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Poole�Hospital�NHS�Foundation�Trust

Board�of�Directors

Board�of�Directors�Public�Meeting�September�2016

28�September�2016�-�10:15

Board�Rooms,�BH15�2JB

AGENDA

1 Apologies�for�Absence

2 Declarations�of�InterestOwner:�Chairman

3 Patient�StoryOwner:�DoN

4 For�Accuracy�and�to�Agree:�Part�1�Minutes�of�the�Board�Meeting�held�on31�August�2016Owner:�Chairman

BoD�Sep�16�4�Aug�16�Draft�Part�1�Minutes 8

5 Matters�Arising�–�Action�ListOwner:�Chairman

BoD�Sep�16�5�Part�1�Action�List 17

6 Chairman’s�ReportOwner:�Chairman

7 Chief�Executive’s�ReportOwner:�Chief�Executive

BoD�Sep�16�7�CE�Report�Sept�16 21

8 FOR�APPROVAL

http://www.eshareuk.com

9 Council�of�Governor�Questions�to�the�Board�of�DirectorsOwner:�Co�Sec/�Chairman

BoD�Sep�16�9a�Cover�engagement�between�the�Council 25BoD�Sep�16�9b�Council�of�Governors�Questions�to�th 27

10 Quality�StrategyOwner:�DoN

BoD�Sep�16�10a�Cover�Sheet�Quality�Strategy�Sept�2 31BoD�Sep�16�10b�Quality�Improvement�Strategy�2016�- 33

11 QUALITY,�SAFETY�&�PERFORMANCE

12 Ward�to�Board�ReportOwner:�DoN

For�scrutiny

BoD�Sep�16�12a�Cover�Ward�to�Board�Q1�6�WCO 57BoD�Sep�16�12b�Q1�Women��Children�Report�V2 59

13 Integrated�Performance�ReportOwner:�COO/�MD/DoN/�DoHROD

For�scrutiny

BoD�Sep�16�13a�Part�1�Cover�Sheet�IPR�Aug 71BoD�Sep�16�13b�Performance�Report�Trust�Board 75

14 Financial�Performance�–�Month�5Owner:�DoF

For�scrutiny

BoD�Sep�16�14a�Financial�Performance�2016-17�Month 99BoD�Sep�16�14b�Financial�Performance�2016�17�Month 101

15 Quarterly�Complaints�Report��-�Q1Owner:�DoN

For�scrutiny

BoD�Sep�16�15a�Complaints�Cover�Sheet�Q1 103BoD�Sep�16�15b�Complaints�Quarterly�Report��FINAL 104

16 Serious�Incident�-�Electronic�Patient�Records�UpdateOwner:�MD

For�information


17 Chairman's�Report�of�the�Finance�and�Investment�Committee�held�on�26September�2016Owner:�FIC�Chairman

For�scrutiny

18 Chairman’s�Report�of�the�Quality,�Safety�and�Performance�Committee�heldon�26�September�2016Owner:�QSPC�Chairman

For�scrutiny

19 STRATEGY�&�PLANNING

20 Sustainability�and�Transformation�PlanOwner:�DoS

For�information

21 Vanguard�UpdateOwner:�DoS

For�information

BoD�Sep�16�21a�Vanguard�cover�sheet�September�2016 112BoD�Sep�16�21b�Vanguard�Board�Update 113

22 GOVERNANCE�&�COMPLIANCE

23 NHS�Improvement�Quarter�1�FeedbackOwner:�CE/DoF

BoD�Sep�16�23a�NHSI�Q1�Feedback�BoD 114BoD�Sep�16�23b�NHSI�Q1�Feedback�FIC��2�Letter 115

24 Today’s�Board�Seminar��-�Stroke�ServicesOwner:�Chairman

25 Questions�from�the�Council�of�GovernorsOwner:�Chairman

26 Any�Other�Business

27 Board�Reflection�on�Current�Meeting


28 Date�and�Time�of�Next�Public�Meeting:�Wednesday�26�October,�10:15am�inBoard�Rooms,�Poole�Hospital�NHS�Foundation�Trust

29 Withdrawal�of�Press�and�Public�giving�the�opportunity�for�Governors�tospeak�with�individual�directors.

30 2016�Meeting�Dates:�26�October,�30�November.

31 NB:�A�glossary�of�abbreviations�that�may�be�used�in�the�Board�of�Directorspapers�will�be�found�at�the�back�of�the�Part�1�Papers.

32 AGENDA�-�PRIVATE�MEETING

33 12.30am�(approximately)�on�Wednesday�28�September��2016�in�the�BoardRooms,�Poole�Hospital

34 For�Accuracy�and�to�Agree:�Part�2�Minutes�of�the�Board�meeting�held�on�31August��2016Owner:�Chairman

35 Matters�Arising�–�Action�ListOwner:�Chairman

36 Chairman’s�Report�to�Part�2Owner:�Chairman

37 Chief�Executive’s�Report�to�Part�2�:�Early�Warnings�&�Feedback�from�NHSImprovement�MeetingOwner:�CE

38 FOR�APPROVAL

39 The�Procurement�Transformation�Plan�(PTP)Owner:�DoF

40 Well-led�Self-AssessmentOwner:�Co�Sec

41 Document�Storage�ContractOwner:�DoS


42 Dorset�Sustainability�and�Transformation�PlanOwner:�DoS

43 QUALITY,�SAFETY�&�PERFORMANCE

44 Risk�Register:�New�Red�and�Amber�RisksOwner:�DoN

For�scrutiny

45 Serious�Incident�ReportOwner:�MD

For�scrutiny

46 Gap�Analysis�on�Trust�RecruitmentOwner:�DoF/�COO/�DoS

For�scrutiny

47 STRATEGY�&�PLANNING

48 Revised�2016/17�Financial�PlanOwner:�DoF

For�scrutiny

49 Proposed�Planning�Framework�for�2017/18Owner:�DoF

For�scrutiny

50 BOARD�SUB-COMMITTEE�MINUTES�FOR�SCRUTINY

51 Draft�Minutes�of�the�Finance�and�Investment�Committee�held�on�Tuesday30�August�2016Owner:�Chairman

For�scrutiny

52 Draft�Minutes�of�the�Workforce�and�Organisational�Development�Committeeheld�on�Tuesday�30�August�2016Owner:�Chairman

For�scrutiny


53 OTHER�COMMITTEE/GROUP�MINUTES�FOR�SCRUTINY

54 Minutes�of�the�Hospital�Executive�Group�Meeting�held�on�Friday�26�August2016.Owner:�Chairman

For�scrutiny

55 Any�Other�Business

56 Board�Reflection�on�Current�Meeting

57 Date�and�Time�of�Next�Private�Board�Meeting:�Wednesday�26�October�2016at�approximately�12:30pm�in�the�Board�Rooms,�Poole�Hospital�NHSFoundation�Trust

Attendees


IndexBoD�Sep�16�4�Aug�16�Draft�Part�1�Minutes.docx......................................................................8

BoD�Sep�16�5�Part�1�Action�List.docx.....................................................................................17

BoD�Sep�16�7�CE�Report�Sept�16.docx..................................................................................21

BoD�Sep�16�9a�Cover�engagement�between�the�Council�of�Govern......................................25

BoD�Sep�16�9b�Council�of�Governors�Questions�to�the�Board�of...........................................27

BoD�Sep�16�10a�Cover�Sheet�Quality�Strategy�Sept�2016.docx............................................31

BoD�Sep�16�10b�Quality�Improvement�Strategy�2016�-�FINAL.doc........................................33

BoD�Sep�16�12a�Cover�Ward�to�Board�Q1�6�WCO.docx........................................................57

BoD�Sep�16�12b�Q1�Women��Children�Report�V2.docx......................................................... 59

BoD�Sep�16�13a�Part�1�Cover�Sheet�IPR�Aug.docx...............................................................71

BoD�Sep�16�13b�Performance�Report�Trust�Board.pdf.......................................................... 75

BoD�Sep�16�14a�Financial�Performance�2016-17�Month�5.docx............................................99

BoD�Sep�16�14b�Financial�Performance�2016�17�Month�05.pdf...........................................101

BoD�Sep�16�15a�Complaints�Cover�Sheet�Q1.docx............................................................. 103

BoD�Sep�16�15b�Complaints�Quarterly�Report��FINAL.docx................................................ 104

BoD�Sep�16�21a�Vanguard�cover�sheet�September�2016.docx........................................... 112

BoD�Sep�16�21b�Vanguard�Board�Update.pptx....................................................................113

BoD�Sep�16�23a�NHSI�Q1�Feedback�BoD.docx...................................................................114

BoD�Sep�16�23b�NHSI�Q1�Feedback�FIC��2�Letter.pdf........................................................ 115

Glossary�of�Abbreviations�August�2016.docx....................................................................... 117

2016-17�Board�Governance�Cycle�August�2016.docx..........................................................122


1

POOLE HOSPITAL NHS FOUNDATION TRUST

BOARD OF DIRECTORS PUBLIC MEETING

Part 1 minutes of the meeting held at 10:15am on Wednesday 31 August 2016 in the Board Rooms Poole Hospital NHS Foundation Trust.

Present: Mrs Angela Schofield Chairman Mrs Debbie Fleming Chief ExecutiveMr Philip Green Non-Executive DirectorMr Ian Marshall Non-Executive DirectorDr Calum McArthur Non-Executive DirectorMr Paul Miller Director of StrategyMr Mark Mould Chief Operating OfficerMr Mark Orchard Director of FinanceMr Robert Talbot Medical Director Mrs Caroline Tapster Non-Executive DirectorMr David Walden Non-Executive DirectorMr Nick Ziebland Non-Executive Director

In attendance: Mrs Mandy Craig Senior HR Business PartnerMs Keeley Hull Senior Staff Nurse (for item 12)Mr Jolyon Lockhart Matron Surgery and Trauma (for item 12)Miss Kylie Nye Board and Council AdministratorMrs Denise Richards Assistant Director of NursingMr Eoin Scott Matron Critical Care (for item 12)Mrs Carrie Stone Company SecretaryDr Angus Wood Deputy Medical Director

The chairman welcomed the governors, staff and members of the public to the meeting. The chairman also welcomed Denise Richards who had joined the meeting in Tracey Nutter’s absence, Mandy Craig as HR representative for the meeting and Angus Wood who was attending as the Hospital Executive Group Representative.

PHFT 327/16 Apologies for Absence

Apologies for absence were received from Tracey Nutter, Director of Nursing.

PHFT 328/16 Declarations of Interest

There were no declarations of interest.

PHFT 329/16 Patient Story

Mrs Richards presented a 10 minute pre-recorded video which focused on a patient’s experience in an outpatient clinic following a fracture. The video was discussed and Mrs Richards noted that the story highlighted the challenge in embedding culture change within individual departments. Mr Mould noted that as services become busier, they can become process driven and it is important to maintain patient experience whilst delivering the best care.

The Board noted that the video would be used for training purposes and disseminated to the appropriate staff. The chairman noted that she

BoD�Sep�16�4�Aug�16�Draft�PartOverall�Page�8�of�125Page�1�of�9


2

writes to all patients on behalf of the Board to express thanks for telling their story.

PHFT 330/16 For Accuracy and to Agree: Part 1 minutes of the Board meeting held on 27 July 2016 (paper 1)

The minutes were AGREED as a correct record of the meeting.

PHFT 331/16 Matters Arising – Action List (paper 2)

It was NOTED and AGREED that all other matters arising unless subject to this or a future agenda had been executed.

PHFT 332/16 Chairman’s Report

The chairman reported that:

The Board would be receiving patient meals during their lunch break. Thanks were given to the catering team for organising the lunches.

A Remuneration Committee had been held on 27 July 2016. This was an annual meeting to review the executive directors’ performance.

An Appointments Committee had been held on 27 July 2016. This had been held to approve the job description, person specification and advert for the post of director of nursing.

The Elections process for staff and public governors is underway. All nomination forms have to be with the returning office at Electoral Reform Services by 5pm on Monday 5 September.

The Trust is holding its Annual Members’ Meeting on Monday 19 September at Poole Salvation Army Hall. Lunch will be served from 1pm with the meeting starting at 2pm.

In light of recent discussions about the possibility of reconsidering a merger with the Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, the chairman’s recruitment process has been slightly delayed from the original timetable. It is now anticipated that the interviews for a new Trust chairman will take place on Wednesday 18 January 2017.

At the last part 2 Board meeting they approved:

The terms of the application for interim support funding and delegated authority to the Chief Executive and Director of Finance to execute on its behalf the Working Capital Facility Agreement up to the value of £6.1m during 2016/17.

the delegation of authority to the Chief Executive and the Director of Finance to agree and sign off a control total within the parameters of up to a £3.9m surplus.



3

NHS Improvement Quarterly Submission and Certifications – Quarter 1 2016/17

Radiotherapy Satellite Building Tender Evaluation

Radiotherapy Satellite Heads of Terms

At the last part 2 Board meeting they received/scrutinised:

Risk Register: New Red Risks Summary Serious Incident Report – June 2016 Summary of Claims Sustainability and Transformation Programme Vanguard Programme Update Update on 2016/17 CCG Funded Investment Plan

The report was NOTED.

PHFT 333/16 Chief Executive’s Report (paper 3)

Mrs Fleming presented her report and highlighted the following key points:

The Trust has agreed a 2016/17 financial ‘control total’ with NHS Improvement. This enables the Trust to earn up to £7.9m Sustainability and Transformation income during the year. This means the Trust will no longer need to apply for additional cash from the Department of Health this year and will be able to maintain a ‘going concern’ status. However, in agreeing the control total, the Trust will have to stretch the original plan by a further £3.1m and this will mean controlling expenditure very tightly throughout the year. Mrs Fleming noted that there will be briefings for staff in the next few weeks to update them on the financial position.

A meeting has been scheduled for the 7 September with NHS Improvement to further discuss potential merger options. This meeting will involve the Chief Executive from Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and a representative from the Clinical Commissioning Group. Mrs Fleming noted that she would report back on the outcome of this meeting at the next Board meeting. ACTION: DF

Planning guidance for the next year from NHS Improvement is scheduled to be released in September 2016. The joint planning guidance from NHS England and NHS Improvement is aimed at the signing of two year contracts for 2017/18 and 2018/19. The final plans will be required before Christmas 2016.

Mrs Fleming provided a verbal update of a serious incident which had taken place the previous week. Mrs Fleming noted that the Electronic Patient Record (EPR) system had experienced significant delays. However, Mrs Fleming noted



4

that staff had managed very well considering the circumstances and significant disruption had been largely avoided. The incident was discussed in detail and Mr Marshall raised concerns that there were delays for a substantial period of time before the issue was resolved. It was agreed that a full report of the incident and mitigating actions would come back to the Board in September. ACTION: MO/RT


PHFT 334/16 Annual Policy Review for Complaints (paper 4)

Mr Talbot presented the report, briefing the Board of Directors on the Trust’s compliance with the policy and procedure for the management of complaints from 1 April 2015 – 31 March 2016.

Mr Talbot reported that the process of managing formal complaints had been reviewed and revised during the year. Response times had been a concern but had gradually improved throughout the year. An audit of the policy and process has been undertaken by the CCG and the Trust’s Internal Auditors, TIAA. Mr Talbot noted that all actions and recommendations identified had been completed. In relation to the Internal Audit report, the chairman asked if the target to respond to 85% of complainants within 25 days was still in place. Mr Talbot confirmed that this is the target the Trust is working to and is reviewed in the quarterly complaints reports that go to the Quality, Safety and performance Committee and the Board.

The Board APPROVED the report.

PHFT 335/16 Statement of commitment to the principles of the Code of Practice: For the prevention and control of Health Care Associated Infections. (paper 5)

Mrs Richards presented the report to confirm Board commitment to the measures in place for compliance with the Code of Practice.

Mrs Richards noted that the statement of commitment forms part of the Trust assurance framework for compliance with the code and is contained within the Trust’s overarching Prevention and Control of Infection Policy. The report was discussed and Mr Ziebland noted that there was no mention of the Quality, Safety and Performance Committee in the statement. Mrs Richards noted that the statement would be amended to include a section on the Quality, Safety and Performance Committee. ACTION: DR

The Board APPROVED the statement.

PHFT 336/16 Ward to Board Report – Surgery, Trauma and Theatre Services (paper 6)

The chairman welcomed Mr Lockhart, Mr Scott and Ms Hull to the meeting and invited them to the table for discussion.

Mrs Richards presented the report providing the Board with a cohesive



5

perspective on ward activities for quarter 1 in Surgery, Trauma and Theatre services. Mrs Richard noted that the Wednesday Ward Watch highlighted that more focus is required with MUST assessment and documentation of pressure ulcer care. Mrs Richards noted that there are issues across the directorate with keeping the drug fridges locked. However, there have been significant improvements across wards in the recording of drug fridge temperatures. Mrs Richards noted that 15 new fridges have been purchased and the Trust is looking into a central monitoring system which will automatically check drug fridge temperatures. In the short term however, Mrs Richards noted that ensuring drug fridges are locked and temperatures are checked is a cultural issue across wards which the matrons and sisters are working with staff to improve.

Mrs Richards reported that in theatres there have been concerns in relation to the WHO checklists. Mr Miller noted that only 50% of the surgical checklists had been completed without prompting. Mrs Richards noted that this issue has been discussed at the quality performance meetings and is being closely monitored. Mr Miller noted that 41 incidents had occurred in theatres in the reporting period and asked if this was above the average number. Mrs Richards noted that the number of incidents in theatres is on par with previous months and there were no significant trends to report.

The impact of delayed discharges and delayed transfers of care (DTOC) were discussed. Mr Lockhart noted that delayed discharges have caused a number of outlying patients to be situated in surgical wards. Mr Mould noted that there are currently issues relating to discharge planning and the 48 hour notice care plan is not in place. Mr Mould advised that there is a Task and Finish Group in place and work continues to manage discharge planning internally and with the local authority.

Mrs Richards noted that the Friends and Family Test had achieved a good response during the reporting period and patient feedback was very encouraging with 98.8% positive feedback.


The chairman thanked staff members for attending and they left the meeting.

PHFT 337/16 Integrated Performance Report (paper 7)

Mr Mould, Mrs Richards, Mr Talbot and Mrs Craig presented the Integrated Performance Report and highlighted the following key points:

Mr Mould provided an update in relation to key operational issues:

In July the Trust achieved the 18 week Referral to Treatment (RTT) waiting times for incomplete pathways but not in every speciality. Work continues to improve this position and Mr Mould noted that the Trust is within the trajectory of performance agreed with NHS Improvement. Mr Mould added that a paper outlining the Trust’s performance trajectories will come to



6

September’s Finance and Investment Committee meeting. ACTION: MMo

All cancer waiting time targets were met in June and quarter one overall. However, the 62 day target still remains challenging and plans are in place to assist in supporting the service. Mr Mould noted that there had not been a single breach in 2 years in relation to the symptomatic breast two week wait target. It was agreed that a letter on behalf of the Board would go to the Breast Screening team to recognise their hard work in achieving this target. ACTION: MMo

The four hour organisational target was not achieved in July. However, Mr Mould noted that there have been improvements month on month. Mr Mould noted that although the 95% target had not been achieved the Trust is within the agreed trajectory of performance agreed with NHS Improvement. Mr Mould further noted that the A&E recovery plan would be discussed later in the meeting.

Mrs Richards provided an update in relation to key quality and safety issues:

Mrs Richards reported there have been 6 reported C-difficile cases for the year to date. There have been no MRSA bacteraemia cases reported in 2016/17 to date.

The Board noted that the safer staffing page now included red flag incidents. There were 9 local staff nursing concerns raised, with two categorised as red flag incidents. All red flag events are actioned promptly by senior nursing staff and are reviewed by the matron, clinical risk manager and the assistant director of nursing (workforce).

Mr Talbot noted that there were not any significant concerns to highlight in relation to Mortality and Medicines Optimisation.

Mrs Craig provided an update in relation to key workforce issues:

Sickness rates continue to stay low at 3.55%. Turnover rates continue to fall with overall turnover at 13.38% which is within the Trust’s 14.00% target.

Appraisal rates for non-medical staff fell by 1% during July to 85% against a 95% target.

Mandatory training compliance rates remained at 88% against a 90% target.


PHFT 338/16 Accident and Emergency Recovery Plan (paper 8)

Mr Mould presented the report providing the Board with the Trust’s four hour organisational plan and the national plan to recover the standard



7

to 95% by the end of 2016/17 as set out by NHS Improvement, NHS England and Directors of Adult Social Services (ADASS).

Mr Mould noted that a Regional A&E Delivery Board has been established to support and oversee the A&E improvement plan across Dorset. There are five mandated improvement initiatives relating to streaming, flow and discharge which are already incorporated in to the Trust’s action plan.

Mr Mould noted that the Trust’s four hour organisational action plan will be monitored through the Hospital Executive Group and the Quality, Safety and Performance Committee (QSPC). The Board noted that this report will be going to September’s QSPC for further scrutiny.

ACTION: MMo


PHFT 339/16 Financial Performance – Month 4 (paper 9)

Mr Orchard presented the report providing the Board with the Trust’s financial performance as at the end of July 2016/17. Mr Orchard noted that the Finance and Investment Committee had scrutinised this report.

The Board of Directors had initially agreed a planned deficit of £9.7m, a projected in-year cash shortfall of £4.9m and a Cost Improvement Programme of £6.1m.

As discussed previously, the Board has since agreed a control total in July 2016 with NHS Improvement and a revised plan has been produced to reflect this. The newly revised plan with the agreed control total is a deficit of £0.8m and a projected positive cash balance each month which assumes receipt of STF income amounting to £7.9m. The delivery of this plan requires an additional £3.1m CIP.

The revised plan has been reflected in the month 4 financial performance. For the month of July the Trust reported a surplus of £2,436k against a planned surplus of £2,424k and overall delivery of the year to date revised plan

Year to date £430k of the CIP is unidentified. However, 90% of the total identified CIP has been delivered in the first four months. The committee noted that a further CIP plan of £3.1m is under development as part of the control total agreement.

In July the Trust had spent £415k on agency and locum staff. This is more than the £370k monthly cap set by NHS Improvement. However, is significantly less than previous months. Mr Orchard noted that a detailed discussion relating to agency and locum staff had taken place at FIC and it was agreed that a paper would come back to September’s meeting highlighting where the Trust has gaps in recruiting to significant posts, the associated impact and recruitment plan.

ACTION: PM/MMo/MO



8


PHFT 340/16 Chairman’s Report of the Finance and Investment Committee held on 30 August 2016

Mr Marshall presented the tabled report of the Finance and Investment Committee and highlighted the following key points:

Following the revised financial plan for 2016/17 a summary of the plan including risks and assumptions will come to September’s Finance and Investment Committee and Board. ACTION: MO

Mr Marshall noted that whilst the risks and assumptions relating to the control total is a key issue, there are a number of other large projects that the Board should focus on including, the Energy Performance Contract, EPMA and the Radiotherapy project in Dorchester.

The contract for a new Outpatient Pharmacy has been signed with our preferred bidder following a number of actions discussed at last month’s Finance and Investment Committee. The Board noted that the development would have a positive impact for both staff and patients.


PHFT 341/16 Chairman’s Report of the Workforce and Organisational Development Committee held on 30 August 2016

Mr Ziebland presented the tabled report of the Workforce and Organisational Development Committee and highlighted the following key points:

The committee were pleased to note that sickness rates and staff turnover continue to be low and still declining. The HR team will continue to focus on ‘hotspot’ departments.

There is ongoing work to ensure that 85% of clinical staff receive their flu jab by the end of December. This is a CQUIN target and therefore non-compliance could result in less income than originally planned.


PHFT 342/16 Sustainability and Transformation Plan – Update Report

Mr Miller provided an oral update on the Trust’s position in relation to the Sustainability and Transformation Plan (STP).

Mr Miller noted that the deadline for submission of the STP had moved from June to October 2016 and noted that a detailed plan was ready to submit. Mr Miller reported that the NHS Investment Board had posed a series of 12 questions which the Trust is working on responding to by the 9 September.



9

The Board noted that the CCG’s consultation period in relation to the Clinical Services Review is now expected to start in early November, with a final decision expected in the summer of 2017. Mr Miller advised that the Board will be briefed in a future meeting on the impact that integrated community services will have on the Trust site.

ACTION: PM The report was NOTED.

PHFT 343/16 2017 Board Meeting Schedule (paper 10)

The chairman presented the report providing an updated schedule of Board and sub-committee dates for 2017.


PHFT 344/16 Charitable Funds – Expenditure over £25k

Mr Miller reported that in July’s Charitable Funds Committee Meeting, the trustees approved the increase from £471k to £1.4m from the Robert White fund and to continue to put aside £1.6m for a second linear accelerator in Dorchester.


PHFT 345/16 Today’s Board Seminar – Well led Self-Assessment

The chairman noted that the Board had received a seminar on the well led self-assessment domains which had been undertaken by both non-executive directors and executive directors.

PHFT 346/16 Questions from the Council of Governors

There were no questions from the Council of Governors. The chairman noted that a paper would come to September’s Board and October’s Council of Governor meeting clarifying the process in relation to how the Council of Governors can pose questions to the Board.

ACTION: CSPHFT 347/16 Any Other Business

There was no other business.

PHFT 348/16 Board Reflection on Current Meeting

The Board agreed that there were a number of important issues raised during the meeting and there had been good challenge and enthusiasm throughout.

PHFT 349/16 Date and Time of Next Meeting:

Wednesday 28 September 2016, 10:15am in Board Rooms, Poole Hospital NHS Foundation Trust




BOARD OF DIRECTORS PART 1 ACTION LIST – SEPTEMBER 2016

Minute No

Meeting Date

Part 1 or 2 Action Deadline Lead Directors Update Closed/ Open

156/16 27.04.2016 Part 1 The structure of the Women’s, Children’s & Oncology Ward to Board will be reviewed and amended.

Sep-16 Tracey Nutter To be included in the next Women's and Children's and Oncology Report in September

Open

261/16 29.06.2016 Part 1 QSPC will receive the 10 point action plan relating to the Trust’s 4 hour standard in September.

Sep-16 Mark Mould On September's QSPC agenda

Open

312/16 27.07.16 Part 2 A paper demonstrating controls with regards to pay bill growth will go to September’s FIC and October’s WODC.

Sep-16 Mark Orchard On September's FIC agenda and October's WODC agenda

Open

333/16 31.08.16 Part 1 Feedback relating to the meeting on 7th September with NHS Improvement regarding a possible merger will come back to September’s meeting.

Sep-16 Debbie Fleming Update as part of Chief Executive Report

Open

333/16 31.08.16 Part 1 Following the investigation of the IT incident relating to EPR, a full report will come back to the Board.

Sep-16 Mark Orchard/ Robert Talbot

On September’s agenda

Open

BoD�Sep�16�5�Part�1�Action�LisOverall�Page�17�of�125Page�1�of�4


335/16 31.08.16 Part 1 The Statement of Commitment to the principles of the Code of Practice: For the prevention and control of Health Care Associated Infections will be amended to include a section on the Quality, Safety and Performance Committee.

