agenda for a public meeting of the board … papers...clinical sciences building, university...

AGENDAFOR A PUBLIC MEETING OF THE BOARD OF DIRECTORS TO BE HELD ON

WEDNESDAY 25 JUNE 2014 AT 1.00 PM – 3.00 PM IN ROOM 20063/64,CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITAL, COVENTRY, CV2

2DX

ITEM TITLE BOARD ACTION PAPER TIME1 Apologies for Absence

Chair2 Declarations of Interest

Chair3 Minutes of Public Board Meeting

Held on the 28 May 2014Chair

For Approval Enclosure 1

4 Trust Board Action MatrixChair

For Assurance Enclosure 2

5 Matters ArisingChair

Verbal

6 Chairman’s ReportChair

For Assurance Verbal 5

7 Chief Executive’s ReportDeputy Chief Executive Officer

For Assurance Enclosure 3 5

Strategy8 ICT Annual Report 2013/14

Chief Operating OfficerFor Assurance Enclosure 4 10

Performance9 Trust Development Authority

(TDA) Accountability Framework2013/14Chief Finance Officer


10 Integrated Quality Performanceand Finance Report Month –Month 2Chief Finance Officer


11 Trust Development Agency (TDA)Oversight Monthly Self-Certification Requirements -June 2014Chief Finance Officer

For Approval Enclosure 7 5

FEEDBACK FROM KEY MEETINGS12 Private Trust Board Meeting

Session Report of 28 May 2014Vice Chair


13 Quality Governance CommitteeMeeting Report from 3 June 2014Chair, Quality GovernanceCommittee

For Assurance Enclosure 9

ITEM TITLE BOARD ACTION PAPER TIME

14 Finance and PerformanceCommittee Meeting Report from3 June 2014Chair, Finance and PerformanceCommittee


15 Audit Committee Meeting Reportfrom 2nd June 2014Audit Committee Chair


Regulatory, Compliance and Corporate Governance16 Any Other Business Verbal17 Questions from Members of the Public in Relation to Agenda Items

Members of the public are invited to raise questions in relation to any of the items thatare on the agenda for discussion.

18 Notice of Annual General Meeting (Chair)The Annual General Meeting of the Trust will take place at 5.30pm in the outpatientdepartment at the Hospital of St Cross, Rugby. At the meeting the Trust’s AnnualAccounts for 2013/14 will be presented. Member so of the public are welcome toattend the meeting and will have the opportunity to raise questions with members ofthe Trust Board.

19 Date of Next Meeting:The next meeting of the Trust Board will take place on Wednesday 30 July 2014 at1.00 pm in the Octopus Centre at the Hospital of St. Cross, Rugby

20 Resolution of Items to be Heard in Private (Chairman)In accordance with the provisions of Section 1(2) of the Public Bodies (Admission toMeetings) Act 1960, and the Public Bodies (Admissions to Meetings) (NHS Trusts)Order 1997, it is resolved that the representatives of the press and other members ofthe public are excluded from the second part of the Trust Board meeting on thegrounds that it is prejudicial to the public interest due to the confidential nature of thebusiness about to be transacted. This section of the meeting will be held in privatesession.

UNIVERSITY HOSPITALS COVENTY & WARWICKSHIRE NHS TRUSTEnclosure 1

Page 1 of 12

MINUTES OF A PUBLIC MEETING OF THE BOARD OF UNIVERSITY HOSPITALSCOVENTRY AND WARWICKSHIRE NHS TRUST HELD ON WEDNESDAY 28 MAY 2014 AT

1.00PM IN ROOM 20063/64, CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITAL,COVENTRY, CV2 2DX

HTB14/558

PRESENT

Mr Andrew Meehan Chairman (AM)

Mr I Buckley Non-Executive Director (IB)

Mr I Crich Chief Human Resources Officer (IC)

Mr D Eltringham Chief Operating Officer (DE)

Mr A Hardy Chief Executive Officer (AH)

Mr E Macalister-Smith Non-Executive Director (EMS)

Mr D Moon Chief Strategy Officer (DM)

Mrs G Nolan Chief Finance Officer/Deputy Chief Executive Officer (GN)

Mrs M Pandit Chief Medical Officer (MP)

Professor M Radford Chief Nursing Officer (MR)

Mr T Robinson Non-Executive Director (TR)

Mrs R Southall Director of Corporate Affairs (RS)

Ms S Tubb Vice Chair (ST)

Professor P Winstanley Non-Executive Director (PW) (from item HTB 14/566onwards).

IN ATTENDANCE

Mrs Barbara Hay (BH) Head of Diversity (for Item HTB 14/570)

Ms Z Cox Minute Taker and Executive Assistant (ZC)

HTB14/559

APOLOGIES FOR ABSENCE

There were no apologies for absence.

HTB14/560

DECLARATIONS OF INTEREST

There were no declarations of interest.

HTB14/561

MINUTES OF TRUST BOARD MEETING HELD ON 30 APRIL 2014

The Board approved the minutes as a true and accurate record of themeeting and these were signed by the Chairman

HTB14/562

TRUST BOARD ACTION MATRIX

The completed actions were noted and the Trust Board RECEIVEDASSURANCE from the Action Matrix.

HTB14/563

MATTERS ARISING

There were no matters arising that were not on the action matrix or theagenda.


Page 2 of 12

HTB14/564

CHAIRMANS REPORT

AM advised the Board that he had attended a Together Towards World Class(TTWC) Listening Event at the Trust which he had found very informative.

With regards to the Non-Executive Director (NED) vacancy AM confirmed that4 candidates had been short-listed and the interviews where scheduled totake place on 9 June 2014.

HTB14/565

CHIEF EXECUTIVE OFFICER REPORT

AH advised that he and the Chief Officer’s (CO) had attended the GroupQuarterly Performance Reviews during the week commencing 5th May 2014and that mandatory training had been raised as a key area of focus for theGroups. During each review, the nursing and ward Key PerformanceIndicators (KPI) had been discussed together with financial KPIs andperformance against the Cost Investment Programme (CIP). AH went on tosay that work was on-going with each Group to help them to meet their CIPfor 2014/15. The Chief Officers would also be meeting with the Groups todeliver formal feedback in line with the agreed process.

AH went on to advise that he had attended the Annual General Meeting ofAssociation of UK University Hospitals (AUKUH) for Chief Executive Officersand Deans of Medical Schools on 15th and 16th May 2014.The main area ofdiscussion was the need for greater collaboration between teaching hospitalsand medical schools and looking at research based projects to generateincome; AH confirmed that this will be encompassed within the Joint Visionbetween the Trust and Warwick Medical School.

Finally, AH advised that he had attended Worcestershire Oncology ProjectStrategic Partnering Board on 21st May 2014 as the Trust is now providingradiotherapy services at the Worcester Hospital site. He went on to say thatfurther work was being developed to create greater strategic alliances on anoutreach basis to other hospitals.Procedural note; PWS joined the meeting

HTB14/566

PATIENT EXPERIENCE AND ENGAGEMENT ANNUAL REPORT 2013/14

MP presented the Patient Experience and Engagement Annual Report2013/14 which detailed the progress that had been made during the year anda comprehensive summary of how patient feedback is obtained and utilisedwithin the Trust.

MR advised that feedback has been used to drive innovation and serviceimprovement and highlighted that 91% of the Trust’s patients and serviceusers had a ‘mainly good’ impression of the Trust in 2013/14.

The Trust Board RECEIVED ASSURANCE from the annual report

HTB14/567

UNIVERSITY HOSPITAL COVENTRY & WARWICKSHIRE SAFERSTAFFING ASSESSMENT


Page 3 of 12

MR noted that this was the second paper that had been presented to theTrust Board in relation to safer staffing levels and followed on from the paperthat had been presented to the April Trust Board meeting.

He advise that the paper set out the analysis of the Trust’s position againstthe National Quality Board (NQB) and draft National Institute for Health &Care Excellence (NICE) guidelines, the latter of which had been published10-days previously. Noting that the NICE guidelines were draft at this stageMR nevertheless felt it important to assess the Trust’s position against theseas an additional source of assurance in relation to staffing levels.

He went on to say that in addition to providing assurance, the assessmentswere useful in terms of demonstrating how investment decisions made by theTrust Board impacted on the frontline. An example of this was the £1.2minvestment into midwifery which had resulted in a positive impact on themidwife to birth ratio. As had been reported previously, the Trust wascompliant with 8 of the 10 recommendations made within the NQB guidance,with partial compliance and plans to achieve full compliance against theremaining 2.

Turning to the NICE draft guidelines, MR highlighted that whilst there wasadditional work to be done around the skill-mix at night, day staffing wasbetter than the recommendation. MR gave assurance that in his professionalopinion, levels of staffing at night were safe but they were not in accordancewith the recommendations made by NICE at the present time. MR remindedboard members that the Trust operates a live staffing database which allowsstaffing levels to be reviewed across all wards and on a shift by shift basis,and this reveals that there was a 97% delivery rate against establishment asat April 2014.

MR highlighted that following investment in staffing on Ward 40 it was nowrunning efficiently and had activity had increased as a result. He commentedthat the Enhanced Care Wards stood out from other wards in the report inthat the ratio of nurses to patients was 1:4. By way of assurance he confirmedhowever that this was because the wards are lower dependency.

EMS expressed concern in relation to national staffing levels being set andurged that temptation to reduce staffing in areas of the Trust where the nursestaffing levels already exceeded the recommended level must be resisted. Healso commented that whilst it was reassuring to know that nurse staffinglevels were such a keen area of focus within the Trust, there were other staffthat provided care to patients e.g. therapy staff.

MR accepted this point and noted that a further factor for consideration wasthe physical ward environment, in that staffing levels had to reflect thephysical space that was available within which to provide care. With regardsto staff other than nurses MR confirmed that whilst the NICE guidelines do notinclude these as part of the patient/carer ratio figures, the Trust very muchsees other staff as part of the ‘hands-on’ patient care team.

PWS queried whether staffing was expressed as a ‘snapshot in time’ andwhether the position was different at the weekend, and MR advised that theestablishment resource was available 365 days per year and the position at


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the weekend was no different to that of weekdays.

MR summarised by stating that he and his team remained committed toensuring safe staffing levels and to adhering to the NQB and NICE guidelines.

The Trust Board APPROVED the recommendations as set out within report;namely around receiving both regular and more detailed reports for on-goingassurance.

HTB14/568

CARE QUALITY COMMISSION REGISTRATION UPDATE

MP presented the report and advised that it had been submitted to provideassurance in relation to the Trust’s on-going registration with the CQC, andan update on the inspections that the CQC had undertaken at the Trust andthe actions/recommendations arising.

She confirmed that a total of 4 CQC inspections had been carried out sinceJanuary 2013 and that whilst the Trust was found to be fully compliant withthe Essential Standards, useful learning points had been identified by theinspectors which were being followed up. MP gave assurance that there wasno element of complacency and that all identified actions and learning pointswere progressed and monitored.

MP then advised that the CQC will inspect and rate all acute hospitals byJanuary 2016 and that all Trusts must achieve a rating of ‘good’ as aminimum before any Foundation Trust application can proceed. UHCW mighttherefore be subject to a full CQC inspection before the end of the year.

TR asked ‘checks and challenges’ were still being carried out by theExecutive Team and AH confirmed that the programme was still in place.

The Trust Board RECEIVED ASSURANCE from the report.

HTB14/569

NATIONAL STAFF SURVEY 2013 IC presented the report detailing theresults of the National Staff Survey for the Trust. He noted that the reportcontained a great deal of data and advised that he would therefore draw outareas in which the Trust had performed well and areas where performancewas less favourable.

In terms of the actual response rate, the Trust’s performance was in the lowerend and IC confirmed that in terms of comparator organisations, the Trustwas better compared to AUKUH Trusts.

The actual number of staff that had responded was 315 which was a smallnumber in comparison to the total but notwithstanding that, IC highlighted thattheir feedback was important, as was the need to obtain feedback from alarger number of staff, hence the launch of the internal Staff ImpressionsSurvey. He went on to say that the survey would take place in the weekcommencing 9th June 2014 following the conclusion of the Listening Eventsassociated with the Together Towards World Class Programme (TTWC). Thefeedback obtained from both would then be triangulated and utilised to inform


Page 5 of 12

the development of a comprehensive TTWC action plan.

AH commented that the Trust’s response rate had reduced year-on-year andacknowledging this, IC advised that feedback obtained from the TTWCListening Events and from Staff Impressions would help to determine why thiswas the case. PWS queried the existence of ‘group think’ within the Trust andasked whether the survey showed any interesting patterns in this regard. ICadvised that the national survey does not allow for that type of analysis totake place but confirmed that the Impressions feedback would be of greatervalue in that it would enable responses to be broken down into demographicsand therefore provide greater data richness.

ST noted that 90% of those that responded said that they had been appraisedin the past 12 months, yet this was an emergent issue from the listeningevents; she therefore questioned whether there was any correlation betweenthe areas in which the Trust had performed well and not so well in thenational survey and the feedback being obtained by the listening events. ICconfirmed that a mass of thought, opinion and ideas had been gathered fromthe listening events and the process of analysing this information usingresearch methodology introduced by MR was underway. Once this analysishas taken place, IC confirmed that early feedback around emergent themeswould be given to those involved via the TTWC work-streams in order tomaintain engagement; these themes would then be informed by feedbackreceived via the national survey and ‘Staff Impressions’. IC also referencedthe fact that the Impressions Survey would be the vehicle by which theequivalent Family and Friends Test question would be posed to staff, and thatthis would be followed up with quarterly pulse surveys. The Impressionssurvey would then be run on a bi-annual basis thereafter.

EMS asked IC if there was a way to reach out to those who do not respond tothe National Staff Survey as the report stated that only 315 responded fromthe randomly selected 850 staff. IC advised that unfortunately as the surveyis completed on an anonymous basis it is not possible to identify individualsand reach out to them.

The Trust Board noted the results of the national staff survey 2013 andRECEIVED ASSURANCE from the work that was on-going in this regard.

HTB14/570

UNIVERSITY HOSPITAL COVENTRY & WARWICKSHIRE NHS TRUSTEQUALITY OBJECTIVES AND PLAN 2012-14 AND 2014-15

IC introduced BH to the Board and explained that the paper was the annualover-arching paper around the Equality & Diversity agenda, whichsupplemented the twice-yearly report that was submitted to the QualityGovernance Committee, and ensured that the Trust was compliant with allstatutory and regulatory requirements.

BH confirmed that she would take the Board through delivery against theEquality & Diversity Plan 2012-14, the overall plan RAG rating which requiredpublication and highlighted that the plan for 2014-15 had also be includedwithin the paper for approval.


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Before turning to the actions, BH advised that the Department of Health (DH)had updated the former Equality Delivery System (EDS) and had producedEDS 2. One of the key actions arising out of the 2012-14 Plan was thedevelopment of an Independent Advisory Group (IAG); she confirmed thatthis had been established and had representation from almost all of theprotected characteristics. She confirmed that the IAG had RAG rated the2012-14 plan and given an overall rating of Amber. This was in recognition ofthe fact that many actions had been rated as green but there were others thatwere developing; any developing actions rated amber have been includedwithin the 2014-15 plan. BH advised that the development of the plan hadbeen influenced by external groups and organisations, and by staff andpatients through a Dragons Den type event, which had culminated in 4 groupspitching their ideas to the Chief Officers; all four pitches have been includedwithin the action plan.

PWS queried how many staff have received equality and diversity trainingand BH confirmed this to be 59%. Exploring this further, PWS asked whetherthis training was ‘face to face’ or whether it was on-line and BH advised thatall staff undertake on-line training as part of their induction and mandatorytraining, but those staff that sit on recruitment panels have additional face toface training as do some other members of staff.

The Trust Board NOTED:

the changes to EDS system

the progress that had been made against the 2012-14 plan, and

the changes to the Interpretation and Translation Service

and APPROVED the following:

the overall Amber rating for the Trust’s Equality Plan 2012-14 as atAppendix 2

the Equality Action Plan 2014-15 as set out at Appendix 4.

HTB14/571

REFERENCE COSTS REPORT 2013/14

GN presented the report and advised that it had been submitted as theDepartment of Health requires assurance from each Trust Board on anannual basis that the process adopted for determining reference costs was ‘fitfor purpose’. She went on to say that the process has been strengthenedsince the previous year and gave confirmation that the Trust’s external auditorhad deemed the Trust’s costs for 2013/14 to be accurate.

AH added that Monitor was now responsible for currently overseeing pricing,and whilst costing and pricing are different, costing is an integral part of theprocess in that it underpins pricing. He also commented that there is anunderstanding on the part of Monitor that patient level costing requiresinvestment if it is to drive change over the coming years.

