at the trust

• Leadership is strong, supportive and visible

• Women are positive about the care they receive on maternity and

gynaecology wards. One woman and her partner said their experience was

“amazing, really impressed”

• Parents and children said the service was “wonderful”. Staff treat children

with kindness, dignity and respect and always go the extra mile

• Family members are happy with the end of life care their relatives receive

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Where did we do well?

• Three services achieved ‘GOOD’ across ALL FIVE ELEMENTS: maternity;

children and young people; surgery at St Albans

• Outpatients and diagnostic imaging at Watford significantly improved their

ratings

• Hemel Hempstead Hospital overall has moved from ‘inadequate’ to ‘requires

improvement’. There is a NOT A SINGLE ASPECT of any service at Hemel

Hempstead that has an inadequate rating – a massive change from nine red

ratings last year to none this year

• St Albans City Hospital also now has NO inadequate ratings

• Nationally, 55% of hospitals’ core services are rated ‘good’ – we achieved

61.5% so we are ABOVE THE NATIONAL AVERAGE

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• Staff knowledge of the duty of candour (openness and transparency) is

evident

• The emergency department has significantly improved the management

and treatment of sepsis

• Staff understand their responsibilities to raise concerns, record and report

safety incidents and near misses

• Staff are confident about reporting safeguarding concerns to protect adults

and children from harm, abuse and neglect

Good practice – many examples

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• There is shared learning from complaints through ward meetings, teaching

sessions, huddles and newsletters

• Significant progress with governance – a new committee structure enables the

board to operate strategically

• Equality and diversity is promoted within the trust

• The trust board and executive team are focused on patient safety and quality

of care

Good practice – many examples

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• Innovations in the children’s emergency department to tackle mental health and

suicide awareness. The design and space of this department enables quick

interventions and is unique for a district general hospital

• The “iSeeU” initiative enabling women to use face-time technology to see their

baby receiving care and treatment on the neonatal care unit

• Focused recruitment and career development programme for band 5 nurses

• At Hemel Hempstead and St Albans, the phlebotomy service engages with

people in vulnerable circumstances, for example home visiting

Outstanding practice – many examples

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• At Hemel Hempstead staff take photos of X-rays, dressings etc to help people

with cognitive impairment understand their treatment

• At St Albans the enhanced recovery care pathways are effective in helping

patients recover more quickly after surgery

• The diagnostic imaging service audited best practice – staff embraced the

importance of changing practice, especially in difficult casualty situations

• Electronic referrals for infants with prolonged neonatal jaundice resulting in

quicker referrals and results

Outstanding practice – many examples

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Areas for improvement

• Urgent and emergency services – rated ‘good’ for effective and caring but ‘inadequate’

overall:

– We have restructured and strengthened clinical leadership in our emergency department, and

opened a new, expanded clinical decision making unit

– We will improve reporting of incidents, identification of risk and management of risk registers to

provide assurance that the service always runs safely and effectively

• Learning from incidents – strengthen how we share learning across the trust

• Mental capacity – where a patient lacks capacity to make an informed decision or give

consent, make a formal decision-specific mental capacity assessment

• Minor Injuries Unit at St Albans – ensure there are effective triage and streaming systems

• Quality – our new Quality Commitment describes how the organisation can make it easier

for our staff to deliver great service and care, and support collaboration between

departments so they can work and learn from one another

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Our strengths

• Mortality rates consistently lower (better) than expected for over two years

• Stroke service consistently achieving the highest rating AA star

• Performance on cancer waiting times remains strong

• A new MRI/CT scanner means we now offer both modalities of cardiac

imaging – one of very few district general hospitals to do so

• Referral to treatment times have improved since the last inspection and are

similar to the England average

• Staff engagement is good – we scored highly in the 2016 annual staff survey

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Our ratings

• Ratings for each site – Watford General Hospital, Hemel

Hempstead Hospital, St Albans City Hospital

• Ratings for the trust overall

• Comparison of ratings in 2015, 2016, 2017

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Inadequate

Safe Effective Caring Responsive Well-led Overall

Urgent and

emergency services

Medical care

Surgery

Critical care

Maternity and

gynaecology

Services for children

and young people

End of life care

Outpatients and

diagnostic imaging


Our 2015 overall rating was ‘inadequate’

Overall

Key

Inadequate

Requires

improvement

Good

Outstanding

Not rated

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Urgent and

emergency services

Medical care

Surgery

Critical care

Maternity and family

planning


and young people

End of life care

Outpatients and

diagnostic imaging


Our 2016 overall rating was ‘requires improvement’

Overall Requires

improvement

Key

Inadequate

Requires

improvement

Good

Outstanding

Not rated

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Our 2017 overall rating is ‘requires improvement’


Urgent and

emergency services

Medical care

Surgery

Critical care

Maternity and family

planning


and young people

End of life care

Outpatients and

diagnostic imaging

Overall Requires

improvement

Key

Inadequate

Requires

improvement

Good

Outstanding

Not rated

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Urgent and

emergency services

Medical care

End of life care

Outpatients and

diagnostic imaging



Overall Requires

improvement

Key

Inadequate

Requires

improvement

Good

Outstanding

Not rated

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Urgent and

emergency services

Medical care

End of life care

Outpatients and

diagnostic imaging



Overall Inadequate

Key

Inadequate

Requires

improvement

Good

Outstanding

Not rated

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Urgent and

emergency services

Medical care

End of life care

Outpatients and

diagnostic imaging



Overall Requires

improvement

Key

Inadequate

Requires

improvement

Good

Outstanding

Not rated

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Minor injuries unit

Surgery

Outpatients and

diagnostic imaging



Overall Inadequate

Key

Inadequate

Requires

improvement

Good

Outstanding

Not rated

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Minor injuries unit

Surgery

Outpatients and

diagnostic imaging



Overall Requires

improvement

Key

Inadequate

Requires

improvement

Good

Outstanding

Not rated

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Minor injuries unit

Surgery

Outpatients and

diagnostic imaging



Overall Requires

improvement

Key

Inadequate

Requires

improvement

Good

Outstanding

Not rated

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2017

2016

2015

Overall trust rating

Requires

improvement

Requires

improvement

Inadequate

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45

32

Comparison of

‘inadequate’ and ‘good’ ratings

2015 2016 2017

Key

Inadequate

Good

20

15

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In conclusion

• We are no longer in special measures

• We are rated ‘good’ for caring

• We’ve made significant improvements across the board

• There is a positive culture

• Staff are proud to work at the trust

• We know where we need to improve

• Leadership is strong, supportive and visible

• Our Quality Commitment will help us to deliver great service and care, and support collaboration between departments

• Patient safety at the heart of everything we do

Thank you to all our staff!

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8.1

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Trust Board Meeting

11 January 2018

Title of the paper Integrated Performance Report

Agenda item 09/55

Lead Executive Sally Tucker, Chief Operating Officer

Author Jane Shentall, Director of Performance


The Integrated Performance Report covers the December reporting period (November data). For this reporting period, the Board is asked to particularly note the following performance changes since the last reporting period: Safe, Effective, Caring:

A&E FFT positive scores fell to 88.9% (from 92.1%)

1 Never event (wrong route medication administration) was reported, taking the year to date total to 3.

% of patient safety incidents that were harmful fell for the second consecutive month from 12.5% to 10.2%

Mixed sex accommodation breaches reduced further with 2 reported in month.

5 cases of Clostridium difficile were reported but with no evidence of transmission between cases - the year to date total of 14 remains below the ceiling target of 23.

Complaints performance fell by 5%, with 55% of complainants receiving a response within the agreed timescale or a month

Combined C-section rates (elective & non-elective) improved significantly at 25% (October 32.7%), underpinned by reductions in emergency (from 18.9% to 14.3%) and elective rates (from 13.7% to 10.7%).

Responsive:

RTT (incomplete) performance fell slightly to 88.3% (88.4% October)

1 52 week breach (in Orthopaedics) was reported

Diagnostic waiting time performance has returned to compliance at 99.4%

ED 4 hour wait performance dropped to 81.9% (83.4% previously)

Ambulance turnaround delays over 60 minutes decreased (by over 37%)

99.3% compliance reported against the breast symptomatic 2ww standard

62 day cancer screening (78.9%*) is provisionally below the standard (*data

is provisional at the time of this report)

Formal delayed transfers of care decreased further to 4.4% Well Led:

Staff turnover (rolling 3 months) has reduced at 15.7% (18.2% October)

Band 5 nursing turnover rates improved by 1.5%, to 25.2%

% agency pay rose above target (85) to 8.7%

Appraisal rates have fallen to 85.9% (3rd consecutive drop)

Maternity FFT response rates improved dramatically, from 30% to 53.4%

Inpatient, day case and A&E FFT response rates decreased and remain below target

Staff FFT response rate showed good improvement at 19.4%(11.87% in September) however % who would recommend fell to 53.8% (59% September)

Further detail is provided in the executive summary and relevant exception reports, including performance trends.

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Tab 9 Integrated performance report - month 8


Where the report has been previously discussed

Trust Executive Committee (Performance) 20.12.2017

Action required:

The report is provided for information and assurance to the board that expectations were either being met or plans are in place to take appropriate mitigating actions to meet key metrics.





PR4a Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance

PR5a Inability to deliver and maintain performance standards for Emergency Care

PR5b Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)

PR7a Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes

PR7b Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure



PR10 System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)

Trust objectives To deliver the best quality care for our patients To be a great place to work and learn To improve our finances To develop a strategy for the future

Benefits to patients/staff from this project/initiatives The Integrated Performance Report provides a view of performance across all key metrics in the areas of Safe, Effective, Caring, Responsive and Well Led

Risks attached to this project/initiatives and how these will be managed The Integrated Performance Report is reviewed monthly at the Trust Executive Committee prior to submission to the Board. Individual performance indicators are also reviewed at divisional level at monthly Performance meetings, where associated risks and issues are discussed and documented, and relevant actions tracked. Data quality is regularly reviewed both internally and by the Trust’s auditors.

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Tab 9 Integrated performance report - month 8


Integrated Performance

Report

December 2017

(November data)

1

The updated report issued on 9 January 2018

contains pages related to the financial position of

the Trust as at November 2017. The financial

summary on page 9 contained activity data at the

top of the main table which had not been updated

from the previous month. This has now been

changed and reflects activity data consistent with

the financial information.

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Tab 9 Integrated perform

ance report - month 8

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Well ledReporting sub committee – PSE

ResponsiveReporting sub committee – TEC

Safe Effective CaringReporting sub committees – COE and S&C

2

Areas requiring performance improvement• VTE risk assessment was below threshold (pages 4 & 18) • Admissions to stroke ward within 4 hours was below the performance standard and marginally worse than the national average (pages 4 & 14) • There were 2 mixed sex accommodation breaches (pages 3 & 24)• Harm free care (new and all harms), as measured through the Safety Thermometer was worse than the performance standard and the national average (pages 4 & 20) • Complaints responded to within agreed timescales was worse than the 85% external performance threshold and the internal improvement trajectory (pages 3 & 15)• Maternity FFT % positive indicator was worse than the performance standard (pages 3 & 36)• Clostridium difficile was worse than the monthly threshold (5 cases recorded) but better than the year to date threshold (14 vs 19) (pages 3 & 16)

New to category this month:• There was one never event reported (pages 4 & 16)

Areas requiring performance improvement• A&E 4 hour wait performance was below standard (pages 5 & 30) • Formal DToCs were below standard (pages 6 & 31) • Ambulance turnaround times' performance was worse than standard (pages 5 & 30)• The RTT incomplete indicator was worse than the standard (pages 5 & 25)• Patients not treated within 28 days of their last minute cancellation was below standard (pages 6 & 26)• The 62 day screening indicator was provisionally worse than the standard (pages 5 & 29)

New to category this month:• The Trust reported one patient waiting 52 weeks on an incomplete pathway (page 5)

Areas requiring performance improvement• The staff turnover rate (rolling 12 months) was below the performance standard (pages 7 & 32)• Staff turnover (rolling 3 months) was worse than target (pages 7 & 32)• The vacancy rate was worse than the performance standard (pages 7 & 32)• Appraisals were worse than target(pages 7 & 33) • Mandatory training was worse than target (pages 7 & 33)• Friends and Family response rate for A&E was below threshold (pages 7 & 35)• Inpatient FFT response rate was worse than the target (pages 7 & 35)

New to category this month:None

Areas of good performance • Mortality indicators show sustained excellent performance (pages 3 & 13)• There were no cases of MRSA bacteraemia (pages 3 & 16)• Patients spending 90% of their time on the stroke unit was better than the performance standard (pages 4 & 14)• Day case FFT % positive indicator was better than the performance standard (pages 3 & 36)• There were no medication errors causing serious harm reported (pages 4 & 18)

New to category this month:• The percentage of patients receiving a caesarean section was better than the performance threshold (pages 4 & 24)• Inpatient FFT % positive indicator was better than the performance standard (pages 3 & 35)

Areas of good performance • The 2WW and breast symptomatic cancer indicators achieved the performance standard (provisional) (pages 5 & 27)• Cancer 31 first, subsequent drug and surgery indicators are delivering to the performance standard (provisional) (pages 5 & 28 - 29)• Hospital initiated outpatient cancellations under 6 weeks performed better than the performance standard(pages 6 & 26) • The 62 day GP indicator was provisionally better than the standard (pages 5 & 29)*NB this indicator was reported as provisionally non compliant last month, but was compliant upon submission to Open Exeter.

New to category this month:• Diagnostic wait times achieved the performance standard (pages 5 & 26)

Areas of good performance • The sickness rate was better than target (pages 7 & 32)• Temporary costs and overtime as % of total pay bill was better than target (pages 7 & 32), including and excluding unfunded beds (two indicators)• Bank pay was within the new target range of 8 %– 12% (pages 7 & 32)

New to category this month:• Maternity Friends and Family response rate was better than target (pages 7 & 36)

Executive Summary

Nov-17 11

Oct-17 10

Sep-17 10

Achieving

Nov-17 10

Oct-17 11

Sep-17 11

Not achieving

Better than

national

average

Nov-17 10

Oct-17 8

Sep-17 11

Worse than

national

average

Nov-17 6

Oct-17 9

Sep-17 6

NB. Indicators achieving relate only to where targets have been set - as seen on the indicator summary. Ratings showing the number of indicators better or worse than the national average relate to only those indicators where the national average

was available. Indicators which are identified in the main pack as provisional may lead to changes to achieving/not achieving counts previous months in Executive Summary.

Nov-17 10

Oct-17 10

Sep-17 9

Achieving

Better than

national

average

Nov-17 9

Oct-17 9

Sep-17 9

Worse than

national

average

Nov-17 5

Oct-17 5

Sep-17 5

Nov-17 5

Oct-17 4

Sep-17 5

Achieving

Better than

national

average

Nov-17 6

Oct-17 5

Sep-17 5

Worse than

national

average

Nov-17 4

Oct-17 5

Sep-17 5

Nov-17 11

Oct-17 12

Sep-17 11

Not achieving

Nov-17 11

Oct-17 11

Sep-17 12

Not achieving

NB. The sum of indicators achieving and not achieving may not be equal between months due to some indicators being reported with a lower frequency than monthly

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Indicator Summary

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Data Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent with relevant standardsAmber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queriesGreen – Data is complete, accurate and consistent with the standards set for the specific indicator

Exception indicators keyRed for a minimum of two data points and amber for one, out of the latest three data pointsRed for the latest data point

l

u

Domain a Indicator Target a Sep-17 Oct-17 Nov-17 a YTD Actual YTD Target aExecutive

LeadMonth

Included

in

Detailed

Reports

National

/ Locala

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

SHMI (Rolling 12 months) 100 89.6 89.5 91.9 MD May-17 Y National 100 May-17G

HSMR - Total (Rolling three months) 100 84.7 85.0 88.4 MD Aug-17 Y National 100 Aug-17G

Crude Mortality Rate (Non elective

ordinary)**3.5% 2.7% 2.6% 2.5% 2.6% 3.5% MD Nov-17 Y National 2.69% (East

of Eng.)Aug-17

G

l 30 Day Emergency Readmissions - Combined * 4.0% 6.4% 7.6% 7.3% 7.3% 4.0% MD Nov-17 Y National 11.4% 2011-12G £

Marginal tariff reimbursement, possible

penalties

30 Day Emergency Readmissions - Elective * n/a 2.6% 2.9% 3.0% 3.0% n/a MD Nov-17 Y National n/aG £


penalties

30 Day Emergency Readmissions - Emerg * n/a 9.7% 11.8% 11.3% 11.0% n/a MD Nov-17 Y National n/aG £


penalties^

Number of patients with a length of stay > 14

days *tbc 326 354 324 2696 tbc MD Nov-17 Local n/a

G £Reduction in reimbursement vs largely

fixed costs. No penalty levied.

Staff FFT % recommended care tbd NHSI^ 61.5% 59.0% 64.5% 62.4% tbd NHSI^ DoW Sep-17 Y National n/aG

Inpatient Scores FFT % positive 95% 94.0% 93.4% 95.8% 93.2% 95% CN Nov-17 Y National 95.8% Oct-17G

A&E FFT % positive 95% 94.4% 92.1% 88.9% 91.6% 95% CN Nov-17 Y National 86.6% Oct-17G

Daycase FFT % positive 95% 97.8% 99.6% 99.2% 98.7% 95% CN Nov-17 Y National n/aG

Maternity FFT % positive 95% 94.6% 94.0% 94.1% 94.6% 95% CN Nov-17 N National 96.3% Oct-17G

l

% Complaints responded to within one month

or agreed timescales with complainant85% 51.4% 60.0% 55.1% 54.0% 85% CN Nov-17 N Local n/a

R

Complaints - rate per 10,000 bed days tbd NHSI^ 34.9 30.8 40.7 36.0 tbd NHSI^ CN Nov-17 N National n/aR

Reactivated complaints 8 9 7 61 n/a CN Nov-17 N Local n/aR

Proportion of complaints with verbal

communication at the beginning of the

process

66.7% 65.0% 80.5% 67.3% CN Nov-17 N LocalR

l Mixed sex accommodation breaches 0 10 5 2 58 0 CN Nov-17 N National52 Trusts

breachingOct-17

G £Penalties from CCG. £250 per day per

service user.

u Clostridium Difficile 1 0 3 5 14 19 CN Nov-17 Y National 2.6 average Oct-17G £

Penalties from CCG, fines from other

statutory authorities. £10,000 per case

above threshold.