Sep-16 Denise Richards A section on QSPC to be included

Open

337/16 31.08.16 Part 1 A paper outlining the Trust’s performance trajectories will come to September’s FIC.

Sep-16 Mark Mould On September's FIC agenda

Open

337/16 31.08.16 Part 1 Mrs Schofield to write to the Breast Screening team on behalf of the Board to recognise their hard work in achieving compliance of the 2 week wait symptomatic breast target for the last 2 years.

Sep-16 Mark Mould/ Angela Schofield

Letter to go to Breast Screening Unit

Open

339/16 31.08.16 Part 1 A paper will come to September’s FIC & BoD highlighting where the Trust has gaps in recruiting to significant posts, the associated impact and recruitment plan.

Sep-16 Paul Miller/ Mark Mould/ Mark Orchard

On September's FIC and Board agenda

Open

340/16 31.08.16 Part 1 As discussed at FIC, In relation to the recently revised 2016/17 financial plan, Mr Orchard will bring a paper to September’s

Sep-16 Mark Orchard On September's FIC and Board agenda

Open



FIC and Board summarising the revised plan including risks and assumptions.

346/16 31.08.16 Part 1 A paper will come to September’s Board and October’s CoG clarifying the process in relation to how the Council of Governors can pose questions to the Board.

Sep-16 Carrie Stone On September's Board agenda

Open

FUTURE ACTIONS

064/16 02/03/2016 Part 1 It was agreed that a future Board Seminar relating to Pharmacy and medicines optimisation would be useful.

Future Seminar

Robert Talbot/ Carrie Stone

Future Seminar Open

258/16 29.06.2016 Part 1 The governors will receive a future session (possibly in a CoG meeting or as part of an informal governor briefing) on the Duty of Candour policy.

Future Informal Governor Briefing

Tracey Nutter Future Informal Governor Briefing

Open

262/16 29.06.2016 Part 1 A review and restructure of the Ward to Board report will be deferred until the new hospital model dashboard has been released by the Department of Health and NHS England.

Future meeting

Tracey Nutter Future Meeting Open



283/16 27.07.16 Part 1 Education Strategy - Healthcare scientists would be keen to present to the Board in the future on Succession Planning is a very important topic looking to develop strategies.

Future Seminar

Mark Mould Future Seminar Topic

Open

260/16 29.06.2016 Part 1 A follow up report following the Board Effectiveness Review Action plan will come to November’s Board meeting.

Nov-16 Carrie Stone On November's agenda

Open

259/16 29.06.2016 Part 1 A 6 monthly update on progress against the action points in the Trust Food and Drink Strategy will go to QSPC.

Jan-17 Mark Mould January's QSPC agenda

Open



BOARD OF DIRECTORS MEETING

SEPTEMBER 2016

REPORT OF THE CHIEF EXECUTIVE

1. Appointment of Director of Nursing

I am delighted to report that we have now appointed a new Director of Nursing to take over from Tracey Nutter when she retires at the end of this year. At the time of writing, we are unable to confirm the name of this individual, as we are still working with her current employer to co-ordinate this announcement. However, we are able to confirm that the successful candidate is a very experienced Executive, having held the post of Director of Nursing within another Foundation Trust for the past four and a half years. She will bring with her a great deal of skill and experience, having previously held the post of Deputy Director of Nursing within a teaching organisation and having worked as a Divisional General Manager earlier in her career.

We are pleased that a very capable Director of Nursing will be joining us at a time when the Trust will be working to maintain its focus on the delivery of safe, high quality patient care, whilst at the same time, reconfiguring services in line with the Dorset Clinical Services Review. We expect this individual to build on all the excellent work that Tracey Nutter has carried out over the past few years, in strengthening our governance arrangements and encouraging a greater focus on safety across the organisation.

2. Junior Doctor Contract and Industrial Action

Work is continuing within the Trust to implement the new contractual arrangements for junior doctors in line with national requirements. A local implementation timetable has been devised which means that new contracts will be offered when existing contracts expire and Dr Sue Brock, Consultant Oncologist, has been appointed as the guardian of Safe Working Hours to ensure that individuals and the Trust are compliant. Additionally, we have established a medical workforce group to facilitate discussion and address any concerns and issues arising out of implementation of the new arrangements locally. Nationally, Junior doctor industrial action is planned for 5 days in October, November and December involving full withdrawal of labour between 0800 and 1700 Monday to Friday and emergency cover will not be provided. Colleagues are working closely with junior doctors to understand, as best as possible, the likely impact. Planning meetings have been arranged to ensure that appropriate arrangements are in place to mitigate as far as possible the consequences for patients and maintain safe services.

3. Proposed Planning Framework 2017/2018 and 2018/2019

At the time of writing, the national timetable and approach for NHS planning was due to be published and expected to formalise:

two-year operational plans for providers and commissioners, underpinned by two-year formal contracts, commissioner allocations, provider control totals and 2017-19 income from the Sustainability and Transformation Fund (STF)

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an advanced timetable requiring draft plans to the regulator during November, followed by final plans underpinned by signed commissioner contracts during December.

4. NHS Improvement Single Oversight Framework

NHS Improvement has published its Single Oversight Framework (SOF), following a five week consultation period. This will be introduced from 1 October 2016 and replaces the Risk Assessment Framework. The SOF aims to provide an integrated approach for NHS I to oversee both NHS Foundation Trusts and trusts and identify the support needed to deliver high quality, sustainable healthcare services. NHSI will oversee and assess Trusts against five themes: quality of care, finance and use of resources, operational performance, strategic change and leadership and improvement capability (well-led). NHSI will segment Trusts into four, from 1 attracting maximum autonomy to 4 for those Trusts in special measures. NHSI has undertaken a shadow segmentation exercise based on how Trusts would have performed under the new framework over the last two months. Over forthcoming weeks regional teams will be contacting Trusts to discuss each organisations shadow segment.

5. Talent Works ‘Living our values every day in everything we do’

As members are aware, we aim to deliver excellent, patient-centred emergency and planned care aligned with the ‘Poole Approach’ to provide friendly, professional person-centre care through our values; compassionate, open, respectful, accountable and safe.

We know our staff, carers and volunteers support each other and endeavour to deliver the best care they can provide.

To enable us to deliver our vision, Talent Works have been commissioned to help us create a behavioural framework. Talent Works have been delivering focus groups to staff, governors and volunteers and they will be meeting our executive team on an individual basis to develop the framework in the coming weeks.

The behaviours framework will be applied to our appraisal process because ‘how we deliver’ an objective is equally important as ‘what we deliver.’ We strongly believe to be able to move forward in an ever changing environment it is essential that we live our values through the Poole Approach in everything we do. By undertaking this piece of work our staff and future leaders will have greater resilience to embrace the changes ahead whilst maintaining the quality of our services.

6. Staff Briefings

To keep staff up to date with the ongoing CSR review, the renewed consideration of plans to merge and other issues that affect Poole Hospital there have been a series of staff briefings during September. These sessions have provided an important opportunity to hear the thoughts of a range of staff, including our consultants and senior nursing staff, as well as providing a platform to discuss our plans for the future.

7. Local Government Reorganisation

The Borough of Poole has written to advise that the nine principal councils in Dorset are collectively undertaking a public consultation about local government



reorganisation. Compared to the government funding received in 2010/11, the nine councils in Dorset now received £142 million less each year towards running local services. Local government’s response to this is to re-think the way they are structured in the future, as a way of reducing costs and so protecting services. All the local government organisations are considering reducing the number of Dorset local authorities from nine to two.

They are very keen to hear from Dorset’s residents, local businesses, town and parish councils, public sector and voluntary, community and other organisations. They are encouraging residents and stakeholders to complete the consultation questionnaire, which is available along with further information at www.reshapingyourcouncils.uk. Paper copies of the questionnaire will also be available in local libraries. The consultation starts on 30th August 2016 and closes on 25th October 2016. The Trust will be responding to the consultation and a paper will be circulated to all Board members with our response.

8. Poole Hospital shortlisted for HSJ award

We have received the good news that Gully’s Place has been shortlisted for the Compassionate Patient Care category in this year’s HSJ awards. These two specialised suites provide end of life care for children and young people for sudden unexpected death and planned deaths, providing choices in end of life care in hospital, at home and beyond with bereavement support for all parents. The awards, which are in their 35th year, celebrate the finest achievements in NHS and will be held on 23 November 2016 at Intercontinental O2, London.

9. NHS Improvement Bulletins

Since the last Board meeting, the Executive Directors of the Trust confirm that they have received 2 NHS Improvement FT Bulletins (31 August 2016 and 14 September 2016) and are cognisant of the information and the requirements contained therein. The content of these bulletins can be found in Annex 1.

Debbie FlemingChief Executive


http://www.reshapingyourcouncils.uk/


Annex 1

31 August 2016

An update was received on the Visitor and Migrant NHS Cost Recovery Programme – letter attached from DH and NHSI to Chief Executives and Finance Directors. The letter is for onward cascade to Overseas Visitor Managers, Reception Staff and the PALS service. Trusts are expected to ensure sufficient focus is placed on cost recovery from overseas visitors, especially when they are situated in areas of tourism hotspots and/or near universities and higher education institutions with high numbers of overseas students.

2016/2017 costing assurance audit. NHSI has commissioned a programme of audits of costing arrangements for 2016/2017. NHSI will be in contact with those Trusts it has chosen to participate – if we have not heard by the end of October 2016, then we have not been chosen.

Update provided on the Health and Care Innovation Expo on 7th and 8th September in Manchester.

An invitation to joint NHSI, the Kings Fund and Sign up to Safety at an interactive partnership event on “Keeping people safer – working in the gap between national strategy and everyday improvement”. 20th October 2016 at the King’s Fund, London.

14 September 2016

The Single Oversight Framework (SOF) has been published and will be introduced from 1 October 2016 at which point Monitor’s Risk Assessment Framework (RAF) will no longer apply;

NHSI has produced a guide on reducing reliance on medical locums – it goes through the steps which medical directors could take to help reduce their Trust’s spend on medical locums and includes a list against which Trusts can check to see if they are taking effective action across 6 steps;

NHSI has issued a Stage 3 patient safety alert to stop the use of open systems for injectable medication – exception is embolization procedures;

NHSI has published tools and supporting guidance to help Trusts diagnose current culture and target the right areas for a collective leadership strategy. The Tools form the first phase of a two year programme;

NHSI and The College of Occupational Therapists have published a safety briefing for clinical staff who prescribe or recommend hospital-style beds for use in a domestic setting;

An invitation to individuals with experience in running elective care services opened to apply for a six month secondment with NHS I’s Elective Intensive Support team has been extended;

A New Framework is approved for all agency staff bookings.



BOARD OF DIRECTORS PART 1– COVER SHEET

Meeting Date: 26 September 2016

Agenda item: 9 Paper No: 4

Subject: Council of Governor Questions to the Board of Directors

Prepared by: Angela Schofield, Chairman and Carrie Stone, Company Secretary

Presented by: Angela Schofield, Chairman

Purpose of paper: To seek the approval of the Board.

Background: A paper describing engagement between the Council of Governors and the Board of Directors was originally drawn up in 2013, to reflect the requirements enshrined in the Trust’s constitution and Monitor’s Code of Governance. This paper reflects a move away from an absolute requirement that the agreement of two thirds of Governors is needed to raise specific issues with the Board, to a more informal approach, enabling individual governors to ask questions under the Part 1 agenda item “Questions from the Governors”.

Key points for members: The key points are: The paper fulfils the requirement of Monitor’s Code of

Governance (provision A.5.6); Reflects Section 6 of Annex 8 of the Trust’s Constitution; Under “Other Communication”, Paragraph 2.1 has been

amended to enable individual governors to put questions to the Board and receive verbal responses so far as is reasonable at the time of the meeting;

Paragraph 2.1 gives discretion to the Chairman to manage questions from the governors in the light of other Board business;

Responses to questions put by individual governors to the Board will be reported in a subsequent edition of the Governors’ e-mail;

The chairmen of the sub-committees of the Board to attend Governor briefings to discuss the work of their respective committees to assist Governors in their duty to hold the non-executive directors individually and collectively to account for the performance of the Board.

Options and decisions required:

For approval

Recommendations: To approve the attached paper.

Next steps: To submit the paper to the Council of Governors at their Council meeting on 27th October 2016

Links to Poole Hospital NHS Foundation Trust Strategic objectives, Board Assurance Framework, Corporate Risk Register

Strategic Objective:BAF/Corporate Risk Register:

(if applicable)Not applicable

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CQC Reference:

Committees/Meetings at which the paper has been submitted: DateNone

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ENGAGEMENT BETWEEN THE COUNCIL OF GOVERNORS AND THE BOARD OF DIRECTORS

1. INTRODUCTION

1.1 The engagement between the Council of Governors and the Board of Directors is enshrined within the Constitution Annex 8, Section 6. This paper fulfils the requirement of the Monitor Code of Governance July 2014 Provision A.5.6.

From the Constitution:

Summary

1.2 Section 6 of Annex 8 describes the processes intended to ensure a successful and constructive relationship between the Council of Governors and the Board of Directors. It emphasises the importance of informal and formal communication, and confirms the formal arrangements for communication within the Trust. It suggests an approach to informal and formal communications between the Council of Governors and the Board of Directors.

Informal Communications

1.3 Informal and frequent communication between the Governors and the Directors is an essential feature of a positive and constructive relationship designed to benefit the Trust and the services it provides.

1.4 The Chairman shall use reasonable endeavours to encourage effective informal methods of communication including:

i) participation of the Board of Directors in the induction, orientation and training of Governors;

ii) development of special interest relationships between Non-Executive Directors and Governors;

iii) discussions between Governors and the Chairman and/or the Chief Executive and/or Directors through the office of the Chief Executive or his nominated officer;

iv) involvement in membership recruitment and briefings at public events organised by the Trust.

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Formal Communications

1.6 Some aspects of formal communication are defined by the constitutional roles and responsibilities of the Council of Governors and the Board of Directors respectively.

1.7 Formal communications initiated by the Council of Governors and intended for the Board of Directors will be conducted as follows:

i) specific requests by the Council of Governors will be made through the Chairman to the Board of Directors;

ii) any Governor has the right to raise specific issues to be put to the Board of Directors at a duly constituted meeting of the Council of Governors through the Chairman but if the Chairman declines to raise any such issue the said Governor may nonetheless still raise it provided two thirds of the Governors present approve his request to do so. The Chairman shall then raise the matter with the Board of Directors and provide the response to the Council of Governors;

iii) joint meetings will take place between the Council of Governors and the Board of Directors as and when appropriate as determined by the Chairman (in his capacity as the Chairman of both the Board of Directors and the Council of Governors.

1.8 The Board of Directors may request the Chairman to seek the views of the Council of Governors on such matters as the Board of Directors may from time to time determine.

1.9 Communications between the Council of Governors and the Board of Directors may occur with regard to, but shall not be limited to:

i) the Board of Directors’ proposals for the strategic direction of the Trust and

the Annual Business Plan;

ii) the Board of Directors’ proposals for developments;

iii) Trust performance;

iv) involvement in service reviews and evaluation relating to the Trust’s services; and

v) proposed changes, plans and developments for the Trust not covered by paragraph 1.8 above.

1.10 The Board of Directors shall also present to the Council of Governors the Annual Accounts, Annual Report and Auditors’ Report in accordance with the terms of the Constitution and of the 2006 Act.

1.11 The following formal methods of communication may also be used as appropriate with the consent of both the Council of Governors and the Board of Directors:

i) attendance by the Board of Directors at a meeting of the Council of Governors;

ii) provision of formal reports or presentations by Executive Directors or senior managers to a meeting of the Council of Governors;




iii) inclusion of appropriate minutes for information on the agenda of a meeting of the Council of Governors;

iv) reporting the views of the Council of Governors to the Board of Directors though the Chairman or Vice Chairman.

Disputes

1.12 Where an individual is held by the Trust to be ineligible and/or disqualified from Membership of the Trust and disputes the Trust’s decision in this respect, the matter shall be referred to the Chief Executive (or such other officer of the Trust as the Chief Executive may nominate) as soon as reasonably practicable thereafter.

1.13 The Chief Executive (or his nominated representative) shall:

i) review the original decision having regard to any representations made by the individual concerned and such other material, if any, as the Chief Executive considers appropriate;

ii) then either confirm the original decision or make some other decision as appropriate based on the evidence which he has considered; and

iii) communicate his decision and the reasons for it in writing to the individual concerned as soon as reasonably practicable.

1.14 Where a Governor is declared ineligible or disqualified from office or his term of office as a Governor has been terminated (otherwise than as a consequence of his own resignation) and that person disputes the decision, he shall as soon as reasonably practicable be entitled to attend a meeting with the Chairman and Chief Executive of the Trust, who shall use their best endeavours to facilitate such a meeting, to discuss the decision with a view to resolving any dispute which may have arisen but the Chairman and Chief Executive shall not be entitled to rescind or vary the decision which has already been taken.

2. OTHER COMMUNICATION

2.1 The Governors are welcomed to Part 1 meetings of the Board of Directors. There is an item on each Part 1 agenda “Questions from the Governors”. These are requested by the Chairman, enabling individual governors to put questions to the Board. Verbal responses will be supplied as far as reasonable at the time of the meeting and reported in a subsequent edition of the Governors’ e-mail. The Chairman has discretion to manage this item in the light of other Board business. It is also a matter for Governors as to whether the question is for a formal Board meeting or can be raised through the informal route. Board time is set aside for informal discussion between individual Governors and Board Members prior to commencement of the Part 1 meetings. Shortly following a Board of Directors meeting a briefing meeting takes place with the Chairman and Governors with the purpose of informing the Governors as far as reasonable about the discussions conducted under Part 2 of the Board of Directors meetings. Where able, Executive and Non-executive Directors are to attend these briefings to support the Chairman and impart further information if required. The Chairmen of the sub-committees of the Board of Directors are also to attend annually to discuss the work of the sub-committees to assist the Council of Governors in their duty to hold the non-executive directors individually and collectively to account for the performance of the Board.




2.2 A weekly email from the Chairman, Chief Executive and Company Secretary will also be sent to Governors containing relevant information and updates.

3. CONCLUSION

3.1 This paper will be made available to the Board of Directors and the Council of Governors.

CARRIE STONECompany SecretarySeptember 2016

ANGELA SCHOFIELDChairmanSeptember 2016

Originated: January 2008.Updated: January 2009 to reflect changes in titles.

April 2010 to reflect changes in the Board day structure and engagement with Council.September 2013 to reflect changes in engagement and the 2012 Health Act.September 2016 to reflect changes in asking questions of the Board of Directors at Part 1 meetings.






Agenda item: 10 Paper No:5

Subject: Quality improvement strategy

Prepared by: Tracey Nutter/Mandy BakerPresented by: Tracey Nutter

Purpose of paper: To provide the Board with a fully revised version of the trusts Quality strategy for approval.

Background: The Quality Improvement Strategy has built on the Quality Strategy 2014-17, which was implemented in July 2014. This new refreshed strategy has taken into account the key changes taking place across the NHS landscape and the changing roles of NHS Improvement, NHS England and the Care Quality Commission. In particular key documents have been taken into consideration to ensure the Trust meets not only its own aspirations for improving quality, but also the expectations of its commissioners and regulators.

In December 2015, the Department of Health published The Government’s mandate to NHS England for 2016/17. The overarching requirement is for NHS England to sustain a comprehensive service, free at the point of use, which constantly improves patient care. The Five Year Forward View remains the plan for delivering this requirement. The mandate includes 7 key objectives to reflect the NHS England’s contribution to achievement of this plan by 2020. One of the objectives describes the ambition for the NHS to become the safest, highest quality health and care service.

Key points for members: The key changes in the strategy are; A new section on capability and culture which identifies

that the trust needs to develop its capability and culture for using quality improvement methodology to improve patient care and outcomes.

Learning from experience and simulation in practice. The Trust has committed to develop its training opportunities to staff through simulation in practice. Such approaches support an appreciation of human factors science and the environmental constraints that may impact of the delivery of high quality care.

Refreshed quality reporting template which now includes a section covering ‘Quality improvement activities’.


For approval

Recommendations: For approval

Next steps: For approval

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Strategic Objective: yesBAF/Corporate Risk Register:

(if applicable)yes

CQC Reference: all

Committees/Meetings at which the paper has been submitted: Date

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1

QUALITY IMPROVEMENT STRATEGY

2016-2017

If this document is printed – please check in the Policies, Procedures and Guidelines section of the intranet to ensure this is

the most up to date version

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2

A) SUMMARY POINTS This strategy aims to ensure that a robust quality governance framework is in place to underpin the

provision of high quality care to all our patients. Applies to all staff. Supports the achievement of the Trust’s key objectives and quality improvements as set out in the

Operational Plan and Quality Account 2014/15 Puts the Poole Approach at the centre of all Trust activities Supports Trust compliance with the CQC five key questions - are services; safe, effective, caring,

well led and responsive to people’s needs. Describes the responsibilities of all staff in delivering this Quality Improvement Strategy. Puts high quality safe patient centred care at the heart of everything we do.

B) ASSOCIATED DOCUMENTS Trust Operational Plan and Objectives 2014/15 Quality Account 2014/15 Risk Management Strategy 2014 Poole Approach Sign up to Safety pledge and Patient Safety Plan Board Assurance Framework ( BAF) Governance arrangements ( Sept 2015) Education Strategy (2016)

C) DOCUMENT DETAILSAuthor: Tracey NutterJob title: Director of NursingDirectorate: NursingVersion no: 1Date: September 2016Target audience: All staff

Approving committee / group: Hospital Executive Group for approval and Quality, Safety and Performance Committee for Scrutiny

Chairperson: Callum McArthurReview Date: September 2017

D) VERSION CONTROLDate of Issue

Version No.

Date of Review

Nature of Change Approval Date

Approval Committee

Author

E) CONSULTATION PROCESSVersion No.

Review Date Author Level of Consultation

1. Sept 2016 TN QS&PC and Board of Directors1. Sept 2016 TN Hospital Executive Group



3

CONTENTS PAGE No

1. Introduction 4

2. Background 4

3. Quality Improvement Strategy Aims 5

4. Quality Strategic Objectives 5

5. Delivery of Quality Improvement Strategy Objectives 6

6. Capabilities and Culture 6

7. Roles, Responsibilities and Accountability Arrangements 7

8. Structures and Processes 9

9. Monitoring 9

10. Approval and Review 10

11. References 10

Appendices:-

A NHS Outcome Framework12

B Governance Map September 201513

C Quarterly Quality Report Template14-23

D Equality Impact Assessment24



4

1. Introduction

The Trust’s overall vision is to deliver excellent patient centred emergency and planned care. This vision is underpinned by the Trust’s values – The Poole Approach – and delivered through the five key strategic objectives:

Deliver safe, responsive, high quality care. Attract, inspire and develop staff Work with partners to develop new models of care and reconfigure services

so that clinically and financially sustainable arrangements are in place across Dorset

Ensure all resources are used efficiently, effectively and economically to deliver key operational standards and targets

Be a well governed and well managed organisation that operates collaboratively with local partners

The Quality Improvement Strategy supports the achievement of the strategic objectives, but specifically ensures that safe, responsive, high quality care is delivered through robust quality governance arrangements.

The Quality Improvement Strategy also dovetails into other strategic documents such as the Education Strategy, which aims to improve the quality of learning, education and training provision throughout the Trust. The Quality Improvement Strategy supports this by ensuring that the Trust builds its capacity and capability for learning methods to continuously improve the safety and quality of care it provides to patients.

2. Background

2.1 The Quality Improvement Strategy has built on the Quality Strategy 2014-17, which was implemented in July 2014. This new refreshed strategy has taken into account the key changes taking place across the NHS landscape and the changing roles of NHS Improvement, NHS England and the Care Quality Commission. In particular key documents have been taken into consideration to ensure the Trust meets not only its own aspirations for improving quality, but also the expectations of its commissioners and regulators.

2.2 In December 2015, the Department of Health published The Government’s mandate to NHS England for 2016/17. The overarching requirement is for NHS England to sustain a comprehensive service, free at the point of use, which constantly improves patient care. The Five Year Forward View remains the plan for delivering this requirement. The mandate includes 7 key objectives to reflect the NHS England’s contribution to achievement of this plan by 2020. One of the objectives describes the ambition for the NHS to become the safest, highest quality health and care service.

2.3 In February 2016, NHS Improvement (NHSI) published Implementing the Forward View: Supporting providers to deliver. Within this document NHSI make it very explicit what they expect providers to do to improve quality by 2020:

For the majority of trusts to move from a CQC rating of “requires improvement” towards “outstanding”



5

Eliminating unwarranted variation and clinical performance in cancer care; mental health; maternity services; dementia care, and urgent and emergency care.

Improving patient safety by engaging with the safety collaborative’s and using quality improvement methodology.

Delivering effective seven-day services.

3. Quality Improvement Strategy Aims

3.1 The overall aim of the Quality Improvement Strategy is to ensure there is a robust quality governance framework in place which will assure the Board of Directors that the organisation is providing safe, high quality care and remains compliant with the CQC regulations, and continues to strive for quality improvements (Appendix A – NHS Outcomes Framework).

3.2 There is no single definition of “quality improvement,” however, a number of definitions describe it as a systematic approach that uses specific techniques to improve quality. The Quality Improvement Strategy addresses the need for the Trust to develop greater capacity and capability in improvement methodology, and strengthen the Trust’s culture towards quality improvement.

3.3 The Medical Director and Director of Nursing jointly lead quality on behalf of the board, ensuring improved outcomes for patients and are responsible for delivering the Quality Improvement Strategy.

4. Quality Strategic Objective

4.1



6

4.2 The Trust’s quality priorities are set out in the Trust’s annual Quality Account, and are the key drivers for quality improvement and improved patient outcomes. These priorities have been derived from feedback from patients, friends and families, external stakeholders, governors, and national standards. They are:

Supporting patient’s to return home by effective discharge planning and improved communication.

Improve our response to the ‘deteriorating patient’ in particular for patients with suspected sepsis and acute kidney injury.

To improve our management of medicines and reduce the number of medication related errors.

Reducing the number of hospital acquired pressure ulcers Improving our nursing assessment documentation including learning

disabilities Enhance our ‘care of the dying’ pathway including improved shared decision

making

5. Delivery of Quality Improvement Strategy Objectives

5.1 The structure and processes for quality governance across the organisation are reviewed and monitored annually (Appendix B – Governance Framework). The Board monitors the effectiveness of quality governance through progress against the annual quality plan (the Quality Account) and the Board Assurance Framework.

5.2 An annual quality plan (the Quality Account) is prepared, agreed, reviewed and monitored by the Quality, Safety and Performance Committee on behalf of the Board. The plan and progress is published in the annual quality report.

