Integrated Performance Report – May 2018 IPR.… · It is to be noted that there is now a much more representative sample ... awaiting assessment from the mental health ... safeguarding

QAH Hospital

Portsmouth Hospitals NHS Trust

Integrated Performance Report – May 2018

28/06/2018 Page 1

QAH Hospital


Contents

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Section Page

1 Corporate objectives 3

2 Quality Performance 6

3 Operational Performance 33

4 Financial Performance 47

5 Workforce Performance 54

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Corporate Objective Outcomes – May 2018

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Corporate Objective Outcomes – May 2018 Summary Alignment of the Integrated Performance Report to the 17/18 corporate objectives demonstrates risks to delivery across each of the five domains. To note workforce metrics have been amended when compared to previous months to include more timely data. During April, the Executive team conducted the monthly Performance Review Meetings with CSC Management Teams covering the key issues across quality, performance, finance, organisational health and strategic change, including a discussion of the key risks. Ongoing issues of non-compliance, as highlighted in this report, were addressed through these meetings. Issues: • Dementia screening – Data is not available for May is not available at the time of reporting. It is expected to be available to meet the

national reporting timetable however we anticipate issues with performance to persist and therefore do not expect the standard to be achieved.

• Medication incidents – Data shows a continued month on month increase in medication incidents from February with 259 in May 2018, compared to 205 in May 2017.

• 12 hr trolley waits – Two breaches of the zero tolerance 12 hr trolley wait standard in May 2018, following 0 reported 12 hr waits in April. In May 2017 there were 38 breaches and over the last 12 months there have been an average of 22 per month.

• Delayed Transfers of Care – Increased to 4.4% in May 2018 compared to 3.3% in April 2018 that is a significant improvement when compared to May 2017 when performance was 8.7%.

• Cancer performance – Predicting achieving 6 of 8 cancer standards. The 62 day First Definitive Treatment standard has been achieved for the previous three months, May 2018 provisional performance is 82.1% against the 85% standard.

• Diagnostic 6 week standard – continues to perform below the 99% standard at 98% but performance has improved from April 2018 and the recovery plan is being delivered and on track to recover by end July.

• Income and expenditure - £0.47 million adverse to financial plan year to date, a marginal deterioration from month 1. • Vacancy rate increased for a second month in May to 7.8%, from 7.3% in April and compared to 6.2% in May 2017 • Turnover rate increased to 13% in May following a stable turnover range of 12.4% to 12.6% since November 17.

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Corporate Objective Outcomes – May 2018 Improvements: • ED 4 hour - Performance remains above trajectory at 87.3% but below the constitutional standard of 95%. There is a continued

reduction in ambulance holds over 60 minutes with 35 in May 2018 compared to 131 in April 2018 and 142 in May 2017. Continued focus on delays over 30 mins is required which remain at 240 for May 2018.

• Medically fit for discharge patients – The number of patients has reduced for the fourth month reducing from 258 in January 2018 to 178 on average in May 2018 compared to 257 on average in May 2017.

• Referral to Treatment – Performance remains above trajectory with performance of 86.6% however, there has been an increase of 546 in the overall waiting list and one breach of the 52 week standard. The number of patients waiting over 18 weeks and 35 weeks has reduced and the patient waiting over 52 weeks has been treated. A focus on the waiting list size is required to ensure the waiting list at the end March 2019 does not exceed that in march 2018.

Other Exceptions to note: • CDiff – One case reported this month with three cases to date this year against a ceiling of seven • Falls – Five falls with moderate or severe harm reported this month with a total of six confirmed falls with severe or moderate harm in

2018/19 to date.

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Quality Report – May 2018

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Quality of Care Overview – May 2018

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Portsmouth Hospitals NHS Trust Page 8 6/28/2018

Quality of Care Overview – May 2018 Sa

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Quality of Care Key Exceptions – May performance

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• Following a change in reporting, as noted last month, a review of the quality scorecard is underway. • The total harm free care has seen a marginal increase to 97.7%; remaining above the national average of 94%.

• 1 C.Diff case has been reported, against a monthly objective of 3, giving a year-to-date position of 3 cases against a target of 7.

• Due to issues accessing the VTE risk assessment data on VitalPAC following a recent upgrade, risk assessment data for May is

unavailable at the time of writing this report. Access to data is planned to be restored prior to the deadline to submit VTE data to Unify.

• The updated Trust HSMR for the 12 months to February 2018 is 107.1 representing a slight decrease on the rate to January of 107.9. This remains statistically higher than expected.

• Similar to VTE risk assessments, following an upgrade to VitalPAC there has been a delay in obtaining performance data for May; however, it is expected to be a similar performance and below the 90% target.

• Non clinical moves between 2100 and midnight have overall improved on a daily basis, with the exception of spikes in activity related to operational pressures, as noted in the increase in moves between 0001 and 0700 for mid May.

• Following the introduction of text and voice messaging during May, the Emergency Departments’ Friends and Family response rate increased to 19.1%. However, this introduction has resulted in an anticipated reduction in satisfaction score and increase in ‘not recommends’. It is to be noted that there is now a much more representative sample of patients responding.

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Mental Health Act &Mental Capacity Act Compliance (Reporting only)

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y • The Trust continues to meet the Care Quality Commission (CQC) requirements to submit weekly compliance information in relation to the Section 31 Enforcement Notice Conditions.

• The Accountable Care System was successful in their bid for capital funding relation to the plans to develop a Mental Health Assessment Unit within the Trust. The planning work has commenced.

• The Trust has now received waiting and response times for patients awaiting assessment from the mental health liaison team; work is underway with the team to agree a format for a report. During May, 35% of patients referred are treated within 1 hour; a reduction on the April figure of 44%. This will be monitored in more depth by the Mental Health and Capacity Board.

• Work continues, in partnership with Mental Health Providers to improve

pathways and care plans to reduce ED attendances for Mental Health high intensity users. Following the success in 2017, system partners are working up the plan to deliver a further reduction in ED attendances for a new cohort of high intensity users.

• Risk assessments for patients attending ED with Mental Health needs continue to exceed 95%; achieving an average of 99% in May.

• The senior nursing team led on patient capacity rounds through May, this involves evaluating patient care in real time with expert support from safeguarding and the corporate nursing team, this promotes individualised and ward based practical application of MCA and DoLS.

• Safeguarding training compliance is noted below. Non-compliance will be

addressed through the Performance and Accountability reviews. HealthWRAP e-learning training is now available; staff have been made aware of the requirements. Compliance for HealthWRAP, Prevent level 3 has increased to 33%, this is being monitored and action taken weekly by the CSC’s to achieve 85%.

Safeguarding training compliance – April 2018

Training Month

Feb. ‘18

Mar. ‘18

Apr. ‘18

May. ‘18

Safeguarding adults 98% 98.8% 98.8% 99% Safeguarding Children Level 1 99% 98% 99% 99%

Level 2 92% 91% 92.5% 93% Level 3 77% 73% 72.4% 79% Level 4 50% 100% 100% 100%

Mental Capacity Act Introduction 94% 94% 94.9% 95% Enhanced 80% 80% 80.8% 81% Introduction & Enhanced combined 89% 87% 89.9% 90%

Deprivation of Liberty Standards

Introduction 94% 94% 95% 95% Enhanced 79% 80% 80.4% 80% Introduction & Enhanced combined 91% 87% 91.6% 92%

HealthWRAP 21% 21% 23% 33%

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Pressure Ulcers - Achieved

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Reported pressure damage • There have been 10 reported cases of pressure damage in May; all of which are under investigation to determine avoidability and

learning. Of these: 5x category 1, 4x category 2 and 1x category 3.

Confirmed pressure damage • There have been 12 confirmed cases of pressure damage in May:

- 5x category 1 and 5x category 2 all confirmed by the Tissue Viability Nurse (TVN) team. - 2x category 3 have been confirmed following review and reported onto STEIS. Both cases occurred in the last financial year; one

in March and one in January. • The current position for confirmed avoidable hospital acquired category 3 and 4 pressure damage occurring in 2018/2019 is:

zero. • The current position for avoidable hospital acquired category 3 and 4 pressure damage confirmed in 2018/2019 which occurred in

2017/2018 is 2x category 3.

Unavoidable hospital acquired pressure ulcers • The Trust confirmed 3 unavoidable category 3 pressure damage within Surgery and Cancer, MOPRS and MSK (occurring in April) in

May.

Actions and progress to date • The TVN team are working with the Dermatology Matron looking at skin cleansers and management of radiotherapy skin damage. • Tissue Viability presented to NHS improvement the journey of PURPOSE T and REACT to Risk framework.

Per 1,000 occupied bed days (OBD) Target: Reduce the rate per 1,000 occupied bed days of avoidable pressure damage (2017/2018 baseline) • The Trust has reported 0.0 confirmed category 3 or 4 avoidable pressure

damage per 1,000 bed days in May.

Present on admission • A total of 147 ‘present on admission’ pressure ulcers were reported in May

compared to 130 in April. • Following review by the TVN team of all present on admission pressure damage,

26 of the 147 reported incidents were deemed to be pressure damage.

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May position Monthly monitoring of incidents resulting in moderate, severe or catastrophic harm.

Reported falls incidents • There have been a total of 5 reported falls with moderate or severe harm:

- 1x death: Medicine (STESIS reported). - 2x severe harm: 1x MOPRS and 1x incident due to be rejected as occurred within QA@Home; both of which are under

investigation. - 2x reported moderate harm falls: 1x MSK and 1x external SCAS incident.

Confirmed falls incidents

• There have been 2 confirmed falls incidents both of which have been reported onto STEIS in May: - 1x Medicine, as noted above - 1x Medicine, which occurred in April 2018.

• There has been 1x confirmed moderate falls incident in May, as noted above (MSK). • The current position for confirmed falls incidents with moderate or severe harm occurring in 2018/2019 is 6 (2x death, 2x

severe and 2x moderate). • The current position for confirmed falls incidents with moderate or severe harm confirmed in 2018/2019 which occurred in 2017/2018

is 1 death (March 2018). Actions and progress to date • Falls Collaborative initiatives continue in AMU, C5, D8, G1, F4 and E8.

Actions as part of the collaborative include: - Use of simulation training to improve awareness and response - Intensive training in falls assessment and care planning, including prevention

strategies. - Use of post fall review (SWARM) to identify modifiable risk factors and learning.

• New falls and bedrail assessment is currently being piloted • MSK and Medicine CSC have a focus on falls month. Actions to include:

Competitions to raise awareness, simulation events and falls competency study sessions.

Falls per 1,000 occupied bed days Target: Sustain or reduce the rate per 1,000 occupied bed days of avoidable injurious falls (2017/2018 baseline)

• The Trust has reported 0.1 confirmed falls incidents per 1,000 bed days in May, comparable to April.

Falls (Quality Contract) - Achieved

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Portsmouth Hospitals NHS Trust Page 13 Page 13 28/06/2018

May position Monthly monitoring of incidents resulting in moderate, severe or catastrophic harm.

• There were 7 moderate or severe harm incidents reported in May, and are all under investigation: Severe harm: 1x MOPRS. Moderate harm: 1x CHAT, 1x Medicine, 1x Emergency Medicine, 3x Surgery and Cancer.