MRSA bacteraemias 0 0 0 0 1 0 CN Nov-17 Y National n/aG £


statutory authorities. £10,000 in respect of

each incidence in the relevant month.

E. Coli Bacteraemia tbc 2 4 4 26 tbc CN Nov-17 Y National n/aG

* Performance may change for the current month due to data entered after the production of this report

** Crude mortality threshold UCL upper control limit (2 standard deviations from mean)

tbd NHSI^ - threshold/target to be determined by Trust Development Agency guidance when available

NB. Where national avg. blank - information not currently available

Financial impact

^Calculation of emergency re-admissions penalty – Re-admission rate is applied to the value of all admitted activity. 25% of this is

then applied on the basis that this proportion is avoidable.

Safe

, Eff

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Indicator Summary

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l

u

Domain Indicator Target Sep-17 Oct-17 Nov-17 YTD Actual YTD TargetExecutive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

l Never events 0 1 0 1 3 0 MD Nov-17 Y National n/aG £


statutory authorities, prosecution^

Serious incidents - number* tbd NHSI^ 5 3 4 26 tbd NHSI^ MD Nov-17 Y National n/aG

% of patients safety incidents which are

harmful*n/a 13.3% 12.5% 10.2% 11.2% n/a MD Nov-17 Y National n/a

G

Medication errors causing serious harm * 0 1 0 0 1 0 MD Nov-17 Y National n/aG

l CAS Alerts: Number issued each month n/a 5 6 6 6 n/a CN Nov-17 Y National n/aG

CAS alerts not acknowledged within 48 hours 0 0 0 0 0 0 CN Nov-17 National n/aG

Number of falls* 96 121 103 827 CN Nov-17 Y LocalG

Number of falls with harm* 19 21 23 168 CN Nov-17 Y LocalG

Number of G3 pressure ulcers (Hospital

acquired)0 3 2 2 15 0 CN Nov-17 Y Local

G

Number of G4 pressure ulcers (Hospital

acquired)0 0 0 0 1 0 CN Nov-17 Y Local

G

l

Safety Thermometer Harm Free Care (acquired

within and outside of Trust)*/**95.0% 89.4% 93.4% 93.1% 91.5% 95.0% CN Nov-17 Y National 94.2% Nov-17

G

Safety Thermometer % New Harm Free Care

(acquired within Trust)*/**tbd NHSI^ 97.4% 98.1% 97.6% 98.2% tbd NHSI^ CN Nov-17 Y National 97.9% Nov-17

G

Safety Thermometer New Harm Free Care:

Catheter & UTI New Harms*/**tbd NHSI^ 3 0 2 17 tbd NHSI^ CN Nov-17 Y National

WHHT 0.35

vs 0.32Nov-17

G

l VTE risk assessment* 95.0% 90.9% 91.7% 91.4% 91.4% 95.0% MD Nov-17 Y National 95.3% Q2 2017A

Caesarean Section rate - Combined* 28.0% 27.2% 32.7% 25.0% 27.6% 28.0% MD Nov-17 Y Local 26.7%Apr15-

Aug15 A

Caesarean Section rate - Emergency* 15.0% 16.6% 18.9% 14.3% 16.1% 15.0% MD Nov-17 Y Local 15.3%Apr15-

Aug15 A

Caesarean Section rate - Elective* 11.0% 10.6% 13.7% 10.7% 11.5% 11.0% MD Nov-17 Y Local 11.4%Apr15-

Aug15 A

Maternal deaths 0 0 0 0 0 0 MD Nov-17 N National n/aG

lPatients admitted directly to stroke unit

within 4 hours of hospital arrival *90.0% 62.9% 60.9% 75.8% 66.8% 90.0% COO Nov-17 Y National 60.2% Jul-17

G

Stroke patients spending 90% of their time on

stroke unit *80.0% 85.7% 89.1% 81.8% 84.0% 80.0% COO Nov-17 Y National 85.7% Jul-17

A

NB Exception reports not provided for FFT scores


Financial impact

^Recovery of cost of procedure or episode plus any additional charge incurred for

corrective procedure or care in consequence to the event.

* Performance may change for the current month due to data entered after the production of this report


** Indicators reported from NHS Safety Thermometer

Safe

, Eff

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Indicator Summary

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l

u

Domain Indicator Target Sep-17 Oct-17 Nov-17YTD

ActualYTD Target

Executive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

l Referral to Treatment - Admitted* 90.0% 69.5% 67.4% 65.5% 71.2% 90.0% COO Nov-17 Y Local 75.0% Sep-17G

l Referral to Treatment - Non Admitted* 95.0% 86.2% 88.4% 88.6% 89.0% 95.0% COO Nov-17 Y Local 89.5% Sep-17G

l Referral to Treatment - Incomplete* 92.0% 88.1% 88.4% 88.3% 89.4% 92.0% COO Nov-17 Y National 89.1% Sep-17G £

CCG penalty of £100 in respect of each

excess breach above the threshold

uReferral to Treatment - 52 week waits -

Incompletes0 0 0 1 1 0 COO Nov-17 National

1778 (all

Trusts)Sep-17

G

Diagnostic wait times 99.0% 98.1% 98.6% 99.4% 99.1% 99.0% COO Nov-17 Y National 98.0% Sep-17G £


excess breach above the threshold

l ED 4hr waits (Type 1, 2 & 3) 95.0% 81.6% 83.4% 81.9% 82.7% 95.0% COO Nov-17 Y National 90.1% Oct-17G £


excess breach above the threshold (cap

off 8% of attendances)

ED 12hr trolley waits 0 0 0 0 0 0 COO Nov-17 Y National 53 (all Trusts) Oct-17G £ CCG penalty £1,000 per incidence

l

Ambulance turnaround time between 30 and

60 mins0 443 401 406 3,148 0 COO Nov-17 Y Local n/a

R £CCG penalty £200 per service user

waiting over 30 mins

l Ambulance turnaround time > 60 mins 0 163 170 106 1,335 0 COO Nov-17 Y Local n/aR £

CCG penalty £1,000 per service user

waiting over 60 mins

Cancer - Two week wait * 93.0% 95.2% 96.5% 96.9% 95.4% 93.0% COO Nov-17 Y National 93.7% Q2 17/18G £

CCG penalty breaches per qtr in excess

of tolerance is £200 for each breach.

Cancer - Breast Symptomatic two week wait * 93.0% 97.6% 97.4% 99.3% 93.7% 93.0% COO Nov-17 Y National 93.3% Q2 17/18G £


of tolerance is £200 for each breach.

Cancer - 31 day * 96.0% 96.5% 99.3% 98.5% 98.2% 96.0% COO Nov-17 Y National 97.7% Q2 17/18G £


of tolerance is £1,000 for each breach.

Cancer - 31 day subsequent drug * 98.0% 100.0% 100.0% 100.0% 100.0% 98.0% COO Nov-17 Y National 99.4% Q2 17/18G £



Cancer - 31 day subsequent surgery * 94.0% 100.0% 100.0% 100.0% 99.2% 94.0% COO Nov-17 Y National 95.8% Q2 17/18G £



Cancer - 62 day * 85.0% 80.7% 86.2% 86.8% 87.4% 85.0% COO Nov-17 Y National 82.2% Q2 17/18G £



l Cancer - 62 day screening * 90.0% 86.4% 72.2% 78.9% 89.3% 90.0% COO Nov-17 Y National 91.7% Q2 17/18G £



*RTT and cancer performance for latest month is provisional and subject to validation


Res

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Financial impact

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Indicator Summary

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l

u

Domain Indicator Target Sep-17 Oct-17 Nov-17 YTD Actual YTD TargetExecutive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

Urgent operations cancelled for a second time 0 0 0 0 0 0 COO Nov-17 Y National n/aG

lNumber of patients not treated within 28 days

of last minute cancellation0 2 4 6 46 0 COO Nov-17 Y National

8 (avg. all

Trusts)Q2 17/18

G

l Delayed Transfers of Care (DToC)* 3.5% 6.9% 5.6% 4.4% 5.8% 3.5% COO Nov-17 Y National 6.0% Feb-16G

Delayed Tranfers of Care (DToC) beddays used

in month1,150 1,093 988 10,221 COO Nov-17 Y National n/a

G

l Outpatient cancellation rate 8.0% 12.0% 10.4% 10.1% 11.2% 8.0% COO Nov-17 Y Local n/aG

Outpatient cancellation rate within 6 weeks^ 5.0% 4.9% 4.1% 3.9% 4.1% 5.0% COO Nov-17 Y Local n/aG

l Patient initiated cancellations (all) 12.8% 12.8% 12.5% 12.8% COO Nov-17 Y LocalG

Hospital + Patient initiated cancellations (all) 24.7% 23.2% 22.6% 23.9% COO Nov-17 Y Local n/aG

Res

po

nsi

ve

^ Excluding valid cancellations (cancellations to provide earlier appointments or where appointment no longer required, cancellations due to where patients have died, cancellations to appointments made in

error and cancellations where there was a change to a clinic template without a change to a patient's appointment date, time or site)


*DToC benchmark estimated by total delayed patients nationaly as percentage of occupied general and accute beds

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Indicator Summary

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l

u

Domain Indicator Target Sep-17 Oct-17 Nov-17YTD

ActualYTD Target

Executive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

l Staff turnover rate (rolling 12 months) 12.0% 16.0% 16.2% 16.1% 16.2% 12.0% DoW Nov-17 Y National 13.5% (Beds

and Herts orgs)Dec-15

G

Staff turnover rate (rolling 3 months) 12.0% 17.7% 18.2% 15.7% 15.2% 12.0% DoW Nov-17 Y National 13.5% (Beds

and Herts orgs)Dec-15

G

Nurse Band 5 Turnover Rate 26.5% 26.7% 25.2% 26.2% DoW Nov-17 Y Local n/aG

% staffleaving within first year (excluding

medics and fixed term contracts)17.7% 18.5% 19.0% 18.8% DoW Nov-17 Y National n/a

G

Sickness rate 3.5% 2.8% 3.0% 3.4% 3.1% 3.5% DoW Nov-17 Y National 3.8% (EoE

orgs)Dec-15

A

l Vacancy rate 9.0% 11.8% 11.1% 10.6% 12.1% 9.0% DoW Nov-17 Y National 11% (local

survey)Dec-15

G

l Appraisal rate (non-medical staff only) 90.0% 89.5% 88.3% 85.94% 85.9% 90.0% DoW Nov-17 Y National 85% (local

survey)Dec-15

G

l Mandatory Training 90.0% 89.1% 89.1% 89.1% 89.8% 90.0% DoW Nov-17 Y Local 86% (local

survey)Dec-15

A

% Bank Pay** 8% - 12% 9.5% 9.2% 10.4% 9.6% 8% - 12% DoW Nov-17 Y Local n/aG

l % Agency Pay** 8.0% 8.3% 8.0% 8.74% 8.4% 8.0% DoW Nov-17 Y Local 11.4% (local

survey)Dec-15

G

Temporary costs and overtime as % of total

paybill** (Inc. unfunded beds)22.6% 18.3% 17.7% 19.5% 18.5% 22.6% DoW Nov-17 Y National n/a

G

Temporary costs and overtime as % of total

paybill** (Excl. unfunded beds)7.7% 7.4% 8.2% 7.7% DoW Nov-17 Y National n/a

G

l Inpatient FFT response rate 50.0% 21.9% 24.2% 21.6% 22.9% 50.0% CN Nov-17 Y National 25.1% Oct-17G

l A&E FFT response rate 15% 5.3% 4.3% 4.2% 4.7% 15.0% CN Nov-17 Y National 12.7% Oct-17G

Daycases FFT response rate tbd NHSI^ 27.5% 33.0% 28.8% 30.4% tbd NHSI^ CN Nov-17 Y National n/aG

l Staff FFT response rate+ 50% 15.7% 11.8% 19.4% 15.6% 50% DoW Sep-17 Y National n/a

G

Staff FFT % recommended work 66% 58.5% 51.1% 53.8% 52.8% 66% DoW Sep-17 Y National n/aG

Maternity FFT response rate 35% 37.1% 30.0% 53.4% 39.7% 35% CN Nov-17 N National 23.3% Oct-17G

*Perfomance for current month may change due to data entry post production of this report

*Medication errors causing serious harm data for latest month is provisional and subject to validation. Temporary costs and overtime performance is provisional for the current month

NB. Exception reports not provided for FFT scores ** Trajectory set as target


+ Staff FFT reports latest quarterly positions in monthly columns (eg. Q1, Q2 and Q3 = month 1, 2, and 3)

Wel

l Led


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Finance (Overview)

8

Operational performanceCurrent deficit of £30.33m is £15.76m adverse to plan as at M8 YTD. All areas are adverse to plan to some degree, with £5.00m due to unachieved CIPs (see left) and £3.67m due to NHS revenue, although it is worth noting that the latter is significantly in excess of the same period in 2016/17.

Recovery plans have been identified to ensure the Trust achieves its revised target of a £35.00m deficit, all of which will be planned and implemented as soon as is practical.

Savings and outlook for FY18Savings achieved at £6.91m up to M8, slightly behind plan by £0.05m, i.e. projects costed vs actual delivery), and behind target by £4.23m (where we wanted to be at this point in the year). 2017/18 Trust savings target is £21.9m, of which £13.7m has been assigned to divisions and £10.34m identified.

Achievement within the £13.7m is on target, albeit with significant up- and down-sides across divisions. Current gap mainly due to centrally-held £8.3m CIP target in additional to those held by divisions.

Operational performanceRevised forecast of £35m accepted by NHSI, compared to agreed 2017/18 control total of £15m. Change driven by challenges re CIP achievement, commissioner challenges, and consequent STF loss.

£m Plan Actual Var

Surplus / (Deficit) 0.2 (2.8) (3.0)

£m

Surplus / (Deficit) (14.6) (30.3) (15.7)

Breakeven

£m % Budget

Medicine 0.4 22

Unscheduled Care (3.3) (30)

Surgery (5.6) (64)

Women's (0.2) (1)

BPPC Clinical Support 0.3 6

Estates & Facilities (0.1) (1)

Corporate 0.3 1

Other (7.4)

Total (15.7)

FY18 YTD Variance by Division

Financial Overview as at 30 November 2017

Statutory / Regulatory Duties

The Trust has a deficit plan of £15m

for FY18.

CRL The Trust has not exceeded its Capital

Resource Limit.

Month 8 Income & Expenditure

Year to Date

EFL The Trust has managed spend w ithin its

External Financing Limit.

10 Days' Cash Cash at 30/11/17 equated to 5 days'

spend

Month 8 performance - 20% (95%

target)

Financial Risk Rating FY18

0

5

10

15

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

Forecast Cash £m

F'cast cash

10 days' cash

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Fe b Mar

Savings £'000

Actuals

Target

0

20

40

60

80

100

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

Rolling BPPC Payment Performance

Target

No.

Value

-50

-45

-40

-35

-30

-25

-20

-15

-10

-5

0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Income & Expenditure FY18 £m

Actuals

Plan

BaseForecastRecoveryForecast

3

GG

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Finance (I&E)

9

Statement of Comprehensive Income (I&E)

Engagement with Commissioners• Contractual HVCCG activity continues to form the bulk of all income (small areas of block contract). • CQUIN management involves formal monitoring and regular operational controls, assuming 90% achievement at this stage less PY adjustment.• Final FY17 income remains under discussion, and is subject to mediation alongside 2017/18.

Operational performanceNHS income was £3.7m below plan YTD (£0.4m below in month), with a favourable variance in Non-Elective (£2.1m) offset by Elective (£2.5m, primarily Surgery), Outpatients (£1.4m) and Other (£1.5m).Other income was £3.1m adverse YTD (£0.9m in month) primarily due to STF income assumptions offset by favourable car parking income.

Outlook for FY18The current income forecast reflects all known and anticipated pressures, including the outcome of the recent MSK tender (subject to confirmation), any STF income forgone as a result of missing the original control total of £15m, and winter pressures. [All areas of NHS income are up on the same point in 2016/17]

Budget Actual Var Budget Actual Var

Volumes

3,740 3,827 87 Elective 42,806 29,015 29,615 600 28,302

4,266 4,336 70 Non elective 49,525 33,174 33,853 679 33,525

40,209 40,515 306 Outpatient 433,803 310,034 298,718 (11,316) 288,758

10,146 9,889 (257) A&E 117,791 78,902 78,786 (116) 78,787

4,807 4,372 (435) Elective 55,461 37,012 34,518 (2,493) 36,189

8,698 8,904 206 Non elective 100,978 67,640 69,720 2,080 64,036

6,069 6,174 105 Outpatient 70,191 46,909 45,560 (1,349) 47,440

1,381 1,320 (61) A&E 16,032 10,739 10,749 10 9,858

1,187 965 (222) Critical care 13,781 9,231 8,800 (431) 9,110

3,702 3,696 (6) Other NHS revenue 42,978 28,789 27,306 (1,483) 27,653

25,844 25,431 (413) TOTAL NHS REVENUES 299,421 200,319 196,653 (3,666) 194,286

22 41 20 Private Patients 259 172 160 (13) 170

1,136 150 (985) Other non-NHS clinical income 11,306 6,228 2,585 (3,643) 9,340

1,157 191 (966) TOTAL Non NHS Clinical 11,565 6,400 2,745 (3,655) 9,510

804 794 (10) Education & Training 9,644 6,429 6,394 (35) 6,270

1,254 1,377 123 Other Revenue 15,356 10,262 10,876 614 11,234

2,058 2,171 113 TOTAL OTHER REVENUE 24,999 16,691 17,270 579 17,504

29,059 27,793 (1,266) NET HOSPITAL REVENUE 335,984 223,410 216,668 (6,742) 221,300

£000's

Month 8 (Nov)Prior Year

Actual

YTD FY18

Budget

£000's£000's £000's £000's £000'sNHS REVENUE£000's £000's

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Finance (I&E)

10

Statement of Comprehensive Income (I&E)

CIP schemesCIP schemes are a combination of expenditure, income, and transformational schemes.All cross-cutting CIP themes are closely monitored through formal meetings and operational actions. Targeted assistance from SD & PMO colleagues for a period of 6-8 weeks from October helped to generate a greater range of CIP ideas alongside the means and expertise to implement them in the best possible way.

Operational performance Pay costs were £5.9m adverse YTD (Medical £2.1m adv, Other Clinical £1.0m adv, Sci / Tech / Prof £0.5m adv & Unidentified CIP £3.8m, offset by Non-Clinical £2.0m fav). Focus on agency management continues agency cost trend established in FY17, £1.0m behind plan YTD (see following slide).