6. Capabilities and culture

6.1 The Trust needs to develop its capability and culture for using quality improvement methodology to improve patient care and outcomes.

6.2 In 2016/17 work will commence to build a competent safety community. This will be led by the Director of Nursing and supported by the Assistant Director of Nursing (Safety).

6.3 The safety community encompasses all staff, patients and visitors to the Trust. Patient engagement work streams will support the sense of community approach and this will be expanded through collaboration with other healthcare providers and the AHSN safety collaborative.

6.4 The Trust will become involved in the NHSI work aimed of providing intensive support for improvement during 2016/17.

6.5 The Trust will develop staff knowledge and skill in improvement methodologies through workshops and quality improvement events.

6.6 The Trust has committed to develop its training opportunities to staff through simulation in practice. Such approaches support an appreciation of human factors science and the environmental constraints that may impact of the delivery of high quality care.



7

6.7 Delivering high quality care requires consideration of the patient, staff and the context of care. These three enablers when delivered in partnership and at every level of the organisation can help to realise the ambition of high quality care.

6.8 The Executive and Non-Executive Directors are responsible for ensuring they are adequately equipped with the leadership, knowledge, skills and values to maintain and improve the quality of all clinical and support services.

6.9 The Executive and Non-Executive Directors have a collective responsibility to ensure that the quality governance processes are providing them with adequate and appropriate information and assurances relating to quality.

6.10 The culture of the organisation and the commitment to quality of all members of staff is a crucial determinant of quality performance. Executives and Non-Executive Directors have a key role in fostering this culture through a focus on quality issues.

6.11 Successful Quality Improvement is communicated across the Trust by various media and acknowledged at the annual Poole Hospital awards. Staff are encouraged to share best practice nationally and internationally.

6.12 As part of the Executive and Non-Executive Directors induction programme a variety of quality and governance training sessions take place via the Trust induction programme, related specific clinical induction pathways, Directing Safely workshop and regular Board and Governor Development sessions.

7. Roles, responsibilities and accountability arrangements

7.1 The Chief Executive

The Chief Executive has overall responsibility for Quality Governance, continuous quality improvement and the delivery of high quality care for all. The Chief Executive has delegated this responsibility to two Executive Leads for Quality, risk and patient safety; the Director of Nursing and the Medical Director. Both Executives are responsible for reporting to the Board of Directors on the progress of quality, safety and quality improvements and for ensuring the Quality Strategy is implemented and evaluated effectively. The Assistant Director of Nursing (Patient Safety), Assistant Director of Nursing (Workforce), Head of Patient Experience, and Head of Quality Governance support the Executive leads for Quality.

7.2 The Medical Director

The Medical Director is the Executive Lead for Clinical Effectiveness & Research and Innovation. The Medical Director leads on the delivery of domain one, two and three of the NHS Outcomes Framework; preventing preventable death, enhancing quality of life, helping people recover from illness. The Medical Director chairs the Trust’s Clinical Governance Group which contributes to the development of the quality strategy and achievement of the quality improvement plan.



8

7.3 The Director of Nursing

The Director of Nursing is the Executive Lead for Safety, Risk and Patient Experience and is the Trust Director for Infection Prevention and Control (DIPC). The Director of Nursing leads on the delivery of domain four and five of the NHS Outcomes Framework; ensuring a positive experience of care and providing a safe environment and protect from harm.

7.4 The Executive and Non-Executive Directors

7.4.1 The Executive Directors are responsible and accountable for ensuring that the Directorates are implementing the Quality Improvement Strategy and related policies to provide assurance via key reports and indicators to the Quality and Governance Committee and Hospital Executive Group (HEG) and via the performance management process.

7.4.2 The Non-Executive Directors have a responsibility as part of the Board of Directors to ensure the Quality Improvement Strategy, supporting structures and processes are providing them with adequate and appropriate information and assurances related to quality, safety and risks against the Trust’s objectives.

7.4.3 Executive Directors provide leadership for the performance management of the systems in place for assuring the effective governance of quality and safety.

7.5 Directorate Teams

7.5.1 Clinical and Non Clinical Directors, General Managers and Matrons are accountable and responsible for ensuring appropriate quality governance processes are implemented within their clinical areas.

Each is required to:

7.5.2 Lead and implement the Quality Improvement Strategy and annual quality report priorities, Risk Management Strategy and related policies.

7.5.3 Ensure activity is compliant with CQC regulations and that services are; safe, effective, caring, well led and responsive to people’s needs.

7.5.4 Develop a clear vision for service development and quality improvement which reflect the quality priorities of the Trust and improves the management of risk and safety. Maintain a Directorate risk register and escalate significant risks to the Executive team as per the Risk Management strategy and related policies.

7.5.5 Ensure staff actively participate in quality improvement activities and events, sharing learning and success

7.5.6 Ensure the Directorate participates in the annual clinical audit plan to provide evidence of good patient outcomes and good practice. Ensure all related policies, protocols and guidance are up to date in line with the Trust’s document control procedure.

7.5.7 Support the application and implementation of research and development studies within the Directorate and lead innovative practise for quality improvement.



9

7.5.8 Report and monitor progress through the use of key quality indicators and performance measures which are reviewed and challenged at the performance meetings with the Executive team.

7.5.9 Ensure that they are actively seeking patient feedback through a variety of means, and listening, learning and responding to this feedback.

7.6 Sisters/Clinical leads and ward/departmental managers

7.6.1 Sisters/Clinical leads and ward/departmental managers are responsible for providing effective leadership and ensuring patients receive safe, effective, compassionate and dignified care in line with the CQC standards and the Poole Approach.

7.6.2 Develop good multidisciplinary team working and networks to ensure patients receive good quality care..

7.6.3 Lead and implement ward and departmental quality improvement initiatives and participate in learning events to help build the Trust’s safety community.

7.6.4 Development plans using available information to analyse the quality of service provision acting upon this analysis to make improvements and learning from patient feedback.

7.7 Individual staff

7.7.1 All staff are responsible for ensuring they provide high quality care to all patients and treat them with respect, dignity and compassion working in compliance with professional registration requirements and local standards of practice and in line with CQC standards, and the Poole Approach.

7.7.2 Work as part of a multidisciplinary team to ensure patients receive good quality care.

7.7.3 Contribute to the progress of the quality priorities, service development plans and comply with related policies to ensure patients receive good quality care reporting risks to quality and safety to the line manager.

7.7.4 Engage in improvement activities to help build the Trust’s capability and capacity to improve safety and quality

7.7.5 Comply with Trust policies, procedures and guidelines to protect the safety and wellbeing of patients and contribute to the related audit programmes.

7.7.6 Understand key quality indicators, performance measures and patient feedback for their area and be involved in quality improvement projects.

7.8 Council of Governors

7.8.1 The council of governors' responsibilities include representing the interests of the Trust members, the appointment and removal of the chairman and non-executive directors, influencing the plans and priorities of the Trust and monitoring the performance of the Trust against its strategic direction and targets.



10

This includes involvement in a variety of quality monitoring programmes and the important role of influencing the Trust in its responsiveness to the needs of both Patients and Staff.

8. Structures and processes

8.1 The Quality, Safety and Performance Committee on behalf of the Board of Directors is responsible for ensuring the Trust delivers and drives the key principles of quality and assures safe, clinically effective, patient centred care, identifying where improvements may be required.

8.2 The Board of Directors provides oversight of operational, health and safety, education and training and human resource functions which impact on quality and safety.

8.3 Directorate Teams undertake regular reviews of ward, team, department and specialities performance and quality. The General Manager, Matron and Clinical Director is responsible for looking at and responding to information on a regular basis and for providing a quality report at performance meetings and quality meetings using the template in Appendix C (Quarterly Quality Report Template).

8.4 Teams, departments, ward or speciality have monthly review meetings led by the line manager to monitor performance and plan and implement improvements. Teams are responsible for recording their quality governance meetings using the meeting minutes.

9. Monitoring

9.1 Monitoring is a key component of assessing whether quality care is being provided and quality improvement supported and must underpin all quality processes. The Board must ensure it has clear, comprehensive reports to enable members to analyse trends and benchmark against others to enable challenges to be made and acted upon if appropriate. Key risks to quality need to be identified and remedial action taken to mitigate the risk or be escalated to the Trust risk register where appropriate.

9.2 The type of quality information the Board should expect to review on a regular basis is:

Trust strategic performance score card and integrated performance report Key quality indicator and performance measures report including HSMR/SHMI CQC intelligence monitoring frameworks Exception reports of quality issues Progress against key national and local audits and peer reviews. Assurance framework, patient safety incidents, risk reports. Patient experience feedback and survey results. Complaints, concerns, comments and compliments. Staff survey and feedback, education, training and development reports. Ward to Board quarterly quality reports from each clinical care group



11

10. Approval and review

10.1 This strategy will be reviewed annually by the Quality, Safety and Performance Committee

10.2 The quality and governance structure will be reviewed annually by the Board of Directors.

10.3 The Head of Quality Governance will monitor the process for governing quality locally to ensure it is being complied with in respect of this strategy. This will be reported at the Directorate Performance meetings with the Executive Directors and within the annual quality governance report.

10.4 Aspects of quality and governance implementation will also be monitored through the annual internal audit review.

11. References

National Quality Board (2011) Quality Governance in the NHS – a guide for provider boards. National Quality Board.

The Government’s Mandate to NHS England for 2016/17

Implementing the Forward View : Supporting providers to deliver



12

Appendix A

NHS Outcomes Framework 2011

Duty of quality



13

Appendix B



14

Appendix C

[NAME] CARE GROUP/DIRECTORATE

QUARTERLY QUALITY REPORT

QUARTER [number] : [months & year]



15

Quality

This report sets out the Directorate quality activity covering the previous quarter to assure the quality, safety and effectiveness of patient care and evidence of continuous improvement.

The information contained in this report mirrors some of the information produced in the Ward to Board reports.

The template below outlines the minimum content for the quality report any additional information such as workforce and performance should be added at the end of the quality section.

Quality improvement activities

[Narrative regarding PDSA cycles, improvement projects, educational events and other related developments]

Infection prevention and control practice

[Narrative regarding positives and areas requiring improvement including actions being taken]

Practice issues compliance:

[Quarter ??]YYYY

Hand Hygiene Results % Bare Below Elbows %

Ward/Department Month Month Month Month Month Month

*Report not submitted


High Impact Audits

Month Ward Ward Ward Ward KeyNo Audit<100%100%




16

Patient safety programme & Patient Safety Thermometer (PST)

[Narrative highlighting any exceptions]

Wednesday Ward Watch:

[copy table for required number of wards]

WARD NAMEAction MONTH MONTH MONTH


Time out in Theatre, WHO Surgical Checklist Compliance

[Insert WHO audit data]


LocSSIPs (Local safety standards for invasive procedures

[List all new LocSSIPs and confirm proforma (see new procedures and techniques procedure on the intranet) has been submitted to the trust Clinical Governance Group and Medical Director prior to implementation for approval]



17

Pressure Ulcers

Ward Month Month Month TotalAcquired Grade 2

Acquired Grade 3

Acquired Grade 4

Total

[Narrative regarding positives and areas requiring improvement including actions being taken to avoid harm]

VTE risk assessment and prophylaxis compliance

Specialty Month % Month % Month %

Inpatient falls resulting in harm

[Total number of falls resulting in harm and location and details of actions in place to reduce harm]

Controlled Drugs report

[Insert table if required]


Medication incidents and actions taken




18

Risk management

Incidents by Risk Grade [Quarter?] YYYY Month Month Month Total

Death/SevereModerateMinorNo HarmTotal number

STEIS Reportable/Serious Incident Inquiries/clinical Reviews/Local Reviews/Never events

[Insert details of outcomes of learning panels and progress with recommendations– include any timescales and how shared learning communicated across the care group/trust]

Top 10 Incidents [insert Datix top ten report for quarter by care group detailing by month & total]

Month

Total 44

Tier ?? Month

Total 44



19

Tier ?? Month

Total

Adverse Incidents

[Insert details regarding trends for positive decreases and detailing where actions are being taken – include any timescales and shared learning across the care group/trust

Risk Register

Grade Month Month MonthRed 0 0 0Amber 1 1 1Yellow 1 1 1Green 0 0 0

[Insert details regarding risks identified and controls and action being taken]

Patient Reported Outcome Measures (PROMS) – Hernia [Surgery specific]

NPSA Safety alerts

[Insert details]

Directorate and cross Directorate projects

[Insert details ensuring each project has an individual topic heading]



20

Mortality Available via Directorate Dashboards

[Insert latest mortality data available from Dr Foster]

[Insert narrative to support data]

Progress against relevant NICE guidance, NCEPOD

[Quarter??] [YYYY]

National Confidential Enquiries and the NICE Quality Standards

[Insert narrative to support compliance]

Compliance against related CQUIN National and local

Detailed narrative of any non-compliance

Clinical Audit

[Insert narrative to support compliance]

Specialty Ref National Clinical Audit Reportable in Quality Accounts

Activity Point(s) Reported

Key Audit Results[Insert narrative to support compliance]

Research and Innovation

[Quarter ??] [YYYY]

[Insert narrative to describe status of any research studies]

Peer Reviews/External Assessments/Accreditations

[Insert details]



21

Care Quality Commission (CQC) Directorate/cluster CQC compliance

[Insert details to support compliance including any current CQC action plan non-compliance]

Health and Safety

[Insert details to support compliance – including number of sharps incidents, all H&S lessons learnt, evidence of shared learning across the care group/trust]

Matron Walkabouts (previously Executive walkabouts)

[Insert narrative to include number and location of walkabouts, actions identified and any shared learning across the care group/trust]

Patient Experience

Complaints and Compliments

[insert details by month where actions are being taken – include any timescales – how shared learning communicated etc]

Month YYYYComplaint refComplaint:

Outcome:

Complaint Status


Outcome:

Complaint Status



22


Outcome:

Complaint Status

Compliments;

Friends and Family Test (FFT)FFT compliance % [Quarter , YYYY]

Ward Month Month Month?? Response Rate?? % Recommended?? Response Rate?? % Recommended

[insert narrative by month regarding comments]

National patient Survey action plan (Inpatient and Outpatient)

[insert key themes and actions being taken and how disseminated]

Safeguarding (adults and children)

[insert narrative]

Female Genital Mutilation

[insert narrative]

Delivering Same Sex Accommodation

[Insert narrative]



23

Service Development & Transformation

7 Day Services Standards [insert table]

Other- narrative

Clinical Governance Group/Risk Management Group

[Insert narrative to include number of representatives attending the trust wide Clinical Governance group and Risk management and safety group. Key issues identified at local groups and any shared learning across the Care Group/trust]

Any other quality concern

[Insert narrative]

Report completed by: Name………………………….Title………………………………………Date: DD MONTH YYYY

Email copy to:Director of Nursing Medical Director Chief Operating OfficeHead of Quality Governance



24

EQUALITY IMPACT ASSESSMENT APPENDIX D

Date of assessment: July 2014

Care Group or Directorate: Nursing

Author: Mandy Baker

Position: Assistant Director of Nursing

Assessment Area:

(i.e. procedure/service/function)

Trust wide strategy

Purpose: To inform all staff of key roles and responsibilities in the delivery of high quality care for all patients.

Objectives: To ensure that a robust quality governance framework is in place and support the achievement of the trusts key objectives and quality improvements in line with the annual quality account.

Intended outcomes: Staff are aware of the strategy and quality improvement initiatives.

What is the overall impact on those affected by the policy/function/service?

Ethnic Groups Gender groups Religious Groups Disabled Persons Other

High/Medium/ Low

High/Medium/ Low

High/Medium

/Low

High/Medium

/Low

High/Medium/

Low

Low Low Low Low Low

Available information:

Assessment of overall impact: Low

Consultation: Board of Directors , key committees and sub groups

Actions: None identified



BOARD OF DIRECTORS PAPER PART 1 – COVER SHEET



Subject: Ward to Board Report – Quarter 1Women & Children & Oncology

Prepared by: Pauline Hawkes, Andrea Moxham, Karen Fernley, Daniel Locker, Helen Ross, Debbie Gritt

Presented by: Tracey Nutter

Purpose of paper: For noting

Background: To provide the Board of Directors with a cohesive perspective on ward activities for quarter 1, 2016-17.

Key points for Board members:

Wednesday Ward WatchGood performance in the Children’s Unit and NICU, Maternity and Oncology require improvement in auditing consistently. Sandbanks need to improve their assessment scores particularly in nutrition and pressure prevention.

Drug fridge temperaturesGood performance in the Children’s Unit, NICU, Postnatal, Durlston and Sandbanks. Improvement is required in Antenatal and Forest Holme. New fridges have been ordered to help improve compliance across the organisation.

Patient safety thermometerGood performance throughout the care group.

Quality indicatorsGood reporting of incidents throughout Maternity. All incidents are thoroughly investigated see section 4.1.4. Three grade 3 pressure ulcers in Oncology which have been subjected to full root cause analysis. No falls results in harm or cases of C. difficile reported for the whole care group. Good compliance with hand hygiene.

There were 5 complaints upheld for the quarter. Two in Oncology, two in Child Health and one in maternity. The overall FFT score for the care group was 98%.


None required

Recommendations: Report to be noted

Next steps: None required

BoD�Sep�16�12a�Cover�Ward�to�BOverall�Page�57�of�125Page�1�of�2




(if applicable)CQC Reference: Safe


BoD�Sep�16�12a�Cover�Ward�to�BOverall�Page�58�of�125Page�2�of�2


1

NURSING & PATIENT SERVICESQUARTER ONE 2016/17 - WARD TO BOARD REPORT: Women & Children’s Services

1. IntroductionThis report provides an overview of quality audits, patient feedback and incidents relating to Children and Women and Oncology. Locations include

Children: Acrewood, Bearwood and ElmwoodMaternity: Postnatal, Antenatal, Transitional Care Unit (TCU) and

Neonatal Intensive Care Unit (NICU)Oncology: Durlston, Sandbanks and Forest Holme

Its aim is to provide a cohesive perspective on ward activities for the Board of Directors during quarter one 2016/17, highlighting areas of good practice and areas for improvement.

2. Wednesday Ward WatchWednesday Ward Watch is a monthly point of care audit carried out on the first Wednesday of every month. It is only applied to inpatient wards and each ward is required to complete data for up to fifteen patients. The charts below show the trends for the three months of quarter one only. RAG-rating has been applied as =/>90% = green, 70-89% = amber, 40-69% = deep amber, =/<39% = red. Grey cells indicate data for which RAG rating is inappropriate and cells marked ‘NA’ (not applicable) indicate that this question did not apply to the group of patients audited.

Data for all the wards in this care group cannot be combined in one chart as each is a discrete specialty with its own quality markers. It has therefore been necessary to show each area’s results on a separate chart, with each month’s results shown as percentages so that fluctuations and potential trends can be easily identified.

Paediatrics

Ref Data collected against a maximum of fifteen patients on the first Wednesday of each month

Apr 2016

May 2016

June 2016

1 Has the child's weight been recorded on admission 100 100 100

2 Has the VIP score been recorded 100 100 100

3 Are 2 identification bands present on the child 100 100 100

4 Has a pain assessment been completed 100 100 100

5 Has the COAST score been completed 100 100 100

6 Has a security tag been fitted to patients under 5 100 100 100

7 Is it documented that parents / carers received a tour of the ward within 12 hours of arrival 100 93 93

8 Is it documented that care is evaluated against care plan within last 12 hours 80 100 100

9 Has the patient received all prescribed medication at the correct time for the past 3 days? 100 100 100

10 Is the treatment room door locked? Yes Yes Yes

11 Is the drug fridge kept locked Yes Yes Yes

BoD�Sep�16�12b�Q1�Women��ChildOverall�Page�59�of�125Page�1�of�12


2


Apr 2016

May 2016

June 2016

13 Have controlled drugs been checked within the past 7 days Yes Yes Yes

14 Has discharge destination been documented in the notes NA 100 100

15 Has the full name of the adult who the child has been discharged to been clearly documented in the notes NA 100 100

16 Has the discharge summary been completed prior to discharge 100 100 100

17 Have TTOs been written up 100 100 NA

18 Sharps Disposal : is each member of staff on duty today aware of the 'skin to bin' practice? Yes Yes Yes

19 Is every sharps bin signed, dated, partly closed and less than 3/4 full Yes Yes Yes

20 Is the ward implementing the SAFER care bundle? 0 NA

Ref 20 is a new question; it is not been RAG rated to date because education regarding the SAFER bundle is in the introductory phase. 98% of the elements (excluding ‘greyed out’ cells) in the paediatric audit were graded green.

NICU


Apr 2016

May 2016

June 2016

1 Has facial cue been checked to control pain adequately 100 100 100

2 Has baby's weight been recorded regularly in the notes 100 100 100

3 Has baby's skin integrity been recorded daily 90 100 100

4 Has VIP score been completed 100 100 100

5 Has badger net been completed daily 90 92 0

6 Patient bedside free from clutter 100 100 100

7 Is it documented that parents/ carers received a tour of the unit within 48 hours of arrival 100 100 100

8 Has parents/carers been supported in choice of milk 100 100 100

9 Patient progress documentation been reviewed in last 24 hours 100 100 100

10 Patient's observations completed as per care plan - baby 100 100 100

11 Has parents/carers received parent craft teaching 100 100 100

12a Is the drug fridge kept locked Yes Yes Yes

13 Has early discharge with parents been documented in notes 100 100 100



3


Apr 2016

May 2016

June 2016

14 Has discharge talk been delivered to parents / carers 100 100 100

15 Have TTOs been written up 100 NA 100

16 Has discharge summary been completed 100 NA 100

17 Sharps Disposal : is each member of staff on duty today aware of the 'skin to bin' policy? Yes Yes Yes


19 Is the ward implementing the SAFER care bundle? NA NA

Ref 5 was not completed in June and therefore a negative score was awarded. 98% of the elements (excluding ‘greyed out’ cells) in the NICU audit were graded green.

Maternity

Antenatal


Apr 2016

May 2016

June 2016

1 Check with patient is pain adequately controlled (record NA if not applicable)? 100 78 9

2 If the patient has been induced, have they been admitted to central delivery suite without delay? 0 67 0

3 Has SBAR been completed NA 100 100

4 Has admission documentation been completed - midwife 100 100 100

5 Has admission form been completed - MSW 33 60 100

6 If No, (ref 5) is the MSW on duty? No Yes NA


8 Patient's observations completed as per care plan - mother 100 100 100

9 Is the treatment room door locked Yes Yes Yes


12 Sharps Disposal : is each member of staff on duty today aware of the 'skin to bin' practice? Yes No Yes

13 Is every sharps bin signed, dated, partly closed and less than 3/4 full Yes No Yes

14 Is the ward implementing the SAFER care Bundle? NA NA



4

Postnatal


Apr 2016

May 2016

June 2016

1 Check with patient is pain adequately controlled? 100 100 100

2 Bladder care plan completed 92 100 100

3 Has SBAR been completed 100 100 100

4 Has VIP score been completed 62 73 91

5 Has admission form been completed - Midwife 73 73 69

6 Has admission form been completed - MSW 67 47 69

7 Patient bedside free from clutter 60 73 77

8 Did dad/partner stay last night? 40 7 46

9 If yes, were the overnight rules adhered to? 50 100 83


11 Patient's observations completed as per care plan - mother 100 100 100

12 Patient's observations completed as per care plan - baby 100 100 100

13 Has the patient had advice and support re feeding method 100 100 100

14 Is the treatment room door locked Yes Yes Yes


17 Has discharge talk been delivered 100 17 100

18 Have TTOs been written up 100 29 100

19 Sharps Disposal : is each member of staff on duty today aware of the 'skin to bin' practice? Yes Yes Yes


21 Is the ward implementing the SAFER care bundle? NA NA

Some audit questions were left blank by antenatal in June and postnatal in May; these were treated as negative responses in line with audit guidance. The overnight rules referred to in ref 8 are a set of 15 guidance points for partners who wish to support patients overnight, relating to such issues as use of phones and respect for the privacy and dignity of other patients. 65% and 72% of the elements (excluding ‘greyed out’ cells) in the NICU audit were graded green for antenatal and postnatal wards respectively.



5

Oncology Re

f

Durls

ton

Sand

bank

s

Fore

st

Holm

e

Total number of patients audited during the quarter 44 45 17

1 MUST completed during this admission 98 91 NA

2 MUST completed within 24 hours of this admission 93 88 NA

3 Appropriate action taken following MUST score 100 93 NA

4 MUST screen recalculated weekly during in-patient stay 100 73 NA

5 Pain assessment completed 100 75 67

6 Bladder/bowel care plan completed 100 96 67

7 Manual handling care plan completed 98 82 67

8 Oral hygiene assessment completed 84 89 67

9 Patient care plan reviewed/ evaluated in the last 24 hrs 100 100 67

10 Has the condition of the pressure areas been documented every shift for past 3 days 89 48 67

11 If the patient requires pressure area care has this been recorded ie turns or 30 degree tilt 100 100 67

12 Has the patient scored high or critical NEWS in the previous 24 hours 7 2 NA

13 If yes to ref 12, is there documented evidence of escalation ie NEWS call or reason not to 100 100 NA

14 Patient DNAR status clear 100 100 67

15 All patients have an EDD in place within 48 hours of admission. 100 100 NA

16 Is the patient medically fit for discharge 9 13 NA

17 If yes to ref 16, is the patient waiting for medication 17 50 NA

18 If yes to ref 16, is the patient waiting for care package/residential home 0 39 NA

19 Is the treatment room door locked 100 100 67

20 Is the drug fridge kept locked 67 100 67

22 Sharps Disposal : is each member of staff on duty today aware of the 'skin to bin' practice? 100 100 67

23 Is every sharps bin signed, dated, partly closed and less than 3/4 full 100 100 67

24 Is the ward implementing the SAFER care bundle? 0 67 0



6

Refs 16 to 18 inclusive have been ‘greyed out’ because these elements are outside the ward’s sphere of influence so it would be inappropriate to RAG rate them. It should be noted that this audit is a snapshot of a proportion of the inpatient cohort and should not be used in isolation. Forest Holme did not submit an audit for May and therefore the maximum which could be scored was 67% for any element. Sandbanks ward grading for ref 10 was adversely affected by their May audit which reduced their average for the quarter. 56% of the elements (excluding ‘greyed out’ cells) in the Oncology audits were graded green.

Drug fridge temperature recordings for the quarter have been removed from the table above and RAG rated as follows (please note that these parameters differ from those outlined on page 1):

95 or above = green 90 to 94 = amber 85 to 89 = deep amber Below 84 = red

Forest Holme’s results have been adversely affected by omitting one audit.

3. Patient Safety Thermometer (PST)Patient Safety Thermometer is completed on the same day as the Wednesday Ward Watch and also only applies to inpatient wards. It is a nationally reported snapshot survey which only captures a percentage of total harms.

It can be seen that in this care group all wards scored 100% for new harm free care with the exception of Forest Holme whose palliative care patient cohort are particularly vulnerable to pressure area damage.