EMS queried when reference costing data would be made available and GNconfirmed that the national cost reference exercise would be carried outduring the Summer 2014 and the results would be available nationally inDecember 2014. A further update will be given to the Trust Board following


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the data release.

ST advised that although the May Finance & Performance Committeemeeting was not quorate, a paper in relation to reference costs had beensubmitted which details the improvements that can be made within budget,and those that required additional investment. ST went on to say that theimprovement work within the current budget was underway.

TR added that the audit committee would receive the report from the externalauditor in due course and AM asked whether the exercise that had beenundertaken by the Auditor had been in sufficient detail to meet the Trust’srequirements. GN responded that the work had been commissioned atnational level and would inform the Information Strategy refresh that wascurrently underway. ST commented that significant investment was requiredin order for the system to produce the required granularity and GNcommented that investment was not just monetary but also in people in thatclinical buy-in was a prerequisite to an effective system. GN concluded byadding that Monitor is currently determining whether or not to impose termsaround reference costs upon Trusts.

EMS suggested that the Audit Committee could do a ‘spot check’ onreference costs as part of its assurance process and TR agreed to investigatethis.

The Trust Board APPROVED the report on the reference costs process for2013/14.

GN

TR

HTB14/572

INTEGRATED QUALITY PERFORMANCE AND FINANCE REPORTMONTH 1 – INCLUDING TRUST DEVELOPMENT AGENCYPERFORMANCE MANAGEMENT REGIME MAY 2014

GN presented the Integrated Performance Report (IPR) for month 1 2014/15(April) and reminded board members that some of the KPIs were cumulativeand others were at a point in time and were therefore absolute.

In terms of finance, GN advised that the Trust’s forecast financial position was£1.8m, which is £1.6m adverse to the financial plan that is monitored by theTDA due to slippage on the capital programme. She explained that this wasdue to some necessary re-profiling relating to a Capital Income Stream andgave assurance that this was neither material to the overall financial positionnor suggestive of difficulties in managing the outturn position.

EMS raised a query around the three overdue serious incidents and asked ifthere was anything that could be done to improve the process for managingthem. MP gave assurance that the Trust is very proactive with regards toserious incidents and emphasised that the focus was very much on ensuringthat all incidents are reported in order that action can be taken wherenecessary to prevent recurrence. To this end the Trust spends a lot of timeensuring the learning is disseminated. MP also commented that the Trustdoes have a high incident reporting rate which demonstrates a good level ofopenness, and cautioned on the inherent danger associated with focussingon reducing the numbers of incidents reported.


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In terms of process, MP confirmed that the Trust’s Serious Incident Group(SIG) meets on a weekly basis for in-depth analysis all serious incidents butemphasised that some incidents are extremely complex and involve otheragencies. Of the 3 incidents being referred to, MP advised that 2 are nowclosed, although 1 does remain open as it is an extremely complex case.

In relation to the MRSA bacteraemia reported in April, EMS asked whetherthe patient had presented with this upon admission or whether it was acquiredduring his stay at the Trust. MR advised that the patient did not have MRSAupon admission but he was able to confirm that a full recovery had beenmade and that an investigation was underway.

Turning to the 4-hour standard in A&E, DE stated that whilst performance wasreported as 95.6%, May 2014 had been an extremely challenging month andhe cautioned that the standard would not be met for May. By way ofexplanation, DE went on to say that there had been unusual attendancepatterns during the month that were not in keeping with the learning derivedfrom the previous two years. Notwithstanding the disappointing position, DEdid however comment that performance was a dramatic improvement of thatin the same period in 2013.

TR noted that the consultant appraisal rate had only improved slightly fromthe previous month and that this showed slow progress. IC advised thatrevised targets had been set and that improvement in performance should beseen going forward.

PWS expressed concern that the Trust was not achieving research targets;AH explained that the target came from the Chief Medical Officer of the NHSin recognition of the need to bring research on-line more quickly. He went onto say that whilst the Trust was not performing as well as other teachinghospitals, no Trusts were achieving the central target. Support is beingsought from Bristol Hospital to improve the Trust’s performance and AHadded that he will be speaking at the Grand Round in relation to a piece ofwork that the Trust is undertaking with Warwick Business School aroundresearch and development activity and innovation. AH emphasised the needto set benchmarks in different clinical areas and confirmed that a furtherpaper around this piece of work would be presented to the Chief Officers andthen the Trust Board in November 2014.

PWS commented that whilst metrics were important there were otherimportant issues that were not captured by the current target. Emphasisingthe importance of translational medicine, PWS confirmed that this would befocussed upon during the July seminar and that Professor Imray had nowtaken up position of Head of Translational Medicine with Warwick MedicalSchool.

Finally, GN drew attention to the requirement to sign off and return the usualCompliance Statements to the TDA and asked members whether they wouldbe content to do this as part of the report as outlined on the cover sheet. Noobjections were raised.


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The Trust Board APPROVED the compliance statements for their submissionto the TDA and RECEIVED ASSURANCE from the April 2014 report

HTB14/573

PRIVATE TRUST BOARD MEETING SESSION REPORT OF 30 APRIL2014

AM advised that there was nothing further to add to this report.


HTB14/574

AUDIT COMMITTEE REPORT OF THE MEETING HELD ON 12 MAY 2014

Further to the written report TR advised that there would be an extraordinarymeeting of the Audit Committee on 2nd June 2014 at which the Trust’sexternal auditor would present the annual accounts to members prior tosubmission to the Trust Board for adoption.


HTB14/575

QUALITY GOVERNANCE COMMITTEE MEETING REPORT FROM 28APRIL 2014

EMS advised the Board that the Committee had spent a great deal of time onpatient safety and drew attention to the positive nature of the Trust’s currentCQC band 6 rating.


HTB14/576

FINANCE AND PERFORMANCE COMMITTEE MEETING REPORT HELDON 6 MAY 2014

ST advised the Board that time was spent at the meeting discussing theevaluation of the Medihome pilot. DE advised that he would be attending ameeting with the Medihome Project Lead on 29th May 2014 for furtherdiscussion to take place.


HTB14/577

BOARD ASSURANCE FRAMEWORK 2014/15

MP presented the Board Assurance Framework for 2014/15 (BAF) to theBoard. She explained that it had been populated following the risk mappingsession that had taken place in April 2014 and the document presented wasthe summary of the strategic risks that the Trust faces as identified by theTrust Board, and the steps that are being taken to manage these.

TR commented that he was pleased to note that the BAF had been presentedto the Trust Board earlier in the year than previously and that the processappeared to be moving forward.

Board members agreed that the identification and management of risk was afundamental area for focus.


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The Trust Board APPROVED the Board Assurance Framework for 2014/15.

HTB14/578

BOARD COMMITTEE ANNUAL REVIEW

RS presented the paper and advised that in line with the Trust’s governancearrangements, a full review of the Committee structure is undertaken eachyear.

She went on to explain that given her newness in post, she had undertakenan interim review based upon the Committee annual reports that had beenpresented to the Audit Committee and suggested that the Committeestructure was fit for purpose. She therefore recommended that no changesbe made at the present time, and that the current terms of reference for eachCommittee be retained, pending a fuller review that would be presented to theTrust Board in September 2014.

The Trust Board AGREED to retain the current Committee structure and toRATIFY the current terms of reference for each Committee pending thereview that will be presented in September 2014.

HTB14/579

ANY OTHER BUSINESS

No other business was raised or discussed.

HTB14/580

QUESTIONS FROM MEMBERS OF THE PUBLIC

No other business was raised or discussed.

HTB14/581

QUESTIONS FROM MEMBERS OF THE PUBLIC

Q. ‘when I attended the hospital, I noticed that the hand sanitizer gel hadrun out by the Outpatient Pharmacy and whilst this did demonstrate thatthe public were using it, conformation was sought as to what measuresare in place to ensure that this does not happen regularly?’A. AH indicated that he was grateful that this had been brought to theattention of the Trust Board and that the gels are regularly replaced as part ofthe Trust’s maintenance programme.

Q. ‘does the Trust have an onsite General Practitioner in the EmergencyDepartment (ED) which would this help reduce the waiting times?’A. AM commented that whilst this has worked in some hospitals across thecountry this, along with other measures aimed at creating capacity in ED hadbeen tried at the Trust in the past and had not been successful. He went onto say that members of the public continued to gravitate towards the EDdepartment because they know that treatment will be provide in a hospitalsetting and that the co-location of an Urgent Care Centre on the Trust’s sitewas under consideration.

Q. ‘Do Consultants have their own forum at which they can addressissues freely?’A. AH advised that the Clinical Directors have a forum and all consultant staff


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meet as part of the Medical Staff Committee.

Q. ‘Does the Trust have an international role model to compare itselfagainst in relation to the Together Towards World Class Programme?’A. AH advised that the Trust is using Warwick Business School to help withthe programme and confirmed that the first role of the work-streamsestablished under TTWC was to identify who was best in class. He went onto say that some hospitals are considered to be ‘World Class’ citing Guy’s andSt. Thomas’ Hospital and University College London Hospital in the UK andJohn Hopkins Hospital and the Mayo Clinic in the USA as examples, andconfirmed that the Trust would look to them to draw down on good practicewhere applicable. He also confirmed that the Trust is a member of the DrFoster Global Comparator Programme and that the Chief Medical Officer hadrecently spoken at their conference in the USA around the research that sheis undertaking.

Q. ‘recently there had been reports of patients and their familiesbullying and harassing staff whilst attending the hospital; how does theTrust deal with this?’A. MR responded that aggression can be an inherent part of some medicalconditions and can create difficulties for staff in terms of treating the patient,but there are staff that are highly skilled and trained in these areas. MRadded however that staff are not expected to tolerate any form of bullying orviolence towards them and that the Trust takes a zero tolerance approach tothis in line with the NHS as a whole. IC went on to add that staff are advisedthat violence and aggression is not acceptable behaviour and that the Trusthad a duty as an employer to ensure that staff do not perceive this kind ofbehaviour as ‘normal’.

Q. ‘Sir David Dalton, CEO at Salford NHS Hospital has produced areport on creating ‘chains’ of elite hospitals linked together that may begeographically unrelated which is of concern if it becomes policy; howdoes the Trust see this working for them and how can this beinfluenced?A. AH advised that the report was due to be published later that week andthat it was likely to have an influence on the way that the health service isconfigured in the future. He went on to say however that there were similarmodels in operation in Europe that were part of initial discussions, and whilstthis model was not felt to be appropriate for the UK because geographicallydiverse arrangements rarely work owing to cultural issues, standardisation ofcare pathways was to be expected.

AH continued that that the Foundation Trust model was not suitable for allhospitals going forward and that the focus of the report would be on howsuccessful Trusts might run neighbouring Trusts that will not achieve FTstatus.

Turning to competition, AH explained that this was felt to be prohibitingchange within the NHS and that as such a new test would be introduced thatwould exclude the need for adherence to the rules and regulations aroundcompetition if it can be clearly demonstrated that the proposed developmentis the interest of patients/the public.


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HTB14/582

DATE AND TIME OF NEXT MEETING

The next public meeting of the Board of University Hospitals Coventry &Warwickshire NHS Trust will take place at 1.00pm 25 June 2014 in theClinical Sciences Building, University Hospital, Coventry.

HTB14/583

RESOLTION TO EXCLUDE MEMBERS OF THE PRESS AND THE PUBLIC

In accordance with the provisions of Section 1(2) of the Public Bodies(Admission to Meetings) Act 1960, and the Public Bodies (Admissions toMeetings) (NHS Trusts) Order 1997, it is resolved that the representatives ofthe press and other members of the public are excluded from the second partof the Trust Board meeting on the grounds that it is prejudicial to the publicinterest due to the confidential nature of the business about to be transacted.This section of the meeting will be held in private session.

HTB14/584

These minutes are approved.

SIGNED …………………………………………............................

CHAIRMAN

DATE …………………………………………............................

Enclosure 2UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

ACTIONS UPDATE: PUBLIC TRUST BOARD MEETINGS25 JUNE 2014

- 1 -

AGENDA ITEM ACTION RESPONSIBLEOFFICER

COMPLETIONDATE

UPDATE REMOVAL

HTB 14/445RESEARCHDEVELOPMENTANDINNOVATIONANNUALREPORT 2013

AH advised the Trust Board that the firstdraft of the joint vision paper betweenWarwick Medical School and UHCW,which was discussed at the Board Meetingon 27 November 2013, would be ready forcirculation mid-February 2014.

AH/PW 30.07.14 Scheduled for JulyBoard Seminarwith formalpresentation toTrust Boardthereafter.

Yes

ACTIONS FROM MAY 2014 MEETINGHTB 14/567UNIVERSITYHOSPITALCOVENTRY &WARWICKSHIRESAFERSTAFFINGASSESSMENT

Report on Staffing Levels to be submittedto each board meeting with a full report tobe submitted in June and December eachyear. NB full report for June 2014 wassubmitted to the Trust Board in May –reporting schedule will therefore applygoing forwards.

MR 26.06.14 Detail includedwithin the IPR. Fullreports added toBoard ForwardPlanner.

Yes

HTB 14/571REFERENCECOSTS REPORT2013/14

Report relating to national reference costdata to be made available to the TrustBoard once the data is released inDecember 2014.

GN 28.01.15 Added to ForwardWork Planner

Yes

HTB 14/571REFERENCECOSTS REPORT2013/14

TR to investigate whether the AuditCommittee can arrange spot checks onthe reference costs system by way ofadditional assurance.

TR 30.07.14 On the agenda forthe July AuditCommitteemeeting; update tobe given thereafter

Not at thisstage.

Enclosure 2UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

ACTIONS UPDATE: PUBLIC TRUST BOARD MEETINGS25 JUNE 2014

- 2 -

The Trust Board is asked to note the progress made with regards to matters arising and to approve the removal of those mattersmarked completed and recommended for removal.

HTB 14/572INTEGRATEDQUALITYPERFORMANCEAND FINANCEREPORT MONTH1 – INCLUDINGTRUSTDEVELOPMENTAGENCYPERFORMANCEMANAGEMENTREGIME MAY2014

Paper to be submitted to the Trust Boardin relation to the joint study with WarwickBusiness School that is underway

AH 26.11.14 Added to theForward WorkPlanner

Yes

HTB 14/578BOARDCOMMITTEEANNUALREVIEW

Board Committee structure full review tobe submitted to the September TrustBoard.

Director ofCorporateAffairs

24.07.14 Added toForward Workplanner

Yes

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

REPORT TO THE TRUST BOARD: PUBLIC

25 June 2014

Subject: Chief Officers ReportReport By: Gail Nolan, Deputy Chief Executive OfficerAuthor: Andy Hardy, Chief Executive OfficerAccountable ExecutiveDirector:

Andy Hardy, Chief Executive Officer

PURPOSE OF THE REPORT:

To update the Trust Board of the key details of meetings and events attended by the Chief ExecutiveOfficer during June 2014.

SUMMARY OF KEY ISSUES:

1) Sign off of the unqualified accounts on 2nd June 2014.

2) Visit to Trust by Kathy McLean, Medical Director, Trust Development Authority on 6th June2014.

3) Visit to Trust by delegates from the Australian HFMA 13th June 2014.

STRATEGIC PRIORITIES THIS PAPER RELATES TO (Please check one):

To Deliver Excellent Patient Care and Experience

To Deliver Value for Money

To be an Employer of Choice

To be a Research Based Healthcare Organisation

To be a Leading Training and Education Centre

RECOMMENDATION / DECISION REQUIRED:

The Trust Board are asked to RECEIVE ASSURANCE from the report.

IMPLICATIONS:Financial: None HighlightedHR/Equality &Diversity:

None Highlighted

Governance: None HighlightedLegal: NoneNHS Constitution: None HighlightedRisk: None Highlighted

COMMITTEES/MEETINGS WHERE THIS ITEMS HAS BEEN CONSIDERED:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee Chief Officers GroupAudit Committee

ENCLOSURE 4


REPORT TO THE PUBLIC TRUST BOARD

25 JUNE 2014

Subject: Information and Communication Technology (ICT) AnnualReport

Report By: David Eltringham, Chief Operating OfficerAuthor: Robin Arnold, Director of ICT

Jackie Weager, Associate Director of ITCharles Yeomanson, Associate Director of IT - Technical

Accountable ExecutiveDirector:

David Eltringham, Chief Operating Officer


To provide assurance to the Board in relation to the progress made with regards to ICTduring 2013/14 and to set out the plans for 2014/15.