Non-pay costs were £3.1m adverse YTD – Increased outsourcing and drugs overspends were offset by favourable depreciation and clinical services.[Further detail is given in the main Finance Report.]

Outlook for FY18Current costs and recovery actions are continually assessed as part of general good practice alongside a formal process with NHSI.

Mitigating actions, including use of the Model Hospital and the internal SDO are at various stages of progress.

Budget Actual Var Budget Actual Var

18,592 18,112 480 Permanent / Bank Staff 223,403 149,266 142,405 6,861 130,606

510 1,735 (1,225) Agency 6,318 4,190 13,089 (8,900) 18,972

(814) (814) Unidentified pay savings (8,699) (3,814) (3,814)

18,287 19,847 (1,560) TOTAL PAY 221,022 149,641 155,494 (5,853) 149,578

1,798 2,186 (388) Drugs 21,205 14,003 15,197 (1,194) 14,665

2,711 2,513 198 Clinical services 32,094 21,474 20,076 1,398 20,953

5,670 5,343 327 Non-clinical services 70,915 47,662 49,735 (2,074) 45,922

(590) (590) Unidentified non-pay savings (5,278) (2,086) (2,086)

9,589 10,042 (454) TOTAL NON-PAY 118,935 81,052 85,008 (3,956) 81,540

1,183 (2,097) (3,280) EBITDA (3,973) (7,284) (23,835) (16,551) (9,817)

808 610 198 Depreciation & Amortisation 8,650 5,770 4,878 892 4,813

128 143 (15) Interest 1,545 1,033 1,194 (161) 1,098

73 (89) 161 Dividends Payable 872 583 422 161 1,576

174 (2,761) (2,936) Surplus / (Deficit) (15,040) (14,670) (30,329) (15,659) (17,304)

Month 8 (Nov)Prior Year

Actual

YTD FY18

Budget

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11

Finance (Agency)Agency spend trajectory

Green – 2015/16 £36.8m, large

proportion of pay costs on

agency spend; agency caps

and other measures

implemented in-year

Red - This year, where we

needed to be in order to

achieve target expenditure of

£17.0m. YTD results M8 were

£1.0m behind plan with plans

being implemented to

maximise the chances of

achieving FY18 targets. The

Purple line shows what may

happen if M8 spend persists.

Blue – 2016/17 £26.5m, a

>£10m decrease on 2015/16

but still a high proportion of pay

spend compared to peers.

Month 1A Month 2A Month 3A Month 4A Month 5A Month 6A Month 7A Month 8A Month 9F Month 10F Month 11F Month 12F

Required trajectory 17/18 1,860 3,438 4,996 6,741 8,163 9,772 11,354 13,089 14,100 15,070 16,040 17,011

Trajectory based M8 1,860 3,438 4,996 6,741 8,163 9,772 11,355 13,090 14,987 16,431 17,815 19,213

Cumulative plan 17/18 1,701 3,571 5,102 6,462 7,823 9,183 10,713 12,074 13,434 14,625 15,815 17,006

Cumulative actual 16/17 2,605 5,416 7,655 9,846 11,932 14,004 16,635 18,938 21,560 23,847 24,973 26,501

Cumulative actual 15/16 2,772 5,712 8,744 11,930 15,236 18,418 21,978 25,157 28,255 31,149 34,046 36,827

Required trajectory 17/18 1,860 1,578 1,558 1,745 1,422 1,609 1,583 1,735 1,010 970 970 970

Trajectory based M8 1,860 1,578 1,558 1,745 1,422 1,609 1,583 1,735 1,897 1,445 1,384 1,398

Months plan 17/18 1,701 1,871 1,530 1,360 1,360 1,360 1,530 1,360 1,360 1,190 1,190 1,190

Months actual 16/17 2,605 2,811 2,239 2,191 2,086 2,072 2,631 2,303 2,621 2,288 1,126 1,528

Months actual 15/16 2,772 2,940 3,032 3,186 3,306 3,182 3,561 3,179 3,098 2,894 2,898 2,780

9



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Detailed reports

129



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Performance relative to targets/ thresholds

Executive lead Clinical lead Operational lead

Nov-17 4 4

Oct-17 3 5

Sep-17 4 4

Hospital

Standardised

Mortality

Ratio

(HSMR)*

Summary

Hospital

Mortality

Indicator*

Not achieving

Reporting sub committee - S&C &

COEC

Safe,

effective,

caring Achieving

Crude

mortality rate

(non-

elective)*

*Dr Mike Van der Watt

Tracey Carter

0

30

60

90

120

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

HSMR (overall) HSMR (weekend) Threshold (HSMR overall)

0

30

60

90

120

Apr 2012 to

Mar 2013

Jul 2012 to

Jun 2013

Oct 2012 to

Sep 2013

Jan 2013 to

Dec 2013

April 2013 to

Mar 2014

July 2013 to

June 2014

Oct 2013 to

Sept 2014

Jan 2014 to

Dec 2014

Apr 2014 to

Mar 2015

Jul 2014 to

Jun 2015

Oct 2014 to

Sep 2016

Jan 2015 to

Dec 2015

Apr 2015 to

Mar 2016

Jul 2015 to

Jun 2016

Oct 2015 to

Sep 2016

Jan 2016 to

Dec 2016

Apr 2016 to

Mar 2017

SHMI (Rolling 12 months) Actual SHMI (Rolling 12 months) 100

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Crude Mortality Non-Elective Actual Mean UPL 2 standard devs LPL 2 standard devs

13

Hospital mortality indices continue to demonstrate sustainedimprovement. Recent intelligence from Dr Foster benchmarks theTrust against the Shelford group, and places WHHT as one of six trustsin that peer group that sit within the ‘lower than expected’ range.

For the 12 month period (September 2016 to August 2017), the Trust’sHSMR of 91.92 was in the ‘lower than expected’ range. Nationally,WHHT had the 33rd lowest HSMR out of 136 non specialist trusts,placing the organisation in the top 25% when compared acrossEngland. The Trust has the 4th lowest HSMR within the East of Englandregion.

There was a peak in crude mortality over the winter period which was mirrored nationally.

The Summary Hospital Mortality Indicator’s (SHMI) latestperformance (for April 2016 to March 2017) was 91.94 and ‘asexpected’ (band 2), placing the Trust 20thnationally.

The Trust continues to hold monthly specialty/departmental MortalityReview meetings, cases from which are then discussed at a bi-monthlyTrust wide Mortality Review, chaired by the Medical Director. The casenote review process is currently being reviewed in order to align withthe recent publication, ‘National Guidance on Learning from Deaths’.

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Stroke 60 mins , s troke care and STeMI 150 mins* (to fol low)

% Emergency

re-admissions

within 30

days

following an

elective or

emergency

spell*

Patients

admitted

directly to

stroke unit

within 4

hours of

hospital

arrival*

Stroke

patients

spending 90%

of their time

on stroke

unit*

0%

2%

4%

6%

8%

10%

12%

14%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

30 Day Emergency Readmissions - Elective % 30 Day Emergency Readmissions - Emergency %

Combined Performance Combined Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%A

pr

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)

0%

20%

40%

60%

80%

100%

120%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)

14

Emergency ReadmissionsCombined readmission rates, including both emergency and electiveadmissions, includes all patients with more than one admission to thehospital within a period of 30 days, regardless of whether the secondadmission was related.

Both elective and emergency re-admission rates have risen but thecombined rate remains lower than the national average

StrokePerformance against the 4 hour admission to the stroke unit target forNovember improved to 75.8% compared to 60% for October.

The national average shown in the latest reporting quarter results forSSNAP (April – July 17) is at 60.2%, which demonstrates WHHT isperforming above this.

The target of 80% of patients staying 90% of their admission on thestroke unit was achieved at 81.8%.

Patients that arrive via a pre-alert ambulance are seen immediately onarrival by the stroke team. However, other potential stroke patientswho, during times of increased pressure, experience longer waits in A&E,are not always admitted to the stroke unit within 4 hours. When waitingtimes to be assessed in A&E are long there is a resultant delay in timelyreferral to the stroke team for specialist assessment.

Maintaining ring fenced capacity for stroke patients remains a focusoperationally.

The latest SSNAP results for April to July 2017, shows that Watford Strokeservices have continued to maintain an “A” rating.

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Number of

reactivated

complaints

% Complaints

responded to

within one

month or

agreed

timescales

with

complainant

Safe,

effective,

caring (continued)

Complaints -

rate per

10,000 bed

days

0

10

20

30

40

50

60

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Complaints - rate per 10,000 bed days Complaints - rate per 10,000 bed days

Mean Upper control limit (3 sd)

Lower control limit (3 sd)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Compliants timely response Target Mean

Upper control limit (3 sd) Lower control limit (3 sd) Trajectory

-30

-20

-10

0

10

20

30

40

50

60

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Reactivated complaints Threshold Mean

Upper control limit (3 sd) Lower control limit (3 sd)

15

Complaints rate per 10,000 bed days77 new complaints were received in November, of which 38% (29) relate to Surgery, Anaesthetics and Cancer (SAC), 29% (22) relate to Unscheduled Care (USC), 17% (13) relate to Women’s and Children’s (WACS), 4% (3) relate to Medicine, 3% (2) relate to environment, 3% (2) relate to corporate and 1 complaint was received for Clinical Support. In 45% of complaints the patient was unhappy with their treatment; half of these were in Surgery, Anaesthetics and Cancer and the rest spread between the other divisions. 13% of complaints related to staff attitude. There were 2 complaints regarding cancelled operations.

Complaints relating to transport have reduced from previous months’ but incidents continue to be reported. Under those circumstances, a letter is sent to patients who have been affected.

% Complaints responded to within one month or agreed timescales with complainant In November 55% (38) of complaints were responded to on time. 65 responses were sent in total. The target of achieving 65% by the end of 2017 remains, with a further target to achieve 85% by the end of March 2017.

Complaints responded to on time, by division, is as follows:

There were seven complaints reactivated in November. 4 relate to Surgery, Anaesthetics and Cancer, two of which relate to the complainant’s belief that they are incomplete. This was not confirmed following reviewo f the response.

There are currently 8 complaints over 4 months old.

N/A denotes – no complaints valid for reply to this month.

Aug - 17 Sep - 17 Oct - 17 Nov – 17Trust wide 46% 51% 60% 55%

Medicine 100% 100% 91% 91%USC 25% 29% 35% 32%

SAC 60% 46% 71% 43%

WACS 20% 14% 33% 67%

Environment 60% 78% 50% 100%

CSS 67% N/A 100% N/A

Corporate 33% 33% 100% 100%

Target Nov 17

% of complainants with verbal communication at the beginning of process (called within 3 working days of receipt of complaint)

95% by Q4 100%

% of complaints acknowledged within 3 working days 100% 100%

% of complaints taken longer than 6 months to investigate (figure taken at the end of October)

>5% 4%9



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*Dr Mike Van der Watt

Tracey Carter

Safe,

effective,

caring

MRSA

bactaraemias

and E. Coli

Bacteraemia

Clostridium

Difficile

Never

events*

Reporting sub committee - S&C &

COEC

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

2015/16 2016/17 2017/18

MRSA bacteraemias Actual 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0

MRSA bacteraemias Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

E. Coli Bacteraemia 3 3 2 3 2 1 1 2 5 0 3 7 1 1 1 4 2 2 5 1 4 4 2 2 1 1 3 8 3 2 4 4

0

1

2

3

4

5

6

7

8

9

0

5

10

15

20

25

30

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Clostridium Difficile Actual Clostridium Difficile Target

Clostridium Difficile Actual YTD Clostridium Difficile Target YTD

Actual YTD (Excl. cases with no lapses in care)

0

1

2

3

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Never events Actual Never events Trajectory Never events Target

16


Nov-17 2 4

Oct-17 4 2

Sep-17 3 3

Achieving Not achieving

Clostridium difficile Infection (CDI)5 cases were reported in November. The full year target ceiling for WHHT apportionedCDI is 23 - year to date actual is 14 cases.

RCAs for the 5 cases have been undertaken. All cases were identified in different clinicalareas. Two cases had the same common ribotype with no evidence of a connection interms of time/date/place and thus no evidence of transmission between the two cases .The other 3 cases had different ribotypes and no evidence of transmission identifiedbetween these cases.

The IPCNs produce a trust wide Clostridium difficile newsletter, highlighting key learningand actions to prevent CDI. The IPC team continues with antimicrobial rounds, weeklyClostridium difficile rounds, and targeted training. There is also increased IPC supportand power training to key clinical areas.

To date there has been agreement with Herts Valleys CCG that there was no identifiedlapse of care in 1 case of CDI.

MRSA bacteraemia (MRSAb)The full year target ceiling for MRSAb is 0 avoidable cases. No MRSAb was reported inNovember.

Key learning relating to the July MRSAb case: Failure to screen wounds on admission,phlebitis from cannula site; failure by staff to identify that a patient was a known MRSAcoloniser. Learning has been shared across all divisions and supported with targetededucation and training. The IPCT are focusing on education and training to improve themanagement of vascular (peripheral and central) devices and plan to undertake a trustwide point prevalence audit in the new year.

E. Coli bacteraemia (E colib )4 cases of post 48hrs E colib were reported in November. The target set for the CCG thisyear is a 10% reduction equating to 36 cases. There is no target for WHHT. The IPCT isrepresented on the WHHT continence group & supports the review of post 48hrs E colibRCAs, the outcome of which will influence WHHT’s focus to support the reduction of theTrust’s apportioned E colib cases. The IPCT plan to undertake a thematic review of all thepost 48hrs for Q1 and Q2 and share across the divisions.

Never eventOne never event was declared in November 2017 relating to a wrong routeadministration of medication. A number of immediate actions were implemented andthe SI investigation commenced in accordance with the Trust’s investigation processes.

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Medication

errors causing

serious harm*

% of reported

patient safety

incidents that

are harmful

Serious

incidents

0%

5%

10%

15%

20%

25%

30%

35%

40%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Actual Target

Upper control and lower control limit to be added

-5

0

5

10

15

20

25

30

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2014/15 2015/16 2016/17

Actual Target to follow UPL will be used Upper control limit (3 sd)

Lower control limit (3 sd) Mean

0

1

2

3

4

5

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Actual Target

17

Serious Incidents4 SIs were declared in November 2017 (3 in October)

• 3 in Surgery, Cancer & Anaesthetics relating to a complication of a surgical procedure, a delay in treatment and a medication administration incident (never event)

• 1 in Unscheduled Care relating to a patient’s treatment

At the end of November 2017 the Trust had 22 open SIs. Investigations are complete for 10of these and the investigations are with the CCG pending formal closure on StEIS. At the endof November there were 12 ongoing SI investigations, which were all within the deadlinefor completion.

Learning from SIsThe following actions and processes are in place to ensure learning from SIs and provideassurance that learning has taken place and changes have been implemented:• 45 day review meetings allow the SI draft report to be discussed and challenged by the

relevant clinical and management teams prior to the action plan being completed.• Each action plan is developed, signed off and monitored by the division leading the

investigation into the incident.• The SI review group (SIRG), chaired by the Medical Director, review all closed SI action

plans where senior divisional representation provides assurance and evidence thatactions have been implemented before the SI is formally closed internally.

Two 45 day meetings were held in November2017.

The SI review group (SIRG), chaired by the Medical Director, review all closed SI action planswhere senior divisional representation provides assurance and evidence that actions havebeen implemented before the SI is formally closed internally. A SIRG meeting was held on 29November 2017. Eight action plans were reviewed but none of these were closed entirely;the outstanding evidence for the action plans presented will be followed up as part of theSIRG action log. The next SIRG meeting will take place in January 2018 with the date to beconfirmed.

% of patient safety incidents which are harmful10.21% of incidents reported in November 2017 were recorded as harmful, which hasdecreased from 12.46% in October 2017.

There has been a reduction in the number of incidents reported with a harm of moderate orabove 19 in November 2017 (23 in October). Of those 19 incidents 11 still require harmvalidation and therefore the harm level is subject to change.

From the 19 incidents above 3 were reported as resulting in death/catastrophic harm in November 2017. Of these, there was one death but it was not related to the incident, one has been declared as a Serious Incident (SI) and one is awaiting discussion at SI panel.

Medication incidents causing serious harm No medication errors were reported as causing serious harm in November 2017 .

9



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Executive lead Clinical lead Operational lead*Dr Mike Van der Watt

Tracey Carter

Safe, effective,

caring

VTE risk

assessment*

Reporting sub committee - S&C & COEC

CAS alerts:a) number issued per month

(not target)

b) number where

acknowledgement overdue* (target = 0)

(Class 4: for information only and

class 2: Action within 48 hours) AprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMar

2015/16 2016/17 2017/18

a) CAS alerts issued 7 4 4 8 19 8 12 8 12 6 5 4 1 22 24 14 11 11 10 7 5 7 4 1 6 11 16 5 16 5 6 6

b) CAS alerts target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

b) CAS alerts overdue 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0

5

10

15

20

25

30

80%

85%

90%

95%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

VTE risk assessment Actual VTE risk assessment Target Mean

Upper control limit (3 sd) Lower control limit (3 sd)

18


Nov-17 1 4

Oct-17 1 4

Sep-17 1 4


CAS alertsAll alerts issued by CAS in November 2017 were acknowledged within the48hr deadline. There were 6 alerts in total issued in November 2017, oneof which was a Medical Device alert, there were 4 Estate & Facilities alerts /notifications and one Patient Safety Alert.

The Medical Device alert actions are complete and the alert is now ready to be closed.

3 of the Estate & Facilities alerts/notifications have been sent to the relevant divisions and actions are currently ongoing and one was not applicable to WHHT and has now been closed.

The Patient Safety Alert has been circulated to the relevant leads and is progressing as per instructions on the alert.

There were no breaches during November 2017 and all alerts with deadlines were closed on time.

VTE The recent small improvement in initial VTE risk assessment compliance hasbeen more or less sustained, but more work is required to target non-compliant areas.

Issued by CAS 6

Breached in month 0

Currently overdue 0

CAS alerts not acknowledged within

48hrs 0

9



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Hospital

acquired

pressure ulcers

Falls and falls

with harm

0

5

10

15

20

25

30

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Mar

2015/16 2016/17 2017/18

Hospital acquired pressure ulcers Hospital acquired pressure ulcers (G3) avoidable

Hospital acquired pressure ulcers (G4) avoidable

0

20

40

60

80

100

120

140

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Nu

mb

er

of

falls

Number of falls Number of falls with harm

19

Hospital acquired pressure ulcersIn November 10 new pressure ulcers were recorded ( a reduction of 17)affecting nine patients: Eight grade 2 and two grade 3 pressure ulcers.Whether the two grade 3 pressure ulcers were avoidable has yet to beestablished

The grade 2 pressure ulcers are validated by the Matrons for the clinical areas but not differentiated between avoidable and unavoidable.

