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Delivering our Vision How are we doing?
January 2018
“We will pursue perfection in the delivery of safe, high quality healthcare which puts the people of our community first”
2
Through integration and partnership we aim to become both a provider and employer of choice
Annual priorities
Reduce avoidable
harm
Improve discharge planning
Staff health, well being and working lives
Create best environment for patients
Improve efficiency of elective care
Values
Safety & quality
One team
Dignity & respect Compassion
Vision We will pursue perfection in the
delivery of safe, high quality healthcare which puts the people of
our community first
Patient
Strategic objectives
Safe Effective Well-led Caring Responsive
3
• We declared two serious incidents in January 2018 (one of these incidents was
also declared a never event).
• Patient safety indicators continue to show expected levels of performance.
• There were no MRSA bloodstream infections and 2 Trust-apportioned
Clostridium Difficile cases in January 2018.
• Mortality is lower than expected for our patient group when benchmarked
against national comparators.
• Readmission indicators improved in January 2018 with Emergency
Readmissions within 7 days returning to green performance with 3.7%.
SAFE - People are protected from abuse and avoidable harm
EFFECTIVE - People’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best
available evidence.
• Friends & Family Test continues to show good patient feedback for the
Emergency department during a time of high demand while Inpatient FFT
reduced to amber on the RAG rating with performance of 94.5% in January.
CARING - service involves and treats people with compassion,
kindness, dignity and respect.
Delivering our vision – How are we doing? January 2018 summary
Serious
Incidents
2
%
Emergency
readmissions
within 7 days
3.7%
%
HSMR
(October-17)
93.4
%
ED FFT
97.6%
Inpatient FFT
94.5%
Safety Thermometer
99.6%
4
• The 4hr ED standard was not achieved in January 2018 with
performance of 88.2%, 1.2% better than January 2017. National
performance for ‘Type 1 Departments’ in January was 77.1% seeing us
perform significantly higher than the national average.
• Cancer TWR and breast symptomatic both achieved the national
standard with performance of 93.3% and 96.9% in January.
• 62 Day GP performance achieved the national standard with 85.9% of
patients starting treatment within 62 days.
• 18 Weeks RTT – We did not achieve the RTT Incomplete pathways
standard with performance of 88.6%. Recovery actions and trajectory
are in place.
• The SASH flu vaccination target for 2017 was met with 70.1% of frontline healthcare
workers vaccinated by 31st December. 66% of non-frontline staff were also vaccinated.
• We have been chosen to join the national streamlining project which is initially focussing on
making the on-boarding process for junior doctors more seamless.
• Significant progress has been made with the introduction of an e-job planning system for all
consultant staff at SASH.
• Results of the 2017 National Staff Survey are expected towards the end of February –
these will be embargoed until the release of benchmarked data in March.
• The SASH One Team Inclusion Strategy has been completed and will be presented for
Board approval in March.
RESPONSIVE - services meet people’s needs.
WELL LED - leadership, management and governance of the organisation assures the delivery of
high-quality person-centred care, supports learning and innovation, and promotes an open and fair
culture
Delivering our vision – How are we doing? January 2018 summary
ED 95% seen
in 4 hours
88.2%
%
Vacancy Rate
9.5%
%
Staff
turnover
16.1%
%
RTT
Incomplete
88.6%
62 Day GP
85.9%
5
FINANCE AND USE OF RESOURCES
Delivering our vision – How are we doing? January 2018 summary
• We forecast a £11m surplus outturn for 2017/18. This is £10.3m adverse to our £21.3m
surplus control total. NHSi has been notified of this new forecast position in accordance
with the relevant protocols.
• We achieved a £9.8m [adjusted] surplus at the end of Month 10, which is £6.4m adverse
to the year to date (YTD) financial plan. The position includes £5.7m Sustainability &
Transformation Funding (STF).
• £4.8m of savings have been achieved YTD.
• Forecast capital spend is £11.6m which is precisely in line with the new £11.6m Capital
Resource Limit (CRL).
YTD £m
Adjusted
Surplus
£9.8m
Action: The Board are asked to note and accept this report
Legal: All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance
on safe high quality care (Including mortality).
Regulation: The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and
therefore license care services under the Health and Social Care Act 2009 and associated regulations.
Patient experience/
engagement: This paper includes significant detail on both patient experience and access to services.
Risk & performance
management
This is the main Board assurance report for performance against quality and financial measures and is
linked to risk management through the SRR.
NHS constitution; equality
& diversity;
communication.
This report covers performance against access standards with the NHS Constitution.
YTD £m
Savings
£4.8m
Are we safe?
Section 2
6
Delivering our vision – How are we doing?
Safe – People are protected from abuse and avoidable harm
7
• Positive Safety Thermometer performance continued for the “New Harm” measure with performance of
99.6% in January 2018.