• There were no moderate / severe medication related incidents confirmed in May.

• The current position for confirmed medication incidents with moderate or severe harm occurring in 2018/2019 is zero.

Actions and progress to date

• The rate of medicines reconciliation completed by pharmacy staff within 24hrs in May was 66%, with a reduction from the expected results due to the data collection day being after the Bank Holiday weekend.

• The Medication Safety Committee (MSC) now reports to Trust Quality and Performance Committee. Initial feedback from the recent CQC feedback was discussed at the recent MSC meeting in May with actions for all CSCs being collated and validated by the MSC and concerns escalated.

• A series of monthly medicines management security panels have been established to ensure that prompt and consistent actions are taken following such incidents, and enable the Trust Accountable Officer to have full oversight.

• Prescribing doses to be given at 20:00 has been identified as a potential cause of missed doses due the constraints of drug rounds. An audit was carried out to investigate this issue and actions are to follow. Sa

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May position Target: Submit data to the National Patient Safety Thermometer

• The Trust achieved 100% data collection for May.

• To date the Trust has maintained high submission rates, with 100% being achieved each month.

• Sustained 100% audit submission on all patients and validation of all harm events occurred.

Actions and progress to date • Sustain 100% audit submission on all patients and validation of all harm events.

Percentage of harm free care (contract) Target: Report percentage of harm free care. • In May, the Trust recorded in-patient harm free care at 98.7%; a slight decrease

compared to April. • The total harm free care, which includes pre-hospital admission harm events,

was 97.7% in May, a marginal increase on April. This is above the national harm free rate 94%.

Actions and progress to date • Continued monthly reporting to the Director and Deputy Director of Nursing and

Head of Nursing for each CSC with feedback to ward teams.

• Specialist nurses working on education. • Clinical Dashboard available as a hard copy and via the intranet. • Service improvement work streams for all harm events.

Patient Safety Thermometer (Contract) - Reporting only

Total harm free care including preadmission data

Total new harm free care

Harm free care

Month Total Harm Free

Care (data collection from number of

patients)

Trust Harm Free

Care

May 2018 97.7% (1048)

98.7%

April 2018 97.2% (1,035)

98.9%

March 2018 97.5% (1,094)

98.5%

Types of harm

Types of harm March 2018

April 2018

May 2018

Pressure ulcers (new and old)

12 14 13

Falls 7 5 5 Catheter and UTI 3 9 6 VTE (new) 5 3 2 Total patients 1,094 1,035 1,073

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Healthcare Acquired Infection (National) - Achieved May position

MRSA (Incidence more than 48 hours after admission) Target: 0 (zero) avoidable

• There have been no MRSA bloodstream infection attributed to the Trust during May, comparable to April.

• The Trust’s year-to-date trajectory position is 0 cases of MRSA bacteremia.

C.difficile (Incidence more than 72 hours from admission) Target : 39 cases

• The Trust reported 1 patient who acquired C. difficile during their in-patient stay in May against a monthly objective of 3; an improvement on the 2 reported in April. This case occurred in 42 year surgical patient who required multiple courses of antibiotics and complex bowel surgery. The patient has made a good recovery and has been discharged home.

• The Trust’s year-to-date position is 3 cases against a target of 7 cases.

E.coli bloodstream infection (incidence more than 48 hours from admission) E.coli bloodstream infection are not subject to DH trajectories, but are closely monitored by the Trust due to the government initiative to reduce Gram-negative bloodstream infections by 50% by 2021.

• The Trust reported 7 patients who acquired an E.coli bloodstream infection during their inpatient stay during May.

• The majority of these patients had previous uro-sepsis which required antimicrobial therapy with 2 antibiotics (Co-amoxyclav and Gentamicin). These antibiotics and their role in generating HCAIs will be discussed at the next Infection Control and Management Committee (ICMC) with the aim of reducing their use.

MSSA bloodstream infection (incidence more than 48 hours from admission) MSSA bloodstream infection are not subject to DH trajectories, but are closely monitored by the Trust due to the high incidence of morbidity and mortality associated with these infections. • The Trust reported 5 patients with MSSA bloodstream infection during May (2x Medicine, 2x

MOPRS, 1x ITU). • This is a higher than expected rate of infection. The majority of these cases were caused by

poor cannula care. An improvement programme to optimise cannulae care is being monitored by the ICMC.

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Venous Thromboembolism Screening (National) May position VTE Screening Target: 95% per month

• Due to issues accessing the VTE risk assessment data on VitalPAC following a recent upgrade, risk assessment data for May is unavailable at the time of writing this report.

• Access to data is planned to be restored prior to the deadline to submit VTE data to Unify.

VTE Appropriate Prophylaxis Target: Monitoring and reporting (new)

• Due to the reasons stated above the appropriate prophylaxis data is currently unavailable.

VTE Serious Incidents Requiring Investigation (SIRIs) and Incidents Target: Monitoring and reporting

• There have been no reported VTE SIRIs in May and 1 moderate harm event.

• 86 VTE events were reported in May compared to 69 in April. - Of these 19 were hospital associated events (HAT), compared to 22 in April and

58 were community associated events (CAT) compared with 64 in April.

VTE Root Cause Analysis (RCA) Target: Monitoring and reporting • All VTE HAT events have RCA investigation requested (100%).

Actions and progress to date • Ward Managers have been contacted to refresh the VTE link nurse network who

are crucial in helping disseminate the recently released new VTE prevention guidelines from NICE.

• Following recent moderate harm events in medical patients who have a contraindication to drug therapy and improve the documentation of decision making by Medical staff a Quality Improvement Plan to target the issues identified has been developed and is currently with the Chief of Service for sharing with teams.

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Serious Incidents (Contract and National) - Reporting only May position

Serious Incidents Requiring Investigation (SIRIs as reported on STEIS) Target: Monitoring and reporting

• 11 clinical SIRIs were reported to STEIS in May, a slight decrease compared to 10 clinical SIRIs reported in April (adjusted from 11 reported last month*).

• Of these; 7 events were reported in May, confirmed and uploaded to STEIS in month. The months the other 4 incidents occurred in are shown in the adjacent table.

• Subject to completion of the investigations there are potentially 3 events which resulted in the death of the patient (1 being an out of hospital maternal death).

• This equates to 0.4 SIRIs per 1,000 occupied bed days in May, compared to 0.3 in April (adjusted to reflect incident downgrade).

• 8 events previously reported were downgraded from SIRI status with agreement from the CCG. 1x November 2017 (Medicine), 3x January 2018 (Medicine), 2x March 2018 (Medicine), 1x February (Surgery and Cancer) and 1x April 2018 (MOPRS*).

SIRIs over 60 day deadline Target: Monitoring and reporting • There were 18 open SIRIs at the end of May exceeding the target date of 60 working

days for submission to the Commissioners. 1x being investigated externally from an incident occurring in Emergency Medicine, 8x Medicine, 4x Women and Children, 2x Head and Neck, 2x MSK and 1x Surgery and Cancer. This is an improvement on the high point of 24 overdue (April), as a result of the intense focus on improving the position.

Never Events Target: 0 (zero) • There have been no Never Events reported in May.

• The Trust year to date position is 1 reported Never Event.

Duty of Candour The Trust is required to inform the patient and/or other relevant person within 10 operational days that the safety incident (moderate and severe harm) has occurred or is suspected to have occurred. • For those events reported in May, all patients or their relatives, where applicable,

were informed of the incident within the deadline and invited to submit concerns or questions to be included within the investigation.

SIRI CSC Incident month

Delayed follow up resulting in loss of vision to right eye x1

Head & Neck

May 2018

52 MRI results not reported / acted on x1

Head & Neck

May 2018

Hospital acquired Category 3 to sacrum x 1

Renal March 2018

Potential delayed treatment of suboptimal dialysis x 1

Renal May 2018

Hospital acquired Category 3 to ankle x 1

Medicine January 2018

Fall resulting in subdural haematoma x 1

Medicine May 2018

Fall resulting in fractured neck of femur x1

Medicine April 2018

Incorrect dose of anticoagulant potentially contributing to stroke x1

MOPRS May 2018

Failure to review medication for colitis x1

MOPRS April 2018

Potential sub-optimal care of deteriorating patient x1

Surgery & Cancer

May 2018

Death mother out of hospital at 11 weeks pregnant x1

Women & Children

May 2018

*Resulting in the death of the patient

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Patient safety incidents (excluding SIRIs) (Contract) - Reporting only May position Target: Increase in overall reporting of low and no harm incidents and reduce severity of harm

• At the time of reporting 1,719 Safety Learning Events (SLE - incidents) had been reported in May.

• The top three reported incident categories are: - Non Clinical Event: 331events (21.3%) - Tissue Damage: 265 events (17.1%). - Medication: 265 events (17.1%).

• This compares to, Tissue Damage, Medication and clinical event in April.

• The reported tissue damage incidents include present on admission from the community.

• Having reviewed the data there is no identifiable theme for the increase in non-clinical events reported this month.

• Of the 368 events reported in ED, 117 were related to present on admission pressure damage

• There were no severe harm incidents relating to admission, discharge or transfer.

Actions and progress to date • All monitoring actions are on-going.

Month Reported

incidents at time of report

Confirmed incidents at

time of report May 2018 1,719 395

April 2018 1,500 704

March 2018 1,646 825

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Patient safety incidents (Contract) - Reporting only

Definitions of harm: Severe : Any patient safety incident that appears to have resulted in permanent harm (directly related to the incident and not related to the natural course of the patient’s illness or underlying condition and defined as permanent lessening of bodily functions, sensory, motor, physiologic or intellectual, including removal of the wrong limb or organ, or brain damage) to one or more persons receiving NHS-funded care. Moderate : Any patient safety incident that resulted in a moderate increase in treatment (defined as a return to surgery, an unplanned re-admission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling of treatment, or transfer to another area such as intensive care as a result of the incident) and which caused significant but not permanent harm, to one or more persons receiving NHS-funded care. Low: Any patient safety incident that required extra observation or minor treatment (defined as first aid, additional therapy, or additional medication) and caused minimal harm, to one or more persons receiving NHS-funded care.

• The ‘Total PHT reported Patient Safety Learning Events May 2016 – May 2018’ graph represents the total number of all patient safety incidents reported by Trust staff (including community incidents).

• Reporting for May has increased above

the average monthly total, there is a continued positive trend showing a sustained number of incidents being reported since the upgraded Datix reporting system implemented in April 2016 and is comparable with the same reporting period over the last 2 years.

• The latest NRLS data release (March – September 2017) indicates there has been a further improvement in the number of incidents reported by PHT, placing the Trust in the top 25% of reporting Organisations.

• It should be noted that all incidents

including SIRIs are graded on the severity of actual harm suffered by the patient.

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May position

Coroners recommendations – Regulation 28 reports (preventing future deaths) Target: Monitoring and reporting

• The Trust received no regulation 28 reports in May.

• To date the Trust has received Zero Regulation 28 reports.

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May position

Central Alert System (CAS) Alerts over deadline Target: Monitoring and reporting

• 14 alerts were issued in May:

• 7 alerts were assessed for relevance to the Trust and subsequently closed as action was not required.