Drug Fridge temperature recording

Apr-16 May-16 Jun-16 Quarter Results

Ward Days Missed

% Days Compliant

Days Missed

% Days Compliant

Days Missed

% Days Compliant

Days Missed this Qtr

% Days Compliant

this Qtr

Children’s Unit 0 100% 1 97% 0 0% 1 99%NICU 0 100% 0 100% 0 100% 0 100%Antenatal 7 77% 7 76% 10 67% 24 73%Postnatal 0 100% 0 100% 3 90% 3 97%Durlston 0 100% 0 100% 0 100% 0 100%Sandbanks 0 100% 0 100% 0 100% 0 100%Forest Holme 0 100% 31 0% 0 100% 31 65%

Old New Total With Harm Old New DVT PE

Acrewood & Bearwood Children 54 0 0 0 0 0 0 0 0 54 100% 100%Total by speciality 54 0 0 0 0 0 0 0 0 54 100% 100%Antenatal Maternity 29 0 0 0 0 0 0 0 0 29 100% 100%NICU Maternity 50 0 0 0 0 0 0 0 0 50 100% 100%Total by specialty 79 0 0 0 0 0 0 0 0 79 100% 100%Durlston Oncology 48 1 0 0 0 0 0 0 0 47 98% 100%Sandbanks Oncology 54 0 0 0 0 0 0 0 0 54 100% 100%Forest Holme Oncology 25 2 1 0 0 0 0 0 0 22 88% 96%Total by specialty 127 3 1 0 0 0 0 0 0 123 97% 99%

Falls

Ward Specialty

No

Pat

ient

s Pressure Ulcers

% H

arm

Fr

ee

Catheter & UTI New VTE

Har

m fr

ee

patie

nts

% N

ew

Har

m F

ree



7

4. Quarterly quality indicatorsThis chart provides an overview of quality indicators, so that different aspects of ward and departmental activity can be viewed cohesively. The following sections will look at each section in more detail.

Ward SpecialtyNu

mbe

r of i

ncid

ents

Num

ber o

f sig

nific

ant i

ncid

ents

Num

ber o

f pre

ssur

e ul

cers

- ac

quire

d 2

Num

ber o

f pre

ssur

e ul

cers

- ac

quire

d 3

Num

ber o

f fal

ls

Num

ber o

f fal

ls w

ith s

igni

fican

t har

m

No. T

rust

attr

ibut

ed C

Diff

icile

No. T

rust

attr

ibut

ed M

RSA

bact

erae

mia

Hand

hyg

iene

%

Bare

bel

ow e

lbow

s %

War

d / d

epar

tmen

t cle

anlin

ess

%

PALS

inte

ract

ions

Com

plai

nts

uphe

ld

% R

ecom

men

ded

% o

f res

pond

ents

Posi

tive

resp

onse

s

Nega

tive

resp

onse

s

% S

taff

sick

ness

% S

taff

Turn

over

Antenatal Maternity 615 686 42 0 0 0 0 0 0 0 100 100 97 0 0 100 14 9 0 3 0Postnatal Maternity 1422 2030 19 0 0 0 1 0 0 0 100 100 93 2 0 92 16 30 1 7 1Delivery Suite Maternity - - 191 20 0 0 0 0 0 0 33 33 98 4 0 95 34 85 3 9 1Haven Birthing Suite Maternity - - 11 0 0 0 0 0 0 0 100 100 97 0 1 97 24 18 0 2 0Transitional Care Maternity 100 14 12 0Total 2037 2716 263 20 0 0 1 0 0 0 83 83 96 6 1 97 20 154 4 5 0Acrewood Children 383 764 20 0 0 0 0 0 0 0 100 100 97 1 0 na na na na 1 0Bearwood Children 706 1020 12 0 0 0 0 0 0 0 100 100 98 2 1 na na na na 3 0Elmwood Children 1631 361 12 0 0 0 0 0 0 0 100 100 99 1 1 na na na na 3 2Neonatal Children 126 1335 27 0 0 0 0 0 0 0 100 100 98 0 0 na na na na 3 1Total 2846 3480 71 0 0 0 0 0 0 0 100 100 98 4 2 0 0 0 0 3 1Durlston Oncology 202 1305 29 0 3 0 2 0 0 0 100 100 97 1 0 100 91 79 0 7 3Sandbanks Oncology 406 1592 39 2 4 1 3 0 0 0 100 100 97 2 2 99 63 150 1 1 0Forest Holme Oncology 90 745 11 2 6 2 0 0 0 0 100 100 96 0 0 100 46 11 0 3 1Total 3544 7122 79 4 13 3 5 0 0 0 100 100 97 3 2 99.7 66.7 240 1 4 1

8427 13318 413 24 13 3 6 0 0 0 94.4 94 97 13 5 98 43.5 394 5 4 1Care group total

Quarterly Quality IndicatorsTable One

Incidents Patient concerns

Infection control

War

d st

ays

Occ

upie

d be

ds a

t mid

nigh

t

Friends & family test

Staffing

Ward Specialty

Rate

s of p

ress

ure

ulce

rs g

rade

3 p

er 1

,000

be

d da

ys

Rate

of f

alls

with

sign

ifica

nt h

arm

per

1,

000

bed

days

Rate

of c

ompl

aint

s uph

eld

per 1

,000

bed

da

ys

Antenatal Maternity 615 686 0.00 0.00 0.00Postnatal Maternity 1422 2030 0.00 0.00 0.00Total 2037 2716 0.00 0.00 0.37Acrewood Children 383 764 0.00 0.00 0.00Bearwood Children 706 1020 0.00 0.00 0.98Elmwood Children 1631 361 0.00 0.00 2.77Neonatal Children 126 1335 0.00 0.00 0.00Total 2846 3480 0.00 0.00 0.57Durlston Oncology 202 1305 0.00 0.00 0.00Sandbanks Oncology 406 1592 0.63 0.00 1.26Forest Holme Oncology 90 745 2.68 0.00 0.00Total 3544 7122 0.42 0.00 0.28

8427 13318 0.23 0.00 0.38Care group total

Patient concerns

Quarterly Quality Indicators - Table 2

War

d St

ays

Occ

upie

d be

ds a

t mid

nigh

t

Incidents



8

4.1.1 Incidents: pressure ulcers breakdown by grade and location

This breakdown gives the total for the quarter including pressure ulcers reported in the patient safety thermometer (section 3). It also includes ungraded pressure ulcers (‘Evidence of deep tissue damage’) which are not included in the patient safety thermometer chart. The table below shows pressure ulcers reported directly to Datix web by ward staff. No pressures ulcers were reported from maternity.

It should be noted that the above totals refer to pressure ulcers and not numbers of patients; for example, four Forest Holme patients had two pressure ulcers each and one Sandbanks patient had three inherited pressure ulcers.

The majority were sacral wounds and heel sores and all have been followed up with appropriate care intervention at ward level.

4.1.2 Incidents : falls breakdownThis breakdown gives the total incidents for the quarter including those reported in the patient safety thermometer (section 3).

Wards No Harm Minor Grand

Total Comment

Postnatal 1 0 1Durlston 1 1 2 Patient sustained bruising to nose and faceSandbanks 2 1 3 1 patient sustained laceration to arm and legGrand Total 3 3 6

4.1.3 Incidents : Medication This breakdown gives the total for the quarter and shows degrees of harm. Only actual harms are

described in the comments in the table below.

Ward No Harm

Minor Harm

Grand Total

Comment

Acrewood 7 3 10 2 extravasation1 prescribing error

Bearwood 0 1 1 1 checking error

NICU 3 0 3Antenatal 6 0 6Postnatal 4 0 4

Delivery Suite 4 2 6 1 delayed administration1 incorrect route of administration

Durlston 3 1 4 1 incorrect formulation of medication

Sandbanks 3 1 4 1 extravasation

Grand Total 30 8 38

Wards Acquired Pressure ulcer Grade 2

Acquired Pressure ulcer Grade 3

Acquired Evidence of deep tissue damage

Inherited Pressure ulcer Grade 2

Inherited Pressure ulcer Grade 3

Inherited Evidence of deep tissue damage

Grand Total

Durlston 3 0 1 1 0 0 5Sandbanks 4 1 0 9 5 1 20Forest Holme 6 2 0 2 2 5 17Grand Total 13 3 1 12 7 6 42



9

No medication incidents were reported from Forest Holme or the Haven Birthing Suite. There were no moderate or severe harm medication incidents from any ward in the care group.

4.1.4 Incidents : most frequently reported categories

MaternityAntenatal Ward Apr 2016 May 2016 Jun 2016 TotalTreatment/procedure delayed 3 6 14 23Blood specimen labelling error 4 0 0 4Total incidents for the quarter 14 11 17 42Postnatal WardDischarge insufficient/incomplete 0 1 3 4Total incidents for the quarter 5 8 6 19Delivery SuitePost partum haemorrhage >1500ml 35 26 38 99Blood specimen labelling error 9 6 8 23Third/fourth degree tears 5 5 5 15Total incidents for the quarter 64 55 72 191Haven Birthing SuiteTotal incidents for the quarter 3 4 4 11

The most commonly reported incident from Antenatal ward relates to delays in treatments/procedure. The majority of these involve augmentation of labour and arise from capacity issues in the unit. This is supported by data from the Wednesday Ward Watch which identifies a high level of delays in patients being transferred from Antenatal to the Delivery Suite. Most incidents reported from the Delivery Suite relate to complications of childbirth and are reviewed to ensure there are no omissions or errors in care delivery.

Twenty significant incidents were reported from the Delivery Suite. Seventeen were maternal haemorrhages, two were maternal tears and one was a baby needing extra support after birth.

No trends were identified during the quarter. Paediatrics

Acrewood Ward Apr 2016 May 2016 Jun 2016 TotalTotal incidents for the quarter 6 6 8 20BearwoodTotal incidents for the quarter 2 7 3 12ElmwoodBlood specimen labelling error 1 2 2 5Blood specimen insufficient/incorrect/incomplete 0 3 0 3Total incidents for the quarter 2 6 4 12NICUTotal 7 8 12 27

No significant incidents were reported from Child Health and no significant trends were apparent during the quarter.



10

OncologyDurlston Apr 2016 May 2016 Jun 2016 TotalBlood specimen labelling error 2 2 0 4Pressure ulcer - preventive/therapeutic Interventions provided but not effective 2 1 0 3Total incidents for the quarter 11 11 7 29SandbanksBlood specimen labelling error 1 3 3 7Pressure ulcer - preventive/therapeutic interventions provided but not effective 1 4 2 7Total incidents for the quarter 7 21 11 39Forest HolmePressure ulcer - preventive/therapeutic Interventions provided but not effective 1 6 0 7Total incidents for the quarter 5 6 0 11

The most commonly reported incidents from the oncology wards related to pressure ulcers, both acquired and inherited. There were two significant incidents on both Sandbanks and Forest Holme all of which were pressure ulcers – 3 inherited and 1 acquired.

4.2 Infection control

‘Ward and departmental cleanliness’ scored an average of 97% across the care group. There were no trust attributed CDiffs or MRSA bacteraemia. Every ward in the care group scored 100% for hand hygiene and bare below the elbows with the exception of the Delivery Suite which only submitted one month’s data and therefore scored 33% bringing the care group average down to 94%.

4.3 Patient concerns

The following table comprises details of complaints received and interactions with the PALS service during quarter one.

ID Response time in days

Theme Action taken Outcome

Antenatal wardNo complaints were upheld on Datix during the quarterNo PALS interactions were recorded during the quarter Postnatal wardNo complaints were upheld on Datix during the quarterTwo PALS interactions were recorded during this quarter. One related to nursing care and one concerned visiting arrangementsDelivery suiteNo complaints were upheld on Datix during the quarterFour PALS interaction were recorded during the quarter. One concerned communication and three were requests for interpreter servicesHaven birthing suite7481 18 Patient care Staff reminded to listen carefully to patient

concernsComplaint partially upheld

No PALS interactions were recorded during the quarterAcrewoodNo complaints were upheld on Datix during the quarterOne PALS interaction was recorded during the quarter and was a request for information



11

ID Response time in days

Theme Action taken Outcome

Bearwood7444 43 Patient care Followed up with staff and care explained

to familyComplaint partially upheld

Two PALS interactions were recorded during the quarter. One concerned tap availability in an en suite and one concerned patient informationElmwood7425 44 Documentation Apology and explanation given to family Complaint partially upheldOne PALS interaction was recorded during the quarter and was a thank you letterNICUNo complaints were upheld on Datix during the quarterNo PALS interactions were recorded during the quarterDurlstonNo complaints were upheld on Datix during the quarterOne PALS interaction was recorded during the quarter and concerned communicationSandbanks7381 46 Patient care Apology given Complaint partially upheld7432 22 Lost property Reimbursement Complaint upheldTwo PALS interactions were recorded during the quarter. One concerned lost property and one regarded patient’s conditionForest HolmeNo complaints were upheld on Datix during quarterNo PALS interactions were recorded during the quarter

4.4 Friends & family test

This test requires all patients who have used hospital services to indicate whether they would be likely to recommend the Trust to their friends and family. Their responses are recorded on a Likert scale which categorises responses as Extremely Likely, Likely, Neither Likely nor Unlikely, Unlikely, Extremely Likely or Don’t Know. Neutral and Don’t Know responses have been excluded from the table.

The national target for percentage of responses for inpatients is 40%. The target for responses was not met in quarter one by maternity who achieved an average of 20% (range 14 to 34%). Oncology, however, achieved an average response rate of 67% (range 46 to 91%) bringing the care group average to 44%.

97% of comments received by the maternity department were positive, as were 99.6% of the comments received by oncology wards. The care group received five negative comments, three from Delivery Suite, one from Postnatal and one from Sandbanks ward. Of these, two related to waiting times, one to care, one to staff attitude and one to medical staff. Two separate responses referred to call bells in maternity not working. 394 positive comments were received from the maternity and oncology wards.

The friends and family test does not apply to the children’s unit.

4.5 Staffing

The percentages for staff sickness and turnover have been included in the chart (section 4). Ward/departmental breakdown for maternity amalgamate both the postnatal and transitional care wards. The sickness data for antenatal is a combination of both antenatal day clinic and the antenatal ward.



12

5. Summary

This report has amalgamated safety incidents, infection control data, patient feedback, staffing in one table, allowing an overview of these quality indicators by ward.

Ward watch data cannot be combined into one table due to variation in ward watch questions, but has been presented separately for each ward, where consistently good scores can be seen across the care group. Drug fridge temperature recording remains a challenge with inconsistent scores being reported from different wards.

The patient safety thermometer audit has been completed in oncology and child health. As reported last quarter, the maternity safety thermometer will be reported separately by the maternity risk leads. A ‘new harm free care’ score of 99% was achieved across the oncology and child health wards.

Cleanliness standards have been high for all the wards throughout the quarter with no department scoring less than 93% with an average of 97% for the care group. Bare below the elbows and hand hygiene results have been consistently high with the exception of the delivery suite.

Friends & Family test response rates, which only applied to Maternity Unit and Oncology wards, have met the national target for response rates due to high returns from Oncology, and have provided positive feedback in over 99% of cases.

Pauline Hawkes Andrea Moxham Karen Fernley Daniel LockyerMatron – Maternity Matron - Oncology Matron – Child Health Matron - NICU

Helen Ross Debbie GrittClinical Advisor Quality Assurance Co-ordinatorRisk & Governance Department Risk & Governance Department

September 2016




Meeting Date: 28th September 2016

Agenda item:13 Paper No: 7

Subject: Integrated Performance Report (August 2016)

Prepared by: Kate ThomasPerformance & Business Intelligence Manager

Presented by: MARK MOULDChief Operating Officer

Purpose of paper:

To inform the Board of Directors of the performance of the Trust during August 2016.

Background:Key points for Board members:

Finance PerformanceNow contained within a separate public facing report.

Operational PerformanceAugust has been another challenging month for the operational standards, with pressure being felt across the hospital, but both ED and Cancer standards show a sustained improvement. Organisational flow has improved and now accounts for around 28% of breaches against the ED 4 hour standard with the other key factor Wait to be seen timers. Constraints on the number of elective patients treated in the month (including theatre staffing) have resulted in RTT performance reducing although the 18 week 92% standard was still delivered. 4 Hour organisational Standard The four hour target was not achieved in August, although improved performance has been sustained since April, and August is 94.0% within the agreed NHSi trajectory. The reason for the non-achievement is predominantly due to medical staffing challenges and patient activity surges late evening in the emergency department resulting in wait to be seen times. Adult Bed occupancy in August was 91.9% compared to July at 93.6%. The trust has updated its four hour plan and will continue to focus on those actions that will improve waiting times in the emergency department and the capacity available to flow patients from the emergency department. The Trust’s performance continues to match the overall national percentage from which the Trust had deviated in Quarter 4; this is illustrated in the new ED benchmarking page.

4 Hour Org standard August 94.0% Q2 92.6%

Referral to Treatment (RTT)As in previous months the national waiting times targets were achieved in August for Referral to treatment waiting time (18 weeks) for incomplete pathways (RTT) but not in every specialty. Work continues to improve speciality level delivery with remedial action plans (RAPS) in place. Referral rates continue to show a year on year increase and have impacted negatively on access times, the year to date rate remains higher than last year. The increase for GP referrals for August to date year on year is 9.2%. Outpatient attendances for the year to date are now consistently meeting or exceeding the previous year. Elective activity levels overall, i.e. inpatient and daycase combined remain higher than the previous year to date, 6%,

Referral to treatment August 92.7% Q2 92.7%

BoD�Sep�16�13a�Part�1�Cover�ShOverall�Page�71�of�125Page�1�of�4


Cancer StandardsAll NHS Improvement (previously Monitor) cancer waiting times targets were met in July, but the position remains challenging for 62 day target (now part of the STP) and escalation actions are in place to enable the sustained delivery of this target. The Trust has a formal remedial action plan in place with the CCG that is being monitored through the Trust Performance reviews and Hospital Executive Committee.

Cancer Standards July 8/8 Qtr. 1 8/8

The Trust has a number of laudable achievements to share. These include: RTT performance for the incomplete pathways standard DM01 access standard delivered in August. Reduction of the percentage of delayed discharges and numbers of bed

days lost to formal delays.

The Trust will continue to focus on the operational standards that are outside the NHS Improvement (Monitor) regime but important to our patients, which include

Focussing on the stroke pathway and the associated standards as part of the SSNAP (Exception report in the IPR)

Challenges on trauma capacity both theatres and bed capacity during the last three months. The rate and numbers of admissions we have experienced for the last three months is a record for the service in relation to increase in operations, June 18.3%, July 11.8% and a 20.6% increase in August.

Quality, Safety, & Patient Experience

C-Difficile levels for 2016/17 are now 7 for the year to date, 1 in August. Currently quarter 2 performance for this metric is within the trajectory.There have been no MRSA bacteraemia cases for the year to date. Work continues to redesign the Patient Experience and Quality and Safety pages, with a new family and friends being expanded. The safer staffing page now includes the red flag incidents.There were 7 red flags raised during August.

Further work is required to ensure that reporting is robust over the 24/7 period in all areas. All red flags were actioned promptly by the senior nursing teams to ensure patient safety and, were all reviewed by the Matron for the clinical area, the Clinical Risk Manager and the Assistant Director of Nursing (Workforce).

August 2016 nurse staffing ‘Red Flags’

There were 7 areas that raised red flags during August.

Further work is required to ensure that reporting is robust over the 24/7 period in all areas. All red flags were actioned promptly by the senior nursing teams to ensure patient safety and, were all reviewed by the Matron for the clinical area, the Clinical Risk Manager and the Assistant Director of Nursing (Workforce).

There were 27 local nurse staffing concerns raised at ward level, 7 areas had red flag incidents. These were managed at the time through a discussion with the senior nursing team. There were no reported harm events.

Action points; A4 Arne: The ward is currently recruiting to the recently agreed increase in nursing establishment.



Lytchett: This ward is in close proximity of an adjacent ward and registered nurses worked across the two wards.B3 & E3(TAU Red): Staff across surgery and trauma were re allocated to meet patient need and acuityC2 (Surgical assessment unit): Extra beds were opened in this area to manage the Trust escalation position, clinical practitioners supported the area.C3 (TAU Green): Staff across surgery and trauma was re allocated to meet patient need and acuity, clinical practitioners supported the area.

Workforce

Sickness: The rolling 12 month sickness rate fell to 3.49%, the lowest recorded by the Trust since April 2007. The lower rate does mask a number of hotspot areas in which targeted work is being undertaken.

Turnover: There overall turnover rate fell again to 12.94%. As with sickness, this is an average rate for the Trust and there are wards and departments which are impacted to a greater or lesser degree.The HCA turnover rate increased in August. This follows a predictable annual pattern due to staff leaving to undertake professional study courses.

Staffing Levels: Substantive staffing numbers increased by 21.55 wte, reducing the Trust’s vacancy level to 4.71%. Two factors are at play – successful recruitment to vacancies and improved retention of existing staff.

Appraisal: The overall appraisal compliance rate fell in August to 83%. Detailed reports are sent to managers monthly identifying staff requiring appraisal. HR Advisors are working with managers to increase compliance levels. Hotspot details will be provided for the next report.

Statutory and Mandatory Training: The overall compliance rate for statutory and mandatory training remains at 88% against a target of 90%. Four modules are compliant with the target, and three of the eight main staff groups are compliant.

Staff Friends and Family Test (SFFT): Comparative inter-organisational results for the Quarter 1 SFFT have been published. The Trust was second in the South West cohort for staff recommending the Trust as a place to receive treatment, and third in the ranking as a place to work. The Trust’s scores for both questions are well ahead of the national averages.


None required

Recommendations: The Board is asked to note :1. Operational Indicators in August.

The continued pressure on delivering the organisational four hour standard and meeting the trajectory

The pressures faced in the trauma service over the last three months The Achievement of Q2 STP trajectories for RTT, ED and Cancer 62

day standards and the reduced resilience against the standards.2. Quality, Safety, & Patient Experience Indicators

On-going review of staffing levels.3. The workforce indicators

Improvements in HR indicators and the actions being taken to further improve performance.

Next steps: 4 hour Plan being reviewed at the Quality & Safety Committee

Trauma bed proposal being shared with HEG in September




Strategic Objective:

Ensure all resources are used efficiently, effectively and economically to deliver key operational standards and targets

Deliver safe, responsive, compassionate, quality care. Work with partners to develop new models of care and reconfigure services so that clinically and financially sustainable arrangements are in place across Dorset

BAF/Corporate Risk Register: (if applicable)

AF4 Principal Strategic Objective : Ensure all resources are used efficiently, effectively and economically to deliver key operational standards and targets - Director of Finance/ Chief Operating Officer1038 Risk of failure in achieving National Targets for Emergency Department

CQC Reference: All Domains

Committees/Meetings at which the paper has been submitted: DateHEGCCG Contract MonitoringSDOP

SeptemberSeptemberSeptember



August 2016

“Friendly, professional, patient-centred care with dignity and respect for all”

Author: Kate Thomas Performance & Business Intelligence Manager

Executive Lead: Mark Mould, Chief Operating Officer

Title of Report: Performance Report

The Poole Approach

INTEGRATED PERFORMANCE REPORT

BoD�Sep�16�13b�Performance�RepOverall�Page�75�of�125Page�1�of�24


8

9

10

11

1

5 Medicines Optimisation 9

6 Mortality 10

CONTENTS

3 5

2 NHS Improvement (Monitor) including STP Trajectories 4

Title PageNo

2-3Trust Performance at a glance1

4 Quality and Safety

13

Cancer Pathway

Elective Care Pathway

Outpatients

12

7

Emergency Care Pathway and Performance Benchmarking

Patient Experience

16

15

14

12-13

17-18

11

Escalation Reports for Standards off Trajectory

Staffing and Organisational Development

6-8

Activity



Target/

LimitSet By Reported Period Apr-16 May-16 Jun-16 Jul-16 Aug-16

Current

or YTD

Actual

YTD

Target/

LimitJan-00

Mixed Sex Accommodation (MSA) occurrences 0 PHFT Aug-16 0 0 0 0 0 ↔ 0 0

Mixed Sex Accommodation (MSA) patient numbers 0 National Aug-16 0 0 0 0 0 ↔ 0 0

0.213 Family & Friends test - % response rate ED 20% National Aug-16 22.6% 22.6% 23.4% 22.6% 25.5% ↑ 25.5%

0.268 Family & Friends test - % response rate Inpatients 40% National Aug-16 25.8% 26.7% 28.7% 28.6% 28.0% ↓ 28.0%

0.269 Family & Friends test - % response rate combined National Aug-16 20.3% 25.6% 22.7% 21.8% 21.2% ↓ 21.2%

Complaints Aug-16 24 21 19 18 34 ↓ 116

Staff Turnover (Overall) rolling 12 months <=14% PHFT Aug-16 14.04% 13.78% 13.39% 13.28% 12.94% ↑ 12.94% <=11% (YE)

% of requests filled by bank (shown as % of filled shifts) 79.25% 80.70% 79.98% 80.65% ↓ 80.51%

% of requests filled by agency (shown as % of filled shifts) 20.75% 19.30% 20.02% 20.02.% ↑ 19.49%

Staff Appraisals 95% PHFT Aug-16 84% 85% 86% 85% 83% ↓ 83% 95% (YE)

Mandatory Training 90% PHFT Aug-16 87% 87% 88% 88% 88% ↔ 88% (YE)

Sickness Absence rolling 12 months <=3.5% PHFT Aug-16 3.62% 3.58% 3.55% 3.55% 3.49% ↑ 3.49% <=3.5% (YE)

Dr Foster Mortality relative risk rating (HSMR 3 month rolling) 100% Dr Foster Mar 16 - May16 94.41 93.25 ↑ 93.25 100%

SHMI (12 month rolling period published quarterly) 100% Dr Foster Jan15 - Dec15 93.82 100%

HSMR deaths - actual as % of expected (Dr Foster) 100% Dr Foster May-16 92.89 83.72 ↑ 83.72 100%

% of Emergency Re-admissions within 28 days to the Trust (in line with Monitor

criteria)yr. on yr.

reduction PHFT Aug-1611.0% 10.1% 9.6% 8.8% 7.9% ↑ 7.9%

% patients discharged before 12pm (excluding day cases and deaths) 35% PHFT Aug-16 18.3% 18.8% 18.9% 18.5% 16.8% ↓ 16.8%

Number of C-Diff infections 15 Monitor Aug-16 2 3 0 1 1 ↔ 7 15 q2 1.0

Number of MRSA infections =<1 PHFT Aug-16 0 0 0 0 0 ↔ 0 =<1 (YE) 0.0

Number of Never events zero PHFT Aug-16 0 1 0 0 0 ↔ 1

Number of Serious Untoward Incidents (SUIs) zero PHFT Aug-16 9 6 6 6 4 ↑ 31 zero

All hospital acquired pressure ulcers (all grades) zero PHFT Aug-16 47 49 43 47 44 ↑ 230