• We declared two serious incidents in January 2018 (one of these incidents was also declared a never
event).
• 2018/1675 – Maternity incident, vaginal swab retained post instrumental birth and perineal suturing.
This incident has been recorded as a never event and a full investigation initiated. Immediate action
taken:
• the retained swab was removed and infection screen undertaken to exclude infection along
with an abdominal x-ray to provide reassurance to the patient. The team have apologised to
the patient and she is aware that investigation will take place.
• the maternity team have issued a “Safety Pin” relating to the avoidance of retained foreign
objects which has been displayed in all clinical areas.
• a safety huddle took place immediately to alert all staff to this adverse outcome. Awareness
is included as part of ongoing safety huddles and as part of all shift handovers.
• the maternity team have removed all swabs without tapes (to enable them to be secured
externally) from the Delivery Suite.
• written communication reiterating the expected practice and processes that must be followed
to prevent an unintentional retained ‘foreign object’ have been distributed to all obstetric and
midwifery staff with a requirement that they provide a signed receipt of knowledge.
• 2018/2003 – Fall. The patient, a 95 year old male, had a witnessed fall resulting in a fractured neck
of femur and a shoulder fracture.
Never Event
1
Safety
Thermometer
99.6%
Safety
Serious
Incidents
2
Delivering our vision – How are we doing?
Safe – People are protected from abuse and avoidable harm
8
• Daily staffing - We continue to monitor ward nursing numbers and skill mix on a daily basis and are
assured that adequate staffing is in place.
• Nurse recruitment - Continues both locally and from overseas. Nurse recruitment events are planned for
Medicine and Surgery in January.
• Retention - The Trust continues to imbed the various work streams outlined in the retention strategy.
• The Trust has now received feedback from NHS Improvement in relation to the retention improvement plan.
The plan was positively received and the constructive suggestions for improvement will be fed in to the
retention work stream going forward.
• The Deputy Chief Nurse is planning a retention focus group with a variety of staff in early 2018, facilitated by
‘Clever Together ‘ who co-produced the staff retention analysis with Health Education Kent Surrey and
Sussex.
Ward staffing
RN Fill Rate
Day
93.1%
RN Fill Rate
Night
95.8%
Delivering our vision – How are we doing?
Safe – People are protected from abuse and avoidable harm
9
• There were 0 cases of MRSA blood stream infection in January 2018
• There were 2 cases of Trust-apportioned Clostridium difficile.
• Twenty nine cases of Clostridium difficile for 2017/18 have been reviewed by the CCG and 7 cases
have been viewed as a ‘lapse in care.’
Infection control
MRSA
0
C-Diff
2
Delivering our vision – How are we improving?
Safe – Reduce avoidable harm
10
• In January 2018, inpatient falls were 5.45 per 1000 bed days. In the last 13 months our
falls rate has consistently remained below the national average.
• In January we had 1 Serious Incident relating to falls which is currently being investigated,
any learning will be shared.
• The Monthly Falls Focus Group continues to meet and share the learning from falls and is
undertaking focused work around repeat fallers, where weekly ward rounds are being
piloted with the Clinical Lead for falls, Deputy Chief Nurse for Innovation and Improvement
and Nurse Consultant for Dementia.
Reduce falls
• In January, we reported seven Grade 2 and three Grade 3 pressure damage.
• The newly appointed Nurse Consultant for Patient Safety/Outcomes has started
and will be focusing on continence prevention and management, moisture lesion
identification and staff education.
• The identification processes for investigating pressure damage and determining
the Root Cause Analysis (RCA) has changed and with case now being presented
to the Serious Incident Review Group.
• The monthly Pressure Damage Focus Group has been reviewed and now has
wider representation from each division where key learning is shared and
disseminated across the divisions.
Reduce pressure damage
Total Falls
108
Falls / ‘000
Bed days
5.45
Total
Pressure
Damage
18
Pressure
Damage / ‘000
Bed days
0.91
Delivering our vision – How are we doing?