A Trust wide improvement plan is in place to ensure continuing focus onreducing pressure damage as part of harm free care. A revised BestShot care plan is undergoing a trial . Some significant improvementshave been made, with over 58% reduction in grade 3 pressure ulcersbetween April and September 2017.

Falls and falls with harmIn November there were 103 inpatient falls with 23 resulting in low harm – falls with harms remains low.

The campaign to address falls continues with the creations of Fall Champions, and with the multidisciplinary falls group.

There is also joint working with Community teams, reviewing falls and common themes.

Support is provided to specific clinical areas in relation to falls and devising resource packs for staff

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NB. Indicator reported at WHHT from April 2017

Adult Safety

Thermometer:

Harm Free Care

and New Harms

Children's

Safety

Thermometer:

Harm Free Care

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

2015/16 2016/17 2017/18

Harm Free Care (acquired within and outside of Trust)

Harm Free Care (acquired within and outside of Trust) Target

New Harm Free Care (acquired within Trust)

New Harm Free Care (acquired within Trust) national average

0%

20%

40%

60%

80%

100%

120%

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Jan

Fe

b

Ma

r

2015/16 2016/17 2017/18

Harm Free Care Actual Harm Free Care national average

20

Adult Safety ThermometerThe Adult Safety Thermometer is a measurement tool for improvement that focuseson the four most commonly occurring harms in healthcare: pressure ulcers, falls, UTI(in patients with a catheter) and VTEs. Data is collected through a point of caresurvey on a single day each month on all patients. ‘Harm free’ care is defined by theabsence of harm in these four areas. In November, Harm Free Care was 93.1%,below the national target of 95%. This includes harms acquired both inside andoutside of the Trust. New Harm Free care (harms acquired in the Trust) forNovember 2017 was 97.6%, slightly below the national average for November at97.9%.

Eight Month Review of Harms.Since August no patient has received more than 1 harm.There was an increase in the November safety thermometer numbers of falls increasing to 11 (last month 10), new VTE to 6 (from 2) and catheters with new UTI from 0 to 2. A reduction has been seen in new and old pressure ulcers , falls with harm and catheters.

Children and Young People's Services Safety ThermometerHarm includes patients with a PEWS completed: triggered but not escalated,extravasation, patients in pain at time of survey and any pressure ulcer or anymoisture lesion. Harm free care was 100% in November for Acute Children’sServices, compared to 85.7% nationally. An analysis of the November 2017 surveydemonstrated that all patients had a set of observations and had been assessed foran Early Warning Score in the last 12 hours. Of those patients with anintravenous (IV) device, extravasation (leakage of a fluid out of its container) wasnot observed in any patient . There were no reports of pressure ulcers or moisturelesions and no patient reported pain at the time of survey.

Harm Free Actions• Urology Steering group monitoring E-coli in conjunction with Infection

Prevention and control with continued monitoring of cathethers• Focus on the Pressure Ulcer improvement plan with Divisions.• Collaborative working with community on harms.• Falls collaboration with community teams• Harm free Care focus on Fridays, prior to Safety Thermometer audits, raising

awareness. • National Stop the Pressure awareness day 17 November 2017• Harm free Care tweets on Thursdays and Tuesdays with key messaging• Targeted ward teaching• Implemented pain assessment recording on PEWs charts.

Indicator Apr17 May17 Jun17 Jul17 Aug17 Sep17 Oct17 Nov17

Number of patients with two

harms - - 1 1 2 - - -

New pressure ulcers 1 3 3 4 5 5 8 6

Old pressure ulcers 31 46 34 51 56 50 26 25

Number of falls 8 3 3 9 13 14 10 11

Number of falls with harm - 1 1 2 3 4 1 -

Catheters 98 103 74 117 86 99 111 106

Catheter & New UTI 1 1 1 5 4 3 - 2

New VTE 2 4 2 3 3 4 2 6

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21

Ward scorecard – key themesWhat is causing the variance in Trust performance

Safety Alerts – There has been an decrease in November ( 37) from October (46). The safety alerts are mainly due to numbers of falls, and falls with harm inclinical areas. The areas with high numbers of falls are Bluebell , Tudor, Stroke, Ridge and Letchmore . Bluebell and AAUB1 had the most falls with harm.These are being reviewed by the Falls Specialist Nurse in conjunction with the clinical areas. Four clinical areas have had hospital acquired C – diff inNovember –AAUBY3 x2 , Tudor, Elizabeth and Red Suite.Process Alerts – November saw a decrease (100) from October (108) The decrease is due to the overall Test Your Care results with improvements forHeronsgate/ Gade (medical), Sarratt (medical), Frailty (unscheduled care), and Flaunden (surgical) and the Tissue viability section completion scores. Thereappears to be a direct link between process – risk assessment and care planning with safety outcomes in relation to pressure ulcers demonstrated by theSafety thermometer data.Summary:• Paediatrics one safety alerts in CED.• Maternity have no safety alerts.• Eleven clinical areas are demonstrating a lower trend of alerts for November compared to October.

What actions have been taken to improve performance

• After care project in Unscheduled care and ED focus groups to improve the level of feedback for FFT• Recruitment and Retention meeting. Targeted project focused on the band 5 RN’s. Rotational programmes. Overseas recruitment• Reviewing support mechanisms for staff such as care certificates, Band 6 and Band 7 development courses.• Education around suitable footwear and incidents with falls being monitored• Targeted ward teaching on Falls prevention and management• Falls Resource Folders for clinical areas• Bed rail audit to be shared for learning• Reviewing falls in the clinical areas• Targeted training in relation to Pressure ulcers with wards – purchased a body map that highlights pressure points• Harm Free Care promotion such as Newsletters, Mr B Harmfree – key messages, and Trolley dashes and use of simulation.• Targeted monitoring on practice and cleaning by infection control around C- Diff• Ward Accreditation being undertaken by all ward areas• Champion Roles in clinical areas

Changes in outcomes

• Improvements have been made with a >58% reduction in grade 3 pressure ulcers developed during April – September 17.• Falls with harm has remained low• No increase in incidents around patient deterioration• Test Your Care has increased across the Trust• Reductions in Thromboembolisms with preventable cases and deaths in the Trust

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C-section rate

Mixed sex

accommodation

13%

9% 11%

11%

9% 11%

11%

11% 15

%11

%11

%11

%8% 11

%11

%10

%9%

16%

11%

8%13

%10

% 14%

15%

13%

12%

11%

10%

11%

11% 14

%11

%

18%

21%

17%

19%

19%

16% 21

%20

%22

%20

%20

%20

%21

% 21%

19%

18%

20%

18%

22%

24% 16

%18

% 16%

14%

17%

18%

13%

17%

13% 17%

19%

14%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Ma

r

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Ma

r

2015/16 2016/17 2017/18

Caesarean Section rate - Elective Actual Caesarean Section rate - Emergency Actual

Caesarean Section rate - Combined Target

0

2

4

6

8

10

12

14

16

18

20

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

MSA breaches Actual MSA breaches Target

24

C-section rate

The caesarean section rate for November returned to a level better than the monthly threshold. The Trust is continuing to work closely with the Consultant and Midwifery team to reduce caesarean section rates further.

Mixed sex accommodation (MSA)The number of reported breaches has improved, down from 5 in October. to 2 in November

All breaches occurred in ITU and were due to pressures on the emergencycare pathway.

The monitoring and management of patients requiring step down fromITU is reviewed daily as part of the regular operational managementmeetings, with the intention of reducing where possible, the number ofmixed sex accommodation breaches that occur. Advance planning forcomplex patients requiring side-room capacity is reviewed as part ofthese meetings.

The Trust policy on mixed sex accommodation has been reviewed andratified.

The completion of the RCA template provided by HVCCG is being trialledin ITU.

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Responsive

Reporting sub committee - TEC


Sally Tucker Jeremy Livingstone Divisional Managers

Access indicators - RTT, diagnostics, cancelled operations

and outpatient appointments

Incomplete

pathways

within 18

weeks

Completed

pathways

within 18

weeks

Incomplete

pathways WL

profile

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ap

r

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Admitted performance Non admitted performance

Non admitted target Admitted target

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

2015/16 2016/17 2017/18

52+ 3 1 - - - - - - - - - - 2 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1

26 < 52 701 657 528 358 349 358 347 347 455 550 492 636 649 761 892 984 1,03 987 990 892 964 884 782 659 661 647 625 748 892 993 921 935

18 - <26 1,62 1,35 1,48 1,29 1,23 1,15 1,10 1,10 1,38 1,34 1,24 1,62 1,83 1,68 2,07 2,21 2,17 2,26 1,96 1,83 1,96 1,65 1,53 1,43 1570 1522 1638 1757 1971 2082 2026 2017

<18 20,7 21,1 21,4 19,6 18,9 17,8 17,4 17,4 17,3 17,2 18,8 19,6 19,2 20,0 22,9 21,7 21,8 21,0 20,5 19,9 19,3 19,1 19,2 20,7 2078021218221782255022629227492258022243

% of PTL within 18 weeks 89.9% 91.3% 91.4% 92.2% 92.3% 92.2% 92.3% 92.3% 90.4% 90.1% 91.6% 89.7% 88.6% 89.1% 88.5% 87.2% 87.2% 86.6% 87.4% 88.0% 86.9% 88.3% 89.2% 90.9% 90.3% 90.7% 90.7% 90.0% 88.8% 88.1% 88.5% 88.3%

83%

84%

85%

86%

87%

88%

89%

90%

91%

92%

93%

0

5,000

10,000

15,000

20,000

25,000

30,000

% p

atie

nts

wit

hin

18

we

eks

Nu

mb

er

of

pat

ien

ts

80%

82%

84%

86%

88%

90%

92%

94%

Ap

r

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Performance Mean Upper control limit (3 sd)

Lower control limit (3 sd) Target Trajectory

25


Nov-17 5 2

Oct-17 5 2

Sep-17 5 2


RTTNovember’s performance, at 88.3%, shows a slight decrease on the previous month’sperformance of 88.4%. The most recent national data available (October) shows thatthe Trust’s performance that month was below the national average (89.3%) with 92%achieved at L&D but not at the RFH (86.9%). Comparative figures for E&NH were notavailable for October. The median waiting time at WHHT (ie the weeks half thepatients on an RTT pathway were waiting) was worse than the national position (6.7vs 7.0 weeks) and marginally worse than the 92nd percentile wait time (20.3 vs 20.6weeks).

Elective Medicine achieved 94.7%, WACS at 97%, and Surgery 83.4% was achieved.

There was one 52 week breach owing to an administrative error and resulting in thepatient being treated 2 weeks beyond the breach date.

Service18 Weeks

Plus

% Under 18

WeeksService

18

Weeks

Plus

% Under 18

Weeks

VASCULAR SURGERY 36 73.91% GASTROENTEROLOGY 38 96.88%

PAIN MANAGEMENT 168 76.57% CLINICAL HAEMATOLOGY 8 97.26%OPHTHALMOLOGY 583 77.34% CLINICAL ONCOLOGY 1 97.37%

TRAUMA & ORTHOPAEDICS 678 82.60% ENDOCRINOLOGY 7 97.63%

GENERAL SURGERY 325 83.01% PAED OPHTHALMOLOGY 3 97.71%

ENT 357 83.15% ORTHOTICS 4 97.81%

ORTHODONTICS 8 86.21% BREAST SURGERY 7 98.03%

UPPER GI SURGERY 7 87.04% GYNAECOLOGY 12 98.52%

UROLOGY 159 87.27% DIABETIC MEDICINE 1 98.65%

NEUROLOGY 98 89.82% GERIATRIC MEDICINE 1 98.92%

ORAL SURGERY 93 90.70% GENERAL MEDICINE 0 100.00%

PAED ENDOCRINOLOGY 4 91.11% OTHER 0 100.00%

COLORECTAL SURGERY 37 92.61% PAEDIATRIC EPILEPSY 0 100.00%

RESPIRATORY MEDICINE 33 92.68% PAED CLIN HAEMATOLOGY 0 100.00%

DERMATOLOGY 157 93.28% HEPATOLOGY 0 100.00%

PAED CARDIOLOGY 3 93.48% STROKE MEDICINE 0 100.00%

NEPHROLOGY 2 94.29% TRANSIENT ISCHAEMIC ATTACK 0 100.00%

PAED GASTROENTEROLOGY 5 94.38% MEDICAL ONCOLOGY 0 100.00%

PAED DERMATOLOGY 2 95.12% CLINICAL NEUROPHYSIOLOGY 0 100.00%

PAEDIATRICS 36 95.49% NEONATOLOGY 0 100.00%

RHEUMATOLOGY 20 95.90% OBSTETRICS 0 100.00%

PAED UROLOGY 5 96.45% GYNAECOLOGICAL ONCOLOGY 0 100.00%

CARDIOLOGY 55 96.63% Total 2953 88.28%

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Diagnostics

Patients not

treated within

28 days of last

minute

cancellation

and urgent

operations

cancelled for

2nd time

Hospital

outpatient

cancellations

all and %

cancelled*

within 6 weeks * Ex c l udi ng v a l i d c a nc e l l a t i ons

( c a nc e l l a t i ons t o pr ov i de e a r l i e r

a ppoi nt me nt s or whe r e a ppoi nt me nt no

l onge r r e qui r e d, c a nc e l l a t i ons due t o

whe r e pa t i e nt s ha v e di e d, c a nc e l l a t i ons

t o a ppoi nt me nt s ma de i n e r r or a nd

c a nc e l l a t i ons whe r e t he r e wa s a c ha nge

t o a c l i ni c t e mpl a t e wi t hout a c ha nge t o

a pa t i e nt ' s a ppoi nt me nt da t e , t i me or

si t e )

0

2

4

6

8

10

12

14

16

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Patients not treated within 28 days of last minute cancellation

Trajectory (28 day standard)

Target (28 day standard)

Mean

0%

2%

4%

6%

8%

10%

12%

14%

16%

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Outpatient cancellation rate Actual Outpatient cancellation rateTarget

Mean Upper control limit (3 sd)

Lower control limit (3 sd) Outpatient cancellation rate within 6 weeks

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

100.5%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2014/15 2015/16 2016/17

Performance Trajectory Target

Mean Upper control limit (3 sd) Lower control limit (3 sd)

26

Hospital cancellations – patients not treated within 28 days of last minute cancellation

There were 6 breaches of the 28 day rebooking requirement. These were in GeneralSurgery (3), the Breast Service (2) and ENT. Five breaches were the result of capacitypressures, and one was deferred by the patient.

Hospital cancellations – patients cancelled within 6 weeks and overall

Short notice, hospital initiated cancellation remains below the Trust tolerance (5%) at3.9% (excluding valid cancellations and patient initiated cancellations).

NB: Total cancellation rate does not equate to unfilled capacity.

Diagnostic wait times

Diagnostics performance has recovered in line with the planned trajectory and is now compliant at 99.4%

All cancellations Under 6 weeks All cancellations Under 6 weeks

10.1% 3.9% 12.5 10.4%

Total cancellations: 22.6%

Hospital initiated Patient initiated

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Sally Tucker Jeremy Livingstone Divisional managers

Recovery plan/ existing actions and update

CWTs

Two week

standard

Breast

symptom two

week

standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Two week wait performance Two week wait target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Breast Symptomatic performance Breast Symptomatic target

27

2wwThe provisional position for November is compliant at 96.9%.

Breast symptomaticThe provisional position for November is compliant at 99.3%.


Nov-17 6 1

Oct-17 6 1

Sep-17 6 1


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31 day

subsequent

surgery

standard

31 day

subsequent

drug standard

31 day

standard

93%

94%

95%

96%

97%

98%

99%

100%

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 31 day Performance Cancer - 31 day Target

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

102%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 31 day subsequent surgery Performance Cancer - 31 day subsequent surgery Target

80%

85%

90%

95%

100%

Ap

r

Ma

y

Jun

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

Ma

y

Jun

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Ap

r

May Ju

n

Jul

Au

g

Sep

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 31 day subsequent drug Performance Cancer - 31 day subsequent drug Target

28

31 day first

The position is provisionally compliant at 98.5%

31 Day subsequent – Drug

The position is provisionally compliant at 100%

31 day subsequent –Surgery

The position is provisionally compliant at 100%

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62 day

screening

standard

62 day

standard

number of

104+ day

waiters

62 day

standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Ju

n

Jul

Aug Se

p

Oct

No

v

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

No

v

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

No

v

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 62 day Performance Cancer - 62 day Trajectory Cancer - 62 day Target

0%

20%

40%

60%

80%

100%

120%

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

Apr

May Ju

n

Jul

Aug Se

p

Oct

Nov

Dec Jan

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 62 day screening Performance Cancer - 62 day screening Target

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

Cancer 62 day patients waiting 104 days+ 24 3 3 4 4 2 3 3 2 0 1

Cancer 62 day PTL (total) 1466 1338 1284 1331 1312 1456 1521 1720 1392 1251 1254

0

5

10

15

20

25

30

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Nu

mb

er

of

pat

ien

ts w

aiti

ng

10

4+

day

s

Nu

mb

er

of

pat

ien

ts o

n P

TL

29

62 day GP – urgentThe provisional position for November is compliant at 86.8% On 18.12.17, there are currently 72 treatments and 9.5 breaches.. To be validatedFollowing validation , it is expected that we will be compliant at final submission

.

104 day waitsThere were 13 active 62 day pathways that have already waited over 104 days (as of 15.12.17)

1 pathway over 104 days was closed in November. The patient was on a LGI pathway

62 day screening Performance is provisionally non compliant at 72.2%.

There were 9.5 cases with 2 breaches – validation is ongoing.