Dementia screening 90% National Jun-16 93% 91% 93% 93%

Patients who spend at least 90% of their time on a stroke unit 80% National Aug-16 88% 86% 84% 93% 87% ↓ 87% 80%

VTE screening 95% National Aug-16 98% 98% 98% 98% 97% ↓ 97% 95% (YE)

Referral to waiting time (18 weeks) for incomplete pathways92% Monitor Aug-16 93.0% 93.2% 93.1% 93.0% 92.7% ↓ 92.7% 92% (QTR2)

1.0

Referral to treatment (18 weeks) for admitted Patients90% Aug-16 72.6% 76.4% 79.9% 78.8% 80.0% ↑ 76.3% 90% (QTR2)

0.0

Referral to treatment (18 weeks) for non-admitted Patients 95% Aug-16 91.3% 91.8% 90.7% 90.5% 91.5% ↑ 91.3% 95% (QTR2)

0.0

Maximum 62 day wait from referral to treatment for all cancers Patients85% Monitor Jul-16 88.6% 85.2% 85.3% 88.1% ↑ 86.5% 85% (QTR2)

62 day wait for 1st treatment - consultant screening service for Patients90% Monitor Jul-16 97.6% 93.8% 94.3% 100.0% ↑ 95.3% 90% (QTR2)

62 day wait for 1st treatment following consultant decision to upgrade the

priority of the patient (all cancers)90% National Jul-16 100.0% 100.0% 95.5% 88.9% ↓ 98.2% 90% (QTR2)

not a Monitor

target

31 day wait for 2nd or sub treatment : Anti cancer drug treat for Patients98% Monitor Jul-16 100.0% 100.0% 100.0% 100.0% ↔ 100.0% 98% (QTR2)

31 day wait for 2nd or sub treatment : Surgery 94% Monitor Jul-16 100.0% 100.0% 100.0% 100.0% ↔ 100.0% 94% (QTR2)

31 day wait for 2nd or sub treatment : Radiotherapy 94% Monitor Jul-16 98.5% 98.3% 99.3% 100.0% ↑ 98.9% 94% (QTR2)

31 days wait decision to start of 1st treatment: All cancers 96% Monitor Jul-16 98.6% 97.9% 99.4% 100.0% ↑ 98.7% 96% (QTR2)1.0

2 week wait from urgent GP referral to 1st apt (susp cancer) 93% Monitor Jul-16 97.6% 99.7% 99.7% 99.8% ↑ 99.0% 93% (QTR2)

2 week wait for Symptomatic Breast Patients 93% Monitor Jul-16 100.0% 100.0% 94.3% 100.0% ↑ 97.7% 93% (QTR2)

Diagnostic patients waiting more than 6 weeks

(DM01 investigations only) <= 1%Aug-16 47 34 69 27 15 ↑ 192

ave 35 per

month

% waits more than 6 weeks for DM01 diagnostic investigations <= 1% Aug-16 1.16% 0.80% 1.72% 0.74% 0.50% ↑ 0.50% <= 1%

Elective Access - rebooking with 28 days 0 National Aug-16 3 0 1 2 0 ↑ 6 0

90% direct admissions to stroke unit 90% National Aug-16 73% 91% 65% 90% 83% ↓ 83%

Higher risk TIA cases who are treated within 24 hours 60% National Aug-16 82% 73% 71% 61% 55% ↓ 55% 60%

Delayed transfers of care to be maintained at a minimal level (OBD lost - excl

angio waits)Aug-16 723 973 771 730 694 ↑ 3891

Delayed transfers of care to be maintained at a minimal level (snapshot) 3.5% NationalAug-16

4.40% 6.22% 6.08% 4.43% 3.22% ↑ 3.22% 3.5% (QTR)

page 2

TRUST PERFORMANCE AT A GLANCE

August 2016

Dire

ctio

n #

Year To Date

Monitor

targets &

weightings

DQ

AF

Ratin

gsForecast *

2016-17

1.0

1.0

Jan-00

Well Led

Caring

1.0

CA

NC

ER

RT

T

Effective

Safe

National

PA

TIE

NT

AC

CE

SS

Jul-16

Responsive

H

H

H

MH

H

H

H

H

U

M

H

H

U

An

ticipated

Au

gust can

cer po

sition

MH



Target/

LimitSet By Reported Period Apr-16 May-16 Jun-16 Jul-16 Aug-16

Current

or YTD

Actual

YTD

Target/

Limit

Forecast

/Rag Rating

Cytology Screening (Wessex std 98% in 10 days) 98% Wessex Aug-16 99.8% 99.5% 99.9% 99.7% 99.9% ↑ 99.9% 98%

Bowel Cancer Screening (100% in 14 days) 100% National Aug-16 92.75% 100.0% 100.0% 100.0% 98.31% ↓ 98.3% 100%

Breast Screening to normal results within 14 days 90% National Aug-16 98.0% 98.0% 97.0% 97.0% 97.0% ↔ 97.0% 90%

Screening to assessment in 21 days - screening to 1st apt offer 90% National Aug-16 99.0% 98.0% 98.0% 98.0% 96.0% ↓ 96.0% 90%

Screening to assessment in 21 days - screening to attended apt 90% National Aug-16 93.0% 95.1% 94.0% 91.0% 85.0% ↓ 85.0% 90%

Round length 90% of eligible woman screened within 36 months 90% National Aug-16 98.6% 99.8% 95.2% 93.0% 98.2% ↑ 98.2% 90%

% of patients within the 4 hour target (3 month qtr.) 95% Monitor Aug-1689.1% 91.1% 90.9% 91.3% 94.0% ↑ 92.6% 95% (QTR2) 1.0

Total time in A+E (95th centile) =< 4 hours National Aug-16 5 hrs 42 5 hrs 30 5 hrs 11 4 hrs 57 4 hrs 32 ↑ 4 hrs 47 =< 4 hours

Time to initial assessment (95th centile) =< 15 mins National Aug-16 5 4 3 4 2 ↑ 3 =< 15 mins

Time to 1st clinician seen =< 60 mins National Aug-16 65 65 64 73 60 ↑ 66 =< 60 mins

Unplanned reattendance rate (all wef 1/4/14) =< 5% National Aug-16 6.70% 5.8.% 6.30% 6.50% 4.30% ↑ 5.80% =< 5%

Left without being seen =< 5% National Aug-16 2.70% 2.90% 3.10% 3.40% 2.70% ↑ 3.10% =< 5%

90% Aug-16 93% 87% 73% 46% 51% ↑ 51% 90%

number

within targetAug-16 66 74 56 44 48 288

85% Aug-16 84% 76% 53% 30% 38% ↑ 38% 85%

number


95% Aug-16 97% 97% 91% 91% 93% ↑ 93% 95%

number


Theatre Utilisation - Main 85% PHFTMay-16 83.3% 86.0% ↔ 86.0% 85%

Theatre Utilisation - Day 80% PHFT May-16 74.1% 70.5% ↔ 70.5% 80%

Day Case Rates (basket of 25 - from Dr Foster) 75% PHFTMay-16 83.3% 82.8% ↓ 83.1% 75%

Outpatient Access : ASIs at = < 4% of successful C&B bookings (local target 10%) - metric not reported as national Choose and Book reporting not currently available

page 3

DQ

AF

Ratin

gs

Dire

ctio

n #

Year To Date

Monitor

targets &

weightings

2016-17

SC

RE

EN

ING

A&

E

(Responsive)

Hip fractures who are medically fit for surgery receive treatment within 36 hrs

Hip fractures within 36 hours of admission (NHFD)

Other trauma inpatients (fit for surgery) receive treatment within 48 hrs

CCG

target

PbR best

practice

tariff

CCG

target

EF

ICIE

NC

YT

RA

UM

A

H

A

H

H

M

$Data Quality Assessment Framework key

H - high MH - medium high M - medium L - low U - not yet classified

H

H

H

H

*Forecast column indicates anticipated deliver for the period defined YE - Year End Green - On track To deliver QTR - Quarter Amber - Delivery at risk M - Month Red - Won't/unlikely to deliver

# Arrow direction indicates

Improvement - ↑ Deterioration- ↓ or no change- ↔ in performance since the previous month

theatre system reports not currently available



STP Trajectories to August 2016

Weighting TargetCurrent

Month

Current

qtr. to

date

Score

of

latest

qtr.

DQAF

ratingRTT

1.0 92% 92.7% 92.7%

-

1.0 95% 94.0% 92.6% 1.0

Jul-16 Qtr 1

85% 88.1% 86.5%

90% 100.0% 95.3%

98% 100.0% 100.0%

94% 100.0% 100.0%

94% 100.0% 98.9%

1.0 96% 100.0% 98.7% -

93% 99.8% 99.0%

93% 100.0% 97.7%

Aug-16 (YTD)

7

4

Executive Lead: Director of Finance

NHS IMPROVEMENT (previously Monitor)

Infection Control :

The target will be deemed to have failed if a quarter is not met , the phasing of

the 2016/17 target (15 cases) is as follows:

Q1 4 cases, Q2 4 cases, Q3 3 cases, Q4 4 cases. Infection control - C. Difficile 1.0 <=15 - 1

2 week wait for Symptomatic Breast Patients

1.0

1.0

1.0

31 day wait for 2nd or sub treatment : Anti

cancer drug treat

31 day wait for 2nd or sub treatment : Surgery

31 day wait for 2nd or sub treatment :

Radiotherapy

31 days wait decision to start of 1st treatment:

All cancers

Maximum 62 day wait from referral to

treatment for all cancers

62 day wait for 1st treatment - consultant

screening service

For RTT , where a month is failed the quarter will be deemed to have failed also,

regardless of the actual quarter result calculated for the quarter. Governance

concerns will be triggered if RTT targets are failed for 3 successive quarters.

* Both the admitted and non-admitted targets have now demised and have be

removed from this section of the IPR.

Aug-16

2 week wait from urgent GP referral to 1st apt

(susp cancer)

A&E : Percentage of patients within the 4 hour

target

Cancer targets are as at July 2016 , and Quarter 1

Referral to treatment waiting time (18 weeks)

for incomplete pathways

-

-

Risk Assessment Framework

Following the replacement of the Compliance Framework used by NHS Improvement

with the Risk Assessment Framework (1st October 2013), the risk rating calculation is

no longer a purely transparent quantitative process in that a variety of external reports

(e.g. CQC) will also be taken into account in addition to weighting scores. Examples

also given include a rapid rise in complaints or infection outbreak such as MRSA,

Monitor have not limited their scope in this respect.

The Risk Assessment Framework is updated annually.

Cancer

Where cancer weightings are held jointly across two or more metrics , if one failed

both will be deemed to have failed and attract a weighting.

Governance concerns will be triggered with Monitor if a 31 or 62 day target is failed for

3 successive quarters. The trust has achieved 62 Day standard in Q3 15/16.

A&E

A&E quarters are no longer based on 13 week periods, following the demise of

weekly SITREPs and return to monthly collections nationally.

Governance concerns will be triggered with Monitor if the ED target is failed in any 2

quarters in a 12 months period and fails in the indicator in a subsequent 9 month

period or the full year. The 4 hour standard has now been triggered for monitor

(non delivery of q4 14/15 , q3 2015/16 & q4 15/16)

H

H

H

H

4 hour ED standard (95%)

period April May June July August September October November December January February March

trajectory 90.00% 90.00% 90.00% 92.08% 92.47% 92.01% 90.05% 90.10% 90.04% 90.00% 90.03% 92.50%

total attendances 5321 5539 5488 5696 5681 5356 5608 5254 5372 5302 5238 5455

4 hour standard breaches 532 554 549 451 428 428 558 520 535 530 522 409

tolerance

performance delivered 89.07% 91.05% 90.92% 91.32% 94.00%

monthly +/- against trajectory -0.93% 1.05% 0.92% -0.76% 1.53% - - - - - - -

cumulative +/- against trajectory -0.93% 0.12% 1.04% -0.76% 0.77% - - - - - - -

RTT Standard (92%)


trajectory 92.99% 93.00% 93.10% 93.20% 93.30% 93.40% 93.50% 93.40% 93.30% 93.20% 93.10% 93.10%

incomplete pathways 12587 12587 12587 12587 12587 12587 12587 12587 12587 12587 12587 12587

18+ backlog 882 882 869 856 844 831 819 831 844 856 869 869

tolerance


monthly +/- against trajectory 0.00% 0.20% 0.00% -0.20% -0.60% - - - - - - -

cumulative +/- against trajectory 0.00% 0.20% 0.20% -0.20% -0.80% - - - - - - -

62 day cancer standard (85%)


trajectory 86.55% 83.33% 90.00% 85.40% 85.37% 85.00% 85.16% 85.16% 85.16% 85.19% 85.29% 85.25%

total patients seen 59.5 60 60 68.5 61.5 70 64 64 64 67.5 51 61

patients who waited >62 days - breaches 8 10 6 10 9 10.5 9.5 9.5 9.5 10 7.5 9

tolerance

performance delivered 88.60% 85.20% 85.30% 88.10%

monthly +/- against trajectory 2.05% 1.87% -4.70% 2.70% - - - - - - - -

cumulative +/- against trajectory 2.05% 3.92% -0.78% 2.70% - - - - - - - -

Diagnostic


trajectory 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%

total diagnsotics waiting (month end) 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000

total diagnsotics waiting 6+ weeks (month end)40 40 40 40 40 40 40 40 40 40 40 40

tolerance


monthly +/- against trajectory -0.50% - - - - - - -

cumulative +/- against trajectory -0.50% - - - - - - -

* not applicable : none as fund allocated based on agreement of trajectories only Finances

total allocation for Poole

RAG rating R failed to deliver trajectory and outwith tolerance for netted off qtr 30% * allocated to trajectory delivery

A failed to deliver trajectory BUT still within tolerance for netted off qtr * split

G delivered trajectory for netted off qtr Q1 Q2 Q3 Q4 Total of 30%

£246,875 £246,875 £246,875 £246,875 £987,500 12.50%

£246,875 £246,875 £246,875 £246,875 £987,500 12.50%

£98,750 £98,750 £98,750 £98,750 £395,000 5%

£592,500 £592,500 £592,500 £592,500 £2,370,000 30%

Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 2016/17

Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 2016/17

not applicable * 1.00% 0.50% no tolerance



Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 2016/17

Total

£7,900,000

£2,370,000

4 hour ED standard (95%)

RTT Standard (92%)

62 day cancer standard (85%)

standard

Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 2016/17


82.00%

84.00%

86.00%

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%

100.00% trajectoryachieved

trajectory

belowtrajectory

plustolerance

88.00%

90.00%

92.00%

94.00%

96.00%

98.00%


trajectory

belowtrajectory

plustolerance

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%


trajectory

belowtrajectory

plustolerance

0.00%

1.00%

2.00%

3.00%

4.00%

5.00% trajectoryplus

tolerancenot achievedtrajectoryplus

tolerance

trajectory



recommednded = likely +extreemty liekly

not = unliely +extrently unlikley

3. Friends and Family Test –Patient ‘Recommend’ % results – Whole Hospital.

5

PATIENT EXPERIENCE

Executive Lead: Director of Nursing and Patient Services / Medical Director

Scorecard - Family and Friends August 2016Description Historical trend

25.5%

28.0%

21.2%

95.7%

0%

5%

10%

15%

20%

25%

30%

0%

10%

20%

30%

40%

50%

0%

10%

20%

30%

40%

Overall response rate for ED (including Ansty) (national target 20%)

Overall response rate for Inpatients (including A3 RACE)(national target 40%)

Overall Combined response rate ( no national target)

93.5%

92.3%

93.8%

95.8%

96.3%

95.1%

95.7%

3.3%

4.7%

3.7%

2.3%

2.2%

3.1%

2.3%

0%

20%

40%

60%

80%

100%

% Recommend

% Not Recommend

Recommendations

Overall positive response rate (likely plus extremely likely) compared with negative response rate (unlikely plu s extremely unlikely)

( no national target)



Target Monthyear to

dateForecast

Aug-16

Patients who spend at least 90% of their time on a

stroke unit80% 87% Aug-16

Percentage of patients admitted directly to specialist

stroke unit within 4 hours of arrival at hospital90% 83% Aug-16

Number of Never Events 0 0 1 Aug-16

Number of serious incidents (incl falls) 0 4 31 Aug-16

Dementia screening 90% 93.0% Jun-16

0

Infection Control - Cdiff cases 15 1 7 q2

Infection Control - MRSA =<1 0 0 (YE)

Discharges with 2 or more ward moves 20 113 Aug-16

Discharges with 2 or more ward moves out of hours

(sub set of above)8 53 Aug-16

Emergency readmissions within 28 days 7.90% Aug-16

Number of complaints received 34 116 Aug-16

6

PATIENT EXPERIENCE, QUALITY AND SAFETY

Executive Lead: Director of Nursing and Patient Services / Medical Director

Trends

Medicines Optimisation has now moved to a dedicated page

Quality and Patient Experience Indicators

0

2

4

6

8

10

12

14

16

Serious Untoward Incidents

Number of serious incidents

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

apr may jun jul aug sep oct nov dec jan feb mar

Percentage of Harm Free Care

2015/16

2016/17

apr may jun jul aug sep oct nov dec jan feb mar

profiled trajectory 4 4 4 8 8 8 11 11 11 15 15 15

2015/16 1 1 2 2 3 4 6 7 12 14 17 18

2016/17 2 5 5 6 7

0

2

4

6

8

10

12

14

16

18

20Cumulative position for Clostridium Difficile

Patient Safety Thermometer monthly snapshot

0

5

10

15

20

25

30

35

40

45

Complaints

2015/16 2016/17



7

QUALITY AND SAFETY

Commentary & Trends

Scorecard - Nurse Staffing LevelsDescription Most recent fill % Historical trend Variation Amber target

as at Aug-16

Staffing levels at < 80%

90.9%

as at Aug-16


97.9%

as at Aug-16


93.5%

as at Aug-16


102.9%

Wards with red flags

7

Shortfalls in staffing that have not been

mitigated and/or the ward has been

declared as having increased risk to

patient safety and experience, need to

be monitored and reported.

Collection of this data started April 2016.

B3 Trauma: 2

Lytchett: 1

C2: 1

A4 Arne : 1

C3 TAU Green: 1

E3 TAU Red: 1

B3 & E3 : Staff were allocated

re patient need and acuity.

Lytchett : R/Ns worked across

two wards. C2 & C3 : Extra

beds opened, clinical

practitioners supported. A4 :

currently recruiting to increase

establishment.

Registered Nurses' & Midwives'

staffing fill rate.

Day shifts only.

Fill rate is actual hours worked as

a proportion of planned hours.

A5 Avonbourne: 77.4%

A5 : Staffing levels were

adjusted to meet patient need.

Registered Nurses' & Midwives'

staffing fill rate.

Night shifts only.



B2 Surgery: 77.9%

B4 Surgery: 79.5%

Kimmeridge: 67.4%

B2 & B4 : Staffing levels were

adjusted to meet patient need;

at night wards were supported

by clinical practioners.

Kimmeridge : This ward was

staffed for escalation which

was not needed.

Clinical Support Workers' /

Healthcare Assitants' staff fill rate.

Day shifts only.



Clinical Support Workers' /

Healthcare Assitants' staff fill rate.

Night shifts only.



B2 Surgery: 78.0%

CCU: 89.1%

Child Health: 79.8%

Forest Holme: 76.9%

Kimmeridge: 84.6%

Sandbanks: 76.4%

B2, Sandbanks & Child health :

Staffing levels adjusted to meet

patient need. CCU & Forest

Holme: Small cohort of staff.

Kimmeridge : This ward was

staffed for escalation which

was not needed.

Critical Care: 83.3%

Critial care : Small cohort of

staff meaning that decrease in

hours have marked effect on

the %, Registered Nurses

provided care needs.

80%

85%

90%

95%

100%

Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16

80%

85%

90%

95%

100%

105%


80%

85%

90%

95%

100%

105%


80%

85%

90%

95%

100%

105%

110%


RegisteredNurse/

Midwife

RegisteredNurse/

Midwife

CareStaff

CareStaff

02468

10121416


Nursing &

MidwiferyRed Flags



Commentary & Trends

8

QUALITY AND SAFETY

Scorecard - Falls and Pressure UlcersDescription Most recent value Historical trend Variation

Wards with most falls last month per 1,000 BD (total)

74

4.70per 1,000 bed days

Wards with most harm falls last month per 1,000 BD (total)

28


Wards with most acquired PUs last month per 1,000 BD (total)

44


Wards with most 3&4 PUs last month per 1,000 BD (total)

3


Wards with most inherited PUs last month per 1,000 BD (total)

56


Wards with most 3&4 PUs last month per 1,000 BD (total)


Number of Pressure Ulcers in

inpatient area inherited from outside

the trust, both as an overall number

and per 1,000 occupied bed days.

Day Case 83.3 (1)

RACE 25.6 (17)

Forest Holme 15.3 (4)

Ansty 7.0 (5)

C4 5.0 (1)

CCU 4.9 (1)

Number of Grade 3 and Grade 4

Pressure Ulcers in inpatient areas

inherited from outside the trust,

both as an overall number and per

1,000 occupied bed days.

(no ward data)

Number of Grade 3 and Grade 4

Pressure Ulcers aquired at the trust

in inpatient areas, both as an

overall number and per 1,000

occupied bed days. The rate per

1,000 bed-days is RAG-rated.

(no ward data)

Number of Falls in inpatient areas

both as an overall number and

per 1,000 occupied bed days.

The rate per 1,000 bed days is

RAG-rated with limits at 2 & 5

RACE 12.0 (8)

Lulworth 11.6 (7)

Portland 10.8 (4)

Stroke Care Unit Acute 10.7 (7)

A5 8.7 (6)

TAU Red 8.5 (6)

Number of Falls in inpatient areas

that resulted in harm to the patient

both as an overall number and

per 1,000 occupied bed days.

The rate per 1,000 bed days is

RAG-rated

(no ward data)

Number of Pressure Ulcers

acquired at the trust in inpatient

areas, both as an overall number

and per 1,000 occupied bed days.

The rate per 1,000 bed-days is

RAG-rated.

Lytchett 11.2 (3)

Forest Holme 7.6 (2)

Critical Care 7.1 (2)

Durlston 6.6 (3)

Lulworth 6.6 (4)

CCU 4.9 (1)

0

20

40

60

80

100

120

Falls01234567

0

20

40

60

80

Acquired Pressure

Ulcers

0

1

2Acquired

Pressure Ulcers

Grade 3 & 4

0

20

40

60

80

100

120

0

1

2

3

Fallswith harm

0

1

2

3

4

0

20

40

60

80

Inherited

Pressure Ulcers

0

1

2Inherited

Pressure Ulcers

Grade 3 & 4

0

1

2

3

4

5



fig 1 fig 4

fig 2

fig 5

fig 3

9

MEDICINES OPTIMISATION

Executive Lead: Medical Director

Commentary & Trends

fig 1 Slight increase in medication errors for July when compared to previous months. Reduction in minor, moderate and severe incidents and increase in “no harm” reports. There were no medication Never Events in July. fig 2 Numbers of patients reviewed by pharmacy teams increased with medicines reconciliation on a par with 12 months ago. Accuracy of data on medicines reconciliation rates remains questionable and is likely to under report the true rate. Improved reporting is being looked at by the senior team. fig 3 Small changes in Pharmacist prioritisation alongside greater ward presence of pharmacy teams and new junior medical teams probably explains July to August rises. fig 4 Dispensing and medication supply increased activity from previous year. Average TTO turnaround time also marginally increased due to inclusion of portering time but still below the 2 hour standard. fig 5 Controlled Drug compliance audits back up to 100% within August. Some continued correlation between completion of compliance audits and decreasing Datix reports of Controlled Drug incidents. No particular theme evident for types of error at present.



Mortality relative risk rating for all in hospital deaths for 12 months to May 2016

Mortality relative risk rating for all HSMR basket of 56 diagnoses May 2016

10

MORTALITY

Executive Lead: Medical Director

Commentary & Trends

The most recent data available from Dr Foster indicates that the Trusts relative risk rate for mortality is overall within the expected range . The relative risk compares the actual with expected numbers of deaths taking into account comorbidities, using February 2016 as the latest available benchmark. The expected number of deaths for May 2016 (all deaths) was 107.42, higher than the 94 observed , a sustained improvement on previous quarters. The position for the 56 HSMR specialties in May also shows a sustained improvement with 74 observed compared with 88.39 expected deaths. The Mortality Group review the Dr Foster reports on a monthly basis at a more detailed level (by condition, diagnosis etc.) ensuring that any alerts are investigated fully and appropriate remedial action taken.



August 2016

Dorset PbR

2016/17 contract

activity variance %

2015/16

actual

2016/17

actual

yr. on yr.

variance%

Daycases (incl RDA) 4.6% 13,509 14,345 836 6%

Elective Inpatients 3.1% 1,484 1,555 71 5%

Elective Sub Total 4.5% 14,993 15,900 907 6%

Non elective 13,646 15,156 1,510 11%

Maternity 2,788 2,560 -228 -8%

Non Elective Sub Total 5.2% 16,434 17,716 1,282 8%

Elective Excess Bed Days 801 749 -52 -6%

Non Elective Excess Bed Days1,400 491 -909 -65%

Non Elective Non Emergency

Excess Bed Days 7,759 8,670 911 12%

Sub Total 9,960 9,910 -50 -1%

New Outpatients 4.2% 35,713 38,793 3,080 9%

Follow -up Outpatients -5.4% 56,040 61,066 5,026 9%

Sub Total 2.2% 91,753 99,859 8,106 9%

Outpatient Procedures 0.0% 5,965 9,146 3,181 53%

New to follow up ratio 1.57 1.57 0.00 0%

A&E 6.4% 27,723 29,147 1,424 5.1%

Sub Total - 27,723 29,147 1,424 5.1%

(source finance

dept mth 2) 11

Demand in terms of GP referrals remains higher than last year. Referral rates continue to show a year on year increase and have

impacted negatively on access times, the year to date rate remains higher than last year. The increase for GP referrals for August

to date year on year is 9.2%

Outpatient attendances for the year to date are now consistently meeting or exceeding the previous year.

Elective activity levels overall, i.e. inpatient and daycase

combined remain higher than the previous year to date, 6%,

as backlog clearance continues, albeit at a reduced rate..

ED attendances for thr year to date exceeded the

previous year by 5.1% .

Non-elective admissions have exceeded

the same year to date period in 15/16 year by 11%.

Increased non-elective activity levels are due in part to the

reclassification of ward attenders. This accounts for about

a third of the increase observed.