SUMMARY OF KEY ISSUES:The Annual Report provides an overview of the work of the ICT Department and its workprogrammes in 2013/14 and 2014/15.

As set out within the paper, the current ICT strategy expires in 2015, having undergone mid-term review at the end of 2013. The next ICT Strategy will therefore start to be developedlater this year and will need to reflect changes in its environment, including national initiativesand local changes such as Together Towards World Class and the Trust’s emergingInformation Strategy.

STRATEGIC PRIORITIES THIS PAPER RELATES TO (Please check one):To Deliver Excellent Patient Care and Experience






The Board is asked to NOTE and be ASSURED by the content of the report and raise anyquestions or issues that arise.

IMPLICATIONS:

Financial: There are no financial implications attached to the Annual Report asit summarises the work that has been undertaken and sets outplanned work for 2014/15.

HR/Equality &Diversity:Governance: ICT is an important function within the Trust and the Board should

therefore be appraised of the on-going work in this regard.Legal: There are no legal issues arising.NHS Constitution: ICT supports the delivery of high quality patient care.Risk: The most significant risk relates to the delay since 2011 in

ENCLOSURE 4


REPORT TO THE PUBLIC TRUST BOARD

25 JUNE 2014

refreshing the ICT main network under the PFI contract. Whilstsignificant progress is being made this will remain a risk until thenetwork is replaced later in 2014.

COMMITTEES/MEETINGS WHERE THIS ITEMS HAS BEEN CONSIDERED:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and PerformanceCommittee

Chief Officers Group 18.06.14

Audit Committee



25 June 2014

Information and Communication Technology (ICT) Annual Report to the Trust BoardIntroduction

This report outlines the progress of Information and Communication Technologies (ICT) at the Trust in 2013/14 and plans for delivery in2014/15, both of these in support of the Trust’s ICT strategy approved by Trust Board in 2012.

The ICT Department consists of three main sections, Programme Delivery, Service Delivery, and Technology. A recent managementrestructure has strengthened the integration between these teams to enhance the way that ICT supports the business of the Trust.Programme Delivery retains responsibility for the delivery of each year’s programme of projects, as set out overleaf and in Annex B, but thereis a much tighter relationship with the Service Delivery and Technology teams to ensure that the annual programme of work is supportedwithout compromising the core ICT service. ICT continues to work with clinical and business colleagues to strive to improve patient carewhilst enabling efficiency savings through the better use of technology.

ICT Programme DeliveryUpdate on the 2013/14 ICT programme

The ICT programme in 2013/14 included a substantial amount of procurement activity to secure the provision of two replacement systems,one for Renal and the other a Patient Observation system, and two new clinical systems to support Electronic Prescribing and ElectronicDocument Management (EDM). In addition, the roll-out of two other large systems, PACS (radiology imaging system) plus associatedinformation system, and a Laboratory Information Management System (LIMS) for Pathology continued alongside significant infrastructurework to put resilient and responsive data storage solutions in place. A review of software licencing was also undertaken to ensure that theTrust is licenced appropriately for the software that it uses (this followed on from the ending of NHS-wide software agreements).

The rollout of the Digital Dictation project continued throughout the year and, in conjunction with the DOCMAN clinical communicationsproject, has delivered significant savings, both through electronic transmission of clinical letters directly into GP systems and the outsourcingof transcription services to a new supplier. These improvements have been welcomed by local GPs as they have substantially improved thespeed of communication of patient information.

Development throughout 2013/14 of the ICT infrastructure has delivered improvements to the IT storage environment bringing significant costbenefits. Further work on the security of the wireless network has also meant that colleagues and visitors will be able to access it from manymore types of wireless devices. ICT has also introduced reciprocal arrangements with other local trusts to allow colleagues from this and othertrusts to connect to their own Trust’s systems directly over the host’s wireless infrastructure while working away from base, improving

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effectiveness and cutting the need to travel. The Trust’s implementation of this innovative technology has been shortlisted for two awards forimprovements to clinical care

A summary of the progress of all of ICT’s significant projects in 2013/14 is set out in Annex B.

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The ICT programme in 2014/15

The 2014/15 draft ICT programme is substantial. Many of the projects from 2013/14 will continue into 2014/15. These include the Pathology LIMS, anupgrade to the Critical Care system, replacement of the Renal system and the full range of Electronic Patient Record (EPR) activities includingimplementation of the EDM and developments of CRRS, the core EPR application. A list of significant projects is set out below, together with some of theirassociated benefits. The ICT department has a full list of projects in 2014/15 available on request.

Scheme Description BenefitPACS additionalmodalities

Integration of images from arthroscopy andvascular scans into the main PACS system

Ensuring that images are stored and managed to an agreed set of standards in asecure and backed up environment with controllable access

Pathology LIMSreplacement

Implementation of a replacement PathologyIT system

The new system is a modern LIMS that will support the Pathology service for manyyears. Both financial and efficiency savings will be realised when implemented.

Electronic patientrecord (EPR)development

CRRS tool to capture CJD risk assessments. Electronic support for risk assessments. Efficient use of theatre sterile equipment

Electronic discharge improvements In support of quicker discharges for patientsModifications to the CRRS infrastructure toensure stability, resilience and to improve thesecurity model

Will put one of the Trust’s most critical clinical systems onto a stable and modernplatform thus reducing the risk of failure and increasing the speed ofdevelopments. This work will also help reduce the number of security incidentscaused by staff accessing patient records inappropriately, although the balancebetween governance and clinical need must be appropriate.

Electronic document management (EDM)system and scanning paper records

Will substantially reduced the paper used to record patient data. Linking this to theelectronic patient record will start to put clinical data all in one place to supportclinicians and improvements in clinical care. Will also reduce the cost of the paperrecords contract significantly

Procurement of an Electronic Prescribing andMedicines Administration (EPMA) system

An e-prescribing system has many clinical benefits including improving the safetyof drug administration and improving discharge rates.

Replace the electronic patient observationsystem currently in use as the current contractexpires

Procurement of a more modern system that may be used effectively over thewireless network to support improved clinical assessment and care at the bedside.This will have an added benefit of providing real time information to managepatient flow proactively

Completion of a system to support bloodtracking

Positively identifies the patient to bring the Trust into line with the latest Europeanlegislation. It also makes processes associated with blood products more efficient

PAS and Maternitysystems scoping

The national contract for both the PatientAdministration and Maternity systems expiresin July 2016. Specifications will be written tocapture the requirements for the two systems.

An option to procure the PAS and Maternity systems together could begin atransition towards an integrated EPR solution and would provide seamlessfunctionality between the two components.

Renal replacementsystem

Replacement of the obsolete Proton system,further to a clinical review of the system.

Together with a review of Renal processes this will improve the input and flow ofpatient data around the Renal department

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Scheme Description BenefitTechnologydevelopments

Upgrade the main Trust IT network as part ofthe standard PFI refresh

Will improve the speed of connection across the main Trust network and replaceselderly components. It will also allow for additional capacity to be built into areasthat have currently reached their limit and can no longer be expanded.

Upgrade to Exchange 2010 (email) Will improve email functionality and security

Further rationalisation of Trust data storage Will improve IT storage capacity and efficiencyUse of a software automation tool forinterfaces between systems

Will support improvements in efficiency of Trust business processes and thequality of data held in Trust IT systems

Microsoft Windows 7/ Office 2010 Support for Windows XP is being withdrawn in 2014. The Windows 7 roll-out willensure that the Trust is appropriately licenced and is operating on a secure andsupported platform.

QIPP and CQUINsupport

No projects identified yet, but included here asa place marker

Single Sign On(SSO)

Logging in once to gain access to a range ofsystems

Clinical colleagues will gain quicker access to systems and will not need toremember several passwords. This will also improve security of access and mayalso support context searches across systems (identifying the same patient acrosssystems)

ICT QualityManagementsystem

Introduction of documentation managementstandards in ICT and implementation of aquality manual.

Will standardise processes within ICT and allow it to move away from dependencyon individual technical excellence to solve problems. It should also support ICT inmarketing its services outside the Trust to bring in valuable income.

ITU upgrade Upgrade of the QS intensive care system Move away from an obsolete version of the software. The current software is endof life and requires an upgrade to make it supportable.

Digital Pathology Provides electronic images of specimens forexamination and communication

Allows multiple access to, and sharing of, specimens/slides. This is an innovativetechnology and the first deployment in the UK.

Progress towards the Electronic Patient Record (EPR)

The Electronic Patient Record programme is well established and has had a number of successes including improvements to clinical functionality in CRRS(the Trust’s base EPR system) and the procurement of an Electronic Document Management (EDM) system. This EDM system will facilitate the scanningof health records, where appropriate, to deliver the Trust’s vision for health records of being paperless by 2016 in the context of the Secretary of State’sannouncement that the NHS will be paperless by 2018. The EPR Programme Board with the Chief Nursing Officer, Mark Radford, as Chair and SeniorResponsible Owner was established in September 2012.

Following the departure of the EPR Programme Director in December 2013, the management structure was reviewed and Dr Alec Price Forbes wasappointed as EPR Lead supported in this role by the appointment of a Head of EPR.

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Progress with the programme over the last twelve months has been hampered by delays to the recruitment to key posts, initially as a result of a Trust widerecruitment freeze and now from a pick-up in the ICT employment marketplace. Complications in the procurement of other key EPR systems (ElectronicPrescribing and Patient Observation) and an understandable shift in software development priorities to support the Trust’s Getting Emergency Care Right(GECR) initiative have put individual programme components behind schedule. Whilst the Trust began its EPR journey in a comparatively strong position itnow risks falling behind some of its competitors in the local and wider health community. In order to place the Trust in a stronger position, Chief Officersasked the EPR programme team how the Trust might accelerate the programme. This review is underway and will be presented back to the Chief Officersfor consideration. In the meantime work continues to deliver against the existing EPR strategy

Nationally, there is now a clear focus on integrated digital care records to be achieved by 2018, signalling a move towards increased and improved recordsharing and partnership working across health and social care providers.

ICT Service Delivery

Within ICT Service Delivery a review has begun of the ways in which ICT interacts with its customers. Wherever possible processes will be streamlinedand as much paper as possible taken out of the system to maximise efficiency and use the technology available to us. Work to enable trust staff to orderICT goods and services on-line through our service desk portal is well underway and the equipment ordering form is being tested by individuals in Financeand Pathology to ensure that the processes are user friendly and efficient. This fits well with the national and local agendas of going paperless by 2016 andwill support our aspirations of gaining ISO9001 quality management accreditation to go with our national accreditation of the UHCW ICT Service Desk. Ourend-users will also be canvassed more regularly for their opinions of our ICT service using the on-line survey tool which is part of the Service Desk. We arecommitted to learn from what we do well and put right what does not work for those that use our services.

The Service Desk team has relocated to the ground floor of the Technology Building allowing a far better working relationship with the IT Engineers whonow work on rotation with the Service Desk providing technical guidance and expertise.

Elsewhere in ICT Service Delivery staff from the System Management and Health Records teams have been working closely with colleagues across theTrust to understand the current processes that support the movement and handling of paper patient records, this to inform the Electronic DocumentManagement (EDM) project. UHCW also became the national test site for changes to Maternity’s Evolution IT system due to the expertise of this sameteam. The team also worked closely with the Emergency Department to develop system management processes for the ED IT system and to put in robustcontractual and change control mechanisms with the Supplier.

The PC estate has been updated replacing many of the older PCs. Priority was given to clinical areas where staff are becoming increasingly reliant on IT todeliver high quality patient care. There remain over 100 PCs that are 5 years old or over which will need to be upgraded or replaced in order to support theimplementation of EPR systems.

ICT Service Delivery staff are also involved as part of the Trust team to transfer services to the City of Coventry site. The provision of adequate ITinfrastructure and communications links to support Radiology and other imaging services will be challenging, but work continues to understand the fullrequirement.

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ICT Technology

In 2013/14 the ICT Technical Services team completed the installation of the ICT infrastructure for the implementation of new RIS/ PACS systems at theend of the national contracts in June 2013 and a replacement Laboratory Information Management System (LIMS). The project to implement the newLIMS system incurred significant supplier delays and this is now scheduled to complete in 2014/15. These systems have critical message interfaces toother patient record systems, both within the Trust and in the local health economy, and considerable interface development and testing has beenundertaken and will now continue into 2015.

The PACS system implementation required the repatriation of very large volumes of image data from the national data centres as these were closed. Thereplacement of the Trust’s main IT storage was brought forward from 2014 to support this and to reduce costs. During 2013/14 data from most of the 80systems that also use this storage was migrated to the new storage, in turn providing further cost and operational efficiencies. A Vendor Neutral Archivesystem (VNA) was procured and implemented in 2013 as part of the RIS/PACS project to manage PACS images. As other Trust imaging systems arereplaced (e.g. Cardiology) in subsequent years, their images will also use the VNA. These images, together with the electronic documents from the patientcase notes (from the EDM system), will provide a common source of data for integration with the CRRS, as part of the Trust’s EPR strategy. With such alarge increase in data storage requirements for the Trust, a review of the backup and archiving software was carried out and a procurement wasundertaken to ensure that the Trust’s data is secured cost-effectively over the coming years.

The replacement of the Trust’s IT storage together with an IT server replacement programme are part of the ICT Strategy to develop a rationalised,virtualised environment and provide a highly resilient IT service. Reducing the number of technologies that ICT has to support (for some 80 ICT systems onover 300 servers) also reduces the range of expertise required to support the services and, in turn, provides for a more robust service, capable ofsupporting 24x7 operations. In 2013/14 a restructuring of the ICT Networking and Unix and ICT Microsoft Technologies teams into the ICT TechnicalServices team took place to support such working, reducing the single points of knowledge in these teams.

The Trust’s critical IT network is due for refresh under the PFI contract and the ICT team has been collaborating with its PFI partner, ProjectCo, to ensurethat the replacement will be fit for the future. An invitation to tender was advertised in 2014 and ICT staff will continue to work with ProjectCo to completethe procurement and implementation in 2014/15.

The core component of the Trust’s EPR, CRRS, has continued to be developed by the ICT Development team. In 2013/14 a results acknowledgementmodule of CRRS was implemented to ensure that results of diagnostic tests are reviewed by clinicians, providing a trust-wide mechanism for improvingpatient safety. This work received national recognition with the project being short-listed for the 2013 UK IT Industry Award for Best Not-For-Profit ITProject. Mobile access to CRRS has also been developed and this is now being trialled in the new wifi environment. This work will continue in 2014/15.

ICT Strategy

The current ICT strategy expires in 2015, it having had a mid term review at the end of 2013. The ICT team will start to develop a replacement strategylater this year. The new strategy will need reflect changes in its environment, such as national initiatives such as the Integrated Digital Care Record and“paperless by 2018”, and local changes such as Together Towards World Class and the Trust’s emerging information strategy.

A summary of the current strategy is at Annex A. The full ICT Strategy document is available on the Trust intranet, or by request to the ICT Director.

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Annex A

Information and Communication Strategy (ICT) 2012/13 to 2014/15

SummaryThe overall aim of the strategy is to outline the key principles and objectives that will deliver improvements in ICT to support UHCW to achieve its strategic

priorities.

The strategy builds on the firm technical foundation delivered by the 2009/11 ICT strategy, while seeking to innovate and be flexible. This new strategy has

as its primary objectives to support improvements in clinical care, in patient safety and experience, and in staff access to information and communication

technologies. As an enabling strategy it underpins delivery of the Trust’s Clinical Strategy and its Mission (to Care, Achieve and Innovate).

Ownership of IT systems and services will be placed in the hands of clinical and business leaders, with the ICT team in a supporting role. This change in

emphasis of ownership of projects and systems will in turn create a challenge between maximising local (department or service) benefits whilst ensuring

the integrity of the overall ICT technical and information architecture at the Trust.

ICT projects and changes will be seen as enablers to service improvements and business transformation, rather than ends in themselves. Thus each ICT

project or change will be considered on merit for the clinical service or safety improvement it supports, or the business transformation that it enables.

The Trust will adapt to the changing ways that people use ICT, from fixed desktop equipment to mobile working and communications; from paper to digital.

The Trust will increase its activities with, and across, the local health community. This will be underpinned by shared information using a coherent local ICT

infrastructure that may eventually be extended into patients’ homes in support of new care processes.