Tumour site October November

Breast 100 100

Gynaecological 85.7 94.1

Haematological 100 -

Head and Neck 50 75

Lower Gastrointestinal 100 52.4

Lung 16.7 42.9

Other 100 -

Sarcoma - 100

Skin 94.1 95.8

Upper Gastrointestinal 60 100

Urological 81.1 96.8

Total 86.2 86.8

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30

Responsive


Executive lead Clinical lead Operational lead Performance relative to targets/ thresholds

Sally Tucker Dr David Gaunt Divisional managers

Nov-17 1 4

Oct-17 1 4

Sep-17 1 4

A&E

* Please note that the A&E trajectory is a working trajectory and awaiting final approval

Ambulance

turnaround

time

Unscheduled care

indicators - A&E,

ambulance turnaround

and DToCAchieving Not achieving

70%

75%

80%

85%

90%

95%

100%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Performance Trajectory Target


0

100

200

300

400

500

600

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Ambulance turnaround 60 mins+ Ambulance turnaround between 30 and 60 mins Target

A&E performance fell in November to 81.9%, compared with 83.4% the previousmonth. Minors performance met the standard at 95.1% for November. CEDperformance dropped to 92.% from 97.8% following a high volume of attendanceslinked to high acuity and respiratory illness.

Work has been ongoing to clarify pathways and improve compliance with the 30minute response time target for Internal Professional Standards (review of A&Epatients by specialty teams). Streaming of patients is occurring much earlier in thepatient pathway although activity is limited when assessment areas are used forbedded patients at peak times.

Focus on ensuring full use of Emergency Surgical Assessment Unit (ESAU), MedicalAssessment Area (MAU), Ambulatory Care (ACU) and Frailty. This has not beenpossible at times of increased pressure and capacity issues. The redevelopment of anew CDU with increased capacity, is planned to open December 2017.

The improvement in the number of ambulances waiting between 30 and 60 minuteshas been more or less sustained. The number of ambulances waiting over 60 minuteshas also improved. The Trust has increased the resource available to care forpatients in the corridor during periods of significant demand, so it can respondflexibly to any queue of ambulances, enabling earlier release of crews. A newAmbulance Response Programme (ARP) inbound screen went live on 16 October2017 providing more information about patient conditions, tracking of arrival timeand providing a more accurate recording of handover times. Additionally there is aprogramme of work to ensure continued improvement in ambulance handover times.

An activity comparison of the current financial period with the same period last year has shown:• Type 1 attendances are up by 0.9%.• Ambulance arrivals are down by 4.5%.• Admission rate from A&E (excluding ambulatory and frailty) is down by 0.1%.• Discharges (Trust wide) are up by 8.5%

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31

Delayed Transfers of CareDToC patients represented 4.4% of occupied beds in November, measuredusing the nationally reported method. This is based on a snapshot of thenumber of patients waiting at a point in time in the month, expressed as apercentage of beds.

The total beds occupied by DToC patients is a helpful measure to illustratethe impact of DToC because it includes all patients waiting in the month. InNovemberDToC patients consumed 988 bed days, the equivalent of 33 beds.

There are regular audits of both DToC and other stranded patients (over 7day length of stay) to identify issues and remove avoidable causes of delay.

Ongoing escalation to system partners via the A&E Delivery Board continues,with significant resource directed to generating additional capacity andimproving discharge processes.

An IDT improvement plan is underway. However its impact will be marginaluntil capacity matches demand for onward health and social care services.

Streamlined processes for data monitoring and reporting have beenintroduced, as well as daily “live” patient monitoring with board briefingswith the discharge planning nurses. Lead roles have been developed inrelation to self-funded patients, and continuing healthcare (CHC)assessments, and a number of staff have been re-allocated to different areasto tackle issues relating to a build up of referrals.

12 hour

trolley waits

Delayed

Transfers of

Care (DToC)

0

10

20

30

40

50

60

0%

2%

4%

6%

8%

10%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Beds used by DToC patients in month DToCs DToC target

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

2015/16 2016/17 2017/18

Performance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0

1

2

Performance Target

0

10

20

30

40

50

60N

um

be

r o

f b

ed

s

Oct-15

Nov-15

Dec-15

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

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Total number of beds used by DToC patients 27.1 35.1 32.5 40.535.7 38.7 38.6 41.2 32.7 31.8 43.2 45.0 41.335.135.2 42.7 47.3 52.8 51.6 47.9 47.6 44.0 37.538.335.3

NHS Days 12 21 25 31 24 29 23 23 17 20 25 26 25 21 19 21 24 25 24 19 20 26 18 17 15

DHSS Days 15 14 7 9 11 9 16 18 15 11 18 19 16 12 16 21 23 28 27 28 27 18 20 21 19

Days (BOTH) - - - - - 0 - - - - - - 0 2 0 1 - 0 0 1 0 - 0 0 0

Beds used by DTOC patients: DHSS vs NHS

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Well led

Reporting sub committee - PSE


Paul da Gama

Sickness rate

Staff turnover

and vacancy

rate

% bank,

agency and

temporary

pay

Workforce indicators - staff turnover, sickness, bank & agency,

vacancy, appraisal, and mandatory training

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Staff turnover Performance Staff turnover Trajectory Staff turnover target

Vacancy rate Performance Vacancy rate Trajectory Vacancy rate Target

0%

5%

10%

15%

20%

25%

30%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

% Bank Pay performance % Bank Pay Trajectory % Agency Pay performance

% Agency Pay Trajectory Temporary costs performance Temporary costs Trajectory

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Sickness rate performance Sickness rate target Sickness rate Trajectory


Jan sickness hard

32

Turnover and VacanciesThe overall Trust vacancy rate has decreased from 15.2% (November 2016) to 10.6%in November 2017. The current rate is the lowest since April 2016. Whole timeequivalent (wte) staff in post has increased by 60wte since September, while theestablishment increased by 4wte. November saw the highest ever number of staff inpost at the Trust, at 4307 wte’s. The vacancy rate for qualified Nursing & Midwiferyposts reduced very slightly to 15%. Recruitment activity has built up a large pipelineof new N&M recruits and a recent recruitment drive in the Philippines in October hasresulted in another 75 job offers. As stated last month, many staff in the pipeline arefrom overseas with long lead-in times, and over the next few months the vacancy ratefor Nursing and Midwives is expected to rise, largely due to the transitional timeneeded for nurses to register with the NMC. The Trust currently has 54 such nursesawaiting registration. Retention is key to continued reduced vacancy rates, and WHHTis working with NHSI to reduce the turnover rate within Band 5 nursing. This hasreduced over the last 3 months from over 27% to just over 25% currently. The 12-month rolling turnover rate reduced slightly, to 16.2%. WHHT has the eighth highestturnover (of 12 organisations) compared to Herts & Beds peers and is above theregional average of 15.4%. Over the last 2 years, turnover has shown a modestdownward trend, although Band 5 nursing as noted above, is relatively high.

% Bank and Agency ExpenditureAgency spend in November increased to £1.73 (£1.58m in October). This spendrepresented 8.7% of the overall pay-bill (target 8%). Agency spend has reducedconsiderably over the last couple of years, with spend in 2016/17 being £10m lessthan 2015/16. Renewed work continues to reduce agency costs via the AgencySteering Group, and through partnership working across Herts & Beds, with theshared staff bank being the latest initiative.

Sickness rateThe sickness absence rate remains low at 3.4%, and is better than the Trust target of 3.5%. The Trust is currently well below the Herts & Beds average of 3.9% at the end of Quarter 2. Over the last 2 years, sickness absence has fluctuated between 3.8% and 2.8%. Average sickness absence in 2015/16 was 3.4%, whereas in 2016/17 it was fractionally lower at 3.2%. It has averaged just over 3.0% in the current year to date.


Sep-17 3 4

Aug-17 3 4

Jul-17 2 5


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Number of

staff leaving

within first

year (excluding

medics and fixed term

contracts)

Mandatory

training

Appraisal rate (non medical staff only)

60%

65%

70%

75%

80%

85%

90%

95%

100%

Apr

May Jun

Jul

Aug Sep Oct

Nov

De

c

Jan

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

De

c

Jan

Feb

Mar

Apr

May Jun

Jul

Aug Sep Oct

Nov

De

c

Jan

Feb

Mar

2015/16 2016/17 2017/18

Mandatory Training Performance Mandatory Training Target Mandatory Training Trajectory


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Appraisal rate Performance Appraisal rate Target Appraisal rate Trajectory


0%

5%

10%

15%

20%

25%

0

50

100

150

200

250

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Number of staff % of new staff

33

Appraisal – non medical staffNovember’s rate is 86%, slightly below the 90% compliance rate for the second monthrunning. There is a significant challenge in maintaining focus and ensuring appraisaldates are aligned to staff increments. HRBPs will continue their work with Divisionsto develop trajectories and monitor and ensure performance is consistently above the90% target. HR Business Partners are also working with managers producing bi-weekly reports to support the transition to effective alignment of appraisals toincrements and to plan the completion of all outstanding appraisals. Currently 33% ofstaff incremental dates are aligned to appraisal dates

Mandatory training Mandatory training compliance is currently at 89%. This figure has been rolled overfrom September as the database requires ongoing validation for competencyrequirements. A working group has been set up to agree the way forward andestablish requirements to ensure accurate compliance reporting. All substantivecurrent Trust staff and new starters are able to access e-learning and book core &essential classroom training through a web-based portal that is accessible outside ofthe Trust.

Acorn, the new self-service Learning Management System, has now beenimplemented across the trust and is available to all staff. An introductory letter anduser guide has been distributed via HR leads, and Divisional Managers for onwardcirculation, providing step by step instruction to enable them to access and use thisnew system. Substantive and non-substantive new starters can access Acorn to

complete their eLearning, even before they commence employment. The next stageof the Acorn rollout involves sending out guidance to line managers to enable themto see at a glance, which of the staff in their team(s) are compliant.

Number of staff leaving within first yearThe overall rate was 19% in November, an increase compared to last month. A year ago the figure was 18%.

The Trust is closely monitoring staff leaver information via the web-based exit leaversystem, particularly regarding reasons for leaving. The reconnect sessions followingcorporate induction continue, bringing new starters back together and offering anopportunity to resolve any issues and gather information to further improve staffexperience in the first year in post. Key work is also under way to support retentionof Band 5 nurses, where there is the highest turnover. This also forms a part of theNursing retention project with NHSI, where Band 5 nursing leavers have beenidentified as a key workforce to reduce leavers overall.

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34

The Board Assurance Framework shows key workforce indicators in the context ofcurrent performance, performance 12 months and 3 months ago, Trust workforcetargets, the distance to these targets and a RAG rating based on 5 scales. It also hasbenchmarking data taken from NHS healthcare providers in the Hertfordshire andWest Essex and Bedford, Luton and Milton Keynes STPs.

The RAG rating is based on distance to targets – if current performance is within 0% to20% (or exceeds) its target then the RAG rating is green. If performance is within 60%– 80% of target then the rating is yellow. This is repeated at 20% intervals for amberand brown until performance is over 80% from the target when the RAG rating is red.If 2 indicators are rated red, then the overall rating is red. If all indicators are ratedgreen, or one is amber then the overall rating is green. Any other combination isamber.

The performance indicators have changed for November to reflect more relevant anddetailed areas of the workforce.. The new indicators include Band 5 Nurse Vacancy,and Band 5 Nurse Turnover, reflecting the focus on recruitment and retention inconjunction with NHSI. Nursing Band 5 vacancy and turnover areas are identified asthe Trusts highest workforce risk factors. Both measure s have improved, showing areduction over the last months. Band 5 Nursing vacancy is rated Red, as thepercentage distance to target is 138%. Band 5 nursing turnover is rated amber.

Appraisals were just below target at 86% and mandatory training compliance is 89%.Please note that the training compliance figure has been rolled over from Septemberdue to ongoing validation of the training database.

The Trust has achieved its target of a sickness rate less than 3.5%

The current agency pay bill percentage is 8.7%, slightly above the 8% target.

The 12 month turnover rate is 16.1%, less than 3 months ago, and one year ago.

The latest Q2 FFT score shows a slight increase compared to Q1, and the currentscore is within 20% of the target.

Benchmark averages are taken from Q2 17/18 data and are from 12 nearby NHSorganisations.

Trust targets reflect benchmarking of targets of other comparable acute Trusts,including those rated as ‘outstanding’ by the CQC. Appraisal and Core Trainingcompliance targets are now 90% rather than 95% previously. Agency costs as a % ofpay bill has changed from 10% to 8% as this reflects the Trust’s NHSI agency target

Workforce BAF scorecard

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Well ledTracey Carter and Paul

Da Gama

Reporting sub committees - PSQ and PSE

Staff scores (%

reccommended

and not

recommended)

and response

rate

A&E scores (%

positive and

negative) and

response rate

Safe, effective,

caring

Friends and family

Inpatient scores

(% positive and

negative) and

response rate 0%

20%

40%

60%

80%

100%

120%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Inpatient Scores FFT % positive performance Inpatient FFT response rate Inpatient FFT response rate Target

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

A&E FFT response rate performance A&E FFT % positive Performance A&E FFT response rate Target

0%

10%

20%

30%

40%

50%

60%

70%

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Staff FFT % recommended work Performance Staff FFT response rate Performance

Staff FFT response rate target

Positive performance targets to follow

35

InpatientsThere has been a reduction in the response rate but an increase in the recommended rate and more marginal improvement in those not recommending the Trust .

The comments made by patients remain overwhelmingly positive with “friendly”,“responsive”, “professional” and “wonderful” most commonly used words.

A&EThere has been a marginal reduction in the response rate and a decreasein recommendation rates, with an increase in the number of patients who would notrecommend the service.

Staff The Trust is in the process of conducting the staff attitude survey for quarter 3, which isrunning until 1st December 2017. Staff have the opportunity to participate in the surveyby completing either the online or paper survey. The survey has been promoted widelyacross the Trust with several “You said, we did” campaigns, a dedicated intranet page, aweekly communication campaign, prize draws and managers walking around the Trustwearing staff survey t-shirts. Results will be analysed in February and key themes reportedback thereafter. Currently the Trust has a 36% completion rate

Well led

Nov-17 0 3

Oct-17 0 3

Sep-17 0 3


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36

dupe

Daycases scores

(% positive and

negative) and

response rate

Maternity (Q2)

scores (%

positive and

negative) and

response rate

Outpatient

scores (%

positive and

negative) and

response rate

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Daycase FFT % positive Performance Daycases FFT response rate Performance

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Outpatient FFT % positive Performance Outpatient FFT response rate Performance

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Maternity FFT % positive Performance Maternity FFT response rate Performance

The Trust is now measuring both the main DSU at SACH and also the Surgicaladmission lounge at WGH.

Analysis of the most common negative comments this month focused on:• delays – in out-patients across all sites (reference to clinics running late)• long waits to be seen in ED and UCC• availability/cost of parking when attending OPD at HHGH & SACH

OutpatientsThere has been a significant increase in responses (circa 1338) but with a marginalreduction (0.1%) in the recommendation rate and no change in those notrecommending the Trust.

Maternity Question 2There has been a significant increase in response rate with a marginal increase inthe recommendation rate but an increase in those who would not recommend theservice.

However, comments were overwhelmingly very positive with constant referencesto the amazing care and great communication with the women and theirpartners/families. The handful of negative comments mentioned the lack offacilities in the bathroom for women post C section and the lack of a welcome orfriendly attitude in different areas within the unit.

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Safer staffingIndicator Performance (November) Threshold Trend Forecast next month

% Nursing hours versus planned 95.0% >95% Up >95%

Care hours per patient day 7.4 n/a Stable 7.2

Indicator by shift and skill mix Shift RN Care staff

% Nursing hours versus planned Day 85.0% 95.8%

Night 95.4% 97.6%

Care hours per patient day All 4.6 2.7

What actions have been taken to improve performance

Enhanced care needs team commenced 13 May 2017 – recruiting to theteam continues, continued use of temporary staff at night to support the team.

Local and international recruitment initiatives continue. Trust Recruitment Group formed chaired by Director of HR and Chief Nurse

Shared bank approach across four Trusts commenced 31st July. Project plan to address the retention rate of band 5s is in place chaired by

Executive Director. External Visit requested by Chief Nurse looking at Safe Staffing to be

rescheduled.

What is causing the variance

Overall the Trust % fill rate for November was 92.2% and increase of 1.9% from last month and below the national threshold. The fill rate within the medicine/USC divisionwas 94.6 % , an increase 1.7%. Within Surgery, the fill rate was 90.5% a decrease 2.8%. Overall the fill rate in WACS was 87.6% , a decrease 1.8%. This can be broken furtherbroken down to show maternity fill rates at 96.4% and paediatrics at 71.8%. Paediatric fill rate have decreased by 9% from last month. The low fill rates are mainly fornursery nurses day and night due to issues around recruitment and retention. This is currently being reviewed by Head of Nursing as part of establishment review, looking atskill mix and role redesign. The number of shifts rag rated green were 73.4% an increase 1.6%. The number of shifts rag rated amber were 25.8% a decrease 1.8%. Thenumber of shifts rag rated red were 0.8% and increase in 0.3%. The areas rag rated red were UCC Hemel, NNU and ITU/Outreach. All were logged on Datix and no harm wasreported. Mitigations were put in place, eg moving staff to the areas, getting out reach to support ITU, supervisory band 7s working, specialist and corporate nursingsupporting in the numbers to maintain patient care and safety. There were no Red Flagged shift of less than 2 registered nurses. There were 20.6% shifts red flagged forregistered nurses more than 8 hours less than planned, an increase 7.1% from last month. A number of areas have fill rates below 80% - AAU Level 1 Yellow, Letchmore andSarratt, Tudor, Heronsgate and Gade. The following areas had fill rates below 70% AAU Level 1 Blue and Flaunden. The following surge areas were open - MAU (4 days), COB(4 days), ESAU (13 days), Ambulatory Care (25 days), Elizabeth (27 days) and Oxhey had an additional patient bed open for (30 days). Patients were cared for in these areas byredeployment of substantive staff and bank and agency. Over 320 patients had enhanced care needs identified and were cared for by the enhanced care team by day andbank/agency at night. The overall Trust Supervisory Hours Lost in October was 41.2% an increase of 3.4% from last month. Currently implementing safe care the 4 earlyadopter wards are Heronsgate and gade, Blue and Yellow level 3, Sarratt and Ridge. Currently on phase 2 which includes ITU and Level 5 surgery.