Safe – Scorecard
11
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Trend
No of Never Events in month 0 0 0 0 0 0 0 0 0 0 0 0 1
Serious Incidents - No declared in month 4 2 2 1 4 4 6 3 4 8 4 5 2
Serious Incidents - No per 1000 Bed Days 0.21 0.11 0.10 0.05 0.21 0.21 0.31 0.16 0.21 0.41 0.21 0.26 0.10
Patient Safety Incidents causing Severe harm or Death - Number in Month 1 0 0 2 1 3 5 1 4 2 1 4 2
Patient Safety Incidents causing Severe harm or Death - Percentage of all patient safety
incidents0.2% 0.0% 0.0% 0.3% 0.1% 0.6% 0.8% 0.2% 0.7% 0.5% 0.3% 0.8% 0.3%
Safety Thermometer - % of patients with harm free care (new harm) 94.2% 97.9% 98.7% 99.0% 99.3% 98.0% 99.0% 98.8% 98.8% 99.3% 98.7% 98.3% 99.6%
Percentage of patients who have a VTE risk assessment 95% 95% 95% 95% 95% 95% 95% 97% 97% 97% 97% 97% 97%
MRSA BSI (incidences in month) 1 0 1 0 0 0 0 0 0 0 0 0 0
CDiff Incidences (in month) 1 5 5 3 4 2 4 6 4 3 2 2 2
MSSA Trust Incidence 3 2 6 8 4 1 1 1 0 1 1 0 0
E-Coli Trust Incidence 3 6 4 5 4 5 7 2 4 5
Average fi l l rate – registered nurses/midwives (%) - Day 97.5% 96.7% 95.6% 95.4% 96.9% 95.9% 94.4% 93.4% 93.5% 95.4% 93.2% 91.8% 93.1%
Average fi l l rate – care staff (%) - Day 91.9% 96.4% 93.0% 96.5% 96.6% 94.7% 94.9% 92.3% 96.3% 94.4% 95.2% 93.8% 95.8%
Average fi l l rate – registered nurses/midwives (%) - Night 97.3% 97.9% 97.4% 96.7% 97.9% 97.0% 97.5% 96.7% 96.0% 95.8% 96.5% 95.5% 95.8%
Average fi l l rate – care staff (%) - Night 95.4% 95.0% 94.9% 96.1% 95.3% 96.6% 96.5% 95.4% 95.1% 94.3% 96.8% 95.7% 96.5%
Falls - Total in month 116 92 101 97 84 96 115 101 76 102 82 98 108
Falls per '000 Bed days 6.00 5.16 5.20 5.15 4.31 5.06 5.91 5.25 4.07 5.23 4.40 4.99 5.45
Pressure Damage (Hospital Aquired) - Total in Month 14 14 17 8 14 16 8 15 19 13 12 17 18 15.0%
Pressure Damage per '000 Bed days 0.72 0.78 0.87 0.43 0.72 0.84 0.41 0.78 1.02 0.67 0.64 0.88 0.91
Safety
Ward Staffing
Infection Control (Trust Aquired)
Reduce Avoidable Harm
Are we effective?
Section 3
12
Delivering our vision – How are we doing?
Effective – People’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence
13
• The Latest HSMR data for the in month rate improved from the September 17 position.
Overall the HSMR increased slightly but still remained ‘better than expected’.
• Our latest SHMI data continues to show positive performance.
• There was a small increase in 28 Day readmissions – whilst this is not statistically
significant we continue to monitor this closely.
Mortality and readmissions
• Our Audit Programme completeness is improving.
• The findings from the National Falls Audit, Intensive Care National Audit & Research
Centre (ICNARC) and the National Chronic Obstructive Pulmonary Disease Audit
(COPD) have been presented to the Clinical Effectiveness Committee.
• A detailed audit is underway examining a wide variety of information relating to
Emergency C-Section rates.
• There was a small rise in the number of adult patients over both 7 and 14 days
however the overall trend is decreasing.
Other effectiveness
HSMR
(October-17)
93.4
SHMI
(Jun-17)
0.95
7 day
Readmission
3.7%
28 day
Readmission (Dec-17)
8.2%
Delivering our vision – How are we improving?
Effective – Improve discharge planning
14
• Daily calls with Senior Leaders from partner organisations to discuss ‘Delayed Transfer of Care’ (DTOC)
patients continue with additional twice weekly calls with Chief Executive Officers.
• There has been a modest but sustained increase in the number of discharges to the community over the
seven day period.
• The post holder to support delivery of the CQUIN ‘Supporting proactive and safe discharge’ has started
in post and is working with the Emergency Dept and Acute Medical Wards to embed processes aimed at
prompt and safe discharge within seven days.
Discharge Planning
• The Trust continues to roll out the ‘ live’ bed board which will further support the embedding
of SAFER.
• An internal working group is being established to improve discharge planning and take
specific actions in response to patient feedback about the discharge process.
• The revised discharge policy is complete and is ready for presentation to the Executive
Team.
SAFER Flow
Delivering our vision – How are we doing?