Benefits from the implementation of this vision will include: For everyone… Equal access to an easy to use high quality information technology environment that provides effective support for Trust clinical

and business processes and fosters innovation

For patients… Ensuring that each clinician involved in their care has access to the right information about them and their care at the point and in

the location that it is needed. Reduction of repeat requests for information, and easy access to information about their health and care

For clinicians… Access to a useful set of coherent information about each patient at the point of care, ultimately increasing the time available for

patient care. Easier means to enter patient data once at the point of care. Access to data to support research and to improve clinical services

For administrators… Simpler means to capture information, entering data only once. Access to information about the performance of their

services to empower local management and stimulate innovation

For directors and managers… Access to indicators about performance across the Trust and particularly for their areas of responsibility.

Aggregate data delivered directly from clinical systems to support decision making using business intelligence tools

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For ICT staff… Automated support systems to reduce manual support interventions. Well trained and effective users of ICT, support by local

ICT champions, reducing the need for central support and allowing more time to implement systems effectively and explore and exploit

technological innovations

For the Trust… A change to the relationship and dialogue between clinicians, business managers and ICT delivering organisation

transformation, through the effective deployment of IT.

Each patient’s experience will be at the centre of the Trust’s approach to delivering information and communication technologies. Thus the delivery of the

electronic patient record is at the heart of the strategy. However there are a number of other elements that are also important. These include:

Replacement of major systems including Radiology’s Picture Archiving and Communication system (PACS) and the Pathology’s Laboratory

Information system

Enhancing and extending the ICT infrastructure to include greater use of mobile and web technologies

The ICT team identifying and supporting new arrangements in the provision of healthcare and becoming more proficient in the exploitation of new

technologies

A safety approach using a local Clinical Safety Management System (CSMS) will be developed, based on national standards.

Trust employees will be encouraged and supported to become proficient in the use of clinical and non-clinical systems. The ICT Training team willintroduce different methods of learning styles (blended learning) to support Trust staff. Wherever possible, training will be tailored to suit the learner’srequirements and it will also reflect the agreed business processes of the Trust. This approach will assist the learner to apply their newly acquiredknowledge when they return to their workplace.

Underpinning all new ICT developments will be a shift in the culture of the organisation and the behaviour of staff, to where the security of information is

valued more highly. The sharing of information with our healthcare partners and third parties will reinforce our responsibility as data controllers. Information

sharing protocols and agreements will assure that legislation is being complied with, and that information is being protected. The Trust will also look to

reduce data duplication, that is, the same data entered in two or more IT systems.

The key principles of this strategy highlight the significance of engaging clinicians as well as business leaders. It is the intention to increase our effort to

communicate and engage with all Trust staff through a greater focus on this within ICT.

The overall implementation of this strategy will be the responsibility of the Director of ICT and the ICT team, reporting to the Chief Operating Officer.

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Annex BSignificant IT projects in 2013/14

Scheme Description Status

PACS replacement Procure a new PACS imaging system toreplace the current national product in use atUHCW

PACS implemented in June 2013.

Pathology LIMSreplacement

Procure a new Pathology IT system to replacethe system supplied by GE

Project on revised schedule to replace existing LIMS in 2014

Electronic PatientRecorddevelopment

Introduction of an electronic patient record tosupport clinical care and move towardspaperless working.

The EPR programme is now re-established with clinical leadership. CRRSdevelopment plan principal achievement has been the introduction of theacknowledgement of test and imaging results. Introduction of an electronicdocument management system has also begun, the solution procured in 2013.

iPM PatientAdministrationsystem upgrade

This upgrade has introduced a number of fixesfor known problems in the current version ofthe software

The upgrade was completed in April 2013.

E-Prescribing Procurement of Electronic Prescribing andMedicines Administration (EPMA) system tosupport ward administration of drugs

The procurement project is underway.

Digital Dictation A computerised dictation system to supportclinicians and their secretarial teams toimprove the efficiency of the production ofclinical letters.

The project will be completed in April 2014.

Pharmacy systemupgrade

System upgrade to support the outsourcing ofthe Outpatient Pharmacy

Completed Summer 2013

Hospital @ Night Supports communication of clinical tasksacross the hospital out of hours

Completed Spring 2014, and is now handling thousands of clinical task requestsimproving patient safety

Opera upgrade Updating the Theatre system and hardware tothe latest version

Completed February 2014

CEBISdevelopment

A new version of the software developed insupport of changes requested the Libraryteam

Complete. The CEBIS software developed by the in house team has also beenmarketed and sold to an IT supplier.

Blood Track TX Introduction of a system using handhelddevices to support blood tracking in line withEuropean legislation

Rollout begun and will be completed early in 2014/15.

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ESR Roll Out Roll out of the electronic staff record (ESR)self service component to all staff

Roll out complete.

Technicalinfrastructureprojects

Reciprocal wireless arrangements to allowNHS staff to work at other Trusts’ sites usingthe hosts wireless network

Implemented at UHCW, George Eliot and the Partnership Trust

Choose and Book system integration withCRRS

Completed Summer 2013

Implement Microsoft Exchange 2010 Implementation underway, to be completed in 2014ED and VitalPAC system hardware upgradesfor resilience

Both completed Autumn/Winter 2013

PC software upgrade from Windows XP andOffice 2003 to Windows 7 and Office 2010

UHCW appears to be one of the first Trusts to undertake this upgrade and hasfaced technical issues, which it has solved. This has caused delays and the projectis now expected to complete in 2014.

Support for bring your own IT device to work(BYOD)

The Trust now supports iPads under the BYOD scheme

Internet firewall replacement Completed Autumn 2013Security of mobile device applications Complete and under testRollout of mobile voice communications inUniversity Hospital

Capability now in place for iPhone and Blackberry smart phones. Issues withAndroid devices are believed resolved and are under test.

Rollout of internet access to patients and othervisitors

Completed early in 2013

Installation of a replacement interface engineand increased interfacing between systems toimprove data quality

Installation in 2012/13. Mass migration of interfaces during 2013/14, to becompleted in 2014.

Web contentmanagementsystem

Introduce new web technology to improve theTrust’s web services, such as the staffintranet.

This project has been deferred as the supplier continually failed to deliver a robustproduct to schedule and the contract with them has been cancelled. This initiativewill be reconsidered as part of the Together Towards World Class programme

Local healthcommunity project

The GP communication improvement projectprovides electronic transfer of clinical letters,including discharge summaries, to GPs

The Trust now sends most clinical correspondence and discharge records toCoventry and Warwickshire GP practices electronically.

ICT qualitymanagementsystem

Introduction of documentation managementstandards in ICT, implementation of qualitymanual including all processes andprocedures

A project structure has been established and leads identified to progress this work.Team processes have been mapped and it is planned to embed a quality systemin 14/15.

Enclosure 5

PUBLIC TRUST BOARD PAPER

Title NHS Trust Development Authority Accountability Framework2014/14.

Author Rebecca Southall, Director of Corporate AffairsResponsibleChief Officer

Gail Nolan, Chief Financial Officer

Date 25th June 2014

1. Purpose

This paper provides an overview of the NHS Trust Development Authority (TDA)Accountability Framework for 2014/151, which is the vehicle by which the TDA willoversee, performance manage and support the Trust in its development and journeytowards Foundation Trust licensing. It also describes the Trust’s approach to thedevelopment of Service Line Management and the performance management frameworkthat the Trust has in place, in order to provide assurance to the Board around therobustness of these arrangements.

2. Background and Links to Previous Papers

Reporting against the TDA Accountability Framework requirements for 2013/14 hasoccurred through the balanced scorecard and Integrated Performance Report (IPR) thatthe Board receives each month and the TDA Monthly Self Certification Requirements.

3. Narrative

The TDA is responsible for the oversight and development of NHS Provider Trusts thathave not achieved Foundation Trust Status. The Trust is required to report to the TDAeach month on a range of compliance metrics, to submit strategic plans and to seekapproval on designated matters such as capital schemes.

The Accountability Framework brings together into one place the policies and processesthat govern the relationship between NHS Trusts and the TDA, and describes how theTDA will fulfill the following functions:

Oversight and escalation

Development

Approvals

Oversight and Escalation

Whilst the 2014/15 Framework builds on its predecessor document, of note is the workthat has been undertaken to bring the work of the TDA, regulators and commissionersinto alignment and clarification of the role of the TDA in the context of the new regulatorylandscape . This includes close alignment of the TDA oversight metrics with the 5

1 http://www.ntda.nhs.uk/blog/2014/03/31/af2014/

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domains in the Intelligent Monitoring System utilised by the CQC although the TDA willhowever utilise a narrower set of metrics than the CQC to reflect:

the different roles of the two bodies the fact that TDA metrics need to be updated more frequently in order that

changes in performance can be acted upon and addressed quickly; and The specific role of the TDA in monitoring whether or not the Trust is delivering on

its commitments to patients as set out in the NHS Constitution on issues such asmaximum waiting times.

The oversight metrics that will be adopted are set out in appendix 1 to this report. Themajority of those that are applicable to the Trust are already contained within theBalanced Scorecard, which is the bedrock of the monthly IPR. There are however anumber of new requirements for 2014/15 which have been introduced, and which willresult in the revision of the balanced scorecard. The Performance and ProgrammeManagement Office (PPMO) is currently mapping the metrics to the balanced scorecardand the revised version will be submitted to the Trust Board once formulated.

In the event that there are serious failings in quality of care and/or financial performancea Special Measures regime has been introduced. The regime is described within thedocument and can be triggered either by a recommendation from the Chief Inspector ofHospitals (CIH) or when the TDA judges it to be necessary; when quality of care is anissue re-inspection from the CIH will be required before the Trust can return to oversight.

TDA will also explore a reduction in the autonomy of NHS Trust Boards at a high level ofescalation during 2014/15; particularly when escalation is due to financial matters.

In addition to performance metrics, the TDA will retain oversight of the following:

A number of Human Resources issues including Chair and NED Appointments. Workforce Assurance Data Quality Information Governance

Development

The TDA acknowledges that provider organisations face a challenging period and at thesame time as holding Trusts to account, it will also provide support to allow organisationsto maximise their potential for delivering high quality, sustainable services. This will beachieved through the following:

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Improving Leadership Improving quality Support for challengedorganisations and highperformers

Build upon the programmesof support previouslyavailable with dedicatedsupport being madeavailable to Trust Boards,NEDs and Chairs, ChiefExecutive Officers and otherExecutive Directors, inaddition to other leaderswithin NHS Trusts.

Trusts will have access tobenchmarking informationand analysis, intensivesupport teams and qualityimprovement events,

Developing partnerships forimprovement or ‘buddying’with high performingorganisations.

Developing the AspirantFoundation TrustProgramme and ensuringthat this is more tailored tothe needs of the individualTrust.

Approvals

The 5-year Strategic Plans that NHS Trusts are required to submit to the TDA areintended to bring fresh impetus to the pursuit of sustainability and facilitate thedevelopment of more radical approaches to meeting future challenges within local healtheconomies.

The TDA is also responsible for undertaking assessments of the Trust’s readiness for theFoundation Trust (FT) Application process and has worked with the CQC and Monitorover the past months to determine how the organisations will better co-operate and howthe assessment process can operate in a more effective and streamlined manner.

The TDA phase of the FT Application process will comprise:

Diagnosis and preparation Development and assurance Approval and referral to Monitor

All aspirant Trusts will also be subject to an inspection by the Chief Inspector of Hospitalsand must achieve a rating of good or outstanding against the CQC Essential Standards inorder to proceed. An assessment against the Quality Governance Framework will alsotake place during the TDA phase of the assessment. Whilst this phase will be intensive,the TDA will move Trusts quickly through to the Monitor phase once they havedemonstrated that they meet CQC requirements together with those set out within theGuide for Applicants.

Further details on the changes to the Foundation Trust Application process will bediscussed at the Trust Board over coming months.

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Meeting the Requirements of the TDA Accountability Framework

Service Line Management

Service Line Management (SLM) is a combination of management and business planningtechniques designed to improve the way healthcare is delivered. It involves theidentification of specialist areas and the management of these as distinct operationalunits, which allows the organisation to understand the complete operational, financial andquality detail of each service.

SLM comprises:

Organisation structure Strategic and annual planning process Performance management Information

The Trust has started to embed SLM in that the operational management of the Trust’sservices is in 16 clinical Groups. Clinical engagement is fundamental to successful SLM,and as such clinicians at the Trust are put at the heart of planning and decision making,with each Group being led by a Clinical Director who is supported by a Matron, a GroupManager and have dedicated finance and HR support.

Operational planning is also becoming embedded with support from the Planning Unitand each group has developed an Operational Delivery Plan (ODP) for 2014/15 whichthe Clinical Director and management team are required to sign-up to and to beaccountable for delivery against. Each Group also has its own bespoke balancedscorecard with a suite of financial, performance and clinical/quality KPIs that are subjectto rigorous scrutiny

Performance Management

In terms of the Trust’s overall performance management, a bottom-up approach is takenwhereby the scorecards that are owned by each Clinical Group feed into the overall TrustBoard scorecard. It is important to note however that the balanced scorecard comprisesnot only TDA compliance metrics but key performance indicators (KPIs) that have beenidentified internally to measure achievement against the key strategic priorities set by theBoard. It is the fusion of compliance and strategic KPIs that provide the ‘balance’ to thebalanced scorecard and ensures that the Board does not lose sight of performanceagainst its strategic priorities.

The Trust has a robust Performance Management Framework in place that mirrors that ofthe TDA and therefore produces a cascade effect.

Individual Group Performance is assessed at a monthly Operational Delivery Meeting(ODM). At this meeting progress against agreed plans is scrutinised together withperformance against KPIs in order to ensure that corrective action can be taken swiftly inareas of underperformance.

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Additionally, quarterly performance review meetings are held, at which the Chief Officershold the Group Management Teams to account for delivery against the KPIs. The ChiefOfficers adopt the same robust approach as that which the TDA takes with the Trustduring performance review meeting and provide both direction and feedback and praisewhere it is evident that improvements are being made. This has resulted in thedevelopment of the Group management as’ management teams’ and is instilling therequired degree of discipline and accountability throughout the organisation that isnecessary to both achieve regulatory compliance and enable to Trust to achieve itsstrategic priorities.

4. Areas of Risk

Clinical; many of the oversight metrics relate to initiatives brought about to improve thepatient experience and clinical outcomes, e.g. referral to treatment targets. If the Trust isunable to meet these there is the risk of poor patient experience and poorer outcomes.Financial; whilst there are no financial penalties attached to failing to meet TDA metrics,there is the risk that penalties will be imposed if the Trust does not meet contractual KPIsand CQUIN requirements which are monitored as part of the performance managementarrangements. Financial penalties will clearly have a negative impact on the Trust’sfinancial position and may consequently impact upon the ability to deliver break even orbetter.Reputation; if the Trust does not meet TDA requirements or the requirements ofCommissioners the reputation of the organization may adversely affected.Business Risks; if the Trust does not meet TDA and commissioner requirements then itis unlikely to be in a position to proceed with a Foundation Trust application.

The Trust’s performance management framework as set out within this paper mitigatesagainst the risk of failing to achieve the performance required to meet TDA requirements.

5. Governance

The oversight metrics set out in the Accountability Framework support the delivery ofseveral of the pledges set out within the NHS Constitution. Achievement against thesewill therefore help the Trust to deliver its responsibilities in this regard. In terms of internalgovernance arrangements performance against the TDA metrics and the internal KPIswill continue to be reported within the monthly Integrated Performance Report.

6. Responsibility

Responsibility for delivery against each of the TDA oversight metrics and internal KPIssits with the appropriate Chief Officer. The Chief Financial Officer has overall responsiblefor performance within the Trust.

7. Recommendations

[A]The Board is invited to note:

1. The publication of the Accountability Framework for 2014/15 and implicationsfor the Trust

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2. The Service Line Management arrangements that are in place within the Trust3. The internal performance management framework that is in place to ensure

delivery against the oversight metrics and internal KPIs.

and

[B]

1. To seek further assurance where required by raising any queries or concerns.

Name and Title of Author: Rebecca Southall, Director of Corporate AffairsDate: 15th June 2014.