• 3 alerts were issued for notification purposes in relation to drug alerts, which have been sent to the Trust’s Medication Safety Officer for review and closed as a response was not required.

• 2 alerts are currently in process of being assessed for relevance with breach dates of June and August 2018.

• 2 alerts were issued, assessed for relevance and completed.

• 3 Alert remains open for the Trust:

• Patient safety Alert issued 9th November 2017 (‘Confirming removal or flushing of lines and cannulae after procedures’) is still being assessed for relevance to the Trust, this alert remains in date with the breach date being 09 August 2018.

• Patient Safety Alert remains open (Risk of death or severe harm from inadvertent intravenous administration of solid organ perfusion fluids) has a deadline of 31 May 2018; actions are underway to ensure compliance.

• Patient Safety Alert issued April 2018 (‘Resources to support the safe adoption of the revised National Early Warning Score

(NEWS2)’) has a deadline of 21 June 2018; actions are underway to ensure compliance.

The Associate Chief Nurse for Patient Safety is working with the specialty leads to complete and close these alerts.

• All CAS / Medical Device Alerts (MDA) are uploaded to Datix with the actions module being used to forward these on to the relevant staff members for their update and action.

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May position All CQUINs expected to deliver (except Sepsis treatment time likely to be partial)

CQUIN Income Details May 2018 (M2) IPR Status

CCG 1a Staff Health & Wellbeing £276 k

•5% point improvement in NHS annual staff survey questions on MSK and stress.

Green - Trust plan in place and under way, monitored via internal CQUIN monitoring process.

CCG 1b Healthy food £276 k•Reduction in display and sale of unhealthy foods for NHS staff, visitors and patients


CCG 1c Staff Flu vaccinations

£276 k•Improving the uptake of flu vaccinations for front line clinical staff


CCG 2a Screening for sepsis £207 k•Timely identification of patients in emergency departments and acute inpatient settings.

Green - Trust plan in place and under way, monitored via internal CQUIN monitoring process and National quarterly monitoring.

CCG 2b Treatment of sepsis £207 k•Timely treatment of patients with sepsis in emergency departments and acute inpatient settings.

Amber - Indicator in Q4 below target. Trust business case for enhanced Critical Care Outreach team to be approved.

CCG 2c Antibiotic Review £207 k•Clinical 72 hour antibiotic review of patients with sepsis

Green - Trust plan in place and under way, monitored via internal CQUIN monitoring process and National quarterly monitoring.

CCG 2d Antibiotic consumption £207 k

• Reduction in use of broad spectrum antibiotics.• Reduction in total antibiotic consumption

Green - Internal action plan formed. Trust business case for enhanced Prescribing Pharmacist team to be approved.

CCG 4 Mental Health £828 k

•Reduce regular attenders with mental health needs who present to A&E

Green - Joint action plan from Y1 under revision for new CQUIN requirements. To continue to be monitored via internal CQUIN monitoring process and monthly joint reporting.

CCG 6 Advice and guidance £828 k•To set up and operate A&G services for non-urgent GP referrals.

Green - Trust plan in place and under way, monitored via internal CQUIN monitoring process and monthly joint reporting..

CCG 9 Risky Behaviours £828 k

•Screen patients for smoking, give advice and nicotine patches / referral if necessary.•Screen patients for Alcohol use, give advice and referral if necessary.

Green - Trust plan in place and under way, monitored via internal CQUIN monitoring process and monthly joint reporting.

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Local and specialised CQUINs: used as an incentive to ensure providers of specialised services offer continuous improvement in line with best practice, benchmarked utilisation, appropriate care and quality indicators.

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CQUIN Income Details May 2018 (M2) IPR Status

NHSE CA1 Enhanced Supportive Care

£140 kInvolvement of Supportive Care (Palliative Care) earlier in treatment of cancer pathways.

Green - Trust plan forming, to be monitored via internal CQUIN monitoring process.

NHSE CA2 Chemotherapy Dose Banding.

£327 k•Adoption of standardised doses for Chemotherapy to reduce production costs and safety incidents.


NHSE CA3 Palliative care shared decision making. £327 k

•Ensure effective and documented peer discussion and patient involvement for patients with low response to treatment.


NHSE GE3 Medicines Optimisation.

£327 k•Adoption of best value medicines in Specialised patients, and additional reporting.

Green - Internal action plan formed. Monitored via internal CQUIN monitoring process.

NHSE GE5 Shared Decision making in Cardiology £280 k

Adoption of best practice Shared Decision Making with patients in Cardiology

Green - Trust plan forming, to be monitored via internal CQUIN monitoring process.

NHSE Dental managed clinical networks. £85 k

•Attendance at Network meetings by clinical leads.


NHSE Orthodontic outcome reporting. £85 k

•Recording of Orthodontic PAR scores pre/post treatment & performance reporting / review of improvement.


NHSE Breast screening programme. £65 k

•Develop service improvement action plan with commissioners, and implement under agreed monitoring.


NHSE Bowel screening programme. £65 k

•Develop service improvement action plan with commissioners, and implement under agreed monitoring.


NHSE Armed Forces Covenant. £65 k

•Embedding the Armed Forces Covenant to improve access to elective services for Armed Forces Personnel.

Green - Planning options agreed with NHSE for next phase.

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Mortality indicators (Contract and Quality Account) - Not achieved May position

Hospital Standardised Mortality Ratio (HSMR) Target: The lower limit of the Trust HSMR not to exceed 100. • The updated Trust HSMR for the 12 months to February 2018 is 107.1;

representing a slight decrease on the rate previously reported to January of 107.9. This sits within a confidence interval of 102.3 – 112.0 and is statistically higher than expected.

• The weekday HSMR for emergency admissions has shown a decrease from the previously reported figures, whilst the weekend HSMR has shown a slight increase of 0.1.

Summary Hospital-level Mortality Indicator (SHMI) Target: To be within expected range.

• The Trust SHMI for October 2016 to September 2017 is 107.19; showing an increase from the previous reported quarter’s figure of 109.13. Whilst this figure is above the National Average of 100, it is within the official control limits.

Actions • The HSMR trend continues to be monitored and validated through the

Mortality Review Group.

• Work continues with the coding department to ensure greater number of patients receiving end of life care are correctly coded as receiving palliative care.

• The latest review in response to Dr Foster data is of Acute and Unspecified Renal failure and Other psychoses; first stage review is under way.

• Second stage review of intestinal infection is also underway.

Definitions: HSMR: The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower would be expected. The national average is 100 and a score of below this indicates less deaths than this average. HSMR covers 56 groups of diagnosis and only relates to patients that have died whilst in hospital. SHMI: The Summary Hospital-level Mortality Indicator (SHMI) is a high level mortality indicator that is published by the Department of Health on a quarterly basis. It follows a similar principal than HSMR, however SHMI covers all diagnosis groups and relates to all patients that have died (whether the patient died whilst in hospital or not). It does not take account of deprivation. SHMI adjusted for palliative care: The variables used in the method to calculate the expected number of deaths differ between the SHMI and the HSMR, for example, the HSMR includes an adjustment for palliative care whereas the SHMI does not. An adjustment/allowance is made to the indicator ‘SHMI adjusted for palliative care’ to allow for the number of expected deaths where palliative care is coded.

HSMR: Emergency weekday and weekend March 2017 – February 2018 Weekday HSMR: 107.0 Weekend HSMR: 106.5

SHMI: October 2016 to September 2017 • SHMI: 107.19 (within expected range) • Adjusted for palliative care: 110.27 (within expected range) • In-hospital deaths: 106.93 (within expected range) • HSMR for the same period: 112.9 (within expected range)

HSMR: March 2017 – February 2018 HSMR: 107.1

QAH Hospital


May position

Step 1: Find, Assess, Investigate and refer* Target: 90% on average over each quarter for the three steps.

• Following an upgrade to VitalPAC there has been a delay in obtaining performance data for May; however, it is expected to be a similar performance and below the 90% target.

• The Trust recognises that improvements are required in some areas of dementia care. There will be a refocus over the coming months, with the Dementia Board being chaired by the Chief Nurse and the Lead Nurse for Dementia and End of Life Care commencing in July.

• There was agreement at the BedView Clinical Forum that the Dementia screening will be moved to BedView to aid compliance. An analysis from IT is in progress and timescales will follow after this review.

• There has been a notes audit and review of the patients (144) who were not assessed in April. At this initial point there is good evidence that the majority of patients had an assessment but not logged in VitalPac and hence this has not effected their care. One patient has been been followed up and there will be some incidental recommendations from this audit that will follow.

Step 2: Diagnostic assessment* Target: 90% on average over each quarter for the three steps.

• Data not available due to reasons noted above.

Step 3: Referred for further diagnostic advice* Target: 90% on average over each quarter for the three steps.

• The Electronic Discharge Summary (EDS) includes a mandatory field to inform the GP of any patients who have had a positive diagnosis of dementia in order that the GP can complete further investigations if required. However, as EDS usage is currently variable across the CSCs, a spread sheet is kept of all patients who have a positive diagnosis of dementia to ensure a letter is generated and sent to the GP.

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Dementia (Contract) - Not achieved (to be confirmed)

* Definition of steps: Step 1 – Case finding: • The number of patients >75 admitted as an emergency who are reported as having a known

diagnosis of dementia or clinical diagnosis of delirium, or who have been asked the dementia case finding question, excluding those for whom the case finding question cannot be completed for clinical reasons (e.g. coma).

Step 2 - Assessment: • Number of above patients reported as having had a diagnostic assessment including investigations. Step 3 – Onward referral – under development: • Numbers of above patients who have a plan of care on discharge that is shared with general

practice.

Dementia compliance March 2018 April 2018 May 2018

Step 1 71.83% 73.58% To be confirmed

Step 2 100% 100% To be confirmed

Step 3 100% 100% To be confirmed

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Mixed Sex Accommodation (National) - Achieved May position

Non-clinically justified single sex accommodation breaches Target: 0 (zero)

• There have been 0 (zero) non-clinically justified mixed sex accommodation breaches in May.

• The Trust year-to-date position is 0 occasions of non-clinically justified single sex accommodation.

Clinically justified single sex accommodation breaches Target: Monitoring and reporting

• There have been 0 (zero) clinically justified breaches in May.

• The Trust year-to-date total is 0 clinically justified single sex accommodation breaches.

Facilities single sex accommodation breaches Target: Monitoring and reporting

• There have been 0 (zero) single sex accommodation breaches relating to facilities in May.

• The Trust year-to-date total is 0 (zero) single sex accommodation breaches relating to facilities. Actions

• There have been 3 investigation panels for potential mixed sex breaches in the Respiratory High Care Unit due to delays in transferring wardable Level 1 patients to the wards due to operational pressures. Both investigations demonstrated good compliance with Trust policy to manage privacy and dignity.

• Potential breaches were escalated appropriately at the Operations meetings with plans to resolve as soon as possible.

QAH Hospital


May position Target: Monitoring and reporting

• A total of 55 complaints were received in May, a slight reduction from April.

• Reporting per 1,000 contacts is one month arrears; data for April equates to 0.69 compared to 0.64 in March.