MONTHLY ACTIVITY

Executive Lead: Director of Finance

year to date activity month 5

COMMENTARY

sep oct nov dec jan feb mar apr may jun jul aug

Total Accepted Referrals rolling 12 months compared wth previous year (dotted line)

15/16 16/17 2,469.00

Jun-16 gp neuro ytd 1176 945 -231 1550 -14.9%

total 1617 1288 -329 4086 -8.1%

14/15 15/16 +/- +/- %

gp refs neuro 1176 945 -231 -19.6%

other specs 15794 17575 1781 11.3%

total 16970 18520 1550 9.1% -15% of extra refs that are neurology

0

all refs neuro 1617 1288 -329 -20.3%

other specs 32520 36935 4415 13.6%

total 34137 38223 4086 12.0% -8% % of extra refs that are neurology



Target Month Qtr

Accident & Emergency Aug-16 Q2

4 hour wait 95% 94.0% 92.6%

Total time in A&E for all patients: 95th percentile* 240mins 272 mins 287 mins

Unplanned re-attendance rate* (now using unlinked rate) 5% 4.3% 5.8%

Left without being seen rate* 5% 2.7% 3.1%

Time to initial assessment: 95th percentile* 15mins 2 3

Time to 1st clinician seen 60mins 60 66

Number of 12 hour trolley waits in A&E 0 0 0

Family and Friends response rate 25.5%

Ambulance Aug-16

Clinical Handovers >30 minutes but <60 minutes of arrival at

A&E - Number of patients0 27 100

Clinical handover >60 minutes of arrival at A&E - number of

patients0 0 3

Discharge Aug-16 ytd

Delayed Transfers of Care 3.5% 3.22%

Patients discharged < 12pm (incl LOS <1) 16.80%

12

28 Day emergency readmissions - Non-Elective

All Emergency admissions within 28 days of discharge, excel all

obstetric, maternity and cancer spells, day case admissions,

discharged as died, and cancer diagnosis in previous 365 days of

EMERGENCY CARE PATHWAY

Executive Lead: Chief Operating Officer

SUMMARY An improved ED position on last month. Headlines: 4 hour wait up to 94% from 91.3% in July and total time in A&E for all patients down to 272mins from 297mins in July. We averaged 185 attendances in August with a high of 219 on 28th of the month. Of the 343 breaches, 108 were due to waiting to be seen by a clinician in ED. Waiting for a bed only accounted for 99 of the breaches in August which implies flow and bed availability was much improved across the hospital for August. There were a large number of 'Other' breaches; reasons include clincial problems, difficult patients requiring further investigations and waiting for specialist teams to review patients. Our 4 hour performance trend is on a positive trajectory. ED CAPACITY In reference to the delays within the ED department with patients waiting to be seen, analysis detailing our functional capacity (how many patients can be seen by the doctors/nurses on rota) compared with the demand coming in has shown some periods of the day where we are clearly lacking the capacity to cope with demand coming through the front door. There is also variation in our performance depending on what day of the week it is. This will help us plan to boost our capacity on certain days and certain times that require more resource. ACTION UPDATES: We will be reviewing our shift patterns and doctor resource accordingly in an attempt to address these shortfalls. We have analysed the gaps in our capacity and identified extra staff requirements to resolve this. The staffing plan is currently being costed and discussed We are also in the process of trialling a phlebotomy service within the department to assess whether this can have an impact on speeding up patient pathways. This trial has now started, Phelbotomy now attending daily as introductory period and will start fully in September. ED GM is investigating the possibility of having a GP present in ED at weekends. Triage nurses will pass on any patients who should have attended their GP rather than A&E. After investigation it seems this can be a very costly and not always effective solution. It would be more beneficial to extend our primary care nurse practitioner staff group. Contact made with relevant parties to move this forward. Extra doctor working at night increase capacity and allow night teams to recover waiting times quicker after busy evening attendances. Other sites have 4 doctors on at night as standard whereas Poole only has 3. This has commenced on a temporary basis and is proving hugely valuable. Plan is to try and incorperate into normal medical rota. NEW ACTIONS: Increased Pharmacy support; ED to have it's own allocated pharmacist who can work in the department to assist with patients drug charts and also educating patients to inform them of over the counter medicines which could have helped them avoid a trip to ED CLINICIAN SEEN TIME We have seen a marked improvement in clinician seen time standard for August. This is an extremely important part of the patient pathway to get right as not only is it good for patients but it gives the trust an early indication of what that patient will require and therefore more time to plan accordingly. AMBULANCES There are still ongoing issues with ambulance handovers however our handover times have greatly improved over the last few months. There are many question marks over the data validity and the time at which ambulance crews are 'signing off'. Ambulance attendances in July back up slightly and still accounting for around 29% of all attendances. ACTION UPDATES: Setup regular meetings with SWAST to discuss data validity and generate ideas that could improve handover time. These meetings are now taking place and proving extremely beneficial to both SWAST and ED. NEW ACTIONS: ED are planning a 'breaking barriers' type event for end of September where there will be an exceptional focus on ambulance handovers



13

EMERGENCY CARE BENCHMARKING


The above chart compares Poole 4 hour standard performance submitted monthly via Unify against both local Trusts and the national position . (July 2016 is the most recent position published, as there is a 1 month time lag) The national minimum is now just above 70% , moving up from quarter 4 , and the the national overall performance at 90.3% , slightly worse than June. In March Poole was lagging behind the national average , but has since improved and is now the national position by a small margin.



August 16 Target Month YTD

New to Follow-up ratio <2.15 1.61 1.57

*'GP referral rate year on year +/- 0% 6.19% 9.21%

total referral rate year on year +/- 0% 5.66% 13.06%

New outpatient appointment DNA rate5%

by 31.3.166.94% 6.83%

Follow-up outpatient appointment DNA

rate7.00% 6.36% 6.54%

TOTAL outpatient appointment DNA

rate7.00% 6.58% 6.64%

Fig 3

14

OUTPATIENTS


Trust to ensure that “sufficient

appointment slots” are made available

on the Choose and Book system - slot

issue rate of < 4% (national target for

ASIs as a % of all successful bookings)

10%

local target

not

reported

not

reported

Commentary & Trends

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

Fig 1: DNA rates

Total attendances First attendances

Follow Up attendances

0

2000

4000

6000

8000

10000

12000

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

Fig 2: Confirmed Accepted Referrals

Total GP Refs 15/16 TOTAL refs 15/16

Total GP Refs 16/17 TOTAL refs 16/17

New to Follow up Rates The Trust new to follow up ratio in July 1: 1:61. The Dr Foster report 12 months to May 16( latest available) shows nationally new attendances are 32.2% of the total , while in Poole the figure was better at 37% (same period). DNA Rate (did not attend : Fig 1) Work is continuing to reduce the DNA rate , focusing on new outpatients and reviewing processes in the outpatient department The national DNA rate reported by Dr Foster (year to May 16) stands at 7.7%, Poole for the same period compared favourably and was reported as 7.3%. The internally calculated DNA for August improved , with the follow up and total rates dropping below the inernal taregt of 7%. While teh new outpatient DNA rate has also imporved , they are higher than the follow-up DNA rate, and more than the 5% target set. Referral Rates (Fig 2) Referral rates continue to show a year on year increase and have impacted negatively on access times, the year to date rate remains higher than last year last year. The increase for GP referrals for August to date year on year is 9.2%, with overall accepted referrals 13% higher than last year . There have been more than 2,800 new outpatient DNA's for the year to date .

Earliest Available routine Outpatients (Fig 3) Work continues through the speciality actions plans to improve access to first outpatient waiting time , against the increase number of referrals being seen. discussions with commissioners have released a small amount of money to reduce access times in the surgical areas of ENT, Oral, & Dermatology.

Earliest Available Routine Appointment in Weeks at:

30/06/2016 31/07/2016 31/08/2016

Cardiology 14 13 11

Child Health 5 3 5

Paediatric Neurology 14 15 11

Clinical Haematology 1 1 2

Clinical Oncology 2 1 1

Colposcopy 4 2 3

Dermatology 15 14 13

ENT Surgery 6 8 8

Gynaecology 2 1 1

Medicine for the Elderly 1 1 1

Medical Oncology 1 1 1

Medicine 1 1 4

Neurology 16 11 3

Ophthalmology 15 17 17

Oral Surgery 7 7 7

Orthopaedics 10 9 9

Paediatric Surgery 7 10 11

Plastic Surgery 5 9 5

Rehab/TBI 15 15 13

Rheumatology 12 10 11

General Surgery 2 2 1

Vascular Surgery 16 16 16

Thoracic Surgery 0 0 0

Urology 13 12 12



Target MonthQtr. 1

to date

Monitor

Weighting

Aug-16

92% 92.7% 92.7% 1.0

90% 80.0% 76.3%

18 Weeks - Non-admitted 95% 91.5% 91.3%

zero 0 0

<1% 0.5%

zero 0 6

zero 0 2

90% 51.0%

8.40% 6.1%

85% 86.0%

80% 70.5%

15

May-15

The total number of incomplete pathways as at 13,107 as at 31st August 2016.

General Surgery , ENT , Oral Surgery and Dermatology have more than 8% of waiters

over 18weeks.

Target Actual

Incomplete Pathways 92% 92.7%

ELECTIVE CARE PATHWAY


Elective Pathway Indicators

18 Weeks - Incomplete Pathways

Commentary & Trends

Hip fractures who are medically fit for surgery receive treatment

within 36 hrs

Theatre Utilisation - Day Theatre

Diagnostic tests >6 weeks

NoF Mortality rate case mix adjusted (per NHFD)

Theatre Utilisation - Main Theatre

Cancelled operations rebooked <28 days

18 Weeks - Admitted

18 Weeks Referral to Treatment

The Trust achieved the incomplete pathways target (92.7% against 92% target) in August, however this is below the 93.4% trajectory target.

The Trust is working with commissioners to address the increase in referral rates, additional activity will be required to address the increase in

numbers contained on the waiting list. A limited amount of funding has been released to address the surgical specialties and agreement reached to

use an external provider for oral surgery, and further plans are being developed to progess the reduction of the backlog.

Both the admitted and non-admitted targets were demised during June 2015, and while both will continue to be monitored, the incomplete backlog

and its reduction will now be the main focus. The national contract now reflects this change and fine tracking is underway.

The current pressure on emergency flow has impacted on Elective activity during March with a number of lists cancelled due to bed availaibility.

At the Trust Weekly Performance meeting, monitoring at patient level continues for all patients waiting over 26 weeks for treatment. Reasons for

pathway delays are reviewed in more detail with Specialty Managers in addition to this. The RTT action plan for specialties is reviewed and

monitored for delivery.

Elective Demand

Referral rates continue to show a year on year increase and have impacted negatively on access times, the year to date rate remains higher than

last year last year. The increase for GP referrals year to date , compared with last year is 9%, and overall accepted referrals are 11% higher

than last year. The high number of open RTT pathways is a result of increased demand as well as constraints such as theatre capacity.

The 18 week backlog now stands at 958, 50 more than July, and the Trust's performance agaisnt the 92% standard has therefore reduced.

RTT Waits of more than 52 weeks

Urgent operations cancelled 2nd time

18 Week Performance Speciality Specific Performance - below standard for Unify specialties

398 396 447

549

687 715 773

725 791 788 801

954 882

845 904 905

958

0

200

400

600

800

1000

1200

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-1

5

Dec

-1

5

Feb

-1

6

Ap

r-1

6

Jun

-16

Au

g-1

6

RTT 18 week backlog

Cancellations for August (23) higher than the same period last year but a sustained improvement on last month. The biggest driver remains the "lack of theatre time", accounting for 18 of the 23 cancellations . All patients were admitted within 28 days of their 1st cancellation in August.

0

10

20

30

40

50

60

Ap

r-14

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Ap

r-15

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Ap

r-16

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Cancelled operations per month split by cause

other

no bed

staff sickness

no theatre time

list cancelled

11192

11834 11857

12299

13003

12157

12195

11896 11977

11440

11792

12442 12587

12463

13094 12939

13107

92.0

92.5

93.0

93.5

94.0

94.5

95.0

95.5

96.0

96.5

97.0

10000

10500

11000

11500

12000

12500

13000

13500

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-1

5

Dec

-1

5

Feb

-1

6

Ap

r-1

6

Jun

-16

Au

g-1

6

Number of Incomplete Pathways (bar) and % waiting 18 weeks or less (line)

0

50

100

150

200

250

RTT backlog of incomplete pathways as at 31st August 2016

with DTA

without DTA



Target Month QuarterMonitor

waiting

Jul-16 Q1 16/17

2 WW - Fast Track referral to 1st appointment suspected cancer 93% 99.8% 99.0%

2 WW - GP referral to 1st outpatient - breast symptoms(non cancer) 93% 100.0% 97.7%

31 Day - Decision to Treat to 1st treatment 96% 100.0% 98.7% 1.0

31 Day - 2nd or subsequent treatment - Surgery 94% 10.0% 100.0%

31 Day - 2nd or subsequent treatment - Drugs 98% 100.0% 100.0%

31 Day - 2nd or subsequent treatment - Radiotherapy 94% 10.0% 98.9%

62 Day - Fast Track GP /GDP referral to treatment 85% 88.1% 86.5%

62 Day - Referral to treatment - Screening 90% 100.0% 95.3%

62 Day - Referral to treatment - Consultant Upgrade 90% ** 88.9% 98.2% -

**Contractual target, no national standard

Looking ahead:

• as previously reported Public Health England continue to run a national Be Clear on

Cancer campaign until 16 October 2016, the campaign will cover lung cancer.

• Cervical Screening Awareness Week ran from 13-19 June 2016

• NIVEA Sun and Cancer Research UK partnership campaign. This campaign encourages

people to protect their skin from harmful UV damage, whether at home or abroad.

• The CCG will roll out the NG12 (the new 2WW referral form) in September. The impact

that this will have is uncertain, however this may have an impact on diagnostic demand.

There was sustained performance against the 62 day target from urgent referral for suspected cancer to 1st treatment with 88.1% of patients starting

treatment ≤ 62 days from receipt of referral (target ≥85%) in July. In total for July there were 9.5 breaches, 2.5 shared with Royal Bournemouth, 1.5 shared

with Dorset County and 0.5 with Southampton.

In addition to the above breaches, there were also 5 breaches due to complex pathways. In July a number of cancer sites did not meet the target at a site

specific level, namely, gynaecological, haematology, head & neck, lower GI, other, upper GI and urological.

1.0

As well as the increase in 2WW referrals, conversion rates to a cancer diagnosis have

increased slightly to 8.54% for July compared to 8.06% for June. The number of patients

subsequently diagnosed with cancer has remained steady with 54 compared with 59 in

June and 54 in May. The total number of patients first treated at Poole (from all referral

sources) has decreased slightly - 135 in July compared with 156 in June.

Results for August indicate that all of the targets were met in the month. There are 7.5 breaches reported on The 62-day target from urgent referral for

suspected cancer to 1st treatment, therefore 53 treatments are needed to achieve the 86% trajectory target (average monthly treatments is 60). 74

treatments have been reported to date. The month has been RAG rated as GREEN.There was a noted increase in the number of haematological patients treated in July (16

compared to 7 in June). Additionally, there were also increases in June in patients treated

for skin (43 compared to 35 in June) and urological (9 compared to 4 in June). The month

also saw decreases in gynaecological (5 compared to 20 in June), head & neck (8

compared to 16 in June) and lower GI (14 compared to 25 in June).

Trends in reported performance to date are given below:

At the time of writing, there are 4 patients defined as ‘long waiters’ (waiting > 104 days) for

1st treatment following a 2WW referral including 2 urology patients, 1 head & neck and 1

upper GI. All have appointments/scans booked to determine the most appropriate

treatment plan. Patients with long pathways are routinely discussed at the relevant MDT

meeting to ensure that there is no clinical harm caused by the extended pathway.

Performance against the 2WW targets remains strong particularly when compared nationally 99.8% compared to 94.4% nationally. The 2WW target for

breast symptomatic (non-cancer) referrals has been achieved without a breach for the last 2 years. The number of 2WW referrals decreased by 14% from

previous month with suspected skin down by 28% and head & neck by 17%, however there were exceptionally high referrals in May and June.

The % of patients seen <7 days following a suspected cancer referral remained steady at 35.6%, however this remains well below the target (internal) level.

1.0

1.0

CANCER PATHWAY


Commentary Cancer Pathway Indicators

Performance summary: All targets were achieved in July 2016 with Poole performance exceeding the national performance in particular the following: Fast

Track referral for suspected cancer to 1st appointment: 5.4% above national performance, 2WW - Symptomatic breast referral to 1st appointment: 7.9%

above national performance and 62 day - Fast Track GP/GDP referral to 1st treatment: 6.1% above national performance

National

performance

POOLE PERFORMANCE Target Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Jul-16

Fast Track referral for suspected cancer to 1st appointment 93% 99.6 98.6 99.5 97.6 99.7 99.7 99.8 ► 94.4

2WW - Symptomatic breast referral to 1st appointment 93% 100 100 100 100 100 94.3 100 ▼ 92.1

31 day - decision to treat to 1st treatment 96% 100 98.2 98.5 98.6 97.9 99.4 100 ▲ 97.8

31 day subsequent treatment (surgery) 94% 100 100 92.6 100 100 100 100 ► 96

31 day subsequent treatment (anti-cancer drugs) 98% 100 100 100 100 100 100 100 ► 99.4

31 day subsequent treatment (radiotherapy) 94% 99.4 98.8 99.4 98.5 98.3 99.3 100 ▲ 97.4

62 day - Fast Track GP/GDP referral to 1st treatment 85% 89.9 87.3 86.7 88.6 85.2 85.3 88.1 ▲ 82.0

62 day – Screening to 1st treatment 90% 92.3 93.3 100 97.6 93.8 94.3 100 ▲ 92.3

62 day - Consultant Upgrade to 1st treatment 90% 66.7 100 96 100 100 95.5 88.9 ▼ 89.3

Comparison between

July & June performance

for Poole

FYE Conversion rate

%

2014/15 2015/16 2014/15 2015/16Apr - July

2014/15

Apr - July

2015/16

Apr - July

2016/17No % Change

0.1 0.4 1 3 0.4 0.0 0.0 0.0 0.0 4

0.0 15.4 0 2 0.0 0.0 28.6 28.6 33.0 #

8.2 4.3 5 5 15.4 4.3 1.9 -2.4 -56.5 $

9.5 8.9 147 148 9.5 8.9 9.5 0.6 6.5 #

0.0 0.0 0 0 0.0 0.0 0.0 0.0 0.0 4

8.8 7.2 48 48 9.8 7.3 6.4 -0.9 -12.3 $

31.8 33.3 19 22 25.0 36.8 41.7 4.8 13.1 #

6.3 6.2 61 83 4.9 7.5 3.0 -4.5 -60.1 $

6.9 7.1 55 64 6.0 10.8 7.3 -3.4 -31.9 $

22.6 23.2 51 68 14.4 19.6 9.5 -10.1 -51.4 $

16.0 12.9 4 4 0.0 14.3 0.0 -14.3 -100.0 $

14.7 10.6 224 205 14.9 10.9 9.1 -1.8 -16.6 $

10.6 11.3 64 68 9.3 11.5 10.0 -1.5 -12.9 $

10.5 9.3 679.0 720.0 10.1 10.0 7.9 -2.1 -20.7

Conversion rate %

Nos. of pts

diagnosed

Change Q1 16/17 compared to

Q1 15/16

Suspected childrens cancer

Suspected gynaecological cancers

Suspected lower gastrointestinal cancers

Outcome of 2WW referrals

Exhibited (non-cancer) breast symptoms - cancer not initially suspected

Other suspected cancers

Suspected brain/central nervous system tumours

Suspected breast cancer

Suspected haematological malignancies (excluding acute leukaemia)

Suspected head & neck cancers

Suspected lung cancer

Suspected sarcomas

Suspected skin cancers

Suspected upper gastrointestinal cancers

Grand Total (excluding non-cancer breast referrals)



17

STAFFING AND ORGANISATIONAL DEVELOPMENT

Executive Lead: Director of Human Resources and Organisational Development

Commentary & Trends

1. Sickness The rolling 12 month sickness absence rate fell to 3.49% equalling the lowest rate recorded for the Trust on ESR - i.e. since April 2007. Salary costs associated with sickness remain at approximately £3.6m in the 12 months. This does not include replacement costs. 2. Turnover Turnover rates have fallen again - the overall rate is currently 12.94%, within the 14% target. The HCA turnover rate rose to 15.00% compared to 14.68% in July. This is still within the 16.5% target for this staff group. 3. Staffing Levels Staff numbers have continued to increase with a further rise of 21.55 wte experienced in August. The overall substantive staff vacancy level has reduced to 4.71% from 5.31% in July. However, there continues to be considerable use of Bank and Agency staff to cover shortfalls. 4. Appraisal The Trust's target is for 95% of all staff who require an annual performance appraisal to have had one on a rolling 12 month basis. The current compliance rate is 83% a 2% fall on July's figure. Work is on-going with managers to achieve the targeted level. 5. Statutory and Mandatory Training The current overall compliance rate for statuatory and mandatory training remains at 88%, equalling the highest recorded rate. Four modules are now compliant against the 90% target, and there is a significant drive to ensure that the targets are met. Three of the eight main staff groups are compliant overall. 6. Staff Friends and Family Test (SFFT) Comparative Quarter 1 results show the Trust is equal first in the South West for care at 91% positive and third for staff recommending the Trust as a place to work at 71%. These scores are also well ahead of the national averages of 82% and 64% respectively. 7. The tables on the following page give more detailed trend data for these KPIs including hotspot information and training module compliance rates.



18

STAFFING AND ORGANISATIONAL DEVELOPMENT

Executive Lead: Director of Human Resources and Organisational Development

Commentary & Trends

Sickness Hotspots in Previous 3 Months Turnover Hotspots - Rolling 12 Months >= 4 Leavers + >= 20% Rate Statutory/Mandatory Training Modules

Bold/Italics = small departments

Ward/Department % Rate Ward/DeptAvg

Heads

Total

Lvrs% Competence Name Compliance

428 Discharge Lounge 25.18% 428 Paediatric Therapies 19.67 8 40.68 Child Protection Level 1 92%

428 M edical Equipment Library 20.46% 428 Medical CCG-w ide Staff 14.42 5 34.68 Safeguarding Children Level 2 92%

428 General M anagement Trauma 16.13% 428 Medical Staff Oral Surgery 11.58 4 34.53 Safeguarding Children Level 3 90%

428 DAIRS Team 16.03% 428 Avonbourne Ward 36.08 12 33.26 Fire Safety 90%

428 Cardiac Rehabilitation 14.94% 428 Lytchett Ward 26.58 8 30.09 Conflict Resolution 89%

428 Obstetric Theatre 13.86% 428 Outpatients Clerical 43.33 13 30.00 Emergency Planning 89%

428 Community Midw ifery Team 12.51% 428 Bow el Cancer Screening 13.92 4 28.74 Manual Handling Theory 89%

428 Logistics and Postal Service 10.85% 428 Medical Staff Obs/Gynae Sub 14.25 4 28.07 Equality & Diversity 89%

428 Post Natal & TCU 9.51% 428 Haematology 28.67 8 27.91 Health & Safety 89%

428 Emergency Admissions 8.40% 428 Nursing Theatres 103.67 24 23.15 Safeguarding Adults Level 1 88%

428 TAU Red (E3) 7.84% 428 Surgical Short Stay Admissions Unit 17.58 4 22.75 Infection Control 86%

428 Nursing Surgery 7.20% 428 Ward A3 48.58 11 22.64 Manual Handling - Clinical 85%

428 Outpatients Nursing 7.08% 428 Clinical Management Team 22.83 5 21.90 Information Governance 84%

428 M edical Staff Haematology 6.77% 428 Catering Department 50.75 11 21.67 Adult Basic Life Support 84%

428 Endoscopy Unit 6.75% 428 Ultrasound 23.25 5 21.51 Safeguarding Adults Level 2 82%

428 Nursing Child Health Services 6.48% 428 Forest Holme 28.42 6 21.11 Blood Transfusion 1yr 81%

428 Oncology Day Care / OPD 6.25% 428 Portland Ward 23.92 5 20.91 Grand Total 88%

428 Sterile Supplies L5 6.16% 428 Lulw orth Ward 24.00 5 20.83

428 Lulw orth Ward 6.15% 428 Medical Investigation Unit 29.17 6 20.57



Escalation Report Aug-16

What is driving the underperformance ? What actions have been taken to improve performance ? What further actions are planned ?

Expected date to meet standard : September 2016 Lead director Author Suzanne Holloway/ Mandy Tanner

Breast Screening 85% achieved against a 90 % target for screen to attended assesment

Targets:

90 % of women who require a second stage of screening must attend

for an appointment within 3 weeks of their original screening

appointment.

Rationale for Breaches in August 2016

Twenty three women failed to attend their first offered assessment

appointment which meant we failed to reach our 90% target. The

individual reasons are as follows; 20 women cancelled their

appointments because of being away on holiday, the majority of this

group were of a younger screening age and therefore affected by School

holidays. One patient was a technical recall which delayed her final

reporting. One patient was delayed because her previous films from

another unit were requested but a delay in receiving them. One patient

had already been RR'd however, a consultant overruled this and the

patient was rebooked beyond her breach date.

We will be running weekly reports throughout the month to monitor these

breaches ahead of our end of monthly report, so we can monitor these

numbers. We always try to accommodate patients who are cancelling

their appointments by trying to bring their appointment date forward,

however, we always need to respect the wishes of the patient and

sometimes especially during a holiday period we have little control of this.

This should be resolved as we are now out of the main holiday period.

NHSBSP recommendations statethat we would not be allowed to contact

these patients prior to their appointment letter being sent. We cannot

refuse to screen a patient even though she has informed us of a

forthcoming holiday, although whenever possiblestrongly advise they

rebook their appointment once they have returned.



Escalation Report Aug-16

What is driving the underperformance ? What actions have been taken to improve performance ? What further actions are planned ?

Lead director Mark Mould Author Yvonne Hunter

Trauma Orthopaedics - 85% compliance achieved against fractured neck of femur target of 90% of clinically appropriate patients to surgery within 36hrs, rising

to 95% by March 2015.

Targets:

CCG 2015-16 Quality Target:

90% of fractured neck of femur (NOF) patients to be operated on within 36 hours of

admission or of being clinically appropriate for surgery, increasing to 95% by March

2016 (internal target remains at 95% on a monthly basis):

August 2016 compliance 51%

When monthly compliance against the 36 hour target is low the Directorate still

generally achieves a high percentage of patients to theatre within 48 hrs of being fit

however in August this fell to 60%.

Internal Target:

95% of other trauma patients to theatre within 48 hours of admission or being deemed

fit for surgery:

August 2016 compliance 93%

There were 551 admissions in total within Trauma during August, 96 of which were

admitted with a fractured neck of femur (NOF). Compared to the last 3 months the

number of admissions were 507 in July and 430 in June and 448 in May.

Rationale for NOF breaches during August 2016

47 patients who were fit upon admission did not receive surgery within 36 hours for the

following reasons:

Other trauma & NOF patients prioritised: 40

Awaited surgeon for THR/Op: 5

Pre-op CT scan to check fracture pattern: 2

For those fit patients who breached, the median time to theatre was 61 hours, within a

range of 37 to 92 hours.