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Appendix 1

Caring Inpatient scores from FFT A&E scores from FFT Complaints; rates per bed days Inpatient survey Q68; Overall I had a very poor/good

experience Mixed sex accommodation breaches

Well-led NHS England inpatient response rate from FFT NHS England A&E response rate from FFT Data quality of Trust returns to HSCIC NHS Staff Survey; % of staff that would recommend

the Trust as a place to receive treatment Trust turnover rate Trust level total sickness rate Total trust vacancy rate Temporary costs and overtime as a % of paybill Percentage of staff with an annual appraisal

Effective Summary Hospital Mortality Indicator HSMR (DFI quarterly) HSMR weekend HSMR weekday Deaths in low risk conditions Emergency readmissions within 30-days following an

elective or emergency spell at the Trust IAPT; proportion of people who complete treatment

who are moving to recoverySafe C-diff

MRSA Never Event incidence Medication errors causing serious harm Percentage of harm free care Maternal deaths Proportion of patients assessed for VTE Serious incidents Proportion of reported patient safety incidents that are

harmful CAS alerts Admissions to adult facilities of patients who are 16

years of age (number)Responsive 4-hour wait A&E

RTT waiting times (admitted) RTT waiting times (non-admitted) RTT waiting times incomplete pathways RTT over 52 week waiters Diagnostic waiting times (over 6 weeks) First definitive cancer treatment within 62 days of

referral from GP First definitive cancer treatment within 62 days of

referral from screening First definitive cancer treatment within 31 days of

decision to treat

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Proportion of patients receiving subsequent treatmentwithin 31 days (drug)

Proportion of patients receiving subsequent treatmentwithin 31 days (surgery)

Proportion of patients receiving subsequent treatmentwithin 31 days (radiotherapy)

Proportion of patients seen within 14 days of urgentGP referral

Proportion of patients with breast symptoms seenwithin 14 days of GP referral

Urgent operations cancelled for a second time Proportion of patients not treated within 28 days of last

minute cancellation due to non-clinical reasons Certification against compliance with requirements

regarding access to healthcare for people with alearning disability

The proportion of those on a Care ProgrammeApproach (CPA) who have (a) had a CPA reviewwithin the last 12-months, (b) had a formal reviewwithin 12 months, and (c) received contact within 7-days of discharge

Admissions to inpatient services who had access toCrisis Resolution/Home Treatment Teams

Meeting commitments to service new psychosis casesby early intervention teams (number)

Category A8 red 1 calls Category A8 red 2 calls Category A call – ambulance arrives within 19 minutes 12 hour trolley waits in A&E Mental health delayed transfers of care

Finance Bottom line I&E position – forecast compared to plan Bottom line I&E position – year to date actual

compared to plan Actual efficiency recurring/non-recurring compared to

plan. Year to date actual compared to plan Actual efficiency recurring/non-recurring compared to

plan – forecast compared to plan Forecast underlying surplus/deficit compared to plan Forecast year end charge to capital resource limit Is the Trust forecasting permanent PDC for liquidity

purposes

Enclosure 6

PUBLIC TRUST BOARD PAPER

Title Integrated Quality, Performance & Finance Report – Month 2 –2014/15

Author Mr J Brotherton, Director of Performance and ProgrammeManagement

ResponsibleChief Officer

Mrs G Nolan, Chief Finance Officer

Date 20 June 2014

1. Purpose

To inform the Board of performance against the Key Performance Indicators (KPIs) forthe month of May 2014 (month 2).

2. Background and Links to Previous Papers

The Trust receives the IPR each month to enable it to fulfill its responsibilities in terms ofmonitoring organizational performance.

3. Narrative

The report covers the suite of external and internally generated KPIs that taken inconjunction provide a balanced picture of performance across the Trust. Exceptionreports are provided where there is underperformance and trends/benchmarkinginformation is provided where available.

In May 2014, the Trust is achieving 37 of the KPIs; 22 of the KPIs are therefore beingbreached/not achieved.

Principal Performance Exceptions by Domain

Excellence in Patient Care and Experience

The Trust reported one MRSA bacteremia case in May, taking the cumulativenumber of cases for the year to two against the annual target of zero cases.

The Trust reported 14 Serious Incidents in May. The Trust reported three Overdue Serious Incidents in May. The number of last minute non-clinical cancelled operations (elective) was 1.73% for

May. Eight patients breached the 28-day guarantee for treatment following cancellation of

an elective procedure. Theatre efficiency remains below target in all theatre areas.

Delivery of Value for Money

The Trust has a Year-to-Date (YTD) liquidity days ratio of -28.6 compared to a YTDplan of -27.2.

The Trust is forecasting £23.7m CIP to be delivered against its target of £33.5m.

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Employer of Choice

The definitions of the indicators for Personal Development Reviews (Medical staff) andPersonal Development Reviews (Non-medical staff) have been updated this month.

Personal Development Reviews (Medical staff) - All medical and dental staff are nowreported together as opposed to Consultant only. This has had an effect on the overallfigures for both Medical and non-medical staff compliance because career grade doctorsmove from one category to another. The indicator now measures whether staff havereceived an appraisal within the previous 15 months in line with revalidationrequirements.

Personal Development Reviews (Non-medical staff) – This indicator no longerincludes career grade doctors. The target remains having had an appraisal within theprevious 12- months.

The Trust has recorded 80.48% against Personal Development Reviews (Non-medical staff).

The Trust has recorded 63.39% against Personal Development Reviews (Medicalstaff), within this Consultant only PDRs were reported at 84.66%

The Trust has recorded 75.25% compliance with Mandatory Training. This is afurther marginal increase but remains below target.

The Trust has recorded a 3.6% Sickness rate which represents betterperformance that the 4% or less target.

Leading Research Based Health Care Organisation

The number of patients recruited into National Institute for Health Research(NIHR) portfolio for 2013/14 is 4538, which is an increase of 328 patients on theprevious financial year.

4. Areas of Risk

Key risks are: Delivering the A&E 4-hour standard at 95% or above and the associated impact on

delivering elective services. Performance metrics around workforce continue to show improvement in some areas

but performance in all areas remains below target, particularly Mandatory Training.

4. Recommendations

The Board is asked to NOTE performance as at month 2, to SEEK further assurancewhere required and to CONFIRM its understanding of current organisationalperformance.

Name and Title of Author: Mr J Brotherton, Director of Performance and ProgrammeManagementDate: 20 June 2014

University Hospitals Coventry and Warwickshire NHS Trust Integrated Quality, Performance and Finance Reporting Framework Reporting Period: May 2014 Report Date: 19th June 2014

Contents

2 Integrated Quality, Performance and Finance Reporting Framework

Section Page

Executive Summary 3

o Summary of performance 4

o Trust Scorecard 6

Domain 1: Excellence in patient care and experience 8

Domain 2: Deliver value for money 26

Domain 3: Employer of choice 30

Domain 4: Leading research based health organisation 35

Domain 5: Leading training & education centre 38

Appendix 1: Financial Statements 40

Appendix 2: Trust KPI Heatmap 46

Appendix 3: Ward Staffing Levels 48

Executive Summary

Integrated Quality, Performance and Finance Reporting Framework 3

Executive Summary Summary of performance

Commentary In this report the Trust has highlighted areas of compliance and underperformance. Areas which are underperforming also include an exception report and trends/benchmarking where available. In this report, 22 of the 59 KPIs for which data is available and reported against are breaching the standard / target. Principal performance exceptions by Domain Excellence in Patient Care and Experience • The Trust reported one MRSA bacteremia case in May, taking the cumulative number of cases for the year to two against the annual target of no cases.

• The Trust reported 14 Serious Incidents in May.

• The Trust reported three Overdue Serious Incidents in May.

• The number of last minute non-clinical cancelled ops (elective) was 1.73% for May.

• Eight patients breached the 28 day guarantee for treatment following elective cancellation.

• Theatre efficiency remains below target in all theatre areas.

Delivery of Value for Money • The Trust has a YTD liquidity days ratio of -28.6 compared to a YTD plan of -27.2.

• The Trust is forecasting £23.7m CIP to be delivered against its target of £33.5m.


Executive Summary Summary of performance

Employer of Choice

• The Trust has recorded 80.48% Personal Development Reviews (Non-medical staff)

• The Trust has recorded 63.39% Personal Development Reviews (Medical staff), within this Consultant only PDRs achieved 84.66%

• The Trust has recorded 75.25% compliance with Mandatory Training. This is a further marginal increase but remains below target

• The Trust has recorded a 3.6% Sickness rate. This achieves the Trust target of 4%.

Leading Research Based Health Care Organisation

• The number of patients recruited into NIHR portfolio for 2013/14 is 4538 which is an increase of 328 patients on the previous financial year.



Executive Summary

Trust Scorecard – May 2014

Domain 1: Excellence in patient care and experience


Domain Summary – Excellence in Patient Care and Experience

9

Commentary

In this summary, we have outlined the overall performance for the Trust for all of the Excellence in Patient Care and Experience indicators. The following areas are covered in more detail overleaf due to their current performance:

• The Trust reported one MRSA bacteremia case in May, taking the cumulative number of cases for the year to two against the annual target of no cases

• There have been 14 Serious Incidents reported for May and there were three overdue Serious Incidents at the end of May.

• The number of last minute non-clinical cancelled ops (elective) remained constant at 1.73% for May, more than double the target of 0.8%.

• Eight patients breached the 28 day guarantee for treatment following elective cancellation.

• There have been 0.12 falls per 1000 occupied bed days resulting in serious harm which is above the target of 0.04. Despite this, the Trust is performing well compared to the National benchmarks.

• Theatre efficiency remains below the target in Main, Day and Rugby Theatres. Further explanation of the metric and challenges for each theatre area is contained in the report.

• The Successful Choose and Book KPI has slightly improved in May with performance now 27.2% which remains significantly above the target of 3%.

• There have been 42 Complaints registered which is above the target of 40 per month, taking YTD to 86 against a target of 80.

• The Friends and Family score for A&E (49.00) did not achieve its target.

• Friends and Family Maternity (overall summary indicator for the four individual maternity service touch points). The Trust has failed to achieve 15% coverage at two of the four touch points in May.

Integrated Quality, Performance and Finance Reporting Framework

Domain Summary – Excellence in Patient Care and Experience

10

Commentary Indicators in a watching or amber status;

• There were two overdue CAS alert for May.

• The Friends and Family Test A&E coverage is reported at 18.94% which is below the target of 25%.

• The Friends and Family Test IP coverage was 31.37% and therefore below the Trust’s stretch target of 50% in April.

• Improvement in Theatre utilisation has resulted in only Day Surgery remaining in an amber.

• Admission of full term babies to Neonatal Care remains in amber.

• The WHO Safer Surgery Checklist is recorded as 99.78% and therefore in amber status against the target of 100%.

No update is available for the HSMR indicator this time due to delays in release of information from the Dr Foster system.

For the first time this month, a report showing Ward Staffing Levels and Wards in exception has been included. This can be found

in Appendix 3.


11

Excellence in patient care – area of underperformance

MRSA Bacteraemia – Trust Acquired

Commentary This indicator reports the total number of new MRSA Bacteraemia in a calendar month cumulatively per annum. The organisation has a target of 0 new incidences per annum. Reduction in MRSA rates is a target set out in the Operating Framework for 2013/14. By achieving this target, the organisation can demonstrate the standard of practice in relation to Control of Infection, links to quality of patient care and to managing its reputation as a healthcare provider. Non-achievement can also affect registration with the Care Quality Commission. In both April and May 2014 the Trust reported an incidence of Trust Acquired MRSA Bacteraemia. The Trust reported two MRSA bacteraemia cases and held thorough Post infection reviews (PIR) with the CCG. Both cases were thought to be unavoidable by all parties. The term unavoidable is a joint decision by UHCW / the CCG when there is no obvious breach of practice that could be deemed to have contributed to the infection. Case 1 was a patient who sustained an acute MI. There were no obvious factors but a cannula placed by the ambulance crew was thought to be the source. The patient appeared well and has since been discharged. Case 2 was also unavoidable : Involving a complex delivery of a new-born. The baby was well and has been discharged.

Overall Trust position


Excellence in patient care – area of underperformance Serious incidents –number and overdue

Commentary

Applicable Frameworks/Contracts: Trust Development Authority Framework Serious Incidents (Number) - This is the total number of serious incidents that were reported to STEIS within the month. These are the serious incidents as monitored by the Significant Incident Group (SIG). There have been 14 Serious Incidents reported for May; These comprised 1 Never event (retained swab), 2 pressure ulcers, 4 serious falls, 1 C Difficile associated death, 1 Norovirus, 2 Maternity incidents and 3 other unrelated incidents. Serious Incidents (Overdue) - This is the number of serious incidents that have not been closed within 45 working days (as at last working day of the month). There were three overdue Serious Incidents at the end of May.

• One was a C Difficile-associated death. This has taken a long

time to investigate as there was doubt about the cause of death and an independent opinion was sought. This is now closed

• One is a joint investigation with George Eliot Hospital and is allowed six months for completion.

• The third case was an investigation involving ED and Obstetrics and took longer than usual to resolve due to disagreement with the final report. It is now closed.



13


Number of never events reported - cumulative

Commentary

Applicable Frameworks/Contracts: Acute Contract - Never Events This indicator reports the cumulative number of never events reported per calendar month. "Never events" are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place. There are 25 "never events" on the current list. Providers of health care are expected to implement systems and processes to ensure that never events do not occur. An event is to be reported as a serious incident and financial penalties can be incurred as a result. There was a Never Event reported in May 2014. A swab was left inside a patient following an elective Caesarean Section. The patient attended ED with abdominal pain three weeks later, when the swab was identified. The patient has received an apology and the swab has been removed. An investigation has commenced, led by the Deputy Medical Director.



14


Falls per 1000 occupied bed days resulting in serious harm

Commentary This indicator reports patient falls (graded as causing major or catastrophic injury) per 1000 occupied bed days. May’s reported position has improved since last month to 0.12 (4 falls as per the serious incidents slide) and breaches the 0.04 per 1000 bed days target. These falls originated mostly from gerontology, orthopaedics, neurology, cardiology and acute medicine. It is anticipated that these areas will have increased numbers of falls because most patients will have a greater number of multi-factorial risks. Around 60% of the falls occurred because of non compliance mostly due to patients having cognitive impairment. A lot of work is being undertaken to improve communication for cognitively impaired patients with the purchase of communication and sensory aids and the organisation of activities to improve the patients’ awareness and social interaction. More falls prevention aids have been purchased to assist with falls reduction such as falls alarms, low rise beds and the Sara Stedy, an aid to assist with patient toileting. Falls education is now provided in mandatory handling and moving training to ensure it reaches a greater number of staff and the second falls educational summit took place in May and was well attended. Most wards now have a link worker who assists with the education in falls reduction and the compliance against the falls care bundle standards and work continues with specific areas that have experienced an increase in the number of falls following the actions set out following the RCA.



It is worth noting that the national safety thermometer shows the Trust is performing well compared to the Regional and National Benchmark for falls with harm.

Source: NHS Safety Thermometer website

15


Complaints

Commentary Applicable Frameworks/Contracts TDA Accountability Framework This indicator reports the numbers of complaints registered by the

Trust. The target is set based upon the Trust’s performance for the previous financial year.

In May the Trust registered 42 complaints taking the cumulative

number for the year to date to 86 against a target of 80. The highest number was recorded against the Orthopaedic Service with 9.

5 - All aspects of clinical treatment 2 – Failure to follow agreed procedure 1 – Aids and appliances, equipment, premises 1 – Admission, discharge and transfer arrangements These related to three incidents that took place in May, two each in

April and March, one with multiple admissions over many months and one where the initial incident was in 2010..

Case Example: Failure to follow agreed procedures - May Patient received a cut to the arm when staff removed a plaster cast. The Plaster had not been applied correctly in theatre. Apologies were given and theatre staff have been spoken to along with their technique being assessed by a consultant.


Case Example: All aspects of clinical treatment - March Patient had surgery for a fracture and on readmission to the hospital continued to experience problems and a plate was removed due to an infection. Care was deemed to be appropriate but the patient had an unfortunate complication of surgery and injury and is due to have a joint plastic and orthopaedic surgical procedure. The Trust acknowledged in the response letter that there were delays experienced in diagnostic scans, appointments and procedures.

Excellence in patient experience – area of underperformance

Theatre efficiency

Commentary This indicator reports on how efficiently the surgical operative pathway is performing. An efficient theatre session is one during which there are no avoidable cancellations and all scheduled operations are completed within the time available without suffering underruns or overruns. This has benefits for patients through shorter waiting times, avoidance of the stress of operations being cancelled at short notice, and a reduced length of pre-operative fasting. Staff also benefit through a reduction in unplanned late finishes. Cancelled operations continue to impact on overall theatre utilisation. Non-clinical cancellations and the route to reducing these are outlined in the cancelled operations section. The current project to standardise and centralise the pre-operative assessment process is intended to reduce clinical cancellations that also impact on theatre efficiency. The initial phase (six specialties) is planned to go live in September. The recent initiatives to improve start times and reduce over-runs as previously reported are contributing to the moderate improvement seen this month. Other projects are now active for theatre rota reconfiguration, theatre scheduling and increasing elective day case rates. These enabling projects are expected to begin to take effect from September. Improvements to the emergency care pathway are also necessary to enable improvement in this KPI.