Plaudits Target: Monitoring and reporting • The Trust received 409 messages

of appreciation during May.

Parliamentary and Health Service Ombudsman (PHSO) (National requirement) Target: Monitoring and reporting • The Trust received no new

notification from the PHSO during May.

Complaint acknowledgment rate (National requirement) Target: Monitoring and reporting • 100% of complaints were

acknowledged within the 3 working day target.

• To date 7 complaints received in April have been responded to within the expected timeframe (30 working days), 40 have breached.

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Complaints (Contract and National) – Reporting only CSC Apr-18 May-18 CHAT 1 3 CSS 2 3 CORP 3 2 EMERGY 10 10 H&N 9 5 MED 6 10 MOPRS 3 2 MSK 6 6 RENAL 2 0 S&C 11 10 W&C 4 4 TOTAL 57 55

APRIL 2018 UPDATE - Complaints

Sent within 30 working days 7 12%

Sent after 30 working days 2 4%

Ongoing past 30 working days 38 67%

Ongoing still on target 10 17%

Complaints Subjects - May 2018 ACT Aspects of clinical treatment 21 38% CPWO Communication 9 16% AOS Attitude of staff 5 9% PCARE Patient care 4 7% APDELI Inpatient Appt Delays and Cancellations 3 5% ADT Admission, discharge & transfer 3 5% PRDIG Privacy & Dignity 2 4% APDELO Outpatient appt Delays and Cancellations 2 4% FTP Failure to follow procedures 2 4% COMPE Competence 1 2% AIDS Aids and appliances 1 2% PRECS Personal records 1 2% CONSE Consent to treatment 1 2%

PHSO Total rec'd

Under review Upheld Part

upheld Not

upheld 2017-18 12 5 1 4 2

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Complaints, PALS (Contract) – Reporting only May position

PALS contacts Target: Monitoring and reporting • 369 contacts were handled by PALS in May. • 161 contacts involved concerns about care and

treatment.

Other types of contacts • 208 of contacts related to various elements

including providing signposting or advice to visitors and support to the Overseas Patient Services.

• 80% of all contacts were resolved within 5 working days.

PALS conversion to complaints Target: Monitoring and reporting • 8 cases were converted to a formal complaint.

Trust wide themes • Common themes through complaints and PALS

include outpatient appointment delays and cancellation (in particular at Audiology).

May – Trust wide themes Complaints PALS Total Outpatient Delays & Cancellations 2 57 59 Aspects of Clinical Treatment 21 27 48 Communication 9 27 36 Inpatient Delays & Cancellations 3 12 15 Admission, discharge & transfer 3 11 14

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Patient Moves and Outliers - Achieved May position Target: <3 non-clinical moves after 2100

• The non clinical moves between 2100 and midnight have overall improved on a daily basis, with the exception of spikes in activity related to operational pressures, as noted in the increase in moves between 0001 and 0700 for mid May.

• The flow teams and CSCs are working together to outlie earlier in the day to improve the patient and staff experience.

• The accuracy of this data has improved since the implementation of clinical validation

• The number of outliers has decreased reflecting the reduced operational pressures.

• The daily focus in the Ops centre to ensure outliers are reviewed by the host CSC is improving patient pathways.

• There is ongoing work to improve the quality of the Outlier risk assessments with a view to integrating these on Bedview

** Please note that for May’s information this now shows the accurate clinically validated data for Non-Clinical Moves *** Please note data source for outliers has now been modified to match other reporting

Medical patient outliers

Month No. Av. per day

May ‘18*** 1,321 43 Apr ’18*** 2,241 58 Mar ‘18 2,656 86

Non-Clinical Patient Moves

Month 2100 - 0000 0001 - 0700

No. Av. per day No. Av. per

day May ’18** 62 2.4 60 2.3 Apr ’18** 65 2.5 46 1.8 Mar ’18 132 4.9 132 4.9

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Friends and Family Test (FFT) (National)

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Trust data May 2018

National data

Inpatient and day cases • 97.1% would recommend • 0.5% would not recommend

Emergency Department • 90.2% would recommend • 4.5% would not

recommend

Outpatient Departments • 92.8% would recommend • 2% would not recommend

Maternity Services • 99% would recommend • 0.9% would not recommend

QAH Hospital


Friends and Family Test (FFT): Increasing response rate and Improving positive responses in ED, In-patient areas (National) – Achieved

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May position Increasing response rates and positive responses Target: Inpatient response rate target to be similar or above national average but not fall below 15%. ED response rate target to be 15% or higher

In-patient areas: • The in-patient response rate increased to 32.4% in May; and remains above the

national average of 24.4% and target of 15%.

• The reported satisfaction rate has remained constant at 97.1%; remaining above the national average of 96% in April.

• The number of patients who would not recommend In-patient areas has also remained consistent at 0.5%. This is below the national average of 2%.

Emergency Department:

• The Emergency Departments’ response rate increased to 19.1% in May. This corresponds to the introduction of text and voice messaging to patients on 23 May. Achieving the 15% target and significantly higher than the national average of 12.9%

• The introduction of text and voice messaging has resulted in an anticipated reduction in satisfaction score and increase in not recommends. A much more representative sample of patients are responding.

• The satisfaction score was 90.2% in May in comparison to 95.5% in April.

• The satisfaction score remains significantly higher than the national average.

• The number of patients who would not recommend the Emergency Department has also increased to 4.5% remaining significantly lower than the national average of 8% in April.

Actions and progress to date • The new Trust-wide provider of FFT services now provides text and voice

messaging options, the ED team will be phasing out paper collections.

Friends and Family Response rates

Month

Total response rate (responses / eligible patients)

ED Target: 15%

In-patient Target:

not fall below 15%

Trust National average Trust National

average

May ‘18 19.1% 2239/11704 - 32.4%

2745/8478 -

Apr ‘18 11.8% 1211/10270 12.9% 32.3%

2577/7967 24.4%

Mar ‘18 10% 1084/10795 12.8% 27.1%

2173/8019 22.6%

Emergency Department - Improving positive responses

Month

% recommend (positive)

% not recommend (negative)


average May. ‘18 90.2% - 4.5% -

Apr. ‘18 95.5% 87% 1.2% 8%

Mar. ‘18 95.3% 84% 1.3% 9%

In-patient - Improving positive responses

Month

% recommend (positive)



average

May. ‘18 97.1% - 0.5% -

Apr. ‘18 97.6% 96% 0.6% 2%

Mar. ‘18 96.9% 96% 0.6% 2%

QAH Hospital


May position Target: Response rate for question 2 to be similar or above the national average but not fall below 15%.

• Women are asked to complete a Friends and Family form at four points of contact and respond to four specific questions. • The national benchmark and; therefore, contract requirement is based on question 2. The response rate has again increased in

month from 25.6% in April and continues to exceed the target. • The responses for questions 1, 3 and 4 are no longer provided to

NHS Improvement. The overall response rate is above the National Average of 15% and remains consistently high in comparison to the national average.

Actions and progress to date: • Maternity response rate is above the national average and the service has continued to see an increase in the response rate for May

following a campaign from staff to encourage women to complete the forms. The management team will continue to reinforce the importance of data collection to maintain the increase in the responses.

• Although questions 1,3 and 4 are no longer reported, these are reviewed for responses. Only one of the negative comments (don’t know) was attributed to question 2. An increasing number of forms have had staff names identified on them, these have been copied and sent to the staff member for revalidation/APDR evidence.

Response themes: The majority of responses remain positive. • Every one was extremely friendly, kind and helpful. The midwives were friendly, helpful and knowledgeable. Everything was

fabulous. I got the help when I needed it – quick and fast. They made me feel relaxed and safe in their care. Breast feeding support was amazing.

Negative comments: • There were four ‘don’t knows’ and one ‘neither likely/unlikely’ responses identified for May across all four questions. The themes for

these were car parking costs, food and noise at night. The service is addressing the noise at night with staff through the daily safety huddles. Parking costs are out of the control of the maternity service, concessions are given when patients/relatives meet the given criteria. The comments regarding food have been fed back to FM services, there has been no change in supplier or catering staff since the change of the FM services provider.

Improving positive responses • The number of patients who would recommend Maternity has increased; remaining

consistently high against the national benchmark of 96%. • There were five negatives received, four of which were ‘don’t know’ rather than

‘not recommend’ the service; 1 response was ‘neither likely or unlikely’.

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Friends and Family Test – Maternity (National) – Achieved

Maternity Friends and Family response rates

Question Mar. 2018 Apr. 2018 May. 2018

2: Intrapartum labour care 17.6% 25.6% 27.7%

Maternity - Improving positive responses

Month % recommend (positive)


May ’18 99.1% 0.9% Apr ‘18 99.1% 0.9% Mar ‘18 97% 3%

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Operational Performance Report – May 2018

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Operational Performance Outcomes – May 2018 Performance Summary The work undertaken before Easter to drive performance improvement focusing on delivery of the urgent care improvement plan and professional standards has lead to improved delivery against the 4 hr standard and flow metrics. This has included a reduction in ambulance delays, a reduction in non-clinical cancellations of procedures and a reduced bed occupancy. 4hr performance for May was 82.4% and 87.3% with St Marys Treatment Centre, there were 2 breaches of the 12 hr standard. The combined performance exceed the 85% improvement trajectory on 19 days in the month. The Trust is forecasting delivery of 6 of the 8 key cancer standards,62 day to first definitive treatment and 62 day screening standard have provisionally not been achieved. The Trust has agreed a Referral to Treatment trajectory that maintains the number of patients waiting for treatment at March 2018 levels and performance as achieved in March. This is as outlined in National Planning Guidance, however within this the Trust is working to agree a clinically acceptable wait for patients. May performance is above trajectory at 86.6%, however there has been an increase in total number of patients waiting. This is being monitored at speciality level and reviewed against activity plan and referrals received. A full review of plans, trajectories and options to reduce the waiting list size is being planned in June to ensure focused action and recovery to trajectory. The diagnostic standard was not achieved, performance was 98.02% (standard 99%) There is a recovery trajectory in place supported by additional capacity to recover the standard by end of July.

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Portsmouth Hospitals NHS Trust Page 37

May performance against the 4-hour A&E and 12 hr Trolley Wait standards. • 4 hr performance was 82.4% and 87.3% with partners,

against a trajectory of 85% • There were 2 breaches of the 12 hr standard. • Attendances with on average 430 per day, 673 (5%)

higher than last May. • There were on average 6 escalation beds open in May

with 0 on 10 days, compared to an average of 66 last May.

• Ambulance holds over 30 mins remained at 240 patients but over 60 min holds reduced from 131 last month to 35.

Contributing factors • Conversion rate to admission was 32.8% (May last year

31% and April 18 35.8%) • However medically fit for discharge numbers have

continued to reduce, from 187 in April to 178 at the end of May (192 may 17)

• Delayed transfers of care increased from 3.3% in April to 4.4% in May but remain significantly better than last year (8.7% May 17)

• Achievement of the weekend discharge targets has continued to improve, 76% in May compared to 71% in April and 71% May last year.