11 patients (10.5%) were unfit for surgery on admission but optimised within 36 hours.

Of the 11 patients, 0 waited longer than 36 hours of being deemed fit for surgery. The

median time was 22 hours, with a range of 1 - 31 hours. The percentage of unfit patients

was within the expected national average of 10-15% this month. Compliance against

the Best Practice Tariff criteria for surgery within 36 hrs of admission was only 51% this

month.

Rationale for other Trauma breaches during August 2016

24 general trauma patients were not operated on within 48 hours of being fit.

Not listed within 48 hours due to other trauma/NOF's being prioritised: 13

Awaiting specialist surgeon: 9 (6 x lowerlimb, 2 x upper limb, 1x other)

The median wait for those that breached was 86 hrs this month with a range of 48 to

286 hrs. The longest waiter was a # ankle which required swelling to decrease and then

waited for available capacity on a list.

The graph below shows the activity during the month regarding numbers from each

days take, the number per day that required surgery against numbers operated on per

day with the overall gross waiting list trend across the top.

Patient who were fit upon admission

Listed but ran out of time/insufficient capacity/other priorities

The month started in stage 2 of escalation with a backlog of patients to operate on due to

being in continued escalation throughout July. Overall the service spent every day in

escalation in August with 9 days in stage 3, 18 days in stage 2 and 4 days in stage1.

With the exception of the 4 days in stage 1, the team spent most of the month moving

between stages 2 & 3.

The first 3 weeks of the month had a high number of paediatric trauma with a second

infux following the bank holiday weekend. This added sigificant pressure as the majority

of paed cases had to be prioritised over the #NoFs, due to the cases consisting of

supracondylar fractures and bent arms.

No lists were reduced but additional operating was scheduled for 1 weekend out of a

potential 4.

Addtional sessions were picked up either side of the bank holiday to make up for the loss

of 1 session.

During the month the situation was managed on a daily basis as usual by:

Prioritisation/re-prioritisation of cases by Consultants and TAC Team.

Close working with theatres, anaesthetics and radiography to maximise capacity

Use of CEPOD where available, mainly at weekends.

Waiting for surgeon:

A total of 4 hip revisions and 8 primary THRs were operated on in August. Out of those

cases 2 revisions and 2 THRs breached target.

Although there remain only a small number of surgeons proficient in hip revision surgery

there are now more surgeons able to undertake primary hip replacements for fractured

hips. No delays awaiting ITU bed this month.

Patients unfit upon admission:

Monitored against actions previously implemented. All patients reviewed at the time and

the department continues to prioritise surgery for these patients once fit, which on

occasions will cause more recently admitted patients to breach. See below for August

2016 NOF admissions and fit/unfit split.

Other relevant information:

Due to being continous escalation, additional trauma huddles were held most mornings

chaired by the Theatre General Manager and/or Trauma Operational Manager. Also in

attendance were TAC Team, Matron and sometimes representation from CMT. These

were to clarify the current position of the day and discuss plans to aid de-escalation. This

was then communicated to the exec team.

Demand on the Neck of Femur Service August 2016:

Detailed review of the period April to September 2015 undertaken by the Lead NP TAC

Team and demand/capacity analysis of the same period carried out indicated current

theatre capacity no longer sufficient to manage surges in activity. Multifactorial reasons

for this, but it is worth noting that there has been no increase in Trauma theatre capacity

since 2011.

Discussions at Quarter 1 Trauma Directorate Performance Review regarding increasing

pressures throughout the whole Trauma service, including options for increasing theatre

capacity and the ability to 'ring-fence' more lists specifically for the treatment of

fractured hips. Proposed changes to the length of the Trauma lists. Cost of increasing

remaining single theatre lists to 4 hrs included in draft 2016-17 investment plan and job

planning review currently underway for Consultants and Middle Grades, which includes

the plan of how to achieve this.

A trauma debrief is planned once relevant representation is available to look at lessons

learned over the summer in escalation, as part of preparation for winter pressures. The

operational manager is also pulling together data as requested by the exec team around

trends and growth in the Trauma service over the last 3 years.

Standard operating procedures for the transfer of cases to Royal Bournemouth will also

be re looked at and updated as part of the escalation policy, should the directorate find

itself in stage 3 of escalation following a major incident.

Activity August 2016



Author: Barry Duell

Escalation Report (pt1) - August 2016

90% Stay / Direct Admissions / CT < 24 hours / TIA Seen & Treated

Stroke - - Achieved LoS 89% on an 80% target (93% July) - Did not achieve direct admissions 83% on a 90% target (90% July) - Scan within 12 hours 92% (83% July) - Scan within 1 hour 42% (49% July) The following graphs show August activity compared to previous months.

TIA - (Target 60% Seen & treated) - 54 actual referrals into the service in June (65 in July). - 34 high risk (ABCD Score of >3) referrals in total (38 in July) - 22 (65%) seen within 24 hours (30/79% in July)

Data for the month of August 2016 shows the following for Poole Hospital Stroke Unit outcomes:

TIA did not achieve the 60% target for seen & treated within 24 hours in July. The service saw an average number of referrals during the month. The TIA service failures for the 12 patients (15 in July) not seen & treated within 24 hours for August are outlined below: 3 due to reduction in RBCH capacity; 3 declined earlier RBCH appointments; 6 delayed by late primary care referrals; 20 (100%) of low risk patients were seen within 7 days.

90% Stay This target has been achieved in August 2016, with a month end position of 87% on an 80% target. 7 patients failed this target for the following reasons: 1 was appropriately admitted to Critical Care with low GCS; 3 were admitted to RACE with differential diagnosis; 1 was admitted to Ansty clinic, then to Ansty ward with ?TIA; 1 was appropriately admitted to Sandbanks for palliative care. 1 was admitted to TUA with #NOF and RIP

90% Direct Admisisons 7 patients failed this target. In addition to those that didnt not achieve length of stay: 5 were inpatient Strokes 2 were ABI repatriations Datix forms are rasied for all non-direct admissions that would ahve been clinically appropriate tohave been admitted. The Stroke team are able to provide a clear understanding of bed availbility during these periods. All outcomes will be discussed and escalated as neccessary.



Author: Barry Duell

Escalation Report (pt2) - August 2016

90% Stay / Direct Admissions / CT < 24 hours / TIA Seen & Treated

Stroke unit admissions have increased slightly over the preceeding 2 months from our lower numbers seen in May & June. Data for close of coding for August shows 44 diagnosed Strokes being admitted via the Stroke.

Scan within 12 Hours 42% of patients received their scan within 1 hour (49% in July). 92% of patients received their scans within 12 hours (83% in July). 4 patients did not achieve scan within 12 hours. Of these 4 patients: 2 scans were requested late pm and were done the next morning; 2 scans were requested the next day;

Summary Overall slight reduction of perfromance in August compared to July. The team will review processes and look at bed capacity when the non-direct admissions ocurred. All teams have been involved in discussions about managing the Stroke pathway and CMT remain hihgly supportinve in their management of the pathway. There were no periods of closures within the unit or issues escalated regarding difficulties in transfer to downstream wards. Agreements made during month to escalate any late referrals to either Matron or GM were made, and no issues were raised directly. Stroke assessment trolley was used as an inpatient only on a couple of

Actions

• Monthly Stroke Steering Group Meetings continue to monitor patient flow and management of the pathway; • Datix forms continue to be rasied for all non-direct admissions; • Improvements in communication between admission units and ASU being developed; • Plan to create trajectory for implementation of 1 hour scan target once agreement has been made with regards to implementation date; • Acute Stroke pathway being reviewed with support of Acute Medicial colleagues in Ansty by steering group; • Stroke performance being reviewed weeklly; • Radiology playing important part in increasing scan within 12 hours; • Discussions about weekly Stroke/SSNAP reporting and predictors with RBCH, awaiting feedback from Peter Gill as to progress being made.



Escalation Report August-16

What is driving the underperformance What actions have been taken to improve performance What further actions are planned

During August 2016, the Dorset BCSP was able to offer 98.31% (58/59) of patients a

diagnostic test appointment within 14 days (100% in July). The single breach was due to

capacity (consultant leave during the month).

The Programme Manager monitors demand and capacity on a daily basis. Recruitment of post when AtR agreed with potential to recruit into further

hours in the near future if service requires.

The programme remains two BCSP accredited screeners down (1 at DCH and 1 at PHFT) Three additional lists delivered at DCHFT during August. Additional lists will

continue to be negotiated as required if demand requires it.

Continues review of demand and capacity to provide responsive provision.

100% (50/50) of all patients were offered a Specialist Screening Nurse Practitioner clinic

appointment within 14 days of their positive FOBt result (100% in July).

AtR submitted for approval (w/b 19/09) for a full time Bowel Scope Nurse

Endoscopist post that has been made vacant due to resignation from within the

team.

Expected date to meet standard : Q1 2016/17 Lead director : tbc Author: Debbie Lennon

BCSP targets: Nurse Clinic waits (14 days) 100%; Diagnostic test waits (14 days) 100%



BOARD OF DIRECTORS – COVER SHEET


Agenda item: 14 Paper No:8

Subject: FINANCIAL PERFORMANCE: MONTH 5 (August 2016)

Prepared by: Andrew Goodwin, Deputy Director of FinancePresented by: Mark Orchard, Director of Finance

Purpose of paper: To report financial performance to 31 August 2016 against the revised 2016/17 plan and control total agreed with NHS Improvement.

Background: Control total: The Board has committed to delivering a control total deficit of no more than £800k, after having adjusted for donated capital. The planned value of donated capital is £2.7m, which would result in a year-end reported surplus of £1.9m before impairments.

Cost improvement plan (CIP): The Trust’s revised financial plan assumes delivery of £9.2m total cost efficiency (3.9% of turnover), that is:

the original £6.1m CIP requirement, plus a further £3.1m stretch – the movement between the

original £9.7m planned deficit and revised £1.9m surplus, less £8.5m STF and associated income.

Cash: Subject to delivery of the control total and associated operational performance commitments:

the Trust will be eligible to access £7.9m income from the national Sustainability and Transformation Fund (STF) and a further £600k from Dorset Clinical Commissioning Group; total £8.5m.

the Trust’s underlying operating cash deficit would be fully mitigated non-recurrently during 2016/17.


As at 31 August 2016, the Trust is reporting:

a surplus for the month of £270k compared to a planned surplus of £167k, after having accrued for STF and associated income in full

£58k ahead of the year-to-date (YTD) ‘control total’ agreed with NHS Improvement

Clinical directorates are in aggregate overspent by £40k in August.

£322k of the original £6.1m CIP remains unidentified at the end of August.

BoD�Sep�16�14a�Financial�PerfoOverall�Page�99�of�125Page�1�of�2


The £3.1m further cost avoidance/ improvement stretch - required to achieve the control total – includes: £1.2m depreciation (non-cash) which is subject to an

independent professional revaluation of Trust estate/ asset lives and external audit sign-off

£860k avoidable contract performance penalties, and £604k net improvement in directorate forecast

expenditure.

At the end of August 90% of total YTD CIP had been delivered (£286k YTD shortfall).

The Trust’s cash balance at the end of August 2016 was within £23k of the revised plan.

The cash plan for the remainder of 2016/17 assumes receipt of STF income during November (£4.3m, Q1-2 in arrears), February (£2.1m, Q3 in arrears) and March (£2.1m, Q4 on account); plus £4.2m CQUIN income.


No decisions are put forward for Members at this time.

Recommendations: Members are asked to note financial performance to 31 August 2016.

Next steps: Management of key financial risks, including:

STF financial income: directorate control total delivery STF performance income: operational delivery Winter/ escalation beyond plan (including medical and

nursing agency assumptions) CIP: identification of outstanding £322k, plus recovery

against £286k YTD shortfall (includes energy performance contract)

Estate revaluation/ asset lives: material audit risk CQUIN delivery, including £363k for flu vaccinations Acute Vanguard/ reconfiguration programme: operate

within nationally funded envelope


Strategic Objective: Ensure all resources are used efficiently, effectively and economically to deliver key operational standards.

BAF/Corporate Risk Register: AF4CQC Reference: Not applicable.

Committees/Meetings at which the paper has been submitted: DateFinance and Investment Committee 26 September 2016Hospital Executive Group 23 September 2016Executive Directors 20 September 2016

BoD�Sep�16�14a�Financial�PerfoOverall�Page�100�of�125Page�2�of�2


INCOME AND EXPENDITURE (I&E) SUMMARY PAY EXPENDITURE

Actual Plan Variance Actual Plan Variance Forecast Plan

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

NHS Dorset CCG 12,461 12,459 2 62,353 62,004 349 149,261 149,261

NHS England (Wessex) 3,809 3,674 135 18,325 18,190 135 43,908 43,908

Sustainability and Transformation Fund 708 708 0 3,541 3,541 0 8,500 8,500

Other Operating Income 3,172 3,032 140 15,184 15,066 118 34,190 34,190

Total Operating Income 20,150 19,873 277 99,403 98,801 602 235,859 235,859

Charitable Income 722 773 (51) 1,031 1,082 (51) 4,577 4,577

Total Income 20,872 20,646 226 100,434 99,883 551 240,436 240,436

Pay - Permanent and Bank Staff (12,829) (12,904) 75 (63,901) (64,038) 137 (154,825) (154,825)

Pay - Agency and Locum Staff (402) (343) (59) (2,402) (2,343) (59) (4,498) (4,498)

Non-Pay - Clinical Supplies and Drugs (3,433) (3,210) (223) (16,744) (16,520) (224) (39,093) (39,093)

Non-Pay - Non Clinical Supplies and Other (2,945) (3,003) 58 (12,623) (12,286) (337) (28,828) (28,828)

Total Operating Expenditure (19,609) (19,460) (149) (95,670) (95,187) (483) (227,244) (227,244)

Finance Charges (993) (1,019) 26 (5,093) (5,140) 47 (11,310) (11,310)

Reported Surplus/ (Deficit) 270 167 103 (329) (444) 115 1,882 1,882

Impairment 0 0 0 0 0 0 0 0

Donated capital adjustment (452) (407) (45) (252) (195) (57) (2,682) (2,682)

Control Total (Deficit) after donated capital (182) (240) 58 (581) (639) 58 (800) (800)

REVENUE ANALYSIS Month Year to Date Full Year

Actual Plan Variance Actual Plan Variance Forecast Plan

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

General Medicine and Elderly Medicine 2,522 2,527 5 12,725 12,730 5 30,984 30,984

Specialist Medicine 880 880 0 4,356 4,356 0 10,606 10,606

Emergency and Ambulatory Care 924 928 3 4,614 4,617 3 11,035 11,035

Radiology and Therapies 1,365 1,345 (20) 6,590 6,570 (20) 16,115 16,115

Pharmacy and Pathology 1,065 1,041 (24) 5,203 5,179 (24) 12,793 12,793

Operational Support and Outpatients 651 611 (40) 3,021 2,981 (40) 7,265 7,265

Anaesthetic, Critical Care and Theatres 1,921 1,904 (17) 9,531 9,514 (17) 22,881 22,881

Surgery 968 968 0 4,901 4,901 0 11,677 11,677

Trauma and Orthopaedics 636 636 0 3,213 3,214 1 7,701 7,701

Oncology and Cancer Services 1,658 1,698 40 7,958 7,998 40 19,031 19,031

Women's Services 1,098 1,106 8 5,630 5,638 8 13,416 13,416

Children's Services 1,030 1,034 4 5,161 5,165 4 12,496 12,496

Clinical Directorates 14,718 14,678 (40) 72,903 72,863 (40) 176,000 176,000

Corporate Directorates 2,618 2,601 (17) 13,042 13,025 (17) 31,351 31,351

Non-Directorate 3,806 3,534 (272) 14,160 13,551 (609) 34,967 34,967

Income (20,872) (20,646) 226 (100,434) (99,883) 551 (240,436) (240,436)

Reported Surplus/ (Deficit) 270 167 103 (329) (444) 115 1,882 1,882

Agency and Locum Staff (£'000) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2016/17 Actual (this year) 526 537 522 415 402

2016/17 Ceiling 370 370 370 370 370 370 370 370 370 370 370 370

2015/16 Actual (last year) 565 597 546 566 434 494 530 508 515 649 579 608

66.3%

2.8%

Plan

FINANCIAL PERFORMANCE: MONTH 5 (AUGUST 2016)

Month Year to Date Full Year

The Trust is reporting a surplus for the month of £270k compared to a planned surplus of £167k, after having accrued for STF

(Sustainability and Transformation Fund) and associated income in full.

Total pay for the month was £16k favourable: £75k underspend against permanent and bank staff, partly offset by agency and locum

expenditure being £59k adverse against plan. Non-pay for the month was £165k adverse to plan, mainly relating to drugs and clinical

supplies, which has been more than offset by operating income being £277k favourable to plan.

The Trust has committed to delivering a control total deficit of no more than £800k, after having adjusted for donated capital. The

planned value of donated capital is £2.7m, which would result in a year-end reported surplus of £1.9m before impairments. The Trust is

reporting that for the first five months it is £58k ahead of the year-to-date ‘control total’ agreed with NHS Improvement.

Internal control totals agreed with clinical directorates have resulted in a net £650k increase against the original approved 2016/17

budget (by Care Group: Medical +£1.1m, Surgery +£400k, Clinical and Operational Support -£700k, Women, Children and Oncology -

£150k). Clinical directorates are in aggregate overspent by £40k in August, predominantly relating to the timing of key assumptions within

clinical and operational support.

Pay Metrics Month

Actual

63.4%

The regulator has set a total agency and locum expenditure ceiling for the Trust at £4.4m for 2016/17 (equivalent to

£370k expenditure per month on average). 2015/16 comparative expenditure was £6.6m (average £550k per month).

During August, expenditure continued to fall markedly for the second successive month, to £402k; with the largest staff

groups being medical (£187k) and nursing (£133k, of which £102k registered and £31k unregistered). The cumulative

YTD position reports £2.4m expenditure against a £1.9m ceiling (£2.7m equivalent YTD expenditure 2015/16).

Medical shifts continue to account for 65% of the total weekly exceptions reported to NHS Improvement against the

new agency rules (nursing, 19%).

Agency and locum expenditure as % of total pay

Total pay costs as % of total income

3.0%

Year to Date

Actual

66.0%

3.6%

Full Year

12,883 12,724 12,709 12,734 12,829

526 537 522 415 402

3.9% 4.0% 3.9% 3.1% 3.0%

0%

1%

2%

3%

4%

8,000

9,000

10,000

11,000

12,000

13,000

14,000

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

Total pay costs with % spent on agency and locum staff

Permanent and Bank Staff Agency and Locum Staff Agency and Locum Expenditure as % of total pay costs

0

1,000

2,000

3,000

4,000

5,000

6,000


Agency and locum staff cost

2016/17 Actual

2016/17 Ceiling

2015/16 Actual

1BoD�Sep�16�14b�Financial�Perfo



Month Year to Date COST IMPROVEMENT PLAN (CIP)

Actual Actual Forecast Plan Actual Plan Actual Plan

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Financial: control total (70%) 461 2,303 5,530 5,530 Medical 56 43 329 304

A&E performance: trajectory (12.5%) 82 411 988 988 Clinical/ Operational Support 139 145 837 859

RTT performance: trajectory (12.5%) 82 411 988 988 Surgical 16 36 93 156

Cancer performance: trajectory (5%) 33 165 395 395 Oncology, Women and Children's 65 81 324 389

NHS Improvement 658 3,291 7,900 7,900 Care Groups 276 306 1,582 1,709

NHS Dorset CCG 50 250 600 600 Corporate Directorates 123 155 648 717

Sustainability and Transformation Fund 708 3,541 8,500 8,500 Trust Wide 204 233 339 430

Total Cost Improvement Plan 603 694 2,570 2,856

CAPITAL EXPENDITURE YTD YTD incl

Actual Commitments Forecast Plan

£'000 £'000 £'000 £'000

Estates 1,620 2,830 10,201 10,201

Equipment 1,138 1,241 8,075 8,075

IT 415 1,178 2,022 2,022

Total Capital Programme 3,173 5,249 20,298 20,298

Of which, financed by Trust depreciation:

Estates 415 1,194 2,235 2,235

Equipment 797 896 4,892 4,892

IT 415 1,178 2,022 2,022

Trust Financed 1,627 3,268 9,149 9,149

CASH BALANCE

Cash Balance (£'000) cumulative Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2016/17 Actual 9,002 6,102 6,534 5,954 5,552

2016/17 Plan 8,263 7,323 5,238 4,737 5,529 2,332 1,607 5,036 3,820 2,548 4,223 4,763

378 378

Full Year

Plan

£'000

Forecast

£'000

(6)

(20)

598

1,885 (22)

(64)

Variance

£'000

598 25

1,885

The 2016/17 revised plan forecast includes £7.5m loan and £3.7m charitable financed

schemes, in addition to £9.1m being self-funded from Trust depreciation (total £20.3m).

£3,173k overall expenditure for the first five months, with a further £2,076k committed

(£5,249k total). Slippage to date relates to loan funded schemes (energy performance

contract and radiology equipment) and a £925k Trust-funded CT scanner which was

ordered on 14 September 2016 for delivery in January 2017.

The Trust’s revised financial plan assumes delivery of £9.2m total cost efficiency (3.9% of turnover). £322k of the original £6.1m

CIP remains unidentified at the end of August. The £3.1m further cost avoidance/ improvement stretch - required to achieve

the control total - includes £1.2m depreciation (non-cash) which is subject to an independent professional revaluation of Trust

estate/ asset lives and external audit sign-off, £860k avoidable contract performance penalties and £604k net improvement in

directorate forecast expenditure. At the end of August 90% of total YTD CIP had been delivered (£286k YTD shortfall).

Subject to delivery of the control total and associated operational performance commitments, the Trust will be eligible to

access £8.5m STF and associated income during 2016/17. With this assumption, the Trust’s previously reported underlying

operating cash deficit can be fully mitigated non-recurrently for this year. The Trust’s cash balance at the end of August 2016

was within £23k of the revised plan (control total) agreed with NHS Improvement. The cash plan for the remainder of 2016/17

assumes receipt of STF income during November (£4.3m, Q1-2 in arrears), February (£2.1m, Q3 in arrears) and March (£2.1m,

Q4 on account); plus £4.2m CQUIN income.

(91)

(32) (68) 1,783 1,795

Full Year

3,695 (29) 3,695

(90) (286) 9,285 9,198

SUSTAINABILITY & TRANSFORMATION FUND

(STF) INCOME

Full Year

The month and YTD reported financial position includes an accrual for 100% of the STF and

associated income to date, which is released quarterly in arrears based on achievement.

However, the Trust will not receive the Q1 STF income (cash) until validation of Q2

performance, due to not agreeing to a financial ‘control total’ until after the Q1

859 934

3,795 (30) 3,720

(65)

(126)

Year to Date Month

Variance

£'000

12

(16)

0

2,000

4,000

6,000

8,000

0

500

1,000

1,500


CIP delivery by month and year-to-date

Plan for Month Actual for Month Plan for Year Actual Year-to-Date

0

2,000

4,000

6,000

8,000

10,000


Cumulative month-end cash balance

2016/17 Actual

2016/17 Plan

2,235

4,892

2,022

1,000

2,683 6,966

500

0

2,000

4,000

6,000

8,000

10,000

EstatesYTD

EstatesPlan

EquipmentYTD

EquipmentPlan

ITYTD

ITPlan

Capital expenditure by type

Loan

Charity

Trust

2

BoD�Sep�16�14b�Financial�PerfoOverall�Page�102�of�125Page�2�of�2





Subject: QUARTERLY COMPLAINTS REPORT – QUARTER 1 2015/2016

Prepared by: Amanda ColmanPresented by: Robert Talbot

Purpose of paper: To brief the Board on the number and nature of formal complaints and their outcome for the period 1 April 2016 to 30 June 2016

Background: The complaints policy for the Trust requires that the Board of Directors must receive quarterly reports on complaints to monitor complaints handling, trends and lessons learned.


The number of complaints (63) fell during quarter 1. (106, Q1 2015)

88% of complaints were responded to within the 25 working day target, which is an improvement on the previous quarter.

Four complaints were referred to the ombudsman during the quarter. All four are in progress the decisions/outcomes awaited.

Patient Experience Facilitators will start in post 1 July 2016 and take forward the patient experience within the Care Groups.


None

Recommendations: None

Next steps: To receive the 2016 Quarter 2 report in November 2016



(if applicable)CQC Reference:

Committees/Meetings at which the paper has been submitted: DateQuality, Safety and performance Committee Sept 2016

BoD�Sep�16�15a�Complaints�CoveOverall�Page�103�of�125Page�1�of�1


of 8

DIRECTOR OF NURSING OFFICE

PALS/COMPLAINTS REPORTQuarter 1

1 April 2016 to 30 June 2016

1. INTRODUCTION

1.1. The responsibility for the Trust’s formal complaints service was transferred to the Patient Experience Department (PE) on 1 April 2015. The merging of the Patient Advice and Liaison Service, (PALS) and complaints process provides a longitudinal perspective across the whole ‘customer care’ spectrum, from minor concerns to more serious complaints. Additionally any trends and themes identified through the joint services can be triangulated with comments received from the Friends and Family Test (FFT), real-time patient feedback, national patient surveys, questionnaires and other patient feedback mechanisms.

1.2. The implementation of the robust system for complaints is now complete. All complaints are added to the database at first contact or when consent has been received if the complaint is made on behalf of another person. All documentation is uploaded and available on the complaints module of Datix for ease of access.

1.3. The complaints acknowledgement times have improved during the quarter, and 97% have received acknowledgement within the three working day standard. Final response rates have also seen an improvement 88%; within the 25 working day time frame. If it is likely that the estimated final reply date will not be met the complainant is contacted and an extended date agreed.

1.4. There has been further work on data quality and data input to ensure consistency and data integrity this will to enable more reliable and accurate reporting. The departments ‘Users Guides’ are being updated as a result.

1.5. Additionally as PALS and Complaints are now combined services a review of PALS/complaints reporting to streamline and reduce duplication was undertaken with the input of the Medical Director and Director of Nursing. This report and the annual PALS/complaints report are a result of this work.

1.6. The Patient Experience Facilitators, PEF start in post on 1 July. This will enable a full implementation of the initial triage of enquires of PALS/complaint where calls/emails are made to the complainant to make early contact and avoid unnecessary escalation. The PEF’s will establish how the concern(s) should be managed and seek to offer an early resolution.

1.7. Each PEF will have responsibility for a specific care group(s). It is therefore envisaged that once established, they will use their network of contacts, to accelerate the process and complaints can be resolved promptly and in the majority of cases met the final reply date.