Last minute non-clinical cancelled ops (elective) Overall Trust position


Commentary

Applicable Frameworks/Contracts: Acute Contract - Quality Schedule This indicator reports the percentage of Elective Care operations cancelled by the Provider for non-clinical reasons either before or after patient admission per calendar month. Performance is measured against a target of less than 0.8%. By achieving this target, the organisation can demonstrate that it offers accessible and responsive services that are delivered in a timely and efficient manner, which can improve outcomes and reduce anxiety for the patient. Performance for last minute cancelled operations in May was 1.73% (101 cases). The Trust has breached the 0.8% target for the sixth consecutive month. The majority of cancelled operations continue to be as result of the impact of pressures on the emergency pathway particularly its limitations on timely patient ‘flow’ through inpatient wards. Day case cancellations are linked to the continued use of the day case facility to provide inpatient beds to support pressures within the emergency pathways.

The heightened daily operational control measures to limit the numbers of on the day cancellations remain in place. The Emergency Care Recovery Board are overseeing work streams to reduce bed occupancy levels that in turn will ease the knock on impact on the elective pathway. In addition to this the sustainable solutions required to achieve this KPI lies within the elective care transformation programme and involve: • Improved scheduling • Increasing the amount of day case procedures undertaken in day surgery by converting activity from main theatres • Theatre rota reconfiguration • Availability of a second emergency theatre

This programme of work is underway with scheduled updates delivered ultimately to Trust Board via Finance & Performance Committee.


Breaches of the 28 day treatment guarantee following elective cancellation



Commentary This indicator reports the number of patients whose operation was cancelled, by the hospital for non-clinical reasons, on the day of or after admission, who were not treated within 28 days. By achieving this standard, the organisation can demonstrate their patient's receive fast access to treatment where they have not been the cause of delay, which can improve outcomes and reduce anxiety for the patient. There were eight breaches of the 28 day treatment guarantee for May. Four patients have now been treated, two have dates in June and two patients are in the process of having dates agreed. The processes in place and overseen via the weekly access meeting scrutinise and challenge the re-scheduling of cancelled patients. The twice daily reviews of the planned operating lists with each specialty provides a high degree of rigour in ensuring these patients are not cancelled for a second time. The high numbers of cancelled operations in conjunction with some of the capacity issues faced by certain specialties create significant difficulties in eliminating breaches. Delivery of this KPI will be enabled by significantly reducing last minute cancelled operations.


Successful Choose and Book Overall Trust position

19

Commentary Applicable Frameworks/Contracts: Acute Contract - Quality Schedule This indicator reports the percentage of patients who could not book into an appointment slot on the Choose and Book system. The organisation’s performance is measured against a target of no more than 3%. By achieving this target, the organisation can demonstrate its commitment to offering accessible and responsive services that are delivered in a timely and effective manner. Choose and Book 'Slot-Issue' performance remains significantly above target this month at 27.71% against the 3% target. May’s poor performance was largely driven by the following specialties: • Dermatology • Orthopaedics • Ophthalmology • Urology • Dermatology are to provide extra appointment slots for patients to book ‘up front’ during June and July to clear the backlog of patients accrued during the previous months. The Deputy Chief Operating Officer (DCOO) for Medicine is undertaking monitoring meetings with the group to support delivery. • Urology, despite increasing capacity, is still challenged. Further actions are being taken to bring the ASI % within tolerance.


• Orthopaedics have a significant capacity issue affecting their performance. A new Consultant appointment is due late August that will improve the situation although further work is needed to deliver a sustainable position. • Ophthalmology’s plans have yet to improve performance. A longer recovery period will be required as part of this solution and involves the recruitment of a Locum Consultant. The weekly access meeting reviews specialty action plans and challenges their recovery trajectories. The DCOO’s also intervene with the most challenged specialties.


A&E 4 hour wait Overall Trust position

20

Commentary Applicable Frameworks/Contracts: NHS Performance Framework Monitor Compliance Framework Acute Contract - Quality Schedule This indicator reports the percentage of A&E attendances where the patient spends four hours or less in A&E from arrival to transfer, admission or discharge. The is a measure against the national waiting time standard, for which the target is 95%. By achieving this target, the organisation can demonstrate their patient's receive fast access to treatment, which can improve outcomes and reduce anxiety for the patient. The Trust achieved 94.18% against a target of 95% for May. The Trust is working hard against its 95% target. It has experienced a significant rise in attendances to its emergency departments through Quarter 1 of 2014, with an overall increase in May 2014 of 7% compared to May 2013, and an increase of 13% for Adult Type 1 attendances for the same period. The increased activity has also been high for patients attending by ambulance, with a rise of 11%. This increased activity has clearly added pressure in the system with a corresponding increase in emergency admissions of 562 patients in May 14 compared to a year previously.


Despite contingency capacity and command and control structures remaining in place, bed occupancy remains under significant pressure, often in excess of 95%, and therefore securing adequate patient flow, particularly in the early part of the working week, has been very difficult and has directly impacted on the Trust's underperformance on the A&E 4 Hour target.

21


30 Day Emergency Readmissions

Applicable Frameworks/Contracts TDA Accountability Framework This indicator reports those patients who readmit within 30 days as an emergency following discharge from inpatient care. The target is set based upon the Trust’s performance for the previous financial year. UHCW’s position spiked quite markedly in January, before reverting downwards to just above the target for both February and March. The performance for March is 8.20% against a target of 7.95% and April has improved on this but it does remain marginally above the line. This indicator is being closely monitored and the reasons for readmissions investigated by the relevant groups.



The Friends and Family test forms a part of the Commissioning for Quality and Innovation (CQUIN) framework for 2014/15. This test intends to improve the experience of patients in line with Domain 4 of the NHS Outcomes Framework. The Friends and Family Test requires the Trust to ask ‘How likely are you to recommend our ward/department to friends and family if they needed similar care or treatment?’ A descriptive six-point response scale is used to answer the question: Extremely likely, Likely, Neither likely nor unlikely, Unlikely, Extremely unlikely, Don’t know. To Achieve the 14/15 patient FFT CQUIN indicators the Trust must meet the following indicators: • Early Implementation of the FFT into Day case and Outpatients by October 2014 • Increase in response rate for Inpatients (IP) and A&E patients by March 2015 • Inpatients: 25% response rate for Q1 , 30% for Q4, an additional payment if 40% is met in March 2015 • Emergency Department: 15 % for Q1, 20% for Q4 • Internal stretch targets have been set.

Excellence in patient experience – standard reporting item Friends and Family Test - Patients


Friends and Family Test – A&E

Excellence in patient experience – standard reporting item Friends and Family Test – Inpatients

Specialty position


Ward position

23

Excellence in patient experience – standard reporting item Friends and Family Test- Trend Analysis


How the Score is calculated: The number of promoters are subtracted from the number of detractors, and the resulting number divided by the total number of responses (excluding the don’t knows). ‘Likely’ is being considered by NHSE to be reclassified as a Promoter.

Response Categories Classification of Respondents

Extremely Likely Promoters Likely Passives Neither Likely nor Unlikely Unlikely Extremely Unlikely Don’t know

Detractors

Financial

Year

Submit

Month

AE Score AE Coverage

(%)

IP Score IP Coverage

(%)

Apr 22.28 23.05 61.67 22.24

May 35.41 20.76 56.84 17.38

Jun 50.55 16.01 60.78 25.3

Jul 49.16 15.19 59.1 27.54

Aug 51.75 17.08 66.76 24.03

Sep 51.99 17.79 66.76 25.45

Oct 50.55 17.36 66.2 28.88

Nov 57.57 17.7 63.46 24.28

Dec 62.8 18.35 62.05 23.03

Jan 57.11 17.81 57.36 23.35

Feb 45.34 20.2 60.41 26.61

Mar 50.97 25.57 63.75 31.61

Apr 49.46 19.74 61.85 23.23

May 49 18.94 65.27 31.37

2013/14

2014/15

Excellence in patient experience – standard reporting item Friends and Family Test- Maternity


Women will be surveyed at three touch points: i. Antenatal care (question 1) – to be surveyed at the 36 week antenatal appointment ii. Birth and care on the postnatal ward (questions 2 and 3) – to be surveyed at discharge from the ward/birth unit/following a home birth iii. Postnatal community care (question 4) – to be surveyed at discharge from the care of the community midwifery team to the care of the health visitor/GP (usually at 10 days postnatal)

The Friends and Family Test (FFT) aims to provide a simple, headline metric which, when combined with follow-up questions, can be used across the maternity pathway to drive a culture change of continuous recognition of good practice and potential improvements in the quality of the care received by service users.

The published guidance states an expectation of a 15% overall response rate - However NHSE have recently advised they are looking at 15% response rate for each touch point. Each midwifery service will receive a score (assuming they provide all these services) for antenatal services, birth (for a labour ward, birth centre/midwife led unit or homebirth), postnatal ward and postnatal community provision.

There has been an improvement across all touch points since January 2014 and the Maternity Team have worked very hard in promoting and encouraging completion of the postcards. There are still improvements to be made in terms of the postnatal return which is still low.

Domain 2: Deliver value for money


Domain Summary – Value for Money

27

Commentary This summary details the overall performance for the Trust for all of the Value for Money indicators in May. The Trust has a YTD liquidity days ratio of -28.6 compared to a YTD plan of -27.2. The Trust’s YTD capital services ratio is on plan at 0.1 The Trust’s combined risk rating is also on plan at 1. The Trust’s forecast financial position is on plan at £1.8m. In month 2, the Trust has submitted a revised financial plan to the TDA, to reflect slippage in the site redevelopment profile, therefore the planned revenue surplus has been revised in month from £3.4m to £1.8m. This accounts for the indicator being on target in May compared to the underperformance noted in last month’s report. The Trust is forecasting £23.7m CIP to be delivered against its target of £33.5m.


Value for Money – area of underperformance

Liquidity ratio

Commentary

This indicator reports the Trust’s liquidity ratio and shows the number of days of operating costs held in cash or cash-equivalent form. It is calculated as working capital balance x 360 days divided by operating costs. To achieve a Monitor rating of 3 or above, Trust must achieve a score of at least -7 days. Based on the 2014/15 financial plan submitted to the TDA the Trust has a YTD plan of -27.2 days for May. The calculation is highly sensitive to minor changes, and in month 2 operating costs were slightly below plan leading to a ratio of -28.6 days. This does not represent any significant unplanned issues arising in month.



Value for Money – area of underperformance

Forecast recurrent and non recurrent efficiency (CIP)

Commentary

This indicator reports the forecast delivery of efficiencies. The Trust has a target of £33.5m for 2014/15. Reporting on the target enables the organisation to assess the progress of efficiency savings. The Trust is forecasting delivery £23.7m savings against a plan of £33.5m. The shortfall of £9.8m is comprised of £2.3m which is potential slippage against identified schemes and £7.5m that is the balance of target not identified. The plan profile for identifying schemes recognises the delay in achieving this and anticipates that all schemes are identified by month 4. The PPMO continues to monitor and report Group performance against targets. Groups are challenged on their CIP performance through monthly operational delivery meetings. CIP Steering Group continues to meet weekly to discuss schemes with Groups and identify any obstacles to implementation and delivery. The Group is chaired by the CFO and attended by the COO to ensure operational representation. Weekly CIP positions updates are provided to Chief Officers and Groups to ensure there remains a continued focus at all levels in the organisation on identifying and delivering CIP.



Red Amber Green In Month YTD Forecast

> -15% > -5% < -5%

of plan < -15% of plan

Indicator Range: Performance Timeframe to meet

Standard

3.2% 1.3% -29.3% end Q4 2014/15

Domain 3: Employer of choice


Domain Summary – Employer of choice

31

Commentary This summary outlines the overall performance for the Trust for all of the Employer of choice indicators. The definitions of the indicators for Personal Development Reviews (Medical staff) and Personal Development Reviews (Non-medical staff) have been updated this month. Personal Development Reviews (Medical staff) - All medical and dental staff are now reported together as opposed to consultant only. This has had an effect on the overall figures for both Medical and none medical staff compliance as career grade doctors move from one category to another. The indicator now measures whether staff have received an appraisal within the previous 15 months in line with revalidation. Personal Development Reviews (Non-medical staff) – This indicator no longer includes career grade doctors. Timeframe for appraisal remains with the previous 12 months. The areas of exception are covered in more detail overleaf: • The Trust has recorded a 80.48% Personal Development Reviews (Non-medical staff)

• The Trust has recorded a 63.39% Personal Development Reviews (Medical staff) - within this Consultant only PDRs achieved 84.66%

• The Trust has recorded 75.25% compliance with Mandatory Training. This is a further marginal increase but remains below target.

• The Trust has recorded a 3.6% Sickness rate. This achieves the Trust target of 4%.


Employer of choice – area of underperformance

Personal Development Review (Non-medical Staff) Overall Trust position

32

Commentary This indicator reports all staff other than medical staff in relation to whether they have received an appraisal in the previous 12 month period. The Trust has established an overall target of 100% of those eligible to undertake an appraisal process. However, this report provides for a target of 80% achievement to move from red to amber and then above 90% to move from amber to green. The group of staff included within this indicator has been amended this month. Historical data for this new categorisation will be included in future months. The completion of an appraisal for staff alongside clear objectives and performance development plan demonstrates a workforce that has clarity in what they should be achieving in relation to their job and aligned to the strategy, values and behaviours of the Trust. Personal Development Review rates continue to improve and currently stand at 80.48%. This shows slight improvement and allows the Trust overall to reach an amber position. However, there are teams/groups that do not allow the Trust to produce even better results. The groups which remain below 80% compliance are: Core (68.76%), Care of the Elderly (71.32%), Ambulatory Services (73.02%), Cardiac & Respiratory (74.88%), Anaesthetics Specialty Group (76.62%) and Pathology (78.77%).

In order to provide improved performance alongside this indicator the following actions are either in place or are planned to take place: • The review of the paperwork and procedure to support the

appraisal process has now been completed and has been rolled out across the Trust following successful feedback from pilot areas.

• That workforce targets including appraisal rates are managed within the new performance framework and management teams held accountable.

• The HRED Committee to consider further analysis and action as to the reasons as to why the three areas indicated continue to perform poorly.


Employer of choice – area of underperformance Personal Development Review (Medical staff)


33

Commentary

This indicator reports the percentage of all medical and dental staff recorded as having received an appraisal within the previous 15 months. The organisation has an overall target of 100%. However, this report provides for a target of 80% achievement to move from red to amber and then above 90% to move from amber to green. In addition, this is a contractual and professional requirement for all consultants to ensure satisfactory revalidation. In addition, consultants are required to demonstrate that they have undertaken a satisfactory appraisal in the previous 15 months as a prerequisite for an application to the clinical excellence awards. The group of staff and time period of Personal Development Review for this indicator have been updated. Historical data for this definition will be included in future months. The overall Trust position for May 2014 is 63.39% for Medical Staff, within this Consultant only PDRs achieved 84.66%


In order to provide improved performance for this indicator the following actions are either in place or are planned to take place: • The Chief Medical Officer to hold Clinical Directors to

account.

• The HR&ED Committee to continue to hold areas of poor performance to account and request action plans to demonstrate improved performance within an agreed trajectory.

• That workforce targets including appraisal rates are managed within the new performance framework and management teams held accountable.

Employer of choice – area of underperformance

Attendance at mandatory training

34

Commentary This indicator reports the percentage of staff compliant with their mandatory training requirements that are required as part of their role on a rolling 12 month basis. The organisation has a target of 100% compliance for those eligible staff. The achievement of full compliance not only reduces our clinical and non-clinical risks regarding workforce but also enhances the skill base of our staff. The Trust’s current overall compliance for May 2014 has again improved to 75.35%, but is still short of the target of 90-100%. The areas that highlight performance below 70% and therefore do not allow the Trust to perform better for this indicator are: Emergency Medicine (68.46%), Pathology (62.20%) and Trauma & Orthopaedics (68.40%). Care of the Elderly, Hospital of St Cross Renal and Theatres are all over 80% while Theatres are 90% compliant.

In terms of particular areas of compliance it is concerning that Blood Transfusion compliance and Advanced Life Support/Advance Paediatric Life support are consistently low. These areas will be highlighted as areas of particular focus for group management teams to ensure better compliance rates. Thromboprophylaxis - Initial, In-Hospital Resuscitation including AED - Annual, Health and Safety - 3 Yearly, Safeguarding Children Level 2 - 3 yearly indicators are all above 80% with infection control reporting over 90%.

In order to provide improved performance alongside this indicator the following actions are either in place or are planned to take place:

• The Learning and OD Team have introduced supported e-learning

sessions in key areas across the Trust; information about these sessions is available on the Intranet.