• This has enabled the Trust to close escalation capacity, reduce bed occupancy and improve flow through the hospital with an average of 6 open during May compared to 59 last May. 17 occasions on OPEL 1

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A&E waiting time standard performance – trajectory achieved standard not achieved

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Actions and progress during May • Urgent Care Plan refreshed with external support and now focused on 4 key

themes:

1. Emergency care • ED & UCC • AMU/AEC/SSU

2. Patient Flow • Internal Processes • Operational efficiency & grip • Discharge to assess and complex discharges

3. Admission avoidance/alternative pathways • Frailty • Suspended admissions

4. Workforce • 7 day working • Workforce redesign • Development & training

• Summer Sprint plans being developed for June/July to support delivery of

the plan

• Winter planning has commenced • Detailed work has been undertaken with external support to identify capacity

requirements across the system and to identify length of stay opportunities and internal efficiencies for PHT

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Referral to Treatment (RTT) - trajectory achieved standard not achieved, waiting list size increased.

May Performance against Incomplete RTT standard • Performance 86.6% and improved from last month (85.9%) and is above

agreed trajectory of 85.7% (standard of 92% ) • Total number of patients waiting increased by 546 to 33,837 (trajectory 33,800) • Numbers waiting more than 18 weeks reduced by 149 to 4,541, and the number

of patients waiting more 35 wks reduced by 27. • There was 1 breach of the 52 wk standard, the patient has been treated. • Performance has improved from April, with cardiology both reducing waiting list

size by 209 and achieving the 92% standard, gastro also improved performance and reduced waiting list size in line with plan to reduce waiting times to a clinically acceptable level. This is masking increases in gynaecology of 165, ophthalmology of 162 and ENT of 101.

Actions, progress to date • Speciality level trajectories have been agreed and signed off. • To support delivery of the trajectory a detailed speciality level plan is being

developed which will include improvement actions so that the Trust can reduce waiting times and waiting list size in recognition that the final quarter of the year may be challenging due to winter pressures.

• Monitoring delivery of demand management schemes being implemented by partners.

• Detailed analysis is being undertaken to understand increase in waiting list size so that effective plans can be put in place and monitored through weekly executive lead performance meeting.

Risk • Due to the legacy of long waiters there is a risk of breaches of the 52 wk

standard as patients are seen late in the pathway if further investigations or treatment is required. All patients are being closely monitored and the trust has improvement trajectories to reduce the maximum waiting time in key specialties and this is being monitored in the weekly assurance meeting.

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Patients waiting longer than clinically determined date to be seen for an outpatient follow-up or treatment (monitor) Patients waiting longer than clinically appropriate date to be seen Please note this is a current snapshot and will contain patients who have tipped into the next waiting time cohort during May. Number of patients waiting past due date has increased by 527 in May with increased in every time band except > 1 month which reduced by 677 patients. The number of patients waiting more than 2 yrs. has increased by 11 to 43 (32 last month) The number of patients waiting past due date for inpatient or day case treatment has reduced from 857 in August 2017 to 188 and of these 98 patients have treatment dates. Contributing factors • Capacity constraints and the need to balance this between new, urgent and cancer

patients as well as patients who have had treatment or who require further monitoring.

• Consultant vacancy in gastroenterology. • Patient compliance (cancellation and DNA) • Consultant vacancy in hepatology, with further delays to locum commencement

due to injury Actions, progress to date and minimising risk of harm • Early indications are that the improvements in gastro pathway have reduced

referrals in May and this is being closely monitored to ensure this is both maintained and that patients do not get referred at a later stage.

• Patients waiting for inpatient or day case treatment are reviewed at the weekly assurance meeting.

• Plans are being reviewed by the Chief Operating Officer to explore the use of insourcing/outsourcing to support an increase in pace of the review and recovery of the outpatient waiting list.

• Cross system clinical harm reviews have concluded.

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Diagnostic 6 wk. referral to test standard – recovery trajectory achieved standard not achieved

May performance against the 6 wk. diagnostic standard Trust performance was 98.02% against the 99% diagnostic standard and improvement trajectory of 97.8%. There were 152 breaches of the standard against a tolerance of 75 and an improvement from last month. There were no patients waiting more than 13 wks for a diagnostic test. Contributing factors • Of the 152 breaches, 129 were waiting for non-obstetric ultrasound, with only

14 patients waiting for MRI or CT and a further 9 patients waiting for other tests. • The non-obstetric ultrasound breaches are due to a combination of unplanned

clinical leave and underlying capacity shortfall which has been managed by flexible working which cannot be maintained during this extended absence.

Actions and progress to date • Demand and capacity modelling has been completed which has identified the

additional capacity required to meet both demand and recover the backlog of patients who have breached the standard.

• Additional capacity to cover this deficit is being provided through a combination of additional sessions from trust staff and a locum, as a short term plan which will provide sufficient capacity to recover the standard from July.

• However there is an underlying capacity shortfall that will need to be addressed longer term to ensure sustainable delivery of the standard which is integral to successful delivery of both cancer and referral to treatment standards.

• Delivery against recovery trajectory is being carefully monitored by clinical support management team and reviewed at the weekly executive lead meeting, so that remedial plans can be quickly actioned if capacity falls short of demand.

• This is being supported by partners who are reviewing diagnostic demand through joint clinical leaders forum.

Risks • Maintenance of additional in-house capacity during summer leave. Securing of

further locum to maintain capacity required to recover backlog. • Failure of CT/MRI equipment remains a risk.

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Cancelled Operations 28 day Guarantee - % cancellation standard achieved, 0 urgent cancellations not achieved

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May Performance Cancelled Operations 28 day Guarantee • There were 6 urgent operations cancelled in May for non-

clinical reasons, 3 urology and 2 ENT patients due to list overrun, 1 maxillo-facial patient due to availability of clinical information. None were cancelled for a second time and all have been treated.

• There were no breaches of the 28 day standard. • 32 patients in total were cancelled on the day for non-clinical

reasons in May compared to 64 last May. • Of these list over run was the biggest factor with 20 (63%)

patients cancelled for this reason. Contributing factors • 5 of the patients cancelled for list over run were on the same

list and were cancelled due to first patient having serious complications.

Actions, progress to date and risks • Surgery CSC have a specific work stream focused on

reducing on the day cancellations with particular focus on the scheduling of patients to maximise throughput.

• Weekly report of all late starts and early finishes set to operational teams.

• All patients who are at risk of on the day cancellation are escalated to the surgical CSC silver command to explore options to prevent cancellation.

• All urgent patients at risk of being cancelled are escalated to the chief operating officer and or medical director to ensure all options to enable treatment to go ahead as planned are reviewed against the clinical risk of delay.

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Cancer Standards (provisional position)- 6 of 8 standards achieved

May provisional performance against national cancer standards and contributing factors ( national reporting deadline 3rd July 2018 performance subject to change including additional shared breaches until submission deadline)

• The Trust is currently forecasting achieving 6 of the 8 key national standards. 62 day first definitive treatment, and 62 day screening have not been achieved, screening has been validated and confirmed, 62 day first definitive treatments may improve once all treatments are confirmed but unlikely that standard will be achieved.

• There were 9 breaches of the 104 day maximum wait standard, 1 would not be attributable to the Trust under breach sharing guidance

• The Trust has agreed an improvement trajectory for the 62 day standard supported by a detailed action plan to return to sustainable cancer delivery. (see below)

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Cancer Standards continued 104 day maximum wait for treatment provisional – 0 tolerance standard not achieved

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Contributing factors and actions taken This is a 0 tolerance standard May – provisionally 9 breaches 1 of which would not be attributable to the trust and this compares to 2 in April and 4 in May last year. • Respiratory – 3 patients (1 not attributable to trust) 1 patient referred at 86 days and treated at day 113 days. Under

breach sharing guidance this would not be attributable to the trust. 1 patient treated at 132 days, complex, patient referred to another

trust for treatment but then referred back when treatment plan changed.

1 treated at 152 days complex with multiple diagnostics required. • Lower Gastrointestinal – 3 patients 1 patient treated at 120 days, patient choice delays at diagnostic

phase which cannot be deducted. 1 patient treated at 119 days, delay in diagnostics and then cancelled

due to medication not stopped. 1 patient treated at 112 days, complex with referral to another

provider for further diagnostics. • Urology -1 patient treated at 111 days, due to diagnostic capacity. • Upper Gastrointestinal - 1 patient treated at 105 days, patient

choice delays at diagnostic and outpatient phase which cannot be deducted.

• Haematology – 1 patient treated at 111 days due to complex diagnostics

Actions to improve performance • All patients waiting >72 days reviewed at weekly cancer operational

meeting, with teams working to minimise and resolve delays, with escalation to trust wide assurance meeting.

• Patients without plans within 104 days reviewed at weekly executive lead performance meeting.

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Cancer Standards continued

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May Performance 62 day first definitive treatment against recovery trajectory (standard 85% trajectory 85.3%) May provisional performance 82.1%, and not achieved, some further improvement is expected once all treatments are recorded but it is unlikely this will be sufficient to achieve the standard. Actions and progress to date • Currently 142.5 patients treated compared to 147 in May last year. • Currently 25.5 patients treated outside standard in May. • The number of patients on a 62 day cancer pathway increased by 14 to 1,770 and

the number of these who have breached the standard increased from 46 to 67. • Real time validation of breaches is taking place led by the Cancer MDT team,

risks and concerns are escalated to the weekly Trust wide assurance meeting and to the executive lead weekly performance meeting.

• The interim cancer manager has started and is focusing on pathway improvement to reduce unnecessary delay.

• The new operational cancer meeting continues to deliver waiting time reductions through a multi-speciality approach targeting diagnostics, facilitating best use of theatre capacity and improved communication and shared learning.

• All patients who have breached the 62 day standard are individually reviewed on a weekly basis and action taken to progress their pathway.

On-going Risks • Capacity shortfall for diagnostic and diagnostic reporting continues to be a

challenge, particularly for urology patients. • 2154 patients were referred on 2 wk wait pathways in May compared to 1672 in

April (482 28% more) this is affecting ability to see patients by day 7 of the 2 wk wait pathway which is optimal for achievement of 62 days as additional capacity is provided at short notice. R

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Stroke Contract Service Standards – 7 of 13 standards achieved

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April Provisional Performance against key Sentinel Stroke National Audit Programme (SSNAP) using DIY analysis toolkit: Reported in arrears • The Trust has provisionally achieved 7 of the 13 key measures for April (see

table) based on 52 cases (clock starts) • For the period December to March the Trust achieved level B for stoke care. • Scan within 1hr: not achieved, 32.3.4% (standard 48%) • Direct Admission to Stroke Unit: not achieved but improved on previous

month, 50.0% (standard 90%) • Swallow Screen ≤4hrs: not achieved 70.9% (standard 85%) • Speech & Language assessment within 72hrs: not achieved 41.2 (standard

90%) Contributing Factors • Lower number of cases currently available to report for the month. • Scan within 1hr performance continues to vary; delays can occur when CT

call for patient in ED or due to uncertainty over initial symptoms. • Multiple factors, including staffing, contribute to non achievement of Direct

Admission target and breaches are being analysed. • Progress with Swallow Screening within 4hrs continues to be hampered by

high RN vacancies, SLT service gaps and ability to release staff for training. Actions and progress to date • Recovery plan actions and delivery continue to be monitored through Stroke

Leads meetings. • 20:20 sprint project commenced to improve compliance with Direct Admit

performance for May. • The roll out of e-Learning Dysphagia training continues. Night staff and

agency staff currently being targeted. • Await outcome of SLT service business case seeking enhanced provision to

the Stroke service.