98.0%

97.1% 97.2%

96.2%

96.9%

97.6%97.3%

94.3%

95.2% 95.0%

93.0%

90.9%

92.2%

5.0

5.5

6.0

6.5

7.0

7.5

8.0

8.5

9.0

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Car

e H

ou

rs P

er

Pat

ien

t D

ay

Pe

rce

nta

ge o

vera

ll p

lan

ne

d v

s. a

ctu

al n

urs

ing

ho

urs

Percentage overall planned vs. actual nursing hours & CHPPD

Care Hours Per Patient Day (CHPPD) % Fill Rate Threshold - fill rate

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End of Life CareNumber of patients who are referred to the palliative care team and who have an identified preferred place of death

In 2008 the End of Life Care Strategy (Department of Health) was published and one ofthe insights from this was that people weren’t supported to die in their place of choice;and although progress has been made, this has been evidenced in many other reports.In July 2014 just over 50% of respondents to the National Survey of Bereaved People(VOICES-SF) felt that their relative had died in a place of their choice (Office of NationalStatistics, 2014).There is now a national focus on reducing the numbers of patientsdying in hospital and offering everyone who is approaching the end of their life theopportunity to express and share their preference for where they want to die as wellas any goals that are important to them (National Palliative and End of Life CarePartnership, 2015).

In November, 122 referrals were made to the Trust Specialist Palliative Care Team.Seventy-seven percent of patients seen by the Specialist Palliative Care Team had anidentified preferred place of death (PPD). This included those patients who hadcapacity and were appropriate to have this discussion.

There were two patients who died in hospital although home was their preferred placeof death. This was due to their physical symptoms not permitting their statedpreference being met for one patient, and a delay in C/C Process (Funding) for theother patient.

The measures of success in the Trust end of life strategy are being reviewed and willform part of the Trust Board committee dashboard from December.

Q1 2015/16 (avg per

month)

Q2 2015/16 (avg per

month)

Q3 2015/16 (avg per

month)

Q4 2015/16 (avg per

month)

Q1 2016/17 (avg per

month)

Q2 2016/17 (avg per

month)

Q3 2016/17 (avg per

month)

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Nursing Home 0 3 5 6 5 6 2 3 11 9 6 6 5 4 5 2 5 4

Hospital 0 3 4 6 10 5 9 19 20 17 6 16 3 6 10 8 6 10

Hospice 0 11 15 12 10 13 1 15 7 8 12 10 10 9 8 6 16 14

Home 28 10 12 15 18 13 6 13 15 11 6 10 17 10 13 9 16 10

Impaired capacity to state a preference 12 14 13 22 17 12 23 35 28 27 23 29 29 23 21 20 26 18

% with identified preference 54.6%58.8%66.9%82.0%79.6%73.0%69.5%94.3%65.1%51.1%81.6%100.0 79.5% 52% 71% 82% 88% 77%

0

10

20

30

40

50

60

70

80

90

0%

20%

40%

60%

80%

100%

120%

Num

ber o

f ref

erra

ls b

y id

entif

ied

pref

eren

ce

Perc

enta

ge o

f ref

erra

ls

Number and percentage of referras with identified preference for preferred place of death, excluding patients unable to state preference, inappropriate referrals or deaths prior to being seen or transferred

back to other HCP’s

Q1

2015/

16

(avg

per

month

)

Q2

2015/

16

(avg

per

month

)

Q3

2015/

16

(avg

per

month

)

Q4

2015/

16

(avg

per

month

)

Q1

2016/

17

(avg

per

month

)

Q2

2016/

17

(avg

per

month

)

Q3

2016/

17

(avg

per

month

)

Jan-17 Feb-17Mar-

17Apr-17

May-

17Jun-17 Jul-17

Aug-

17Sep-17 Oct-17

Nov-

17

Total referrals 63 59 67 71 75 69 78 98 111 120 103 96 108 84 72 90 120 112

-

20

40

60

80

100

120

140

Nu

mb

er

of

refe

rral

s p

er

qu

arte

rReferrals to Trust Specialist Palliative Care Team

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Trust data quality, by exceptionData Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent

Amber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queries

Green – Data is complete, accurate and consistent with the standards set for the specific indicator

39

Domain a Indicator a

Data

Quality

RAG

a Description of issues Improvement action plan Target date for 'Green' rating

Safe, Effective, CaringDischarges between 8am and 12pm*

(main adult wards excl AAU) A

Safe, Effective, Caring% Complaints responded to within one month or agreed

timescales with complainant

R

Operational and clinical pressures has meant it has been

challenging to find the time for clinical and operational staff to

respond to concerns on time.

The Unscheduled Care Division are recruiting a 0.5 WTE

position to assist clearing the backlog.

The team are recruiting a new complaints manager and have

approach NHSP and agencies to fill the vacancy.

The Surgery Division has held a complaints workshop to

address backlog. The same will be done in Unscheduled Care.

The Women and Children’s Division are recruiting a post to

deal with complaints. The Environment and Medicines Division

have improved their response times considerably.

Recruitment expected to be completed by end of Summer.

Improvements are hoped to be seen by end of 2017.

Safe, Effective, Caring Complaints - rate per 10,000 bed days

R Capturing complaints across the Trust.

All complaints are captured and triaged daily. All complaints

are logged daily and there are systems in place to capture all

complaints received through the CEO, executive assistants,

through NHS net and on social media. Reminders are sent to all

staff about forwarding complaints received in clinical areas.

There is a system for auditing all new complaints taken through

triage on the following day. This risk is being minimised as much as possible.

Safe, Effective, Caring Reactivated complaints

R Increase in reactivated complaints

We telephone every reactivated complaint to talk through

concerns. We consider if someone independent needs to

investigate. We send reactivated complaints to external

investigators in complex cases. We invite complainants to

meetings to discuss their concerns.

We now record the reason for reactivated complaints and will

audit this. We have asked Healthwath Hertfordshire to review

a pool of complaints and provide feedback. We will ask that

they include a small pool of reactivated complaints also. This risk is being minimised as much as possible.

Safe, Effective, Caring Hospital Acquired Pressure Ulcers - Grade 3A

Safe, Effective, Caring Number of Falls*A

Safe, Effective, Caring VTE risk assessment*A

Paper based VTE forms used for assessing compliance by clinical

coding team. Evidence elsewhere within notes demonstrating

compliance not on form not previously identified.

Clinical Advisory Group has approved new process for coding

team to assess VTE compliance. Electronic system required to

improve compliance to green.

July 2017 (Amber). Electronic system date of implementation TBC

(for Green)

Safe, Effective, Caring Caesarean Section rate - Combined*A

Perception that there is a difference between caesarean section

rate on CMiS compared to what has been clinically coded

Review of clinically coded notes and comparison to CMiS to

review discrepancies July 2017

Safe, Effective, Caring Caesarean Section rate - Emergency*A As above As above As above

Safe, Effective, Caring Caesarean Section rate - Elective*A As above As above As above

Safe, Effective, Caring Stroke patients spending 90% of their time on stroke unit *A

Responsive Ambulance turnaround time between 30 and 60 minsR Identified inaccuracies in timing of Ambulance Service data Ongoing work with ambulance service TBA

Responsive Ambulance turnaround time > 60 minsR As above Ongoing work with ambulance service TBA

Well Led Sickness rate

A

1. Potential for under reporting

2. There can be issues with data recorded on ESR but this will be

fixed with the implementation of the new ESR 2 system.

1. HR undertook a number of audits to look into areas who were

reporting 0% sickness throughout 2016 and have implemented

learning from those audits, including a new process for

capturing absences if medical staff.

2. implementation of the new ESR 2 system.

September 2017 (linked to the ESR implementation). There will

also be ongoing audits to ensure that absence data is still being

accurately recorded

Well Led Mandatory TrainingA

1. Potential for reporting inconsistencies on ESR in certain staff

groups A project group has been set up to investigate and correct

reporting issues Feb-18

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Trust Board Meeting

11 January 2018

Title of the paper Quality Improvement Plan Progress Update (November data)

Agenda item 10/55

Lead Executive Tracey Carter, Chief Nurse and Director of Infection Prevention and Control

Author Rita Oye – Head of PMO

Executive summary

The QIP was discussed at the Strategy Delivery Board (SDB) and Safety and Compliance committee in December 2017. Progress was noted and that any further actions from the most recent CQC inspection will be added to the QIP and finalised on publication of the report. The QIP as currently composed (CQC-specific) will run through until the end of March 2018 and be monitored by the SDB, and the Safety and Compliance Committee. From 01 April 2018 any outstanding QIP project deliverables will continue to be monitored by the PMO office. The projects will be delivered through quality improvement activity run by the Quality Hub as part of the quality compliance framework. There are 5 projects reported through the QIP reporting cycle this month. The overall status for the QIP at the end of November is green; the forecast status for December is also green. For the month of November 2017, 13 actions were closed resulting in a total of 13 open actions for this reporting period.


Strategy Delivery Board – 13 December 2017

Action required: The Trust Board are asked to note the review by the Strategy Delivery Board and receive this paper for information and assurance.

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PR4a Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance

PR5a Inability to deliver and maintain performance standards for Emergency

Care

PR5b Inability to delivery and maintain performance standards for Planned

Care(including RTT, diagnostics and cancer)

PR7b Failure to secure sufficient capital, delaying needed improvements in

the patient environment, securing a healthy and safe infrastructure

PR8 Failure to engage effectively with our patients, their families, local

residents and partner organisations compromises the organisation’s

strategic position and reputation.

Trust objectives X To deliver the best quality care for our patients X To be a great place to work and learn To improve our finances X To develop a strategy for the future

Benefits to patients/staff from this project/initiatives The QIP will deliver significant quality and safety improvements across the Trust in response to the CQC recommendations which will result in improved outcomes and patient experience. 10



of 12

Agenda Item: 10/55

Trust Board – 11 January 2018

Quality Improvement Plan Progress Update (November’s)

Presented by: Tracey Carter, Chief Nurse and Director of Infection Prevention and Control

1. Purpose

1.1 The purpose of this paper is to provide information and assurance that the quality improvement plan (QIP) is being delivered effectively.

1.2 The QIP was formally submitted to the CQC and the Trust Development Authority

(TDA), now NHS Improvement, on 8th October 2015 and is published on the Trust’s website www.westhertshospitals.nhs.uk/CQC/. The QIP was refreshed following the full CQC re-inspection in September 2016 and a further full review has been completed in response to the publication of the CQC Quality Report in March 2017.

1.3 The QIP has been migrated onto the new project management software, PM3,

which is now being used for all major projects.

2. Background

2.1 To date (including this reporting period), sixteen projects have been completed: Vision, Safe Staffing, Information Governance, Data, Recruitment, Caring for our most acutely unwell patients, Outpatients, Patient Flow, Capital Programme, Environment Estates and Facilities, Safety Equipment and Security, Clinical Training, Medicine Management, Urgent and Emergency Care, Environment 2016 CQC Review Action Plan projects and Harm Free Care.

2.2 The two IT Projects, ICT & Information and ICT & Transformation have been closed and taken off the QIPP Programme as agreed at SDB TEC, both projects will be reported through other governance structures.

2.3 The QIP is designed to deliver improvements in outcomes and key performance

measures. 2.4 This report summarises the progress of the QIP projects at the end of November

2017 and is reported using the Red, Amber and Green (RAG) rating.

2.5 There are 5 projects reported through the QIP reporting cycle this month. The overall status for the QIP at the end of November is green; the forecast status for December is also green.

10



http://www.westhertshospitals.nhs.uk/CQC/

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2.6 The must and should actions from the most recent CQC inspection are being distilled into the relevant Quality Improvement Plan (QIP) projects. The QIP as currently composed (CQC-specific) will run through until the end of March 2018 and be monitored at the Strategy Delivery Board TEC, and the Safety and Compliance Committee.

2.7 From 01 April 2018 any outstanding QIP project deliverables will continue to be monitored by the PMO office. The projects will be delivered through quality improvement activity run by the Quality Hub as part of the quality compliance framework.

2.8 To provide assurance regarding progress and effectiveness of the QIP, an updated quality compliance framework will be presented to the Quality and Safety Group in February following a pilot in the Women and Children’s division for review. An overall assurance report will be provided twice yearly to the Safety and Compliance Committee. This will include progress on implementation of the framework and the results of divisional quality compliance self-assessments and internal clinical reviews.

10



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3.0 QIP Programme Analysis The Portfolio Performance Report below highlights the status of each project (Active plans), the status of each key milestone and the number, and status, of the risks and issues associated with each project. Information presented as Changes in the Active Plans and Key Milestones is a sample of the projects in the QIP and the full detail is presented in section 4.

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3.1 Activity Trends

3.2 In the current reporting period there are 5 QIP projects incorporated into the one QIP Programme making a total of 6 active plans this reporting period. All 5 QIP Projects are currently reporting as green.

3.3 Two projects have been closed this month.

ICT & Information

ICT & Transformation

3.4 After review with the CIO it was agreed that the ongoing ICT & Information and ICT & Transformation projects currently reported within the QIP should be removed from report as the remaining ICT & Transformation actions are all part of the Trust-wide Make IT Happen programme. This programme is managed within the ICT department’s governance structure. The CIO formally reports monthly on progress to the Finance and Investment Committee, which in turn provides assurance to the Board.

3.5 The remaining ICT & Information actions are part of the Trust’s ICT Transformation Programme, which reports through the ICT Transformation Group. Overall governance of this and the Trust’s other Transformation Groups is through the Strategy Delivery Board. Decisions regarding overall prioritisation and alignment with Trust strategy are taken at this meeting.

3.6 The PMO continues to work with the project managers to close or review the forecast delivery dates of the outstanding actions.

3.7 Key Milestones – Status Trends

3.8 There are 13 open actions within the QIP in this reporting period, this

reduction from the 26 open actions last reporting period. 11 of the 13 actions are currently rated as green and are on track to deliver as agreed in the milestones, 2 milestones are rated amber, there are no milestones rated as red this reporting period.

3.9 7 actions have been completed in the month of November and closed. 6 further actions have been closed due to the termination of the ICT & Transformation and ICT & Information Projects.

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4.0 Project Activity Detail – RAG Status and Expected Project Completion month by Project

4.1 The table above shows the current RAG status of each of the 5 live QIP projects and 1 QIP Programme. The table also details

expected completion month by Project.

Portfolio Name Plan TypeParent

Plan IDRAG Summary Rationale Sponsor Plan Name

Nov

Dec

Jan

Feb

Mar

Apr

May

Jul

Aug

Sep

Oct

Nov

Dec

Programme QIP

Project/

Scheme

213 Project Closed Kevin How ell Capital Programme

Project/

Scheme

213 Project Closed Tracey

Carter

Clinical Training

Project/

Scheme

213 Project on Track for Delivery Tracey

Carter

End of Life Care

Project/

Scheme

213 Project Closed Environment 2016 CQC

review Action Plan

Project/

Scheme

213 Project Closed Kevin How ell Environment, Estates, and

Facilities

Project/

Scheme


Carter

Harm-free Care

Project/

Scheme

213 Project Closed Lisa Emery ICT and Information

Project/

Scheme

213 Project Closed Lisa Emery ICT Transformation

Project/

Scheme

213 Project Closed Paul Da

Gama

Leadership

Project/

Scheme


Carter

Maternity

Project/

Scheme

213 Project Closed Mike van der

Watt

Medicine Management

Project/

Scheme

213 Project Closed Arla Ogilvie Outpatients

Project/

Scheme


Carter

Paediatrics

Project/

Scheme


Carter

Patient Feedback

Project/

Scheme

213 Project Closed Sally Tucker Patient Flow

Project/

Scheme


Carter

Quality & Risk

Project/

Scheme


Carter

Safeguarding

Project/

Scheme

213 Project Closed Kevin How ell Safety, Equipment, and

Security

Project/

Scheme

213 Project Closed Jeremy

Livingston

Surgery

Project/

Scheme

213 Project Closed Tammy

Angel

Urgent & Emergency Care

Project Activity Details

Q4 Q1 Q2 Q3

2017 2018

Q4

ID

Jun

QIP 213

252

229

1019

255

227

1168

221

223

266

215

1788

219

217

233

225

235

277

237

286

231

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5.0 Recommendation

5.1 The Trust Board are asked to note the review by the Strategy Delivery Board and receive

this paper for information and assurance.

Tracey Carter

Chief Nurse and Director of Infection Prevention and Control

January 2018

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Appendix 1

Oversight Metrics Performance Challenges

A&E performance (WGH time to initial assessment % within 15 mins) No baseline however, A&E performance declined this month from 85.5% in September; 85.9% in October to 84.4% in November. This continues to be below the target of 95%

Mandatory training compliance remains the same as October at 89.1%. HR continues to implement the new e-learning system although the 95% target has not been achieved.

Outpatients Appointments:

Cancelled appointments improved from October figure of 4.1% to 3.9% in November. This is below the target of 5%

Vacancy rate:

The vacancy rate continued to improve this month from 11.8% in September; 11.1% in October to 10.6% in November. Vacancy rate continues to be behind the trajectory.

Harm Free care (Test Your Care):

Compliance with equipment checks (Test Your Care excluding Maternity, Oxhey and Gade) has increased in October to 96.4% from 92.5% in October (Target is 90%). Accurate Record Keeping also increased slightly this month to 94.2% from 90.9% in October.