Effective – Scorecard
15
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Trend
HSMR (56 Monitored diagnoses - 12 Months) 96.7 95.9 96.5 96.2 94.8 93.6 92.3 91.2 93.9 93.4
SHMI 0.95 0.95
Emergency readmissions within 7 days 3.6% 3.5% 3.7% 3.7% 3.8% 3.9% 3.5% 3.5% 3.7% 3.8% 4.1% 4.1% 3.7%
Emergency readmissions within 28 days 7.5% 7.2% 7.8% 7.6% 8.0% 8.0% 7.5% 7.7% 7.8% 7.7.% 8.4% 8.2%
Maternity - C Section Rate - Emergency 12.8% 17.9% 17.1% 20.0% 20.0% 19.4% 16.4% 18.2% 15.2% 15.9% 21.2% 20.6% 17.0%
YCM - Were you kept informed of your estimated date of discharge from hospital? 71 68 67 70 64 68 67 67 69
YCM - When you were ready to be discharged, were you satisfied with the plan that was put in
place?84 79 79 82 79 77 83 74 78
Average No of Adults Over 7 Days 297 293 277 293 280 290 295 285 280 289 273 250 264
Average No of Adults Over 14 Days 184 179 171 182 171 185 188 180 174 182 166 139 156
Discharge Planning
Mortality and Readmissions
Other Effectiveness
Are we caring?
Section 4
16
Delivering our vision – How are we doing?
Caring – service involves and treats people with compassion, kindness, dignity and respect
17
Outpatient
FFT
89.3%
• Inpatient FFT – Inpatient FFT is down slightly from 96.2% to 94.5%. The response rate has
decreased to 24%.
• Daycase FFT – Daycase FFT increased to 97.3% in January with the response rate also
increasing to 17.49% (12.43% in December).
• Emergency Department FFT - The FFT score has increased from 96.5% in December to
97.6% in January. The response rate has also increased to 10.36% for January (5.98% in
December).
• Maternity FFT – The FFT score for the postnatal ward has increased from 93.68% for
December to 97.5% for January. The Delivery/birthing centre score is 100% up from 83.3%
however, there were only 5 responses. The combined score for all maternity touch points is
97.31% and the response rate is 11.98%
• Outpatients FFT - The FFT score for outpatients has increased to 89.3% in January with an
increase in responses from 1157 in December to 1599 in January.
Friends and family test
ED FFT
97.6%
Inpatient FFT
94.5%
Raising awareness and supporting carers –The carers steering group continues to meet regularly and the two
carer support organisations visit wards throughout the week to identify and provide assistance to carers of patients.
Carers
Delivering our vision – How are we doing?
Caring – service involves and treats people with compassion, kindness, dignity and respect
18
• Mixed Sex Breaches – We continue to report zero mixed sex breaches in January
• Complaints – The number of complaints increased by 30% in January to 47, compared to 33 in December 2017. 100% of
complaints have been acknowledged within 3 working days, as per statutory requirements, consistently for the last 10
months. 97% of complaints were closed within the agreed timeframe in January compared to 95% in December. The
same number of complaints (6) were re-opened and no cases were referred to the Parliamentary and Health Service
Ombudsman (PHSO).
• Accessible Information Standard – The testing phase for producing patient letters in alternate formats is currently
underway.
• Way Finding – Signage has been installed to the ‘Chipstead’ area and we are currently undergoing a period of evaluation.
Surveys are being conducted by the provider in order to plan for full installation.
Other Patient Experience
Complaints
per 10,000 pt.
contacts
10
Mixed Sex
Breaches
0
• Responsiveness to feedback – Automated actions generated by the Meridian system require key staff to make
appropriate and continuing improvements in their areas. Areas with a low or decreasing FFT score are monitored and
work streams arise from this feedback. The Patient Experience Committee (PEC) always begins with a patient story
which is discussed and focusses the committee.
• Focusing on priorities for improvement at ward/departmental level – Priorities are consistently being raised to key
staff through the alerts system on the reporting platform and by the monthly batch reports provided to the clinical areas
by Meridian. The monthly PEC analyses data from Meridian. Performance maps which allow areas to understand their
top priorities for patient experience are being used more widely.
Patient experience platform
Delivering our vision – How are we improving?
Caring – Create best environment for patients
19
• Work continues on the design work for the different elements of the Neonatal project. These will be used to inform the tenders
which will be issued in spring 2018.
• The capital programme for 2018/19 is currently being put together – the largest development of which will be the Neonatal Unit
refurbishment.
Estate / Building Developments – Major Schemes
A variety of improvement works have been undertaken across the hospital wards and the following table summarises the main
activities:
Ward Improvement Works
Ward Works Status
Abinger MDT Room Complete Abinger/Meadvale Corridor Lighting Complete Buckland Over-bed lighting and power Complete Burstow MDT Room (CF) Underway Chaldon Flooring In plan Charlwood Create quiet room In plan Delivery Suite Bathrooms Complete Delivery Suite Sluice and SANDs room In plan Holmwood General refurbishment Complete Holmwood Circulation area decoration In plan Leigh Over-bed lighting and power Complete Leigh and Newdigate Sluice, Store room Complete Leigh and Newdigate Staff WC Underway Meadvale MDT room Complete Newdigate Over-bed lighting and power Underway Outwood Bathrooms Underway Outwood External windows Underway Rusper Telephone Triage room (CF) Underway Tandridge General refurbishment In plan Various Yellow toilet and shower doors Underway Various New Nurse Call System Complete
Delivering our vision – How are we improving?