QAH Hospital


Finance Report – May 2018

28/06/2018 Page 47

QAH Hospital


Finance : Overview at Month 2 2018-19

Page 48 28/06/2018

Enab

lers

- Fi

nanc

e Finance and Use of Resources Metric R (Surplus)/Deficit A Cash A

Liquidity Capital Servicing

OverallPlan Actual Variance Plan Actual Variance

Year to Date 4 4 4 In Month £k 3,651 3,992 (342) Year to Date £k 1,000 2,632 1,632Year End Forecast 4 4 4 Year to Date £k 8,681 9,149 (468) 1,000 1,000 0

Income A Operating expenditure A Capital G

Plan Actual Variance Plan Actual Variance Plan Actual Variance

In Month £k (45,273) (45,201) (72) In Month £k 45,750 45,995 (245) Year to Date £k 1,546 1,270 276Year to Date £k (88,700) (88,697) (2) Year to Date £k 91,063 91,510 (448) Year End Forecast £k 21,108 21,108 0

Cost improvement plans A Pay bill G Agency Cap RPlan Actual Variance Year to Date £k Plan Actual Variance Ceiling Actual Variance

Year to Date £k 2,788 2,583 (205) Substantive 49,215 47,460 1,755 Year to Date £k 2,533 3,549 (1,016)Bank 2,830 3,621 (791)Agency 3,032 3,549 (517)

55,077 54,629 447The 2018 -19 plan submitted to the Regulator included detailed workforce expenditure commitments for both substantive and temporary workforce costs. The plan reflected a moderate increase in the size of the substantive workforce in the course of the year. This was offset by a more substantial reduction in the use of temporary workforce costs, in particular high cost agencies and premium rate internal locum costs.

The Trusts external reporting includes the monitoring of its agency staffing as a component part of temporary workforce costs. This covers in month costs and performance against agency caps. The rules require compliance against a ceiling set for total agency expenditure, the use of approved frameworks to procure all agency staff at rates set at or below the capped rates. The Trust has set up a workforce steering group to oversee the agency reductions required.

The Trust has spent £1.27m of capital in the year. The Trust has made representation to NHS Improvement in relation to concerns about the revised methodology for the calculation of the Trust's CRL. Discussions with NHSi are continuing in order to resolve this issue but remain outstanding at this time. Included in the Capital Plan is £4.9m capital spend that is currently not agreed with NHSI. The Capital Priorities Group has submitted a Capital Plan based on a confirmed allocation and this is on the Board agenda for the July meeting.

The Finance and Use of Resources Metric came into effect from November 2016 and has 3 further metrics. The Trust’s overall rating at the end of the month is a ‘4’ and the end of year forecast is also a '4' (1 is the best on a scale of 1 to 4). These metrics reflect the current liquidity issues the Trust is facing (NB - the best overall use of resources score that a Trust scoring 4 on any individual metric can obtain is a 3). This does not reflect the new continued use of resources rating and the Trust is currently developing its reporting arrangements to reflect these changes.

The month 2 financial position shows a continuation of the significant levels of expenditure reported in previous months. The year to date deficit is now £9.2m against a planned deficit of £8.7m and an adverse variance to plan of £0.5m. The key variance year to date is in non pay at £0.9m adverse to plan, offset by pay which has a favourable variance to plan of £0.4m. There remains a need to secure financial improvements to maintain performance against the plan. Progress is being maade against a range of opportunities managed through the Recovery Board. These are expected to deliver increasing financial improvements in the remainder of the financial year.

The Trust had a cash balance of £2.6m at the end of May which is within expected limits.

The Trust received interim financial support of £3.5m for May as per the mandate request approved by the Board in April 2018. A further sum of £2.3m has been requested in July which was also recommended at the same Board meeting.

The Trust is reporting a break even position on its income plan year to date against all forms of income. As a part of this, the Trust SLA income has an over performance of £0.2m. This is based on high level principles and expected income levels. For the non-local CCGs income is based on actuals for M1 and planned levels for M2. Non clinical income is marginally under planned figures, however, there is a corresponding reduction in expenditure.

Pay expenditure for the month was favourable to plan by £0.4 m (however some corporate CIP projects are yet to be allocated). Non-pay costs were adverse to plan by (£0.9m). There was a continuation of the use of Further Assessment Beds of (year to date £0.2m), a continued use of Out of Hospital Care for Elderly Medicine patients provided by QA at home (£0.3m), an overuse compared to plan of outsourcing by T&O of (£0.1m) and a higher than planned costs of international recruitment of (£0.2m). An adverse variance in other non pay of (£1.4m) relates to CIP targets which are in the process of being allocated to projects including pay.

The year to date plan required savings of £2.8m. Against this delivery has been valued at £2.6m. The adverse variance of £0.2m has primarily been associated to workforce plans. Further work is underway with a focus upon an improved delivery in conjunction with an expansion of wider opportunities consistent with the requirements of the financial plan for the year.

QAH Hospital


Month 2 Financial Position – Headlines

Page 49 28/06/2018

QAH Hospital


Finance: Executive Summary

Page 50 28/06/2018

The Trust is reporting a deficit position of £9.1m for the period to 31st May 2018. This is an adverse variance to the year to date plan of £0.47m. The plan is based upon the Trusts submission to NHSi on 30th April 2018. The Month 2 reported positions by Clinical Service Centre and Corporate Functions is set out in Table 1. The budgets held within Clinical Services Centres represents the expenditure limits delegated for the year and the period to the end of May 2018, and the actual expenditure incurred in this period. Clinical Income from activities is excluded and this is held and reported centrally. Performance reviews with Clinical Service Centres will review and agree action plans to address any areas of overspend.

Table 1: Variance analysis by CSC or CSC equivalent

CSCAnnual Budget

£'000YTD Budget

£'000YTD Actual

£'000YTD Var

£'000 CommentsCHAT CSC 51,363 8,697 8,579 118 Clinical Support CSC 64,399 10,641 10,631 10 Emergency Care CSC 29,437 4,935 5,137 202- Continued high use of temporary staffingHead and Neck CSC 31,128 5,240 5,009 231 Unutilised RTT related funding (+£76k), balance is drugs and clinical suppliesInternal Medicine CSC 56,992 9,712 9,604 108 MOPRS CSC 30,892 5,179 5,291 112- Continued high use of temporary staffingMuscular and Skeletal CSC 28,683 5,031 4,882 149 Overuse Outsourcing (-£50k) offset by PbR drug exclusions Renal CSC 32,242 5,373 5,403 30- Surgery and Cancer CSC 54,173 8,877 9,478 601- PbR Drug exclusions (-£375k), Other drugs (-£95k)Women and Children CSC 37,497 6,251 6,259 7- Corporate Services 24,359 4,249 4,261 13-

Overheads/Infrastructure/other 76,047 14,351 14,483 132- Use of QA at Home for Elderly Medicine (-£295k), further assessment beds (-£150k)Clinical Income 487,312- 79,855- 79,869- 13

Grand Total 29,900 8,680 9,149 469-

QAH Hospital


Finance: Executive Summary Cost Improvement Programme. An assessment of the impact of the cost improvement programme for month 02 has been completed. The assessment has concluded that there is an under-delivery of CIP in the year to date position of £206k. A summary report of the CIP delivery to date by Work-stream is table below;

Page 51 28/06/2018

Table 2: CIP Year to date performance

There are two main variances to note. The over-performance in CSC/Corporate services delivery to date which includes non recurrent pay savings. These will be normalised as part of the establishment review process agreed with the Executive Team. Secondly, in relation to the under delivery of Procurement savings, good progress has been made in seeking opportunities although the benefits in terms of reduced run rate have yet to be fully identified through CSC expenditure accounts.

CIP: Year to date performance (M2) by Workstream

Plan Delivered VarianceWorkstream £'000 £'000 £'000

Capacity savings (pay & non pay) 22 - (22)Income 68 143 76CSC/Corporate services 657 1,224 567Pharmacy 114 - (114)Procurement 835 366 (469)Theatre Productivity / Surgery 34 - (34)Corporate/CSC workforce projects 456 246 (210)Other 604 604 -

2,789 2,583 (206)

QAH Hospital


Finance: Executive Summary Clinical Income The Trust is reporting breakeven on Clinical Income as set out in Table 3 below. Access to the risk pool has been agreed with Commissioners in respect of the continued use of Further Assessment Beds for a temporary period up to the point at which the use of this community capacity is concluded and/or redesigned within the system.

Page 52 28/06/2018

Table 3: Clinical Income by Commissioner/Income source

The position reported is based upon the securable income from the Aligned Incentive Contract (AIC) and PBR contracts. There is significant over-performance against the non-elective activity levels in the AIC contract which need addressing to enable the Trust to deliver the efficiency savings required. Using the PBR values as a proxy this would equate to £1.79m year to date.

QAH Hospital


Finance: Executive Summary

Page 53 28/06/2018

Table 4: Aligned Incentive Contract and Activity

• The key hot spots for non-elective activity are A&E and MAU.

• The non-elective position has been raised at a joint meeting with the Commissioner and a sub group is being convened to understand the factors causing the continued high levels of activity and propose actions.

• The AIC working group have specifically been tasked with validating the non-elective activity reported position and action plan to address.

• Elective activity is very slightly under plan (-11) whilst day cases is 3% below plan (-236 spells). This is across most specialties but significantly within Trauma and Orthopaedics (-158 spells equating to -26%). Cardiology is above plan (+130 spells equating to 66% above plan) due to the returned use of the CDU.

Actions and Next Steps • CSC Performance Reviews - agree remedial action plans to address expenditure

overspends against budget - week commencing 25th June • Workforce CIPs – agreed process with Executive Management Team to review and remove

vacant posts from establishment – Month 04 budgets - action Turnaround Director • AIC Working Group – validate and propose an action plan to address Non-Elective activity

levels to Executive Contract Review Meeting – 30th June 2018

QAH Hospital


Workforce Report – May 2018

28/06/2018 Page 54

QAH Hospital


Workforce Executive Summary – key exceptions to note W

ell L

ed –

Wor

kfor

ce P

erfo

rman

ce

Them

e Performance Theme

• The funded establishment increased in May 18 to 7061 FTE. This is an increase of 2 FTE since April 18 and an increase of 266 FTE since April 17.

• The total workforce capacity increased by 17 FTE to 7122 FTE in May 18, this is 61 FTE over the funded establishment.

• The evidence collected for May 18 indicated that overall staffing levels increased from 101.6% to 102.9% compared to planned

levels.

• In May 18, 22.5% of the total workforce were BME, 1.2% of the workforce were either ‘undefined’ or ‘not stated’ and the remaining 76.3% were white.

• Appraisal compliance increased to 79.6% in May 18, but remains below the 85% target.

• Essential skills compliance increased to 89.6% and continues to record above the 85% target. • Sickness Absence Rate (12 month rolling average) decreased to 3.7% in April 18 and remains above the target. The in-month

sickness absence rate in April 18 decreased to 3.4%.