• The Subject Matter Experts (SMEs) within the Trust will examine the compliance data and refocus their work in the clinical areas where compliance remains low on key topics, as well as the staff groups where this remains the case. This will be monitored by the monthly Mandatory Training Committee (MTC).

• HR Business Partners to indicate specific risks associated to no-compliance with particular emphasis on clinical risks alongside specific staff groups/areas.



Domain 4: Leading research based health organisation


Domain Summary – Leading research based health care organisation

36

Commentary In this summary, we have outlined the overall performance for the Trust for the Leading research based health care organisation indicators. • The number of patients recruited into NIHR portfolio for 2013/14 is 4538 which is an increase of 328 patients on the previous

financial year. • Current performance in initiating clinical research is at 17.39% against the 80% target resulting in exception. • Performance in delivering clinical research is currently at 64.44% against the 80% target, which is a significant improvement from the

previously reported position. This KPI is now in amber status.

The above two metrics for clinical research are updated on a quarterly basis.


Leading research based health care organisation

Overall Trust position 1st April 2013 to 31st March 2014 Commentary

Applicable Frameworks/Contracts: For clinical trials, from 2012, the NIHR has published outcomes against contract NIHR benchmarks. The NIHR has established 2 performance benchmarks that NHS providers are measured against. The two benchmarks are as follows: Initiating Clinical Research – 70 day benchmark Clinical trials to be set-up and operational within a 70 day period (basically this looks at how quickly studies are set-up and recruited to). The submission requires justified reasons for not meeting the benchmark. These are legitimate reasons outside of University Hospitals Coventry & Warwickshire (UHCW’s) control that have caused a delay to the set-up and initiation of a clinical trial. For the reporting period 1st April 2013 to 31st March 2014 a total of 17% of studies achieved the 70 day target, the top 4 justified reasons (those that occur most frequently) are as follows: • Delays caused by sponsor (57%) • Delays caused by sponsor and NHS Provider (0%) • Delays caused by neither the sponsor or NHS Provider (28%) • Delays caused by NHS Provider (15%) Delivering Clinical Research- time and target Recruitment of commercial clinical trials to time and target (i.e. whether or not the target number of patients have been recruited within the agreed specified timeframe).

Benchmark Assessment criteria

> 80% 60 > x <

80%

< 60%

Initiating Clinical Research

– 70 day benchmark

17%

Delivering Clinical

Research

- time and target

64%

Performance in Initiating and Delivering Clinical Research

For the reporting period 1st April 2013 to 31st March 2014 , a total of 64% of studies recruited to time and target. Reasons for not recruiting to time and target include:

• Care pathway changed • Study closed earlier than planned • Difficult to recruit patient groups • Studies being closed earlier than planned

UHCW is required to submit data for the Performance in Initiation and Delivery of clinical research (PID) on a web-based submission system on a quarterly basis. The next submission date is 31st July 2014 for the period 1st July 2013 to 30th June 2014. NB: We have been undergoing extensive data cleansing and while it is unlikely that this will have an immediate effect on the data we should start to see an affect over the next 2 quarters (July and October 2014). Integrated Quality, Performance and Finance Reporting Framework 37

Domain 5: To be a leading training & education centre


Domain Summary – Leading training & education centre

39

Commentary The Job Evaluation Survey Tool (JEST) is run by the West Midlands Deanery and includes responses from all trainee doctors (foundation and specialty trainees). There are three key reporting dates throughout the year; April, August and December and these updates will be included within the IPR upon release. The date range reported this time is August 2012 to July 2013. A set number of questions are included in the survey with responses ranging from 5 (excellent) to 1 (unsatisfactory). Any responses of 1 and 2 are considered low. The score represents an average of all responses. The target has been set at 3.5 to allow for future improvement. The figure included this month is 3.7 which is marginally above the target. In this summary, we have outlined the 2 KPIs that are being scoped for inclusion in future reports to reflect the organisations realisation of this objective. GMC Annual Survey This survey of all trainees’ is undertaken during March and April each year and results compiled by the Deanery. Information could be presented as a Trust overview and may be comparable with other Trusts. It could also be shown at specialty level for internal reporting as well as good practice identification and to highlight concerns and trends. The target would be no unsatisfactory ratings. GMC accreditation standards These are new standards for all teachers / trainers of junior medical staff. The standards aren’t yet in force but will be by 2015. They will vary according to the specific role. UHCW are completing their initial gap analysis survey. Once complete this could be reported and updated periodically throughout the year (3 monthly at most). In theory 100% of undergraduate trainers and 100% of post graduate trainers should meet GMC requirements. As this is a new requirement a 90% target is thought to be challenging yet realistic.


Appendix 1: Financial Statements


40

Month 2 – 2014/15

Statement of Comprehensive Income – Primary Statement


Statement of Comprehensive

IncomeTDA Plan Plan

Forecast

OutturnVariance Plan Actual Variance Plan Actual Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Income

Contract income from activities 449,207 459,792 461,876 2,084 71,940 70,924 (1,016) 36,861 35,341 (1,520)

Other income from activities 25,031 13,824 11,720 (2,104) 2,167 1,948 (219) 546 937 391

Other Operating Income 64,702 63,135 64,464 1,329 10,182 10,917 735 5,089 5,558 469

Total Income 538,940 536,751 538,060 1,309 84,289 83,789 (500) 42,496 41,836 (660)

Operating Expenses

Pay (300,296) (302,050) (318,086) (16,036) (52,726) (52,408) 318 (26,414) (25,871) 543

Non Pay (177,506) (176,403) (185,025) (8,622) (30,544) (30,781) (237) (15,386) (15,223) 163

CIP gap to target delivery 9,845 9,845

Additional savings required 5,271 5,271

Reserves (11,723) (8,883) (663) 8,220 (401) 0 401 (271) 130 401

Total Operating Expenses (489,525) (487,336) (488,658) (1,322) (83,671) (83,189) 482 (42,071) (40,964) 1,107

EBITDA 49,415 49,415 49,402 (13) 618 600 (18) 425 872 447

EBITDA Margin % 9.2% 9.2% 9.2% 0.7% 0.7% 1.0% 2.1%

Non Operating Items

Profit / loss on asset disposals 0 0 0 0 0 0 0 0 0

Fixed Asset Impairments 0 0 0 0 0 0 0 0 0

Unwinding Discount (49) (49) (49) 0 (49) (49) 0 (49) (49) 0

Depreciation (17,795) (17,795) (17,795) 0 (2,966) (2,964) 2 (1,483) (1,482) 1

Interest Receivable 100 100 113 13 17 19 2 8 11 3

Interest Charges (228) (228) (228) 0 (38) (38) 0 (19) (19) 0

Financing Costs (26,665) (26,665) (26,665) 0 (4,456) (4,428) 28 (2,265) (2,238) 27

PDC Dividend (3,078) (3,078) (3,078) 0 (513) (514) (1) (257) (257) 0

Total Non Operating Items (47,715) (47,715) (47,702) 13 (8,005) (7,974) 31 (4,065) (4,034) 31

Net Surplus/(Deficit) 1,700 1,700 1,700 0 (7,387) (7,374) 13 (3,640) (3,162) 478

Net Surplus Margin % 0.3% 0.3% 0.3% -8.8% -8.8% -8.6% -7.6%

Note: After technical adjustments for donated assets, the net surplus of £1.7m is increased to £1.8m

2014/15 Year To Date Month

Month 2 – 2014/15

Statement of Financial Position


Statement of Financial Position PlanForecast

OutturnVariance Plan Actual Variance

Planned

Change

Actual

ChangeVariance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Non-current assets

Property, plant and equipment 393,325 393,325 0 352,472 352,470 (2) (1,075) (1,226) (151)

Intangible assets 1,143 1,143 0 1,143 1,143 0 0 0 0

Investment Property 5,007 5,007 0 5,007 5,007 0 0 0 0

Trade and other receivables 15,173 15,173 0 36,041 36,242 201 (343) (195) 148

Total non-current assets 414,648 414,648 0 394,663 394,862 199 (1,418) (1,421) (3)

Current assets

Inventories 10,293 10,293 0 10,293 10,423 130 0 (129) (129)

Trade and other receivables 21,365 21,365 0 33,785 26,666 (7,119) (9,484) (19,394) (9,910)

Cash and cash equivalents 893 893 0 7,467 9,773 2,306 (1,052) 6,398 7,450

32,551 32,551 0 51,545 46,862 (4,683) (10,536) (13,125) (2,589)

Non-current assets held for sale 0 0 0 352 250 (102) (105) (207) (102)

Total current assets 32,551 32,551 0 51,897 47,112 (4,785) (10,641) (13,332) (2,691)

Total assets 447,199 447,199 0 446,560 441,974 (4,586) (12,059) (14,753) (2,694)

Current liabilities

Trade and other payables (43,062) (43,062) 0 (66,292) (61,837) 4,455 8,325 10,856 2,531

Borrowings (6,470) (6,351) 119 (8,156) (8,020) 136 0 119 119

DH Working Capital Loan 0 0 0 0 0 0 0 0 0

DH Capital loan (1,500) (1,500) 0 (1,500) (1,500) 0 0 0 0

Provisions (196) (196) 0 (3,421) (3,421) 0 0 0 0

Net current assets/(liabilities) (18,677) (18,558) 119 (27,472) (27,666) (194) (2,316) (2,357) (41)

Total assets less current liabilities 395,971 396,090 119 367,191 367,196 5 (3,734) (3,778) (44)

Non-current liabilities:

Trade and other payables

Borrowings (267,367) (267,486) (119) (269,635) (269,639) (4) 23 18 (5)

DH Working Capital Loan 0 0 0 0 0 0 0 0 0

DH Capital loan (5,250) (5,250) 0 (6,750) (6,750) 0 0 0 0

Provisions (2,422) (2,422) 0 (2,616) (2,618) (2) (116) (68) 48

Total assets employed 120,932 120,932 0 88,190 88,189 (1) (3,827) (3,828) (1)

Financed by taxpayers' equity:

Public dividend capital 48,470 48,470 0 33,870 33,870 0 0 0 0

Retained earnings 23,638 23,638 0 13,670 13,669 (1) (3,827) (3,828) (1)

Revaluation reserve 48,824 48,824 0 40,650 40,650 0 0 0 0

Total Taxpayers' Equity 120,932 120,932 0 88,190 88,189 (1) (3,827) (3,828) (1)


Month 2 – 2014/15

Cash Flow


Cash Flow Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-14 Total

£000 £000 £000 £001 £002 £003 £000 £000 £000 £000 £000 £000 £'000

EBITDA 394 207 1,860 6,299 1,618 4,254 6,941 4,358 6,828 6,553 2,833 7,257 49,402

Donated assets received credited to revenue but non-cash 0 0 0 0 (50) (50) (50) (69) 0 0 0 0 (219)

Interest paid (6,704) 0 0 (6,703) (51) (25) (6,730) (24) (24) (6,584) (23) (25) (26,893)

Dividends paid 0 0 0 0 0 (1,645) 0 0 0 0 0 (1,536) (3,181)

Increase/(Decrease) in provisions 0 0 (1,048) (1,000) (1,000) (225) (48) 0 0 (49) 0 (49) (3,419)

Operating cash flows before movements in working capital (6,310) 207 812 (1,404) 517 2,309 113 4,265 6,804 (80) 2,810 5,647 15,690

Movements in Working Capital 12,790 7,867 (6,822) 4,310 2,352 (3,004) 6,691 (69) (1,974) 5,648 679 (3,633) 24,835

Net cash inflow/(outflow) from operating activities 6,480 8,074 (6,010) 2,906 2,869 (695) 6,804 4,196 4,830 5,568 3,489 2,014 40,525

Capex spend (2,137) (1,757) (732) (1,360) (1,615) (3,091) (5,514) (5,497) (5,388) (5,914) (7,444) (4,782) (45,231)

Interest received 9 11 9 9 9 9 9 9 9 9 9 12 113

Cash receipt from asset sales 216 207 250 0 0 0 0 0 0 0 0 0 673

Net cash inflow/(outflow) from investing activities (1,912) (1,539) (473) (1,351) (1,606) (3,082) (5,505) (5,488) (5,379) (5,905) (7,435) (4,770) (44,445)

CF before Financing 4,568 6,535 (6,483) 1,555 1,263 (3,777) 1,299 (1,292) (549) (337) (3,946) (2,756) (3,920)

Public Dividend Capital received 0 0 0 0 0 1,508 1,127 1,140 891 2,514 4,101 3,319 14,600

Public Dividend Capital repaid

DH loans repaid 0 0 0 0 0 (750) 0 0 0 0 0 (750) (1,500)

Capital Element of payments in respect of finance leases and PFI (2,063) (137) (23) (2,074) (23) (23) (2,189) (144) (144) (2,187) (144) (29) (9,180)

Net cash inflow/(outflow) from financing (2,063) (137) (23) (2,074) (23) 735 (1,062) 996 747 327 3,957 2,540 3,920

Net cash outflow/inflow 2,505 6,398 (6,506) (519) 1,240 (3,042) 237 (296) 198 (10) 11 (216) 0

Opening Cash Balance 870 3,375 9,773 3,267 2,748 3,988 946 1,183 887 1,085 1,075 1,086 870

Closing Cash Balance 3,375 9,773 3,267 2,748 3,988 946 1,183 887 1,085 1,075 1,086 870 870

Month 2 – 2014/15

Capital Expenditure


PlanForecast

Outturn

Variance

fav/(adv)Plan Actual

Variance

fav/(adv)Plan Actual

Variance

fav/(adv)

£000 £000 £000 £000 £000 £000 £000 £000 £000

Confirmed CRL 0 0 0 0 0 0 0 0 0

Forecast CRL for PFI 25,129 25,129 0 686 686 0 343 343 0

Forecast CRL for Finance leases 3,135 3,135 0 109 0 (109) 40 0 (40)

Forecast CRL for non PFI 18,453 18,453 0 (120) (116) 4 (80) (293) (213)

Total Forecast CRL 46,717 46,717 0 675 570 (105) 303 50 (253)

PlanForecast

OutturnVariance Plan Actual Variance Plan Actual Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Major Schemes

PFI lifecycle 25,129 25,129 0 686 686 0 343 343 0

Onsite Developments 2,285 2,285 0 0 4 (4) 0 2 (2)

Endoscopes & Stack Systems 1,680 1,680 0 0 0 0 0 0 0

E'Prescribing 1,500 1,500 0 0 2 (2) 0 0 0

VitalPAC replacement system 2,062 2,062 0 0 0 0 0 0 0

4th Catheter lab 1,200 1,200 0 0 0 0 0 0 0

Move 3T MRI scanner to Rugby St. Cross

800 800 0 0 0 0 0 0 0

New PET-CT waiting area 750 750 0 0 0 0 0 0 0

0

Aggregated Other Schemes 12,203 12,203 0 310 301 9 65 (88) 153

Total Capital Expenditure 47,609 47,609 0 996 993 3 408 257 151

Less: Donated/granted Asset Purchases 219 219 0 0 0 0 0 0 0

Less: Book value of assets disposed of: 673 673 0 321 423 102 105 207 102

Net Charge against CRL 46,717 46,717 0 675 570 105 303 50 253

Under/(Over)Commitment against CRL (total) 0 0 0 0 0 0 0 0 0

Year To Date Month

Capital Resource Limit (CRL)


Capital Expenditure Programme

2014/15

Month 2 – 2014/15

Capital Financing


2014/15

Original

Plan 4-4-14

submission

£'000

2014/15

Revised June

Plan

resubmission

£'000

Movements

£'000 Comments

Capital Expenditure

Gross Capital Expenditure 41,655 47,609 5,954 Reduction in the programme predominantly relates

to the partial re-phasing of site infrastructure scheme

into 2015/16.

Less: PFI Capital Expenditure -17,487 -25,129 -7,642 Additional PFI spend identified by GEMS for

equipment slipped from 13/14 now confirmed to be

replaced in 14/15.

Total Non-PFI Capital Expenditure 24,168 22,480 -1,688

Capital Financing

Depreciation

Gross Depreciation 17,795 17,795 0

Less: PFI Depreciation -10,888 -10,888 0

Net Depreciation 6,907 6,907 0

Movement in Capital Payables/Receivables

Finance Lease Repayments (non-PFI) -332 -1,002 -670 Repayments increased mainly as a result of

VitalPAC replacement scheme to be funded by a

finance lease.

New Finance Leases (non-PFI) 1,223 3,135 1,912 VitalPAC replacement scheme to be funded via a

finance lease.