Caring – Create best environment for patients
20
In addition to work in ward areas a number of other smaller projects have taken place or are planned, these are shown below:
Estate / Building Developments – Other Improvement Works
Area Works Status
Angio Modular Office New Temporary Office Accommodation Complete Audiology Sound booth In plan Bereavement New office Complete Car Park New Hard Surface and relining Complete Camomile Courtyard New dementia garden Designer Appointed Chipstead New OPD consulting room, ECG room and assessment space Complete
Diagnostic Imaging Various works Complete Diagnostic Imaging Changing cubicles (P&D) In plan ED New flooring Complete Fire Doors Replacement of Fire Doors across East Surrey Underway Hand Therapies Redesign and refurb In plan Kitchen New Ventilation System Complete Lung Function Refurbishment Complete Modular 1 Refurbishment and office moves Underway Mortuary Visitors’ Room Refurbishment Complete Outpatients / ECG General refurbishment Complete
PGEC New reception and seating for lecture theatre In plan
Phlebotomy and Haematology Minor works including new back-door Complete
Security New office Complete
Sunshine Day Nursery Garden (Health & safety) In plan
Sunshine day Nursery Kitchen (charitable funds awaited) In plan
Trust HQ Toilet refurbishment Complete
Trust HQ Entrance canopy Complete
Wayfinding Improved wayfinding throughout ESH Underway
Delivering Our Vision – How are we doing?
Caring – Scorecard
21
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Trend
Emergency Department FFT - % positive responses 96.3% 96.6% 96.9% 96.3% 95.7% 93.8% 95.7% 93.7% 95.5% 96.7% 98.3% 96.5% 97.6%
Inpatient FFT - % positive responses 96.7% 96.2% 95.8% 96.6% 95.6% 95.2% 96.2% 95.2% 95.7% 94.5% 93.8% 96.2% 94.5%
Day Case FFT - % positive responses 96.7% 96.2% 95.8% 96.6% 96.9% 94.4% 94.7% 93.9% 96.1% 95.5% 95.4% 92.8% 97.3%
Outpatient FFT - % positive responses 89.7% 90.7% 90.6% 88.0% 88.7% 88.6% 88.0% 90.5% 89.0% 88.8% 89.7% 88.3% 89.3%
Maternity FFT - Antenatal - % positive responses 98.5% 95.2% 95.9% 100.0% 94.7% 90.6% 87.5% 96.8% 100.0% 100.0% 100.0% 100.0% 100.0%
Maternity FFT - Delivery - % positive responses 97.8% 97.3% 98.8% 96.7% 100.0% 100.0% 83.3% 100.0% 100.0% 80.0% 100.0% 83.3% 100.0%
Maternity FFT - Postnatal Ward - % positive responses 92.3% 89.0% 92.1% 95.8% 91.0% 94.9% 95.2% 97.3% 95.6% 89.6% 96.8% 93.6% 97.5%
Maternity FFT - Postnatal Community Care - % positive responses 100.0% 92.0% 100.0% 97.7% 96.2% 100.0% 96.6% 97.2% 100.0% 100.0% 96.6% 97.8% 95.9%
Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0
Complaints - Number received in month 56 43 57 41 50 55 37 42 36 51 36 33 47
Complaints - Rate per 10,000 patient contacts 12 10 11 10 10 11 8 9 8 11 7 8 10
Friends and Family Test
Other Caring
Are we responsive?
Section 5
22
Delivering our vision – How are we doing?
Responsive – services meet people’s needs
23
ED 4hr
88.2%
Amb
Handover
over 60min
87
• The ED 4hr standard was not achieved in January 2018 with performance of 88.2%. National
performance for ‘Type 1 Departments’ in December was 77.1% showing our performance
significantly exceeded the national average.
• SASH system LAEDB performance was 92.8% for January 2018 placing performance in the top
decile of non-specialist hospitals.
• Ambulance turnaround performance dropped with 87 breaches of the 1hr standard. We are
working with the wider system and will launch an initiative to reduce delays in March 2018.
Emergency department
• The TWR national standard was delivered with performance of 93.3% in January. TWR breast
symptomatic also achieved the standard with performance of 96.9%.
• 62 Day GP performance returned to green performance achieving the national standard with
performance of 85.9%.