• Turnover Rate (12 month rolling average) increased to 13% in May 18 and remains above the 10% target.

• In-month turnover rate was maintained at 1.0% in May 18 and is below target. • No whistleblowing or NMC Professional Registration referrals were received in May 18. However, 3 safeguarding referrals were

received.

QAH Hospital


Exception Report: Workforce Capacity

Page 56 28/06/2018

Safe

– W

orkf

orce

cap

acity

Where we want to be: targets and benchmarks Target: Establishment of 6,596 FTE, with target of substantive staff in post at 100% of establishment

Key Terms and Definitions • Funded establishment excludes CIP and includes investments around anticipated

activity growth and patient demand in 18/19. • Total workforce capacity is the sum of the substantive establishment plus the

temporary workforce. • Temporary workforce capacity is the sum of the bank and agency workforce. Trends and Patterns • The funded establishment increased in May 18 to 7061 FTE. This is an increase

of 2 FTE since April 18 and 266 FTE since April 17. • The total workforce capacity increased by 17 FTE to 7122 FTE in May 18 and is

61 FTE over the funded establishment. • Substantive workforce capacity has decreased to 6509 FTE in May 18. • The temporary workforce capacity increased by 40 FTE to 613 FTE in May 18 and

comprises of 8.6% of the total workforce capacity. This is an increase in comparison to April 18.

Root Cause analysis and insights • A significant temporary staffing resource is still required to fill existing vacancies

across all areas and to staff escalation areas that have opened. Actions and progress to date • Temporary Pay Control Meetings continue with each CSC to monitor temporary

usage and put further actions / controls in place to reduce reliance on our temporary workforce. Retrospective bookings made for temporary workers have decreased and off-framework Registered Nursing (RN) bookings have ceased.

• Weekly Workforce Steering Group, chaired by the Director of OD and Workforce, continues to manage the price, volume and control our workforce, including Cost Improvement Programmes (CIPs) workbooks.

• New recruitment agency commenced international programme for Nurses with IELTS level 7 to supplement current recruitment plan

CHAT

Clinical Support

Emergency

Head & Neck

Medicine

MOPRS

Musculo-skeletal

Renal

R&D

Surgery & Cancer

Women's & Children's

Corporate Functions

Total Trust

CHAT

Clinical Support

Emergency

Head & Neck

Medicine

MOPRS

Musculo-skeletal

Renal

R&D

Surgery & Cancer

Women's & Children's

Corporate Functions

Total Trust

2627853415114344200283617613

Funded Establishment

Vacancies

768 31

360

Substantive

638

1402 100521 35

763

7371303487

512 59372 36

454336

404 44750 112

298 2527382 82 0

Workforce Capacity FTE

564 40728 687 41

7122

29382593724606

Substantive Staffing FTE

380

1330572

789596

394

7061 6509 552618 589 29

605

Temporary Total Workforce

Staff Groups Funded Establishment Substantive Vacancies Temporary

Total Workforce

TWC over Funded (%)

Medical and Dental 1011 934 76 82 1016 101%Registered Nursing 2356 2024 321 262 2286 97%Non Reg Nursing 951 980 -36 213 1194 125%Scientific & AHP 1420 1333 71 40 1373 97%Admin & Clerical 1322 1238 95 15 1253 95%Total Trust 7061 6509 552 613 7122 101%

Full Time Equivalents (FTE)

QAH Hospital


Workforce – Workforce Race Equality Standard (WRES)

Page 57 28/06/2018

Wor

kfor

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iver

sity

Where we want to be: targets and benchmarks Target: BME % that is representative of our local population (16%) Data Source: Electronic Staff Record

Key Terms and Definitions • The WRES return monitors the proportion of BME (Black Minority Ethnicity)

workforce, against the total workforce expressed as a percentage (%). • Following WRES reporting guidance, any ethnicity that includes; White-British,

White-English, White-Irish and White-Scottish fall under the category of ‘White’ and all other ethnicities are recorded under ‘BME’.

• Any ethnicity record that states ‘Undefined / I do not wish to disclose’ or ‘Not stated’ are reported as a separate category.

Trends and Patterns • In May 18, 22.5% of the total workforce were BME, 1.2% of the workforce were either

‘undefined’ or ‘not stated’ and the remaining 76.3% were white. Root Cause analysis and insights • Emergency, Medicine, Renal and Surgery & Cancer CSC have the highest

proportion of BME staff. • MOPRS, CHAT and Corporate Functions also have a higher percentage where the

ethnicity is ‘not disclosed or not stated’. • Both Medical & Dental and Nursing & Midwifery workforces have a high BME

percentage at 39.7% and 31.2% respectively, both recording above the 16% target. Actions and progress to date • Equality and Diversity report presented at Aprils Trust Board • Action plan in place to address the areas of concern identified against the Workforce

Race Equality Standards • BAME Network launched • Listening into Action event taken place with BAME network, which identified some

actions: • BAME freedom to speak up advocate appointment • Staff Awareness programme of culture difference • Social media networks groups formed

• Successful application on the NHS England Equality and Inclusion partnership 12 month programme

White BME Not Stated

TARGET 16%CHAT 79.5% 18.8% 1.7%

Clinical Support 84.4% 14.6% 0.9%

Emergency 65.1% 33.5% 1.5%

Head & Neck 77.8% 21.7% 0.4%

Medicine 66.4% 32.7% 0.9%

MOPRS 67.5% 29.6% 2.9%

Musculo-skeletal 69.4% 29.9% 0.6%

Renal 59.9% 39.2% 0.9%

R&D 83.8% 15.0% 1.2%

Surgery & Cancer 66.2% 32.2% 1.6%

Women's & Children's 85.8% 13.8% 0.3%

Corporate Functions 88.4% 10.1% 1.8%

Total Trust 76.3% 22.5% 1.2%

White BME Not StatedTARGET 16%Medical & Dental 57.7% 39.7% 2.6%Nursing & Midwifery 67.9% 31.2% 0.9%STT 82.2% 16.6% 1.2%Admin 93.1% 6.2% 0.7%Estates & Ancillary 100.0% 0.0% 0.0%PHT Total 76.3% 22.5% 1.2%

BME Rate

BME Rate

QAH Hospital


Appraisal and Essential Skills Compliance

Page 58 28/06/2018

App

rais

als

Where we want to be: targets and benchmarks Target: The compliance target for Appraisals is 85%

Trends and Patterns • Appraisal compliance increased to 79.6% in May 18, but remains below the 85% target. • Large acute trusts within the local area for April 18 have an average appraisal

compliance rate of 81.9%. PHT is below the local average. Root Cause analysis and insights • In May 18, the 85% appraisal target has been met by CHAT, Clinical Support, Renal and

Research & Development CSC. • All CSCs have either maintained or increased their compliance in-month. Actions and progress to date • A condensed appraisal conversation form has been cascaded and added to the policy to

support reaching compliance in those high pressurised areas. • Appraisal audit to be undertaken in June with findings and recommendations back to line

managers • Monitoring of compliance continues via the Clinical Service Centre Performance

Management Framework

Where we want to be: targets and benchmarks Target: the compliance target for Essential skills is 85% (Target for Information Governance is 95%)

Trends and Patterns • Essential skills compliance increased to 89.6% and continues to record above the 85%

target. Root Cause analysis and insights • Overall Safeguarding Children compliance (All Levels) currently records at 91.3% and is

above the 85% target. Level 2 increased to 93.2% and Level 3 increased to 80.3%. • Fire Safety (face to face training) increased to 80.9%. • Information Governance Training decreased to 73.7% Actions and progress to date • Compliance not improving. Main contributing factor is attendance at classroom sessions.

Offering ‘pick and mix’ drop in sessions and will publish a monthly league table of compliance attributed to departmental managers on the intranet so all can see how departments are performing.

Esse

ntia

l Ski

lls

TARGETCHAT 96.1% 89.0%

Clinical Support 86.3% 93.5%

Emergency 76.0% 86.9%

Head & Neck 84.3% 87.9%

Medicine 82.5% 86.3%

MOPRS 53.5% 87.7%

Musculo-skeletal 62.4% 86.8%

Renal 89.0% 89.2%

R&D 88.5% 96.8%

Surgery & Cancer 81.1% 88.4%

Women's & Children's 79.9% 90.4%

Corporate Functions 74.8% 93.4%

Total Trust 79.6% 89.6%

Staff GroupsMedical and DentalRegistered NursingNon Registered NursingScientific & AHPAdmin & ClericalTotal Trust

79.8%79.6%

Compliance (%)

80.6%89.4%87.2%93.0%94.7%89.6%

95.3%74.3%75.2%81.1%

Appraisals & Essential SkllsAppraisals Essential Skills

85% 85%

Essential Skills %Appraisals %

QAH Hospital


Safe Staffing Reports / NQB

Page 59 28 June 2018

SAFE

Where we want to be: targets and benchmarks Target: Planned staffing levels are 100%, planned skill mix 70.4% RN:29.6% HCSW ratio

Trends and Patterns • The evidence collected for May 18 indicated that overall

staffing levels increased from 101.6% to 102.9% compared to planned levels.

• The skill mix for May 18 increased to 63.1% for Registered Nurses and decreased to 36.9% for Health Care Support Workers (HCSWs).

Root Cause analysis and insights • Continued high RN vacancies, supported by the temporary

workforce which leave position of less RNs than planned on the wards.

Actions and progress to date • Regular meetings with Medical CSC has produced an increase

in RN recruitment. Using Daily SKYPE process jointly with HR and nursing to recruit overseas nurses from multiple agencies. Good pipeline building with 40 potential overseas recruits in September along with the Newly Qualified Nurses.

QAH Hospital


Workforce Capacity – Turnover

Page 60 28/06/2018

Turn

over

Where we want to be: targets and benchmarks Target: < 10%

Trends and Patterns • Turnover Rate (12 month rolling average) increased to 13% in May 18 and remains

above the target and is higher than the local acute trust average, currently recording at 11.5%.

• In-month turnover rate was maintained at 1.0% in May 18 and is below target. • The Stability Index Rate is a measure that indicates how well the organisation

retains its experienced staff who have greater than 1 years length of service. The latest data available is March 18 on the national database. The trusts stability index rate recorded at 85.6% which is above the recommended target of 85% and has decreased in comparison to the previous month, but higher in comparison to the national large acute trust average which recorded at 84.5% in the same reporting period.

Root Cause analysis and insights • The annual rolling 12 month turnover increased for Clinical Support, Emergency,

Head & Neck, MSK, Research & Development, Surgery & Cancer and Women’s & Children’s CSC.

• Medicine CSC has the highest annual rolling turnover rate at 16.1%. This rate has been consistently high for the last 10 months.

• The Scientific, Technical and Therapeutic workforce has the highest staff group turnover.

Actions and progress to date • Launched culture change programme on 14th March based on national best

practice and personally led by CEO. • Have now recruited 14 ‘change agents’ to undertake cultural audit • Retention working group triangulating data to identify top three areas of action to

improved retention at PHT. • Commissioned an independent review of bullying and harassment – staff survey

cascaded to inform key actions. • Recruited to a freedom to speak up guardian and 17 advocates • Analysis of National Staff Survey results underway to inform action planning.