Other Capital Payables/Receivables (non-PFI) 45 24 -21

Movement in Capital Payables/Receivables 936 2,157 1,221

Other Funding Sources

Grants and Donations 219 219 0

Net Book Value of Non-Current Asset Disposals 632 673 41

Other Funding Sources 851 892 41

Revenue Surplus

Surplus for the Year (excl impairments/capital

contributions)

0 0 0

Add: capital contributions 3,250 1,700 -1,550 Reduction in the capital contribution that can be

recognised for the site infrastructure scheme

following the scheme re-phasing.

Less: Donated Assets (incl in surplus) -219 -219 0

Less: Applied to Finance PFI -2,057 -2,057 0

Less: Applied to Working Capital Loan Repayments 0 0 0

Less: Applied to Other Working Capital 0 0 0

Surplus Applied to Capital 974 -576 -1,550

Total Internally Generated Funds 9,668 9,380 -288

External Funding

New Public Dividend Capital (PDC) 16,000 14,600 -1,400 Slippage in the site infrastructure scheme has

reduced the requirement for PDC funding..

Capital Investment Loan Repayments -1,500 -1,500 0

Total External Funding 14,500 13,100 -1,400

Total Capital Funding 24,168 22,480 -1,688

Capital Surplus/(Deficit) 0 0 0

Appendix 2: Trust KPI Heatmap


46

Trust Heatmap


Appendix 3: Ward Staffing Levels


48


The figures reported above are submitted to the DoH via Unify on a monthly basis to support NHS England Safer Staffing along with the ten expectations from the NQB. These figures show the previous months Trust wide Nurse staffing, along with exceptions and actions being taken. Patients are able to view this information on the Trusts Internet Site.


REPORT TO THE TRUST BOARD PUBLIC

25 JUNE 2014

Trust board/templates/header sheet (public) version 6 – August 2011

Subject: Trust Development Authority (TDA) Oversight Monthly Self-Certification Requirements June 2014

Report By: Gail Nolan, Chief Finance OfficerAuthor: Lynda Cockrill, Head of Performance & Programme AnalyticsAccountable ExecutiveDirector:

Gail Nolan, Chief Finance Officer

PURPOSE OF THE REPORT:To be present the proposed self-certification and Board compliance statements for June forAPPROVAL in line with TDA requirements.

SUMMARY OF KEY ISSUES:Appendix A; lists current compliance status against the statements contained in the TrustSelf-certification Board Statement that is required to be submitted to the TDA on the lastworking day of the month. The Board Statement covers elements of Clinical Quality,Finance and Governance.

Appendix B; sets out current compliance against the twelve conditions that must be met tofulfil Monitor Licence Requirements for NHS Trusts. Further detail on the conditions can beaccessed through the links provided.

The statements in both appendix A and appendix B are unchanged from last month.






RECOMMENDATION / DECISION REQUIRED:The Trust Board is asked to APPROVE the statements made in appendix A and appendix Bfor submission to the TDA.

IMPLICATIONS:Financial: There are no financial implications associated with the report.HR/Equality & Diversity: N/AGovernance: As an NHS Trust the organisation is required to comply with the

TDA Accountability Framework.Legal: There are no legal issuesNHS Constitution: The Trust is required to provide high quality care.Risk: The achievement of FT status will only be possible for NHS

Trusts that are delivering the key fundamentals of clinicalquality, good patient experience, and national and localstandards and targets, within the available financial envelope.


REPORT TO THE TRUST BOARD PUBLIC

25 JUNE 2014

Trust board/templates/header sheet (public) version 6 – August 2011

COMMITTEES/MEETINGS WHERE THIS ITEMS HAS BEEN CONSIDERED:Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee N/A Remuneration Committee N/AFinance and PerformanceCommittee

N/A Chief Officers Group N/A

Audit Committee N/A

APPENDIX A

OVERSIGHT: Monthly self-certification requirements - Board Statements Compliance

CLINICAL QUALITY

1. The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model (supported byCare Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses toadopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcareprovided to its patients.

YES

2. The Board is satisfied that plans in place are sufficient to ensure on-going compliance with the Care Quality Commission’s registration requirements. YES

3. The Board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met therelevant registration and revalidation requirements.

YES

FINANCE

4. The Board is satisfied that the trust shall at all times remain a going concern, as defined by the most up to date accounting standards in force from timeto time.

YES

GOVERNANCE

5. The Board will ensure that the trust remains at all times compliant with the NTDA accountability framework and shows regard to the NHS Constitutionat all times.

YES

6. All current key risks to compliance with the NTDA's Accountability Framework have been identified (raised either internally or by external audit andassessment bodies) and addressed – or there are appropriate action plans in place to address the issues in a timely manner.

YES

7. The Board has considered all likely future risks to compliance with the NTDA Accountability Framework and has reviewed appropriate evidenceregarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued compliance.

YES

8. The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliverthe annual operating plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily.

YES

9. An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance framework requirements that supportthe Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).

YES

10. The Board is satisfied that plans in place are sufficient to ensure on-going compliance with all existing targets as set out in the NTDA oversight model;and a commitment to comply with all known targets going forward.

YES

11. The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit. YES

12. The Board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that there are nomaterial conflicts of interest in the board of directors; and that all board positions are filled, or plans are in place to fill any vacancies.

YES

13. The Board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge theirfunctions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.

YES

14. The Board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual operating plan; and themanagement structure in place is adequate to deliver the annual operating plan.

YES

APPENDIX B

OVERSIGHT: Monthly self-certification requirements - Compliance Monitor

PageReference

(PDF document)†

Annex PageNumber ‡

Compliance

1. Condition G4 – Fit and proper persons as Governors and Directors (also applicable to those performing equivalent orsimilar functions). 64 5 YES

2. Condition G5 – Having regard to monitor Guidance.66 7 YES

3. Condition G7 – Registration with the Care Quality Commission.68 9 YES

4. Condition G8 – Patient eligibility and selection criteria.69 10 YES

5. Condition P1 – Recording of information.74 15 YES

6. Condition P2 – Provision of information.76 17 YES

7. Condition P3 – Assurance report on submissions to Monitor.77 18 YES

8. Condition P4 – Compliance with the National Tariff.78 19 YES

9. Condition P5 – Constructive engagement concerning local tariff modifications.79 20 YES

10. Condition C1 – The right of patients to make choices.80 21 YES

11. Condition C2 – Competition oversight.81 22 YES

12. Condition IC1 – Provision of integrated care.82 23 YES

† https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285008/ToPublishLicenceDoc14February.pdf

‡ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285009/Annex_NHS_provider_licence_conditions_-_20120207.pdf



25th

June 2014

Subject: Private Trust Board Meeting Session Report of 28 May 2014Report By: Sam Tubb, Vice ChairAuthor: Rebecca Southall, Director of Corporate AffairsAccountable Executive Director: Andrew Meehan, Chairman


To report in public the substantive agenda items discussed at the private section of the Trust Boardmeeting held on 28th May 2014 and the extraordinary meeting on 2nd June 2014 and the keydecisions/outcomes made by the Trust Board.

SUMMARY OF KEY ISSUES:Items discussed included:

Legal Case; the Board discussed an on-going legal matter. A decision was reached in this regardbut remains confidential at the present time given that it is the subject of on-going legal proceedings.

Additional Consultant Posts; the Trust Board approved the establishment of a new ConsultantPost.

Annual Accounts; the Board adopted the Annual Accounts for 2013/14. An unqualified opinion wasissued by the auditors and the financial statements will be included within the Annual Report2013/14, which will be made available to the public at the Annual General Meeting on 30th July 2014.







The Board is asked RECEIVE the report.

IMPLICATIONS:Financial: There were financial implications associated with the appointment of

a new Consultant and the legal case. These matters arecommercially sensitive and legally privileged respectively, and for thatreason are not discussed in the public domain.

HR/Equality & Diversity: None identifiedGovernance: This paper is submitted in-line with the principles of being open and

transparent.Legal: The legal issues around the outcome of the legal case were

discussed.NHS Constitution: None identifiedRisk: The risks identified in relation to all of the items considered by the

Board were discussed as an integral part of that item.



25th

June 2014

COMMITTEES/MEETINGS WHERE THIS ITEMS HAS BEEN CONSIDERED:Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee NA Remuneration Committee NAFinance and Performance Committee NA Chief Officers Group NAAudit Committee NA

ENCLOSURE NO: 9

INTERIM COMMITTEE REPORT TO BOARD

Purpose: This report has two purposes; firstly to assure the Board that thecommittees that it has formally constituted are meeting in accordance with theirterms of reference and secondly to advise Board Members of the businesstransacted at the most recent meeting and to invite questions from non-committeemembers thereon.

Committee Name: Quality Governance Committee

Committee Meeting Date: 3rd June 2014

Quoracy: Yes

Apologies: Andy Hardy, Peter Winstanley & Andy Philips

Chair: Ed Macalister-Smith

Report submitted by: Paul Martin, Director of Governance

1. The minutes of the April meeting were approved; and actions were noted ascompleted.2. Quality Governance Framework (QGF); it was reported that due to manydevelopments, including stability of the Board, the IPR report and other relevantfactors, there has been significant improvement.3. Complaints & PALS Annual Report 2013/14 and Action Plan – ImpressionsReport showed 91% of the Trust’s service users gave positive feedback in2013/14. There had been a slight increase to complaints, but most complaints hadbeen responded to within the 25 day target.4. Quality, Performance & Finance Report – It was noted that many issueshighlighted within the report relate to the Emergency Care pathway which iscurrently undergoing a programme of improvements. The Integrated PerformanceReport (IPR) is also being re-developed to provide more specific information. Thismonth has seen higher incidents of falls than in the past 18-months and analysis isunderway to determine whether there is any commonality. The Committee wasadvised that there had been one case of MRSA against a target of zero; assurancewas given however that investigation was underway and there was no underlyingcause for concern.5. Draft Quality Account – The Committee was advised that due to therescheduling of the meetings the report was later than in previous years. Memberswere invited to comment on the content.6. HR Equality & Diversity – the Committee received reports from the HREDcommittee.

7. Training, Education and Research (TER) meeting reports were received.

8. Patient Engagement and Experience Committee – changes to the Committeewere proposed; these included a strategic and operational focus on alternatemonths and membership from patient representatives with recent experience ofcare at the Trust in order to engage with them, obtain their feedback and moveissues forward. The Committee agreed to the proposals on the basis that finalisedterms of reference are submitted for ratification.9. Patient Safety Committee – the Blood Compliance Report and RadiationReport were the key issues discussed and it was confirmed that all necessaryactions are in progress. It was further noted that the Annual Audit Awards werescheduled to take place in July.

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10. Hospital Standardised Mortality Rate (HSMR) & Summary Hospital-levelMortality Indicator Report (SHMI)– the report content of the report was noted.

11. Significant Incident Group – during April 2014, 15 Serious Incidents (SI)were opened; 9 SI investigations were completed and 20 Serious IncidentsRequiring Investigation (SIRI) were reported to commissioners. 3 SIRI were notclosed before the 45 day target but these were complex and it was necessary toextend the investigation period to ensure that a thorough investigation wasundertaken and a robust action plan approved12. Information and ICT Committee– the Committee was advised there areissues with regards to attendance which has meant that meetings have not beenquorate. It was agreed that this would be reviewed to ensure that the root cause isaddressed.13. Risk Committee – there were 25 red risks and 0 Board Assurance Framework(BAF) risks recorded on the risk register. Risk Register guidance has been revisedand redistributed to staff and Risk Management training sessions have beenprovided for senior managers by an external provider.14. Blood Transfusion Annual Report 2013/14– the Committee was advised thatthe Trust is monitored on blood usage and that as this had decreased by asignificant amount a large amount of money had been saved. Some issues werehighlighted with regard to labelling and these are receiving focus. The 100%Mandatory training target was also not achieved.15. Human Resources Strategy & Workforce Report – there has been asignificant improvement in performance regarding appraisals, sickness absencerates and compliance with mandatory training, although there continues to beincreasing concerns regarding the high levels of expenditure for agency staff andsignificantly worse performance regarding the number of Consultants with anagreed and current job plan.16. Information Governance Toolkit; the Committee was given an update on theestablishment of an Information Governance Unit and was advised that adedicated IG team is now in place. Much work has been done and a robustsystem is now in place as a result. Mandatory training is still a key issue and is theonly red-graded unsatisfactory area.17. Cancer Performance; the Committee was advised of the actions that arebeing taken to improve on the current 85% achieved waiting time target. Withregard to any quality issues it was highlighted that the actual cause of death wasimportant as it can often give misleading results. Assurance was also given that ifa patient needed to be seen urgently, they would be given an appointment; theissue was continuing care owing to the impact of emergency care on elective.Inability to fill key-staff posts was also a major concern.18. Surgery Nursing Key Performance Indicator Action Plan; the Committeewas advised that although there had been no significant improvement in theworkforce indicators for the past 3 months the recruitment of new nurses was inthe pipeline and due to commence shortly. The interim temporary staffingsolutions were mitigating any shortfalls and were being reviewed daily. It wasfurther noted that the rise in clostridium difficile cases within some areas during Q4had been addressed, with only one further case since February. There were somereports of negative patient experience through ‘impressions’ that were beingactioned by the senior nursing team. The Committee was assured that all areas inneed of attention are receiving focus and all action plans are in hand.

of 3Interim Report to Board

19. Nursing Care Assurance Assessment Review, Mulberry Ward – theCommittee noted that the report was excellent and very positive. Comments fromthe reviewers and from students reported first rate experiences on the ward and itwas noted that patients felt truly cared for. There were no concerns highlighted inrelation to care delivery, patient experience or mandatory training etc. Manyexamples of good practice were identified, such as effective and proactiveleadership by the Ward Manager; active involvement of patients in their careprogramme and discharge plan; excellent clinical and non-clinical staff knowledge;a clean and welcoming ward environment; commendable ward infection preventionand control practices and supportive learning environment for students.

The Board is asked to note the business discussed at the meeting, to raiseany questions in relation to the same.

ENCLOSURE NO: 10



Committee Name: Finance and Performance Committee

Committee Meeting Date: 3rd June 2014

Quoracy: Yes

Apologies: None

Chair: Sam Tubb

Report submitted by: Alan Jones Associate Director of Finance – CorporateServices

PERFORMANCE REPORTS - INTEGRATED PERFORMANCE REPORT; adetailed report on current performance against the A&E four hour standard and theimpact upon elective activity and referral to treatment times was given. Work iscurrently being undertaken on a capacity plan which will be presented at a futuremeeting of the Committee.

PERFORMANCE REPORTS – DELIVERY REPORT – CIPs CQUIN, QIPP; thereport provided the Committee with an update on the identification of the Trust’sefficiency programme for 2014/15 and delivery as at Month 1. An update onCQUIN and QIPP was also included. The Committee was also advised that theCIP Steering Group has a fixed work programme and is focussing on theidentification and resolution of barriers to the delivery of CIPs.

PERFORMANCE REPORTS – INTEGRATED FINANCE REPORT; the reportdetailed the financial position of the Trust at Month 1; the need to identify anypotential impact of cost pressures and risks to the delivery of CIPs as early aspossible was discussed along with potential changes to the Financial Planfollowing on from changes to the Capital Programme. The Committee was alsoadvised of a piece of work that was underway to align financial and workforcecontrols.

PERFORMANCE REPORTS – FINANCIAL RISKS; the Committee was advisedthat the Trust’s financial risks were being reassessed in light of the 2014/15 BAF.

STRATEGY DEVELOPMENT – CAPITAL PLAN; the Committee was advised thatfurther work was being undertaken in relation to the Capital Programme inpreparation for submission of a capital financing application to the TDA.

COMMITTEE WORKPLAN; the Committee reviewed its work-plan for the year andtaking into account the changes to the timing of the meeting it was agreed that aseries of “deep dives” into a number of key areas would be added to the workprogramme.


ENCLOSURE NO: 11

Page 1 of 1Interim Report to Board



Committee Name: Audit Committee

Committee Meeting Date: 2nd June 2014

Quoracy: Yes

Apologies: None

Chair: Trevor Robinson

Report submitted by: Rebecca Southall

1. EXTERNAL AUDIT ISA 260 REPORT 2013/14

The report was received following a presentation that was given on the annualaccounts which covered the matters within.

2. DRAFT QUALITY ACCOUNT 2013/14

The draft was received and Committee members were advised that the Trust’sexternal auditor had provided feedback, which would be incorporated into thedocument before presentation to the June Trust Board.

3. ANNUAL ACCOUNTS 2013/14

The Committee recommended the adoption of the Annual Accounts 2013/14 to theTrust Board.


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