• Performance against the 62 day screening standard was 80.0% against a target of 90% as a
result of four breaches. Three on the Breast pathway (2 delayed referrals and 1 complex
pathway) and one colorectal pathway (internal delay).
Cancer treatment
Two Week
Wait
93.3%
62 Day GP
85.9%
Delivering our vision – How are we doing?
Responsive – services meet people’s needs
24
• We improved performance against the RTT Incomplete pathway standard with performance of 88.6%
in January.
• Whilst we did not achieve the national 92% standard, maintaining performance and continuing our
improvement journey during a time of significant system pressure provides assurance that our
organisation continues to make progress against individual improvement trajectories.
• Delivery of RTT standards remain a challenge with the impact of emergency pressures, increased
trauma, as well as specialty specific capacity issues being the root causes of the under performance.
Improvement trajectories are in place and being monitored by the executive committee.
• Whilst we continue to commit to the reduction of patients waiting over 52 weeks for treatment. Due to
the impact of patient choice over the Christmas period and the on-going challenge in Neurology, we
did not see reduction in the number of patients waiting over 52 weeks, with 17 patients in January.
Individual treatment plans are in place for all patients and we continue to work closely with the clinical
team to ensure that patients move through the Neurology pathway as quickly as is clinically
appropriate .
• No patient harm has been identified from RTT 52 week breaches and root cause analysis of the
pathway is undertaken by clinical divisions.
• The 6 week diagnostic standard was achieved in January with performance of 0.7%.
RTT and diagnostics
RTT
Incompletes
88.6%
6 Week
Diagnostic
0.7%
Delivering our vision – How are we improving?
Responsive – Improve efficiency of elective care
25
• Outpatients continues to see positive performance with £940k of savings YTD. The
DNA rate increased slightly in January to 7.3% while the un-booked rate reduced
from 11.4% to 9.3%. Clinic utilisation was 84.1% which is the best performance
since measurement began.
• Recruitment to the Outpatient Booking Office continues with a number of new
starters in February. Final moves to the central booking centre are also being
progressed over coming months.
• Theatres productivity remains behind plan, although NHS Improvement
benchmarking shows us above average when compared nationally.
• Theatre cases per session decreased to 2.90, although some specialties are
continuing to show improvements compared to prior year. Cancellations were a
significant driver with 147 patients cancelled in January, with bed pressures being a
major contributor with 40 cancellations.
• A number of new task and finish groups are now in place to support the theatres
programme and the existing work underway around scheduling. These include Pre-
Assessment, cancellations and Cerner EPR usage.
• Endoscopy productivity remains positive with £88k of savings YTD but in month
performance was impacted with patients and points per session being adverse to
trajectory as a result of the area being used for escalation. Performance to date in
February is positive.
OPD (OBO)
DNA Rate
7.3%
OPD (OBO
Un-booked
Rate
9.3%
THR - Cases
Per Session
2.90
THR
Cancellation
Rate
9.5%
Endo -
Patients Per
Session
5.71
Endo - Points
Per Session
7.81
Overview of January 2018
Delivering our vision – How are we doing?
Responsive – Scorecard
26
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Trend
ED 95% in 4 hours 87.0% 90.9% 95.1% 92.9% 92.6% 92.8% 93.6% 94.4% 94.1% 93.2% 95.0% 92.3% 88.2%
Patients Waiting in ED for over 12 hours following DTA 0 0 0 0 0 0 0 0 0 0 0 0 0
Ambulance Turnaround - Number Over 30 mins 253 194 249 188 253 199 246 306 225 299 206 319 290
Ambulance Turnaround - Number Over 60 mins 66 34 19 27 46 50 33 47 40 38 38 73 87
Cancer - TWR 94.7% 94.4% 95.0% 92.2% 93.0% 93.7% 90.6% 91.1% 91.6% 94.0% 94.6% 94.9% 93.3%
Cancer - TWR Breast Symptomatic 95.4% 93.0% 95.7% 93.0% 93.5% 93.5% 95.7% 90.5% 85.7% 94.1% 83.9% 96.5% 96.9%
cancer - 62 day Referral to Treatment Standard 87.9% 86.0% 86.4% 87.9% 86.0% 85.2% 86.9% 85.7% 86.3% 90.4% 85.8% 100.0% 85.9%
Cancer - 62 Day Referral to Treatment Screening 100.0% 100.0% 100.0% 71.4% 100.0% 81.8% 75.0% 80.0% 87.5% 75.0% 91.7% 100.0% 80.0%
Cancer - 31 Day Diagnosis to Treatment 97.7% 99.0% 98.7% 100.0% 99.2% 98.6% 99.2% 95.5% 95.2% 97.3% 96.6% 96.6% 96.2%
Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.5% 100.0% 100.0% 92.3% 80.0% 100.0%
Cancer - 31 Day Second or Subsequent Treatment (DRUG) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 86.7% 100.0%
RTT Incomplete Pathways - % waiting less than 18 weeks 90.5% 90.0% 90.1% 88.7% 87.3% 87.3% 86.9% 86.4% 86.1% 86.6% 87.9% 87.9% 88.6%
RTT Patients over 52 weeks on incomplete pathways 13 15 19 19 53 51 33 23 20 22 19 17 17
Percentage of patients waiting 6 weeks or more for diagnostic 0.4% 0.3% 0.2% 0.4% 0.7% 1.0% 0.9% 0.7% 0.8% 1.19% 0.7% 0.3% 0.7%
No of operations cancelled on the day not treated within 28 days 7 3 9 7 18 21 15 5 11 19 8 15 22
Cancer Access
RTT
Emergency Department
Are we well led
Section 6
27
Delivering our vision – How are we doing?