Emergency 1.0% 13.5%

Head & Neck 0.7% 13.1%

Medicine 2.1% 17.6%

MOPRS 0.7% 10.9%


Renal 0.4% 10.7%

R&D 0.0% 14.1%





TARGETMedical & Dental 0.7% 6.0%

Nursing & Midwifery 1.1% 14.2%

STT 0.9% 13.8%

Admin 1.2% 14.2%

Estates & Ancillary 0.0% 13.4%


Turnover rateIn Month Rolling 12 Months

12% 12%

Turnover rateIn month Rolling 12 months

10% 10%

QAH Hospital


Workforce Capacity – Absence & Health and Wellbeing

Page 61 28/06/2018

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Where we want to be: targets and benchmarks Target: < 3%

Trends and Patterns • Sickness Absence Rate (12 month rolling average) decreased to 3.7% in April 18 and remains

above the target. The in-month sickness absence rate in April 18 decreased to 3.4% • The latest data available on the national database is February 18. The trusts in-month sickness

absence rate recorded at 3.7% in January 18, this is above the internal target of 3% however it records lower in comparison to the national large acute trust average which recorded at 4.6% in the same reporting period.

Root Cause analysis and insights • Medicine, MOPRS, Renal and Women’s & Children’s CSC have the highest rate of in-month

sickness absence. • Highest in-month sickness absence rates are seen in Registered & Non Registered Nursing and

Scientific, Technical and Therapeutic staff groups. Actions and progress to date • The in-month sickness absence rate for April,18 has decreased again to 3.4%, (a .4%

improvement from April,17’s rate of 3.8%). • The HR Team have identified to specifically work with some CSCs to reduce sickness absence. • Since March 18 to date, a lower number of long term sick cases (44), in comparison to a monthly

average of between 70-80 cases. • Annual absence surgeries held with CSCs to support and provide action plans to improve CSCs

sickness absence. • If sickness slowly increases over the coming months, letters will be sent out to managers to

distribute to staff who have breached the sickness absence triggers as the Management of Attendance policy is to drive sickness absence down and to turn off temporary workforce where necessary.

Occupational Health and Safety Report • There were 3 RIDDOR incidents reported in May 18 in F Level Corridor, Theatres, and outside De

la court House. • There were 19 sharps injuries reported in May 18. These were reported within CHAT, Emergency,

Medicine, MOPRS, Surgery & Cancer and Women’s and Children’s CSC. Training in safe disposal and management of sharps injuries is offered to all CSCs.



Emergency 2.3% 3.4%

Head & Neck 3.8% 3.1%

Medicine 4.0% 3.3%

MOPRS 5.9% 6.0%


Renal 4.0% 4.8%

R&D 0.4% 3.8%





TARGETMedical & Dental 0.8% 1.1% Nursing & Midwifery 4.7% 4.9% STT 2.9% 3.6% Admin 2.7% 3.3% Estates & Ancillary 0.0% 0.3% PHT Total 3.4% 3.7%

Sickness Absence rateIn Month Rolling 12 Months

3% 3%

Sickness Absence rateIn Month Rolling 12 Months

3% 3%

QAH Hospital


Workforce Capacity – Absence & Health and Wellbeing

Page 62 28/06/2018

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Health Safety and Wellbeing Service • Staff survey question: In the last 12 months have you experienced musculoskeletal problems as a result of work activities? 26% overall

identified they had, however some directorates reported 39-43%. Hot spot areas within CSCs have been identified.

• Back care awareness and other support has been offered to try to support the increasing number of MSK referrals.

• An ergonomics project with Sonographers within PHT is being undertaken by one of the Manual Handling Advisors to look at a workshop

and exercises to improve the posture and wellbeing of Sonographers working within the Trust.

• Initial contacts have been made with regard to reducing MSK issues within theatres/DSU

• Additional physio support/training has been undertaken within the eye directorate to improve posture and back care awareness

• MOPRS and specifically

• General MSK – Health and Safety have worked with Procurement and have identified a more ergonomic chair for general purpose which is

more cost effective and is available for purchase.

Events for Health Safety and Wellbeing • Men’s Health Day 13 June Manual Handling Training Room 10am-2pm

• Women’s Health Day 20 June Manual Handling Training Room 10am-2pm

QAH Hospital


Organisational Development S

AFE

/ W

ell L

ed

Staff Friends and Family Test Pulse Quarter 4 2017/18 (March 2018)

Quarter 4 results 2017/18 for Wessex are now available. The Pulse survey was open to all staff by paper or online survey and unregulated, meaning that it was not restricted to one response per person. The survey was open for a 4 week snapshot period in March 2018, 1083 staff completed the survey which is a 15% response rate.

Staff recommending this organisation as a place to receive care and treatment. At 78% Portsmouth placed 121st of the 223 Trust surveyed, which is a declined position of 29 places for the same time last year (Q4 2016/17). Quarter 4 results were 1% higher than Quarter 2 results (Quarter 3 measures the National Staff Survey), 2% lower than the England average of 80% and 8% lower than the Wessex average of 86%.

Staff recommending this organisation as a place to work. At 58% Portsmouth placed 150th out of 223 trusts, which is a declined position of 82 places for the same time last year (Quarter 4 2016/17). Quarter 4 results were 7% higher than Quarter 2 results (Quarter 3 measures the National Staff Survey), 5% lower than the England average and 11% lower than the Wessex average.

Data has been shared with CSC’s for in depth analysis and priority will continue to be given to addressing the key areas of concern.

Key initiatives/actions • The Culture Change Programme – stage 1, Discovery • PHT Quality Improvement Academy • Strategy, Vision and Values launch in July 2018 • Mindfulness E-Learning for staff • Minority staff networks

QAH Hospital


New Apprenticeships and Care Certificates

Page 64 28/06/2018

Lear

ning

and

Dev

elop

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New Apprenticeships - Targets: Health Education England set an annual target of 2.39% of our workforce (171) to have started an apprenticeship Trends / Patterns: 3 new apprenticeships started in May 2018. This is far lower than the 31 that started in April however we remain above trajectory to meet our end of year target. Root cause analysis / insights. The increased number starting in April can be attributed to the new Nursing Associate Programme. Recruitment of existing staff to apprenticeship programmes has declined. On going issues still are a reluctance to commit with a 20% off the job expectation and concern that the Trust is yet to agree a strategic approach to funding the salary for these roles in line with Employers Guidance which will particularly impact on recruitment to degree apprenticeships. Actions / Progress to date:. This graph will be shared with the organization via Team Brief in July. We will be ‘rebranding’ the 20% off the job training as protected learning time and will be issuing guidance on how this can be achieved with Team Brief.

Care Certificates Targets: All clinical new starters at bands 1 – 4 are expected to complete the Care Certificate within 12 weeks of their start date at the Trust. The Trust has set the 6 month period as the final completion date to correspond with the probationary period

Trends / Patterns: In May there were 8 staff due to complete within 6 months of their start date, 6 of whom did so, giving us a rate of 75%. Although an improvement on the previous month, it is still some way off the performance in October and November last year. Root cause analysis / insights: The 2 staff members that did not complete within 6 months are based in Renal CSC and are still yet to complete. The CSCs that tend to perform well are those that have an Associate Practice Educator who can spend time supporting staff on the completion of their Care Certificate. A variety of offers to CSCs whose compliance is noted as low to assist mentors and support workers have not been taken up or afforded the outcome expected. Actions / Progress to date: • Ongoing action plans to support specific individuals. • Highlighted at Professional Forums for HoN to take action

Care Certificates currently in progress: 111 On target to achieve: 83 (75%) Target already breached: 28(25%)

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Student Placement Activity

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Student Placement Activity Targets: Whilst no formal targets are set, the Trust is committed to the provision of high quality placements that support and engage learners, therefore developing a future workforce.

Trends / Insights: Due to the curriculum requirements of our partner universities utilisation of student placements fluctuates monthly. In addition, we also have students on elective placements, those undertaking the Trainee Nurse Associate programme that isn’t represented in this data. Root cause analysis / insights There are currently several cohorts of students from University of Portsmouth, Bournemouth and Southampton on placement. Whilst we have seen a reduction in the number of student nurses recruited to commence their pre-registration nursing programme at the University of Southampton, the University of Portsmouth has three cohorts of students on their Nursing programme. The Open University plans to develop other fields of nursing starting with Learning Disability– planned in 2019. Actions / Progress to date: • The L.A.C.E.S pilot project (Learning and Coaching Environment for Students) is now completed on D8 and will continue to run for future students allocated to the ward. The next phase of the project has commenced on D5 and D6. • Targeted mentorship courses for wards/depts that have low numbers to maintain our placements opportunities until the new Supporting Learning in Practice Standards are introduced in 2019. • Planned accreditation visit to Immunology to review Scientific Trainee Programme went very well. • Visit to Audiology dept planned for 12/06/2018

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EU and International Nursing Recruits

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International Nursing Recruits Targets: There is no national target however we benchmark against the NMC data which has an overall pass rate of 55%. PHT pass rate was 77% last month which is higher than the national pass rate Trends / Patterns: Since January 2018 we have seen a decrease nationally in the pass rate of OSCE both at first and second attempt, which has been reflected locally. We have 8 nurses undertaking a second OSCE attempt. Root cause analysis / insights: This is an exceptionally difficult examination to pass (national pass rate for first attempt is 46 – 52%). We meet with our OSCE candidates following their exam for feedback so that we can target our support aimed at the practice areas that they failed. Actions / Progress to date: • We are sharing good practice via the HIOW STP group exploring collaborative training and

support for the candidates. • We are pursuing another test center in Ulster which appears to have a different philosophy

to the examination process and is having better outcomes. The first candidate from PHT will sit the exam at the end of June

EU Nursing Recruits Targets: There is no national target for passing the English language tests to achieve NMC registration. These are IELTS (International English Language Testing System) and OET (Occupational English Test). Trends / Patterns: We have had no more passes since the last report from the cohort that took the OET examination. This cohort are now awaiting feedback from OET before re-booking the exam. A response was received from OET in relation to complaints of candidates not being acknowledged and a representative from OET will be calling Head of Nursing Midwifery Education on 18 June 18 to discuss. Root cause analysis / insights: Following written complaints from our candidates and many others the COO and Principal Venue Auditor and Trainer of OET flew to London from Melbourne to manage the situation and put checks in place to avoid similar operational issues in the future Actions / Progress to date: We have another OET preparation programme starting in July and are putting action plans in place for all EU nurses who still have to pass their English exam for registration

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Workforce Governance

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Whistleblowing / Safeguarding / Professional Registration • No Professional Registration referrals were received and reported in May 18

• No whistleblowing referrals were reported in May 18.

• 3 safeguarding referral was received or reported in May 18.

Revalidation of Medical Staff • 11 doctor have been revalidated as at 30th May 18.

• 3 doctor have been deferred as at 30th May 18.

• No medical staff have been reported as non-engaged in the validation process as at 30th May 18.

Documents

Integrated Performance Report – May 2018 IPR.… · It is to be noted that there is now a much more representative sample ... awaiting assessment from the mental health ... safeguarding