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Appendix 1 – Oversight Metrics – November data

Theme Project Metric Target Trend

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17

Our PeopleLeadership and People

DevelopmentMandatory Training 90.00% 86.0% 86.4% 87.7% 87.4% 89.4% 87.9% 87.7% 86.6% 87.2% 88.1% 86.5% 89.1% 87.7% 89.2% 92.1% 91.7% 90.1% 89.1% 89.1% 89.1%

Our People Recruitment and Induction Vacancy rate 9.0% 13.5% 14.2% 14.5% 15.2% 15.9% 15.7% 15.6% 15.2% 14.3% 13.5% 13.1% 12.5% 13.0% 12.7% 13.0% 12.3% 12.7% 11.8% 11.1% 10.6%

Our PeopleLeadership and People

DevelopmentAppraisal rate (non-medical staff only) 90.0% 76.5% 85.7% 89.2% 94.0% 91.7% 87.9% 84.6% 80.9% 75.9% 74.6% 73.2% 73.3% 76.5% 90.0% 90.0% 91.2% 89.5% 88.3% 85.9%

Our People Safe Staffing Red rated shifts (8 RN hours+ less then planned) < 20% 8.6% 6.4% 8.8% 15.8% 19.4% 16.4% 14.2% 10.8% 17.2% 20.1% 16.6% 20.8% 21.0% 18.1% 19.3% 24.3% 32.4% 29.4% 27.7% 20.6%

Getting the Basics Right Information Governance IG breaches - Level 1 5 3 5 4 5 5 3 4 4 3 4 2 8 3 5 15 10 7 5 13 6

Getting the Basics Right Information Governance IG breaches - Level 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Getting the Basics Right Harm Free CareCompliance with equipment checks (Test Your

Care excluding Maternity, Oxhey and Gade)90% 88.6% 90.1% 93.2% 93.6% 93.4% 93.3% 91.4% 94.0% 94.4% 92.2% 94.6% 94.9% 94.8% 96.5% 94.0% 93.7% 94.0% 96.7% 92.5% 96.4%

Getting the Basics Right Harm Free CareMedicines audits - (Drug omissions from

quarterly Pharmacy audit)5% 5.0% 5.4% 5.4% 7.1% 5.2%

Patient FocusCaring for our acutely ill

patients

A&E performance (WGH time to initial

assessment % within 15 mins)95% 75.4% 75.0% 73.9% 76.4% 78.8% 79.5% 74.9% 80.4% 75.0% 78% 76.9% 75.8% 75.9% 87.3% 91.4% 89.0% 88.9% 85.5% 85.9% 84.4%

Patient FocusCaring for our acutely ill

patientsReturns to ITU within 48 hours 2 3 2 5 2 2 4 400.0% 7 1 5 7 3 4 2 5 3 3 6 3

Patient Focus OutpatientsCancelled appointments with less than 6 weeks'

notice by the hospital^5% 5.3% 4.1% 3.8% 4.2% 3.7% 3.8% 3.7% 3.2% 3.6% 3.1% 4.1% 4.8% 4.9% 4.0% 3.8% 3.8% 4.1% 4.9% 4.1% 3.9%

InfrastructureEnvironment, Estates and

facilitiesCompleted Fire and H&S risk assessments 95% 98.9% 99.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.0%

InfrastructureEnvironment, Estates and

facilitiesSecurity - completed checkpoints 95% 92.2% 92.0% 87.7% 96.1% 99.5% 99.8% 99.0% 1 98.0% 99.0% 98.0% 99.0% 99.0% 100.0% 98.0% 97.0% 98.0% 99.0% 97.0% 97.0%

Governance, risk

management and informed

decisions

Quality GovernanceAccurate record keeping (Test Your Care

excluding Maternity, Oxhey and Gade)90% 84.7% 85.6% 89.3% 90.0% 89.7% 89.5% 89.6% 1 91.6% 89.5% 92.2% 91.9% 93.1% 94.2% 90.8% 92.0% 92.4% 93.6% 90.9% 94.2%

Governance, risk


decisions

Quality Governance Number of SIs submitted to the CCG within time 95% 88.9% 66.7% 33.0% 83.0% 60.0% 50.0% 67.0% 29.0% 0.0% 100.0% 25.0% 100.0% 0.0% 100.0% 100.0%

Governance, risk


decisions

Risk Processes

Risk - Completed SIs and complaints

investigations with documented actions on

Datix.

90% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

* Indicator measured using response sections: Infection Control, Privacy and Dignity and Resuscitation Trolley. Community Midwifery and Maternity Delivery Suite Care Indicators excluded along with new wards included on TYC in 16/17, Oxhey and Gade.

* Note that targets for mandatory training, appraisal and vacancy rate have been amended to reflect new Board-agreed levels

^ Excluding valid cancellations (cancellations to provide earlier appointments, cancellations due to where patients have died and cancellations to appointments made in error)


Performance

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Appendix 2

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%A

pr-

17

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Mar

-18

Accurate Record Keeping

Actual

Target

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

Cancelled Outpatients Appointments

Actual

Target

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Vacancy Rate

Actual

Target

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Mar

-18

Compliance with Equipment Checks

Actual

Target

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Appendix 2

REFERRAL TO TREATMENT PERFORMANCE IMPROVEMENT

November 2017 (October’s performance)

Plans must be put in to place to ensure referral to treatment (RTT) times continue to improve so that

they are similar to or better than the England average

…to improve the percentage of patients to be seen within 18 weeks of referral from a GP for an

outpatient appointment

Submitted performance

Performance for October was 88.45%, better than the previous month (88.1%). The most recent

national data available (September) shows that the Trust’s performance that month was below the

national average (89.1%) with 92% achieved at L&D but not at the RFH (87.4%). Comparative figures

for E&NH were not available for September.

Recovery trajectory 2017/18

Performance and PTL 2017/18

10



1

Trust Board Meeting 11 January 2018

Title of the paper Summary report on corporate risk register

Agenda item 11/55

Lead Executive Helen Brown, Deputy Chief Executive

Author Leigh Gibson, Deputy Head of Risk


The latest update of the corporate risk register has been updated by the executive owners of each risk. Between April 2016 to December 2017 there has been an overall decrease of risks on the corporate risk register. Data for this report was extracted from Datix on 08 December 2017. At this time, 22 risks were recorded on the corporate risk register with a current score of 15 or more. There were two new risks, one escalated risk and two risks approved for de-escalation by the risk review group.


Risk review group – 19 December 2017

Action required: The Board is asked to receive the report for assurance on the approach taken to identify, assess and manage corporate risks.



Trust objectives To deliver the best quality care for our patients

Benefits to patients/staff from this project/initiatives Effective risk management frameworks and reporting provides a source of assurance that identified risks to patients are being identified, assessed and mitigated.

Risks attached to this project/initiatives and how these will be managed Nil identified

11

Tab 11 Summary report on corporate risk register


2

Trust Board meeting – 11 January 2018

Corporate Risk Register update Presented by: Helen Brown, Deputy Chief Executive

1. Purpose

1.1 The aim of this paper is to provide a summary update of the status of the corporate risk register and corporate risk profile of the organisation.

2. Background

2.1 The Safety and Compliance Committee leads on the development and monitoring of risk and governance arrangements across the Trust to ensure that the organisation delivers key priorities and manages risk efficiently.

2.2 The Safety and Compliance Committee meets bi-monthly to review the overall corporate risk profile and seek assurance that risks are being appropriately identified and managed.

2.3 The Risk Review Group reviews all changes to risk scores for corporate risk entries including risks escalated to 15 or above and risks that are recommended for de-escalation due to effective mitigation or changes in circumstances.

3. Analysis/Discussion

3.1 The risk register is a live document recorded on Datix and risk leads regularly review

and update entries.

3.2 Data for this report was extracted from Datix on 08 December 2017. At this date 22 risks were recorded on the corporate risk register with a current score of 15 or more.

3.3 The chart below demonstrates the risk score movement on the corporate risk register from April 2016. From April 2016 to December 2017 there is an overall decrease of risks on the corporate risk register.

3.4 Work continues both at a corporate level with Board sub-committees and with

Divisions to improve the alignment, recording and management of individual risk registers and the corporate risk register (CRR) which contains all risks with a current score of 15 or more.

3.5 The chart below shows the risk score movement of all risks on the risk register from

April 2016.

11



3

There was a gradual decrease of the number of risks scored at 15 between July 2017 and October 2017; followed by small increases in November 2017 and December 2017. The number of risks scored at 16 and 20 has remained reasonably consistent over recent months.

There has been a gradual decrease with the number of risks scored 9 and a small increase with the number of risks scored between 10-12. Appendix 1 includes a summary of the current status of all risks on the corporate risk register.

4. Risks

4.1 The corporate risk register is an integral part of Trust risk management arrangements.

5. Recommendation

5.1 The Board is asked to receive the report for assurance on the approach taken to

identify, assess and manage corporate risks.

Helen Brown Deputy Chief Executive 27 December 2017

11



4

Appendix 1

ID The Risk Update

Co

nse

qu

ence

(cu

rre

nt)

Like

liho

od

(cu

rren

t)

Rat

ing

(cu

rren

t)

Principal Risk

(Primary)

Board Assurance (Primary)

Lead

NEW/ESCALATED RISKS

3652

Lack of back up mammography facilities/existing machine 9 years old

At SACH there is currently only 1 digital mammographic machine; which is currently 9 years old; and no mammography facilities at Watford General or Hemel Hempstead Hospitals. If the machine breaks down patients would need to be transferred to other Trusts or private providers for their mammograms and could result in delays for patients on the cancer pathway. There would be an increase in operational costs due to transfer costs. A full business case is due for completion by 30/12/17 – options to provide space at St Alban’s City Hospital to install a second machine are currently being assessed.

Mo

der

ate

Cer

tain

12

→ 1

5

PR5 Safety and

Compliance Committee

ST

3957 Lack of anaesthetic machines and monitors

Due to faults and/or damage to anaesthetic machines and monitoring, the theatre departments have insufficient anaesthetic equipment to provide a safe working environment if all available areas are in use. Short term lease agreements have been put in place to ensure all equipment is available, pending completion of a business case to purchase the equipment required. This risk has been recommended for de-escalation and is due to be reviewed at the January Risk Review Group.

Cat

astr

op

hic

Po

ssib

le

NEW

15

PR1 Safety and

Compliance MvdW

3958 Risk of condensate tank failing – WGH boiler house

A site survey undertaken in December 2017 identified that the boiler on WGH site has corroded and requires replacement. A business case is being written for submission in January 2018 with aim for boiler to be replaced March 2018. In the meantime weekly maintenance inspections are being carried out.

Maj

or

Like

ly

NEW

16

PR3 Safety and

Compliance KH

CURRENT CORPORATE RISKS

11

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5

3894

ICT Applications reduced availability, poor reliability & performance

41/53 applications have been migrated. A revised schedule for migration of the remaining 12 applications has been agreed with CGI; the programme is scheduled to complete by end June 2018. M

ajo

r

Cer

tain

20

PR4 Finance &

Investment Committee

LE

3892

ICT Data Centres reduced availability, poor reliability & poor performance

Off-site data centres are in place with applications that have been migrated now stable and improved performance. Further assurance on operational functionality will be required following completion of the work to resolve network issues which are currently impeding overall performance of the system. (See risk 3896)

Maj

or

Like

ly

16

PR4 Finance &


LE

3896

ICT Data Networks reduced availability, poor reliability & performance

Following remedial work on MPLS between mid Oct17 to late Oct17 speed and latency testing was undertaken. This demonstrated improved performance, however there remain some residual performance issues. As a result further investigations into the Local Area Network (LAN) at each site has been undertaken and additional remedial work is being undertaken which it is anticipated will resolve the issues. A further set of speed and latency tests will be undertaken in January to confirm whether this risk has been resolved and can be de-escalated.

Maj

or

Cer

tain

20 PR4

Finance & Investment Committee

LE

3899

ICT Trust Bleep System

The Trust bleep system is out of date and not resilient. Operational mitigations are in place to minimise down time and associated clinical risk and these are working effectively. A pre-business case is being submitted to Capital Finance Planning Group to access funding to develop an outline business case (OBC). Target timeline for completion of the OBC April 2018. C

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3893

ICT Servers reduced availability, poor reliability & performance

Progress is closely linked to the Applications migration work as servers are upgraded as they are migrated to the CGI data centres. The exceptions to this include the Trust's Data warehouse and eHandover system which currently continue to require on site hosting. A risk assessment and plan for these servers is being developed. Target timeline for completion January 2018.

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3897

Internal, external malicious or unintentional breaches of, or attacks on information systems

An external IT Health Check for Cybersecurity was completed in early December. A full report has now been received with a number of recommendations as to how the Trust’s cyber-security arrangements can be strengthened. The Head of Information Security is developing an action plan. This will be presented, together with a progress update, to the

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resulting in loss of Information and Communication Technology (ICT) services, data or both.

February Safety & Compliance committee.

3890

Limited ability to Dispose of Biological Hazard Group 2 and 3 Organisms in the Microbiology Department

Delivery date now 12th January 2018. HSE contacted and have extended derogation until end of February 2018.

Cat

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15

PR1 Safety &


KH

3912

High turnover rate within Band 5 nursing population

Comprehensive action plan in place to address. Delivery oversight via fortnightly steering group. Regular updates provided to Patient and Staff experience committee (PSEC) M

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Patient and Staff

Experience Committee

PdG

3825

Workforce and Finance risks linked to the introduction of the Apprentice Levy

Apprentice Levy delivery group in place – meets fortnightly. Good progress has been made in establishing approach and framework and action plan in place. The Trust pays £70k per month levy (£840k per annum), current commitments for apprenticeships total £800k over two years – ie 50% of the ‘gap’ has been bridged. Hard launch of the programme planned for national ‘Apprenticeship Week’ in early March. A detailed updated paper is being provided to next meeting of Patient and Staff Experience Committee (PSEC). Consideration to be given to de-escalating this risk.

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Experience PdG

3845

CCG financial situation and consequent impact on WHHT - 2017/18

Full briefing on mediation outcome provided to Trust Board in December. Range of actions in place to mitigate risk from implementation of agreed changes to contract –e.g. prior approval processes. Negotiation on process and scope for review of local prices not yet concluded – WHHT have proposed way forward to resolve. Formal arbitration process has been requested regarding 16/17 issues.

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DR

3742

Failure to achieve sufficient efficiencies to support Annual and longer term plans

Targeted Strategic Delivery Office (SDO) & Programme management (PMO)support for cost improvement schemes for both 2017/18 and 18/19 is in place. Divisional opportunity packs developed and produced by the SDO. Interim resource to strengthen 2017/18 provision within Finance. C

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3744

Inability to secure sufficient capital funds to meet investment plans in the Annual and Strategic Plans.

Independent Trust Financing facility (ITFF) application for capital funding completed in July 2017. NHS Improvement (NHS I) review has been undertaken by the East of England team – the finance and estates teams continue to liaise with NHS I to respond to queries and seek progress updates.

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DR

3737

Risk of failing to deliver the Annual Plan due to changing clinical capacity in an unplanned way

Trust Executive to continue enforcing time-limited approvals for emergency changes and the need for recovery plans. This will ensure that where unplanned changes are made there is a break clause to ensure proper review and a sustainable plan put in place. A number of service changes are in progress via the CCG QIPP programme and the outworking of recent tender processes; in addition work around re-establishment of a Trust-wide private patient function is underway.

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3741

Risk of failure to achieve financial plan resulting from failing to meet all Sustainability and Transformation Fund (STF) conditions.

A detailed reforecast exercise was undertaken in October 2017, within formal NHSI processes, acknowledging that the STF conditions for 2017/18 would not be satisfied for Q2-4. This resulted in a current risk rating change to 20 as the financial impact increased to a certain £9.3m. Risk remains in place as work goes on to minimise future impacts in 2018/19 and beyond.

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DR

3930

Disruption to Endoscopy & Bronchoscopy Services due to decontamination failure

Operational mitigations in place to support business continuity. Business case for replacement washers at HHGH and WGH approved. Work commenced and scheduled to complete by end April.

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Safety and Compliance Committee

KH

3503

Hardware Support for McKesson Systems (Cardiology)

McKesson and IT currently building environment for upgrade. Go live target date set for 31/01/2018. Service continues with control measures in place. M

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3120 Patient Medical Notes missing, Delayed or poor condition.

Business case for offsite medical records solution was approved at TEC on 8th November. The approved option is to start scanning records with the ultimate aim to move to a full Electronic paper record. A tender specification is being written for the scanning option which will then go out to tender. Once costs have been received, a final case will be presented to TEC to approve the finances to move forward with this option. Target timeline for full business case – March 2018. A working group has been set up to oversee implementation of scanning.

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3781 Unscheduled Care medical workforce - gaps in rota

ED: rotas restructured to provide increased consultant presence. Additional consultant post recruitment in progress – interviews scheduled end January. ANPs fully recruited with majority of staff now in post. Nurse Consultant post successfully recruited. Middle grade rota gaps reduced from 4 to 2. Medicine: Medicine: additional training grade doctors recruited across a number of specialties – rota gaps reduced as a result. This risk to be disaggregated to reflect changes to operational structures – potential for de-escalation within the next 2-3 months, to be reviewed via risk review group.

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PdG

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3786

Failure to maintain safe and effective emergency care services; failure to meet national emergency care standards.

Monthly detailed updates provided to Trust Board on comprehensive action plan to address emergency care pathway pressures and risks. New CDU operational December 2017. Winter resilience funding confirmed to WHHT and system partners to provide additional capacity through to end March. CAG / TEC are developing plans to respond to the National Emergency Pressures Panel guidance issued on the 2nd January.

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CLOSED/DE-ESCALATED RISKS

3485

Unsafe Chimney Stacks on Boiler House - Hemel Hempstead

Works completed on 30.11.17

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3422

Potential low levels of workforce engagement will negatively impact retention and productivity, which in turn will lead to poor recruitment and retention.

Trust is joining new NHSI programme to look at improving retention rates, this programme will complete in December 18. New staff engagement programme has commenced in emergency care services to improve staff and patient experience. Oct 18. Bullying & Harassment and Freedom to Speak Up initiatives have been undertaken across the Trust to improve understanding and procedures to be followed. Weekly Recruitment meeting to progress short term actions intended to ensure the pipeline of staff and in particular band 5 nurses are maintained and effective. Bi-weekly retention meetings are taking place to monitor actions to support the reduction of turnover and improve staff experience as part of the retention programme.

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Agenda item: 12/55

Report to: Finance and Investment Committee

Title of Report: Assurance Report to Trust Board

Date of meeting: 11 January 2018

Recommendation: For information and assurance

Chairperson: John Brougham, Non-Executive Director

Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Finance and Investment Committee at its meeting on 21 December 2017

Background The Committee meets monthly and provides assurance on:

Scheduled reports from all Trust operational committees with a finance and information technology brief according to an established work programme.

The meeting was held a week earlier than usual due to the Christmas break and the Chair thanked the executives for preparing the papers, recognising that the early timing did not allow the usual depth of analysis of actual performance and subsequent action planning. The Committee agreed however that, for any papers recommended for review by the January Board, and which require further analysis, there would be sufficient time to produce a quality report.

Financial Performance

i. I&E Deficit

The Committee reviewed the actual performance in the month and year to date, and focussed on the challenging action plans in place to deliver the forecast deficit for the year of £35m, which has now been agreed with NHSI.

The Committee was concerned with the high level of deficit in November of £2.8m which was £0.9m worse than forecast. Lower income and higher pay costs both contributed to the adverse performance in the month and a fuller explanation of the causes, and associated recovery actions will be presented to the January Board. Previous FIC reports to the Board have recognised that achievement of the £35m forecast is extremely challenging and that in the region of £5m of deficit reduction actions are still to be underpinned, and the performance in November has added further

12

Tab 12 Assurance report from Finance and investment committee


2

pressures. The Committee also reviewed the status of income disputes with HVCCG totalling several million pounds. A mediation meeting with NHSI and NHSE took place earlier in December and proposals made to the Trust and HVCCG.