Well led – leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture
28
Vacancy Rate
9.5%
• Vacancy rates across all staff groups has reduced by 0.7% to 9.5%. For Nursing, vacancy rates have also
reduced this time by 0.3% to 17.1%.
• Turnover has reduced by 0.7 to 16.1% for all staff groups, and for nursing has reduced by 0.1% to 17.3%.
• We continue to review opportunities for recruitment and retention and are developing a campaign to recruit
from the local community.
• We continue to liaise with NHSi regarding our retention plan which aims to reduce overall turnover by 1%
across all staff groups in the 12 months from October 2017 to November 2018.
• We will commence work in February with an external provider to support the development of the SASH
Leadership Framework, talent management and succession planning programmes. This work has been funded
following a successful bid to Health Education England Kent, Surrey and Sussex.
• The Nursing Associate apprenticeship is following the procurement process; staff will commence training in
March 2018.
Establishment
Turnover
Rate
16.1%
• MAST figures have fallen slightly to 77.04%.
• All clinical Divisions have a compliance rate of at least 77%, with Cancer & Diagnostics and Surgery achieving
83% or more (against a green RAG rating KPI of 80%).
• There has been a considerable increase in compliance in Estates & Facilities, (increasing from 55% to 62%),
and we are reviewing other bespoke solutions to increase this further.
• Achievement Review completion rates continue to increase and we are currently at 92.2%, as at the end of
December, having met the 90% target in November.
• Our HR Business Partners are working with Divisions to ensure all relevant staff who are yet to have their
achievement review have this undertaken.
Training and Achievement Review
MAST
Compliance
77.0%
Achievement
Review
92.2%
Delivering our vision – How are we improving?
Well Led – Staff health, well being and working lives
29
• Overall Sickness has increased by 0.4% to 4.7%.
• There has been an on-going increase in absences for ‘seasonal’ conditions (i.e. ‘colds,
coughs, and flu’), and this is currently the highest reason for sickness absence.
• Absence for issues related to mental health conditions fell compared to last month however it
remains the second highest reason for absence and absence for this reason is higher than
the same period last year.
• Training provided by SLaM on resilience and techniques for coping with stress is being very
well received.
Sickness
• We have had a very successful Flu vaccination campaign with 70.1% of frontline staff vaccinated by
31st December. This enabled us to meet our CQUIN target.
• We are moving to the second phase of the mental health impact assessment work which we are
undertaking with South London & the Maudsley, (SLaM). This will support staff managing their mental
health.
• The Smokefree SASH campaign, which aims to make the East Surrey Hospital site Smokefree, as
well as offering support to all staff, patients and visitors in giving up smoking, is being developed.
• We are delivering updated training on Conflict Resolution, Conflict Management, Communicating
Excellence (customer care), Assertiveness, Wellbeing, & Resilience.
• We have been asked by a neighbouring Trust to provide details of our ‘It’s Not Okay’ campaign as
they are keen to learn from our positive experiences of this.
Health and Well being strategy
Sickness %
4.7%
Delivering our vision – How are we doing?
Well Led – Scorecard
30
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Trend
Total Establishment (WTE) 3952 3925 3932 3929 3944 3950 3961 4006 4006 4027 4031 4030 4033
Vacancy Rate (All Staff) 11.0% 9.8% 9.4% 9.5% 9.5% 9.6% 10.4% 11.1% 11.6% 10.9% 10.0% 10.2% 9.5%
Staff Turnover rate 16.4% 16.1% 15.8% 16.0% 15.7% 15.8% 15.9% 16.1% 16.5% 16.2% 16.4% 16.8% 16.1%
% of Staff who have had an Achievement Review YTD 97.0% 97.2% 97.6% 1.3% 11.5% 19.5% 39.7% 53.0% 65.0% 84.0% 90.3% 92.0% 92.2%
%age of staff who have completed MAST training in the last 12 months 80.3% 76.8% 78.0% 77.2% 76.0% 77.0% 75.0% 77.0% 76.6% 76.1% 76.0% 77.9% 77.0%
Overall Sickness Rate 4.1% 3.7% 3.5% 2.8% 3.5% 3.6% 3.8% 4.1% 3.8% 4.1% 4.5% 4.3% 4.7%
Establishment and Training
Staff health, well being and working lives
Do we use resources effectively
Section 7
31
Delivering our vision – How are we doing?