The Committee recommends that the recovery plans and risks associated with achieving the £35m deficit forecast are reviewed in Part 2 of the January Board, including the latest position on the income disputes with HVCCG

ii Productivity Improvement Plans The Committee reviewed an update on actions and plans to deliver productivity improvements across the Trust in both clinical and non clinical areas. These include the recommendations from GK Transformation, Model Hospital benchmarking, and the status of plans to achieve maximum efficiency in payroll and finance systems. Recommendations on actions are expected in the final quarter of this financial year, and will be incorporated into the plans for the next two years. The Committee was also informed that the in depth review of the nursing establishment scheduled for December 2017 will now take place in late January 2018. Progress on all the above is a standing item on each month’s FIC agenda.

iii Capital Spend/Funding

Capital spend in November of £0.6m brings year to date spend to £3.1m, and the Committee was assured that commitment and spend continues to be carefully prioritised and managed not to exceed the current NHSI authorisation limit of £7.7m. The Committee remains concerned, as the months go by, at the lack of approval for further essential capital spend this year. The ITFF application for a further £14.5m of spend was in line with the recommendation of the Project Appraisal Unit of NHSE, and has now been submitted to DoH for final approval. Once approval has been received it is hoped that the inevitable underspend this year can be carried forward into the 2017/18 plan.

iv Revenue Funding

Funding of revenue spend by NHS is subject to monthly approval and, following review, the Committee recommends ratification by the Board of a loan of £3.245m which is to meet the funding requirements for December.

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BAF Action Tracker The Committee reviewed the Tracker and asked for one rating change to be made, from red to amber, now that the date for the nursing establishment review by NHSI has been agreed for January 2018.

Corporate Risk Register

The Committee reviewed the risks under its remit rated at 15 or more on the CRR. The Committee agreed that there should be no changes to the ratings of the 11 risks (6 IM&T, 5 Finance) previously approved, and was assured that all mitigating actions and reviews were up to date.

Watford General Hospital Car Park Solution. The Committee received a verbal, work in progress, update on the milestones to deliver the planned multi-storey car park in line with the SOC approved by the Board in June 2017 and submitted to NHSI. The Committee recommends that an update is presented to Part 2 of the January Board

Information & Communications Technology The Committee was updated on the latest status of the infrastructure

improvement plan, noting that the rollout of end user devices has now

reached 96% coverage of the Trust’s three sites. The Committee

was also updated regarding planned dates for migration of key

clinical applications to the offsite datacentres, some of which have

now moved into April 2018.

Risks to refer to risk register

None.

Issues to escalate The Committee recommends the following:

To Part 1 of the December Board for ratification:

i. the NHS revenue support loan of £3.245m to cover funding requirements in December

To Part 2 of the December Board for review:

ii. the plans and risks in achieving the £35m deficit forecast, including the latest position on the income disputes with HVCCG

iii. an update on milestones to meet the Watford General Hospital car park plans

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4

Attendance record

Attended

John Brougham, Non-Executive Director (Chair)

Don Richards, Chief Financial Officer

Katie Fisher, Chief Executive

Lisa Emery, Chief Information Officer

Phil Townsend, Non-Executive Director

Stephen Dunham, Assistant Director of Finance & Commercial Development

Prof. Steve Barnett, WHHT Chair

Tim Duggleby, Head of Strategic Development & Compliance (for item 15, car park update)

Tom Drabble, Patients’ representative

Apologies

Helen Brown, Deputy Chief Executive

Jeremy Livingstone, Divisional Director, Surgery, Anaesthetics & Cancer

Lesley Headland, Chair of Staffside

Mike van der Watt, Medical Director

Paddy Hennessy, Director of Environment

Sally Tucker, Chief Operating Officer

Clerk

Clare Ransom, Executive Assistant

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1

Agenda item: 14/55

Report to: Trust Board

Title of Report: Safety & Compliance Committee Assurance Report to Trust Board

Date of board meeting:

11 January 2018


Chairperson: Phil Townsend, Non Executive Director Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Safety and Compliance Committee at its meeting on 14 December 2017.

Background The Committee meets bi-monthly and provides assurance on:

CQC standards

Compliance with external bodies, eg. NHS Litigation Authority, Health and Safety Executive, Health Service Ombudsman

Actions taken and lessons learnt in response to adverse clinical incidents, complaints and litigation

Compliance with clinical and non-clinical governance, standards and guidance

Risk and governance strategy

Board Assurance Framework

Business undertaken

Review of Readmission data year to date The Medical Director presented a case for adjusting the re-admission target in the performance report after research shows that the Trust had a target inconsistent with national performance. The Committee recommended that the Trust’s target be changed from 4% to 8.17% in line with the national average. Performance Report The Committee reviewed the September and October data in the October 2017 performance report and noted the areas of good performance and areas requiring performance improvement. It was agreed that, due to the Committee taking place bi-monthly, there was a need to ensure timing and mapping of performance data with the Board schedule.

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Tab 14 Assurance report from the Safety and compliance committee


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Never Events The Committee received a report and update on three recent Never Events and was assured that actions were already taking place to mitigate the risks. Corporate Risk Register report The Committee received a report on the risks scoring 15 or more on the corporate risk register and the risks aligned to the committee with progress against the action plan. It was noted that, as of this date, there had been no new risks added to the corporate risk register aligned to the Safety and Compliance Committee. Board Assurance Framework action tracker The Committee reviewed the status and progress of actions in the Board Assurance Framework, designated to the committee. Emergency Planning and Business Continuity Report The Committee received assurance on emergency planning, resilience and business continuity plans development and preparedness across the Trust. It was also reported that the annual NHS England emergency preparedness, resilience & response assurance process had taken place and had indicated that the Trust remained fully compliant. Medicines Optimisation six monthly report Members noted the progress with the Medicines Optimisation Strategy and associated key performance indicators which provided a look forward to short and medium term priorities. Medical Devices Update The Committee reviewed progress on a medical device audits and, although progress was being made, the Committee was not fully assured and asked for this area to continue to be closely monitored. Emergency Care Establishment Review The Committee received the report on emergency department staffing and the implications to budget planning and recruitment which would be presented to the Board in February 2018. Dementia Annual Report The Committee welcomed a dementia annual report and associated action plan and noted the excellent report. Quality Improvement Plan (QIP) Progress Update The Committee reviewed recommendations from the strategy delivery board on the future management of the QIP and was assured of the

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3

monitoring of the progress. Fire Safety Update The Committee received an update with regards to fire safety measures and management procedures throughout the Trust. Premises Assurance Model The Committee was updated on the implementation of a premises assurance model and noted the progress to address five areas currently graded ‘inadequate’. RSM Internal Audit Report The Committee received a report on an audit undertaken by RSM regarding information governance arrangements. The audit found limited assurance, however this was agreed to be ‘borderline’. Unfortunately, the recommendations had not been discussed with the department before the report was presented. The Committee used some of the time to provide the department with guidance on their preferred actions.


There are 5 risks on the corporate risk register aligned to the Safety and Compliance Committee (scored at 15 and over).

Key decisions

None

Issues to escalate

1. Corporate Risks 2. Fire Safety Update 3. Medical Devices Update

4. Emergency Planning & Business Continuity Report

5. RSM Internal Audit Report

Challenges and exceptions

None

Future exceptional items

None

Attendance record

Phil Townsend, Non-Executive Director Jonathan Rennison, Non-Executive Director Katie Fisher, Chief Executive Helen Brown, Deputy Chief Executive Sally Tucker, Chief Operating Officer Mike Van der Watt, Medical Director Tracey Carter, Chief Nurse Paddy Hennessey, Director of Environment Martin Keble, Divisional Manager, Clinical Support Rachael Corser, Deputy Director of Governance and Assistant Chief Nurse Maxine McVey, Deputy Chief Nurse Angela White, Head of Nursing, Unscheduled Care Lisa Morris, Executive Assistant (minute taker) For individual items: Tim Duggleby, Director of Environment (Premises Assurance Model)

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Agenda item: 15/55


Title of Report: Assurance report from Clinical Outcomes and Effectiveness Committee



Chairperson: Jonathan Rennison, Chair

Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Clinical Outcomes and Effectiveness Committee at its meeting on 30 November 2017

Background The Committee meets bi monthly and provides assurance to the Board on:

Safe and effective patient care

Prevention, early intervention, recovery and rehabilitation

Ensure that the Trusts responsibility for infection control is effectively fulfilled

Promoting a culture of learning and continuous improvement.

Measure change using clinical outcome measures to monitor the impact of the services provided by the Trust.

Business undertaken

Integrated Performance Report (IPR) The Committee received and reviewed the IPR and was assured that appropriate actions were being taken to maintain and improve performance across a range of measures. In particular, the Committee was informed that compliance of prevent awareness training was now included in the IPR, Healthwrap 3 training would be given to all front line staff and the Trust was planning to roll this out. The committee noted that ‘harm free care’ was showing an improvement on the previous two months. VTE risk assessment was below the target however compliance was improving. The Committee was informed that the Trust’s focus was now on the re-assessment of VTE risk after the 24 hours of admission and would be receiving assurance reports on this in the future.

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Tab 15 Assurance report from the Clinical outcomes and effectiveness committee


2

GIRFT (Getting it Right the First Time)

1. The Committee received two reports relating to Getting it Right First

Time: one on vascular and one on orthopaedics.

The Committee was assured that the outcomes from the GIRFT

inspections had been reviewed, clear actions identified with time

scales for implementation. The Committee was assured that learning

from these visits had been noted and that the actions identified

supported the application and embedding of learning.

NCEPOD report on NIV – achieving compliance The Committee received a NCEPOD report on NIV (Non Invasive

Ventilation) and the work that the Trust would be undertaking to

achieve compliance with national standards. The Trust is non-

compliant with 16 of the 21 standards. The report was clear and set

out areas where the Trust already had compliance and made well

defined recommendations for actions to achieve compliance in other

areas. The committee was assured that the Trust executive had

reviewed the report and had asked for a paper to be presented on

the risks and priorities linked to a business case.

Learning From Deaths NQB Framework update and progress

The Committee received an update on the learning from deaths

framework and was assured that work was being undertaken to

ensure that the Trust was compliant with national recommendations.

It was reported that the Trust was largely on track with the action

plan and any variations were explained with clear actions to maintain

progress.

Quality strategy update

The Committee received an update on the development of a quality strategy. Key items to note are:

A clear set of plans against the Trust’s visions and aims which are supported and guided by the Trust’s strategy and priorities.

It was agreed after staff engagement to move away from a quality strategy to a quality commitment which is accessible to staff

The final quality commitment describes ‘the West Herts way’ which shows the Trust’s priorities through its culture, ways of working and to be supportive to organisational changes

COE Committee risk register to include risks at 15 There was one risk with a score of 15 associated with this committee,

relating to emergency care and patient flow. The committee was

assured that the actions and mitigation in place were appropriate and

acknowledged the considerable challenge that ED performance and

patient flow poses for the Trust.

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3

BAF Action Tracker 2017-18 The Committee reviewed the Board assurance framework and was assured that all actions were appropriate and on track. The Committee requested one target to be amended to reflect changes in the learning from deaths action plan. Bi-Annual Infection Prevention and Control Report Q1 &Q2 The Committee received the bi-annual report for this area and

reviewed the report and the evidence presented in it. The Committee

was assured that appropriate actions were in place and that the Trust

was managing this area well within the constraints of the estate and

some of the workforce challenges. The Committee commented on the

quality of the report – it was shorter, clearer and provided an

excellent summary of the key areas of focus for the committee, while

also directing us to the available evidence to support the points being

made in the report.

Quality Account six monthly review against 2017/18 priorities

The Committee received a six month update on this and we were

largely assured that the Trust was performing well against the targets

that it set for itself at the start of the year. There were a number of

areas where the Trust had set targets but where it did not collect data

against these targets. The Committee asked that this be reviewed,

especially for the next year to ensure that the Trust did not set targets

that could not be measured. The Committee noted the improved

quality of the report.


None

Issues to escalate to Board

Increased focus on the emergency standards and work underway to support this target. – ongoing.

Attendance In attendance for Specific Items

Ginny Edwards, Non-Executive Director Tracey Carter, Chief Nurse & DIPC Mike van der Watt, Medical Director Rachael Corser, Deputy Director of Governance and Associate Chief Nurse Anna Wood, Associate Medical Director of Clinical Standards and audit Arla Ogilvie Divisional Director Medicine Jackie Birch, Head of Risk, Assurance and Compliance Lisa Emery, Chief Information Officer Linda Tarry, Executive Assistant to Chief Nurse (minutes) Mr Sarin, Orthopaedic Consultant Konda Shruthi, Respiratory Consultant Patricia Yunger, Respiratory Consultant

15



Agenda item: 16/55


Title of Report: Charitable Funds Committee Assurance Report to Board


Recommendation: For discussion

Chairperson: Jonathan Rennison, Non-Executive Director Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Charitable Funds Committee at its meeting on 30 November 2017.

Background The Committee meets quarterly and provides assurance to the Board:

that robust processes are in place to manage charitable funds and to ensure they are implemented;

that donated funds are utilised in a way that takes into account any stipulations set out by donors and ensure best value is obtained from the funds donated;

that further donations are being encouraged;

that systems comply with regulation and governance of NHS Charities.

Business undertaken

Outcome of options appraisal for charity structure.

There has been initial interest from Kingston Smith and further discussions are now underway. The committee agreed that as the next Charitable Funds committee was not until March 2018, the Director of Communications would circulate and update the committee on progress outside the meeting either by email or a teleconference. It was expected that further scoping around the STP footprint would take place in early January 2018.

Update on governance support The committee received an update on a proposed piece of work on charity governance and was advised that Kingston Smith had shown an interest in undertaking this area of work and further discussion would take place shortly. It was also suggested that an approach would be made to the Royal Free charity. Further discussions on proposed action plans and timeframes would be taking place.

Progress on strategy The committee reviewed an action plan for the delivery of the charity’s strategy. It was noted that a number of actions and timelines were in place and the committee would undertake a further review at its next meeting. The Director of Communications updated the committee that progress on delivery had been slower than anticipated, mainly due to resource issues and a lack of articulation on individual tasks and areas for action that were required in order for the strategy to be delivered.

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Tab 16 Assurance report from the charitable funds committee


Investment Management Update The Chief Finance Officer updated the committee on a tender for investment management services. It was noted that all parties had been informed and were actions were in place to handover to the new service. Outcome of internal audit report on review of financial controls of charity fundraising The committee was updated on an internal audit that had been undertaken as part of a key financial control audits for 2016/17. The audit provided reasonable assurance. All actions were now reported to be completed. Overview of funds The committee received a report on the charity’s financial position and financial performance as at the end of October 2017. The report included the balance sheet, a statement of financial activity, an investment trend report and a cash flow forecast. The committee was assured that investments were performing well and were being well managed. The committee also received an update on new income, grants and donations. Overview of donations and fundraising activities The committee received a paper on the overview of donations and fundraising activities and was advised that despite the departure of the head of charity, charitable income had been forthcoming, although not as healthy as in previous years. It was noted that the charity had invested in Grant finder to identify funding opportunities and training was being provided to executive leads and other members of the team. It was reported that the Michael Green Foundation had presented a donation of £15,000 to the diabetes team on 14 November 2017. Report on staff visit to Intermountain and IHI The committee received a presentation from the Deputy Chief Executive, Divisional Director and Divisional Manager of Women’s Services on a Boston and Utah study tour and the learning and proposed actions resulting from the trip.

Escalation to the Corporate Trustee

Update on the options appraisal on the future of the charity

Head of charities and governance support function

Internal audit report

Presentation on the visit to Intermountain

Attendance record Jonathan Rennison, Non-Executive Director Ginny Edwards, Non-Executive Director Tracey Carter, Chief Nurse Don Richards, Chief Financial Officer Louise Halfpenny, Director of Communications Paul da Gama, Director of Human Resources Sandhya Patel, Financial accountant (Charitable Funds) Leigh Franklin, Assistant Trust Secretary (notes)

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Tab 16 Assurance report from the charitable funds committee


of 2


AGENDA

Agenda item: 20/55

01 February 2018 at 9.30am – 12.00noon

Terrace Executive Meeting Room, Spice of Life Restaurant, Watford Hospital

Apologies should be conveyed to the Trust Secretary, Jean Hickman on [email protected] or call 01923 436 283

Item ref

Title Objective Previously presented

Lead Paper or verbal



02/56 Patient experience presentation

To receive N/A Chief Nurse Presentation

OPENING



04/56 Conflict of interests To note N/A Chair Paper

05/56 Minutes of the meeting held on 11 January 2018

For approval

N/A Chair Paper

06/56 Board action log from 11 January 2018 and previous meetings and decision log




08/56 Chief Executive’s report To note N/A Chief Executive

Paper

PERFORMANCE

09/56 Integrated performance report – month 9

To note Trust Executive Committee

Chief Operating Officer

Paper

SAFE EFFECTIVE CARE (BAF RISK 1)


For information

and assurance


Chief Nurse

Paper

11/56 Quality learning from deaths report

For information

and assurance

Clinical outcomes and effectiveness

committee

Medical Director Paper

20

Tab 20 Draft agenda for the next board meeting


of 2

DELIVER A LONG TERM STRATEGY (BAF RISK 9)

12/56 Strategy update – month 10 To note Trust Executive Committee


Paper

GOVERNANCE

13/56 Formal annual review of corporate governance structure and committee membership

For information/assurance



Paper

COMMITTEE REPORTS

14/56 Assurance report from Finance and Investment Committee

For information

and assurance

Finance and Investment Committee

Committee Chair/ Chief Financial

Officer

Paper

15/56 Assurance report from the Patient and Staff Experience Committee

For information

and assurance

Patient and Staff Experience Committee


Human Resources

Paper

16/56 Assurance report from Clinical Outcomes and Effectiveness Committee

For information

and assurance

Clinical outcomes and effectiveness

committee

Committee Chair/Chief Nurse

Paper

17/56 Assurance report from Audit Committee

For information

and assurance

Audit Committee Committee Chair/Chief

Financial Officer

Paper

ANY OTHER BUSINESS

18/56 Any other business previously notified to the Chairman

N/A N/A Chair Verbal

QUESTION TIME


To receive

N/A

Chair Verbal

20/56 Questions from our patients and members of the public

To receive N/A Chair Verbal

ADMINISTRATION


To approve N/A Chair Paper

22/56 Date of the next board meeting in public: 01 March 2018, Terrace Executive Meeting Room, Watford Hospital


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Tab 20 Draft agenda for the next board meeting


trust board meeting in public agenda 11 j… · trust board meeting in public agenda 11 january...

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