Effective use of resources
32
• We are forecasting a £11m surplus outturn for 2017/18. This is £10.3m adverse to the £21.3m surplus
control total. NHSi has been notified of this new forecast position in accordance with the relevant
protocols.
• We achieved a £9.8m [adjusted] surplus at the end of Month 10, which is £6.4m adverse to the year to
date (YTD) financial plan.
• The YTD position includes £5.7m Sustainability & Transformation Funding (STF).
• £4.8m of savings have been achieved YTD.
• The 2017/18 savings programme totals £6.2m.
• The Programme includes:
• £2m saving in agency premium,
• £2.4m productivity savings,
• £1.8m non pay savings,
• YTD achievement is £4.8m (including £2m use of contingency reserves) against a plan of £4.8m.
Savings Plan
YTD Savings
£m - Actual
£4.8m
YTD £m
Adjusted
Surplus
£9.8m
Income and Expenditure
Delivering our vision – How are we doing?
Effective use of resources
33
• Forecast capital spend (excluding donated assets additions) is £11.6m which is precisely in line with the new
2017/18 £11.6m Capital Resource Limit (CRL).
• The £7m of loan funded projects (including EPR and Pathology Joint Venture) included in the original capital
programme have been moved into 2018/19 capital programme.
• The cash balance at the end of January 2018 was £3.3m.
• We repaid £3.5m revolving working capital in April 2017 and borrowed a further £1.3m in July and
£1.8m in Sept . A further £3.1m was been repaid in January 2018 bringing the balance down to
£12.5m at the end of January 2018.
• This cash has supported our Better Payment Practice Code performance which was 73% by
volume, 77% by value in the first ten months of 2017/18.
Capital Plan
Cash Management
Delivering our vision – How are we doing?
Resources – Scorecard
34
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Trend
Outturn £m Surplus / (Deficit) - Plan 15.2 15.2 15.2 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3
Outturn £m Surplus / (Deficit) - Forecast 5.0 5.0 5.0 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3 21.3 11.0
YTD £m Surplus / (Deficit) - Plan 6.8 10.1 15.2 (1.6) (0.3) 1.1 2.7 3.0 4.3 7.1 9.6 9.7 16.2
YTD £m Surplus / (Deficit) - Actual 3.6 2.0 3.5 (1.0) 0.1 1.2 2.7 3.1 4.4 5.3 7.1 9.7 9.8
Annual Outturn UNDERLYING £m Surplus / (Deficit) - Plan 7.5 7.5 7.5 12.5 12.5 12.5 12.5 12.0 12.5 12.5 12.5 12.5 12.5
Annual Outturn UNDERLYING £m Surplus / (Deficit) - Actual (2.8) (2.8) (4.3) 12.5 12.5 12.5 12.5 12.0 12.0 11.9 11.9 11.9 5.3
YTD Savings £m - Actual 6.8 8.0 9.2 0.3 0.7 1.0 1.4 1.8 2.2 2.8 3.5 4.1 4.8
OT Risk £m Surplus / (Deficit) - Assessment (2.5) (2.5) 0.0 (8.0) (8.0) (8.0) (16.3) (16.3) (16.0) (16.0) (16.0) (16.0) (5.5)
Outturn Cash position £m Fav / (Adv) - Forecast 2.5 2.5 5.6 2.7 2.7 2.7 2.7 2.7 2.7 2.7 2.7 2.7 2.7
YTD Cash position £m Fav / (Adv) - Actual 4.4 2.9 5.6 3.8 5.9 2.6 3.9 5.4 5.1 6.0 4.7 4.9 3.3
YTD Liquid ratio - days (7.0) (11.0) (12.0) (14.0) (13.0) (12.0) (11.0) (10.0) (9.0) (8.0) (6.0) 1.0 (3.0)
YTD BPPC (overall) volume £m 82% 83% 83% 94% 93% 92% 88% 86% 82% 74% 67% 70% 73%
YTD BPPC (overall) value £m 80% 82% 82% 97% 94% 91% 87% 87% 83% 78% 74% 75% 77%
Outturn Capital spend Fav / (Adv) - forecast 11.3 11.4 11.4 18.8 18.8 18.8 18.8 18.8 18.8 18.8 18.8 18.8 11.6