1.8 . Priority is now being given to the accurate collection of complaint outcomes, lessons learned and actions taken. A revised checklist has been introduced and is circulated to those involved in the complaint investigation. The form which sets out action(s) taken in accordance with the CQC principles, Safe, Caring, Responsive,

BoD�Sep�16�15b�Complaints�QuarOverall�Page�104�of�125Page�1�of�8


of 8

Effective, and Well led, is completed by the lead investigator(s) identifies the root cause(s) of the complaint and also confirms what action has been taken, to whom the information is disseminated and with whom it has been discussed. Where appropriate, lessons learned in one specialty/care group are shared with other areas.

1.9. The Department for Medicine for the Elderly have agreed that action plans drafted as a result of complaints and subsequent changes implement as a result will be shared and included with the final reply letter to evidence, where appropriate, that lessons have been learned and action taken to minimize reoccurrence as a result.

1.10. All complaints received by the Trust are managed in accordance with the Statutory Instrument 2009 No 309 “NHS England, Social Care, England – the Local Authority Social Services and NHS Complaints (England) Regulations 2009”. The Complaints Policy for the Trust requires that the Board of Directors must receive quarterly reports on complaints in order to monitor arrangements for local complaints handling, consider trends in complaints and in particular consider any lessons which can be learned from complaints, particularly about service improvement. Reports must avoid any possible any possible breach of patient confidentiality.

2. Summary – Patient Experience Q1 2016/17

2.1. Complaints, PALS & Health Information enquiries

A breakdown of the figures for the current and preceding QTR are shown in the table below:-

QTR42015/2016

QTR1 2016/2017 TREND

Complaints 102 63 PALS 625 551 HIC 579 689



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2.2. PALS & HIC Q1 2016/2017

2.3. During this quarter the Patient Experience Team dealt with:

551 PALS received enquiries - a decrease of 8.8% on last quarter. 689 HIC enquiries - an increase of 35% on last quarter.7 NHS Choices

This represents a combined total of 1247 enquiries handled by the Patient Experience Team during Quarter 1 – 2016/17.

2.4. There were 551 PALS enquiries received during this quarter. These were categorised as follows:-

332155

734

810

5

Enquiries resolved by PALS Defused complaints Intended to make a formal complaintOngoingUnresolved/UnresolvableOther/Onward referralTo other PALS

2.5. Interpreters

There were 161 requests for foreign language interpreters and 27 requests for interpreters for the deaf.

Detail for QPR Q1 2016/17

3. PALS enquiries & complaints analysis

During Q, 7 enquirers indicated that they intended to complain formally, despite considerable PALS efforts to resolve their concerns. At the time of reporting only 1 of these had proceeded to a complaint. This complaint is ongoing at the time of reporting.

0

200

400

600

800

1000

PalsHelp &

Supportresolved

Complaints DefusedComplaints Unresolvd Ongoing Other

Trustweb

enquiriesHIC Total

Enquiries

PALS 332 7 155 8 34 15 7 0 0Health Info Centre 332 7 155 8 34 15 7 689 0Total 332 7 155 8 34 15 7 689 1247

PALS / HIC Enquiries - Q1 April - June 2016



of 8

0

100

200

300

400

500

600

700

PALS Enquiries & Complaints 2011 - 2016

Q1 2011 Q1 2016/17

PALS Enquiries

Complaints

3.1. NUMBER OF COMPLAINTS RECEIVED

The number of formal complaints the Trust received in this quarter was 63: for the same quarter last year the total was 106. Looking at the trend the average number of complaints received is declining overall and even comparing the significant increase in Q4 the overall annual figures indicate a fall in the number of formal complaints by 135, which represents a decrease of 27%.

The Patient Advice and Liaison Service (PALS) still continues to have a positive impact on addressing patients’ concerns, preventing and reducing the likelihood of issues escalating to a complaint. The service also provides an additional route through which patients can raise issues.

106

86

70

102

63

Qtr1 15/16 Qtr2 15/16 Qtr3 15/16 Qtr4 15/16 Qtr1 16/17

Complaints Received

Complaints Received Qtr1 15/16 to Qtr1 16/17



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0

10

20

30

40

Patient Spouse Parent Relative/CarerSeries 1 38 7 5 13

Complaints - Who Complained? Q1 2016/17

Num

ber

3.2. Making Experiences Count” and the Statutory Instrument make it clear that a complaint may be made orally, in writing or electronically, ensuring that the arrangements for making complaints are easily accessible. Complainants have utilised the following methods to communicate this quarter:-

Email 31% Letter 24% Telephone 33% In person 12%.

3.3. Complaint submitted by

3.4. Complaint Response Times

All complainants receive a written response from the Chief Executive or the Medical Director in her absence. There are no longer timescales for the local resolution stage of the complaints procedure, but the Trust has decided to continue to monitor response rates against the 25 day standard, aiming to respond to 85% within this timescale.

Acknowledgement

2.4 Q1 %Acknowledged <=3 working days 61 97%

Reply

Q1 %

Replied <=25 working days 23 88%

3.5. 37 complaints are still open, of which; 11 are overdue either awaiting a response from the investigators or are in the process of developing the final reply.



of 8

4. GRADE OF COMPLAINTS RECEIVED

4.1. All complaints are graded according to severity, which is based on an assessment of the likelihood of the event occurring again and the consequence to the individual and the organization.

4.2. Action has been taken to improve risk assessment; complaints are now triaged immediately on receipt. Adjustments are made to the risk rating throughout the complaint process, as necessary, following this initial grading.

4.3. There were no Red cases at time of reporting.

5. NATURE OF COMPLAINTS RECEIVED

5.1.The percentages for categories of complaints received during this quarter are illustrated in the following table:

6. OUTCOME

6.1. In terms of outcome, of the 26 complaints which were closed the following resolutions were recorded:-

6.2Outcomes by Care Group

There were 26 closed complaints with the following outcomes:-

Green Yellow Amber Red84% 14% 2% 0%

Subject QTR42015/2016

QTR1 2016/2017 TREND

All aspects of clinical treatment 42% 52% Attitude of staff 19% 21% Appointments, delay/cancellation (out-patient) 1.5% 1%Appointments, delay/cancellation (surgery) 2% 2%Availability of Service (Inpatients / Outpatients / A&E) 15% 3% Communication/information to patients (written and oral) 9% 3%

Discharge and transfer arrangements 2.5% 2%Patients' property and expenses 7.5% 11% Other 1.5% 5%

Not Upheld 6Partially Upheld 15Upheld 2Withdrawn 1Reimbursement 2

OUTCOMES - By number of complaints responded to:

CARE GROUP WITHDRAWN

NOT UPHELD

PARTIALLY U/H REIMB UPHELD TOTAL %

MEDICAL 1 5 8 1 0 15 58%



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7. LEARNING LESSONS

7.1. Summaries of lessons learned following investigations at local resolution are illustrated in the following table:

7.2. The embedding of the new PALS/complaints process has been completed. Although there will continue to be adjustments and refinements, the focus is now on the outcomes and learning aspects of both services.

ID Description Lessons learned7458 Removal of a security tag from a new-

born baby using inappropriate equipment

Only the correct equipment is now used, all other equipment has been removed.

7470 Inconsistency of documentation of the grade of sacral sore Also the perception of how we view the CHC paperwork and how this comes across to the NOK

Documentation, accuracy and consistency discussed with all qualified nurses in the department

7495 Dr unavailable when on call due to communication failure

Dr reviewed his personal communication procedures when on call.

Inaccurate guidance on information when administering pre medication before a procedure.

Update of guidelines for patients with swallowing difficulties due to take Gastrogafin.

Member of ward team not trained to administer thickened fluid

Training given in fluid consistency to ensure fluid intake is maintained.

Nursing staff reminded of the fundamentals of nursing if/when leaving a patient unattended

7487 Lack of specific explanation when undertaking a gynaecological examination

Consent form to be changed to incorporate more detail about vaginal examination as part of a laparoscopy.

8. REQUESTS TO THE HEALTH SERVICE OMBUDSMAN

There have been four cases referred to the Parliamentary and Health Service Ombudsman during this quarter.

All four cases are still in progress awaiting a decision.

SURGICAL & ONCOLOGY 0 1 4 1 1 7 27%

WOMEN & CHILDREN 0 0 2 0 1 3 12%

OTHER HOSPITAL 0 0 1 0 0 1 4%

Total 1 6 15 2 2 26



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9. Trends and themes from PALS enquiries and Complaints:

9.1. An emerging trends during Q1 was:

Increased waiting times for routine orthopaedic follow up appointments raised with the appropriate departmental manager – there ongoing capacity issues which are currently under discussion.

10. Conclusion

The revised systems and processes for PALS and complaints are fully implemented and operational. Ongoing adjustments will be made to refine the system.

The number of complaints fell by 27% on the previous quarter (4). With a significant improvement in the ‘three working day’ acknowledgment times, 97%. Quarter one also indicated a gradual improvement in the turn-around time for final response letters.

Priority is now being given to improving data collection of complaints outcomes, lessons learned and action taken. The circulation of a revised feedback form should improve this. Two new Patient Experience Facilitators start in post on 1 July. By setting up contacts and networking with key staff their role will greatly improve communication of patient feedback and enhance understanding of the patient experience from the patient’s perspective.

Tracey NutterDirector of Nursing

Robert Talbot Medical Director

Amanda ColmanHead of Patient Experience

Please note: All the figures and graphs within this report are based on the data extract which was taken on the 1 7 2016 at 10:54hrs.





Agenda item: 21 Paper No: 10 Subject: Vanguard Programme

Prepared by: Stephen Killen (Programme Director) and Sally-Ann Webb (Programme Manager)

Presented by: Paul Miller (Director of Strategy)

Purpose of paper: To update the Trust Board on progress on the Dorset vanguard Programme as at mid-September 2016

Background: Builds on the previous reports to the Trust Board on this issue


The report is very concise and reports on four areas;

(a) Dorset programme Infrastructure(b) National Programme discussions(c) Joint Venture(d) Local programme priorities


To note

Recommendations: None

Next steps: To be kept briefed



(if applicable)CQC Reference:


BoD�Sep�16�21a�Vanguard�cover�Overall�Page�112�of�125Page�1�of�1


Infrastructure

Terms of Reference agreed for - Executive Steering Group - Chairs & Chief Executives ….- Medical Director & Chief Operating Officer Oversight Group Medical Director leads established for clinical workstreamsDorset Vanguard presenting at CCG Clinical Working Group 21 September 2016- General overview of progress- Stroke update- Workshop – What does Pathology in the future look like?Feedback received from PPEG on suggested engagement activities and methods and process agreed for engagement in pathway redesignDCH board to receive recommendation on outcome of Dorset and Yeovil discussion regarding partnership arrangement for obstetric and paediatric services.

Joint Venture

National Programme

Decision received from the National Care Models Team for funding the remaining quarters of 2016/17 – total funding for the year now agreed as £1,090k Inaugural Acute Care Collaboration Vanguards Community Of Practice meeting held with representation from Dorset Vanguard ProgrammeThe Vanguard Programme Team are in discussion with national team about other support opportunities available.Attended the New Care Models Zone at Health & Care Innovation Expo 2016 exploring innovative new ways of delivering better care to local people

Local Priorities

Update on Dorset Vanguard September 2016 ‘Developing One

NHS in Dorset’

Dorset County Hospital NHS Foundation TrustPoole Hospital NHS Foundation Trust

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Agreement to proceed with the exploration of a ‘prime contractor’ joint venture.Areas of focus include Pathology Services and Business Support Services

Recruitment for Joint Ophthalmology Paediatric Consultant post underway and space identified in community for potential surgery sessions (Swanage, Wimborne & Blandford hospitals)Strategic Outline Case for One Pathology Service being presented to 3 Trust Boards and work underway on quick winsWorking with Stroke Association and Trusts to identify recent stroke survivors to co-design new models of careHealth Informatics and Business Support Services workstreams now extended to include DHUFT & CCG and work progressing on required response on consolidation to NHSI mid October.Agreement of four sub-specialty areas to focus on standardising and improving cardiology pathways; Cardiac Rhythm management, chest pain, heart failure and ImagingDependency and acuity tool for paediatric services shared for use Pan- DorsetWork on honorary contracts to enable cross site working for radiologists

BoD�Sep�16�21b�Vanguard�Board�Overall�Page�113�of�125Page�1�of�1


BOARD OF DIRECTORS – COVER SHEET



Subject: NHS IMPROVEMENT:QUARTER 1 (2016/17) FEEDBACK

Prepared by: Mark Orchard, Director of FinancePresented by: Mark Orchard, Director of Finance

Purpose of paper: For information.Background: The Trust is required to make quarterly submissions to

NHS Improvement (the regulator) in accordance with the Risk Assessment Framework.


NHS Improvement have confirmed (31 August 2016 letter attached):

Financial sustainability risk rating: 2 Governance rating: Green

NHS Improvement further noted the Trust’s failure to meet the A&E clinical quality standard during Quarter 1, 2016/17 (total time in A&E under 4 hours target).

NHS Improvement has decided not to open an investigation to assess whether the Trust could be in breach of its license at this stage.


No decisions are put forward for Members. This paper is information.

Recommendations: Members are asked to note the feedback received from NHS Improvement relating to Quarter 1, 2016/07.

Next steps: 1. The Trust will continue to address its longer-term financial sustainability, working with partners across the Dorset health and social care system.

2. The Trust implemented a new 2016/17 A&E Improvement Plan during August 2016, which is being monitored through the Hospital Executive Group and Quality, Safety & Performance Committee, with escalation to the Board of Directors if the improvement trajectory is not maintained.


Strategic Objective: Ensure all resources are used efficiently, effectively and economically to deliver key operational standards.

BAF/Corporate Risk Register: AF4CQC Reference: Not applicable.

Committees/Meetings at which the paper has been submitted: DateFinance and Investment Committee 26 September 2016

BoD�Sep�16�23a�NHSI�Q1�FeedbacOverall�Page�114�of�125Page�1�of�1


31 August 2016 Mrs Debbie Fleming Chief Executive Poole Hospital NHS Foundation Trust Longfleet Road Poole Dorset BH15 2JB

Dear Debbie Q1 2016/17 monitoring of NHS foundation trusts Our analysis of your Q1 submissions is now complete. Based on this work, the trust’s current ratings are:

Financial sustainability risk rating: 2

Governance rating: Green These ratings will be published on NHS Improvement’s website in September.

NHS Improvement is the operational name for the organisation which brings together Monitor and the NHS Trust Development Authority. In this letter, “NHS Improvement” means Monitor exercising functions under chapter 3 of Part 3 of the Health and Social Care Act 2012 (licensing), unless otherwise indicated. The trust has been allocated a financial sustainability risk rating of 2 and has failed to meet

the A&E Clinical Quality – Total time in A&E under 4 hours target.

NHS Improvement uses the measures of financial robustness and efficiency underlying the

financial sustainability risk rating as indicators to assess the level of financial risk and the

above targets (amongst others) as indicators to assess the quality of governance at

foundation trusts. A failure by a foundation trust to achieve a financial sustainability risk

rating of 3 or above and the targets applicable to it could indicate that the trust is providing

health care services in breach of its licence, which could lead to consideration of

enforcement action1.

We expect the trust to address the issues leading to the financial sustainability risk rating

and the target failures and achieve financial sustainability and sustainable compliance with

the targets promptly, and in line with its submitted improvement trajectory. The relationship

1 Under the Health and Social Care Act 2012, taking into account, as appropriate, our published guidance on

the licence and enforcement action including our Enforcement Guidance (www.monitor-nhsft.gov.uk/node/2622) and the Risk Assessment Framework (www.monitor.gov.uk/raf).

Wellington House 133-155 Waterloo Road London SE1 8UG T: 020 3747 0000 E: [email protected] W: improvement.nhs.uk

BoD�Sep�16�23b�NHSI�Q1�FeedbacOverall�Page�115�of�125Page�1�of�2

http://www.monitor-nhsft.gov.uk/node/2622

http://www.monitor.gov.uk/raf


team notes that the trust met the A&E improvement trajectory for Q1 and will continue to

monitor delivery against this during 2016/17.

NHS Improvement has decided not to open an investigation to assess whether the trust could be in breach of its licence at this stage. The trust’s governance rating has been reflected as ‘Green’. Should any other relevant circumstances arise, NHS Improvement will consider what, if any, further action may be appropriate. A report on the aggregate performance of all NHS providers (Foundation and NHS trusts) from Q1 2016/17 is available on our website (in the Resources section), which I hope you will find of interest. For your information, we have issued a press release setting out a summary of the report’s key findings. If you have any queries relating to the above, please contact me by telephone on 020 3747 0334 or by email ([email protected] ). Yours sincerely

Smitha Nathan Senior Regional Manager cc: Ms Angela Schofield, Chair

Mr Mark Orchard, Director of Finance

BoD�Sep�16�23b�NHSI�Q1�FeedbacOverall�Page�116�of�125Page�2�of�2

mailto:[email protected]


POOLE HOSPITAL NHS FOUNDATION TRUSTGLOSSARY OF ABBREVIATIONS

AA&E Accident and EmergencyA&G Audit and Governance CommitteeAfC Agenda for ChangeAHPs Allied Health Professionals AIRS Adverse Incident Reporting SystemAMM Annual Members’ MeetingAQP Any Qualified ProviderASI Appointment Slot Issues

BBAF Board Assurance Framework BME Black and Minority EthnicBoD Board of Directors

CCAU Clinical Assessment UnitC.Diff Clostridium difficileCCG Clinical Commissioning Group CCU Coronary Care Unit CE Chief ExecutiveCEA Clinical Excellence AwardsCEPOD Confidential Enquiry into Perioperative DeathCGG Clinical Governance Group CHKS A national independent provider of comparative performance and healthcare dataCIP Cost Improvement PlanCOAST Children’s Observations and Severity ToolCoG Council of Governors COO Chief Operating OfficerCoSRR Continuity of Service Risk Rating CP Chief PharmacistCQC Care Quality CommissionCQUIN Commissioning for Quality and InnovationCRES Cost Releasing Efficiency SavingCRT Clinical Record TrackingCSR Clinical Services Review CT Computerised Tomography

DDatix National Software Programme for Risk Management DBS Disclosure and Barring Service DNA Did not attendDoF Director of FinanceDoH Department of HealthDoN Director of NursingDDoN Deputy Director of Nursing DoW&OD Director of Workforce and Organisational Development

Glossary�of�Abbreviations�AuguOverall�Page�117�of�125Page�1�of�5


DoS Director of StrategyDr Foster Provides health information and NHS performance data to the publicDToC Delayed Transfer of Care

EEBITDA Earnings Before Interest, Taxation, Depreciation and AmortisationEBME Electrical, Biomedical EquipmenteNEWS National Early Warning ScoreENT Ear, Nose and ThroatERCP Endoscopic Retrograde CholangiopancreatographyESR Electronic Staff Record EWTD European Working Time Directive

FFCE Finished Consultant Episode FFCE First Finished Consultant Episode FFT Friends and Family Test FIC Finance and Investment CommitteeFOI Freedom of InformationFT NHS Foundation Trusts FPPRG Future Plans and Priorities Reference Group. FRP Financial Recovery Plan.

GGTDRG Governor Training & Development Reference Group

HH@N Hospital at Night HDU High Dependency UnitHFMA Healthcare Financial Management Association HoC Head of CommunicationsHR Human ResourcesHRG Healthcare Resource Group HSE Health & Safety ExecutiveHSMR Hospital Standardised Mortality Ratios

II&E Income and ExpenditureICU or ITU Intensive Care Unit or Intensive Therapy UnitIG Information GovernanceIPG Investment Planning Group IPR Integrated Performance ReportIT or IM&T Information Technology or Information Management & Technology

KKPI Key Performance Indicator



KSF Knowledge & Skills Framework

LLCFS Local Counter Fraud Specialist LiNAC Linear AcceleratorLNC Local Negotiating Committee LocSSIPs Local Safety Standards for Invasive ProceduresLoC Letter of ClaimLoS Length of StayLTFM Long Term Financial Model

MMARS Mutually Agreed Resignation SchemeMD Medical DirectorMDT Multi-Disciplinary TeamMERG Membership Engagement and Recruitment GroupMortality rate The ratio of total deaths to total population in relation to area and time.MRI Magnetic Resonance ImagingMRSA Methicillin Resistant Staphylococcus Aureus MSC Medical Staffing Committee

NNatSSIPs National Safety Standards for Invasive ProceduresNCEPOD NCEPOD (National Confidential Enquiry into Perioperative Death) NED Non-Executive DirectorNHSINHSIQ

NHS Improvement - The independent regulator of NHS Foundation TrustsNHS Improvement Quality

NHSLA National Health Service Litigation Authority NICE National Institute for Health & Clinical ExcellenceNICU Neonatal Intensive Care UnitNMG Nursing and Midwifery Group NPfIT National Programme for Information TechnologyNPSA National Patient Safety AgencyNREC Nominations, Remuneration & Evaluations Committee NSF National Service Framework NVQ National Vocational Qualification

OOD Organisational DevelopmentOFT Office of Fair TradingOMF Oral Maxillo Facial

PPA/SPA Programmed Activities and Supporting Professional ActivitiesPACS Picture Archiving and Communications System – the digital storage of x-raysPALS Patient Advice and Liaison Service PBC Practice Based Commissioning PbR Payment by Results



PEAT Patient Environment Action Team PET Position emission tomography scanning systemPEWS Poole Early Warning System PFI Private Finance InitiativePHFT Poole Hospital NHS Foundation Trust PID Project Initiation DocumentPLICS Patient Level information and costing systems – data collection systemPMO Project Management OfficePROM Patient Recorded Outcomes MeasuresPST Patient Safety Thermometer PTIP Post Transaction Implementation PlanPYLL Potential Years of Life Lost

QQIA Quality Impact Assessment QIPP The Quality, Innovation, Productivity and Prevention ProgrammeQPR Quarterly Performance ReviewQSPC Quality, Safety & Performance Committee

RRACE Rapid Assessment and Consultant Evaluation for older peopleRBH Royal Bournemouth & Christchurch Hospitals NHS Foundation TrustRCI Reference Cost Index RTT Referral to Treatment. The current RTT Target is 18 weeks.

SSALT Speech and Language Therapy SAU Surgical Assessment UnitSHMI Summary Hospital Mortality IndicatorSFIs Standing Financial InstructionsSI Serious Incident SID Senior Independent DirectorSIRO Senior Information Risk OwnerSLA Service Level Agreement SLM Service Line ManagementSLR Service Line ReportSMR Standardised Mortality rate – see Mortality Rate SPF Staff partnership Forum SpR Specialist Registrar – medical staff grade below consultantSTEIS Strategic Executive Information SystemSTP Sustainability and Transformation Plan

TTAL NHS Direct provides The Appointments Line service as part of Choose & BookTIAA The trust’s internal auditorsTOR Terms of Reference

V



VfM Value for Money VIP Score Visual Infusion Phlebitis of intravenous cannuloe – scoring systemVSM Vey Senior ManagerVTE Venous Throboembolism

WWODC Workforce and Organisational Development CommitteeWTE Whole Time Equivalent

YYTD Year to Date

August 2016




BOARD OF DIRECTORS

GOVERNANCE CYCLE 2016/17 (April 2016)

MONTHLY REPORTS Lead Part 1/2

Chairman’s Report (Receive) – To include reports from the Remuneration Committee and Appointments Committee when appropriate. To also include the Council of Governors’ meeting report.

Chairman Part 1/2

CEO Report (Receive) CEO Part 1/2

Any Red Risks added to the Risk Register DoN Part 2

Integrated Performance (Scrutinise) - Summary of Summary Paper Part 1 (£/ Contract /MPE/HR Activity/Compliance/Quality ) (Including FRP and if needed also to Part 2 of BoD

(Note detail to FIC, QSPC, WFC & HEG)

Lead DoF

Support COO/DHR/DNPS

Part 1

Ward to Board Report DoN Part 1

Financial Performance Report (including 2016/17 CIP Report) DoF Part 1

Update on Dorset Clinical Services Review (from March 2015) CE Part 2

Vanguard Update Report (from Sept 2015) DoS Part 2

Finance and Investment Committee Chairman’s Report Including any issues for SBAR (Tabled Report) Chairman FIC Part 1

Board Sub-Committee Minutes – Finance and Investment Committee/ Workforce and Organisational Development Committee/ Audit and Governance Committee/ Quality Safety and Performance Committee

Co Sec Part 2

Hospital Executive Group Minutes Co Sec Part 2

Serious Incidents Report (Including Initial Notification of Potentially Serious Incidents)

MD/ DoN Part 2

Patient Story DoN Part 1

BI-MONTHLY REPORTS LEAD PART 1/2Audit and Governance Committee Chairman’s Report Including any issues for SBAR (Tabled Report)

Chairman A&G Part 1

Quality and Safety Performance Committee Chairman’s Report Including any issues for SBAR (Tabled Report)

Chairman QSPC Part 1

Workforce and Organisational Development Committee Report Chairman’s Report Including any issues for SBAR (Tabled Report)

Chairman WODC Part 1

EXCEPTION REPORTS (e.g.) Lead Part 1/2

Charitable Funds – Expenditure Over £25,000 DoS Part 2

Monitor Concerns CEO Part 2

Working Capital Utilisation Report (Receive) DoF Part 2

Commissioner Contract Variations (Approve) DoF Part 2

Cash Investments (Approve) DoF Part 2

Amendments to Directors’ Interests (Receive) CoSec Part 1

2016-17�Board�Governance�CycleOverall�Page�122�of�125Page�1�of�4


Board Governance Cycle (Approve) CoSec Part 1

Regulatory Exception Reports e.g. HSE Reports (Health and Safety Executive), Care Quality Commission (CQC) Reports.

DoN Part 1

QUARTERLY REPORTS Lead Part 1/2

Monitor Quarterly Certifications - Submissions (Approve)(Q3 – January; Q4 - April; Q1 - July; Q2 - October)

CEO Part 2

Quarterly Complaints Report(Q3 – February; Q4 - May; Q1 – September ; Q2 - November)

DoN Part 1

Progress on Delivery of the Annual Plan (Part 1) (Part of CE Briefing) (Q3 – January; Q4 - April; Q1 - July; Q2 - October)

CEO Part 1

Quarterly Strategy Report (Q3 – January; Q4 – April; Q1 – July; Q2 – October

DoS Part 1

½ YEARLY & ANNUAL REPORTS Lead ½ Year Annual Part 1/2

Board Assurance Framework Close/sign off previous year’s

framework.

DoN --- April/May Part 1

Board Assurance Framework Annual Framework (Approve) DoN

--- May Part 1

Board Assurance Framework ½ Year Review (Scrutinise)

(Subject to A&G scrutiny of process - Nov)DoN Oct/ Nov --- Part 1

Risk Register Report DoN October April (AR) Part 2

Patient Experience Report DoN January July Part 1

Nursing Establishment Review (from Jan 2015)

DoN January July Part 1

Summary of Claims MD January(April – Sept)

July (Oct – March)

Part 2

Information Governance SIRO (Summary) DoF November April Part 1

Annual Complaints & PALS Summary Report

DoN (also see quarterly reporting)

July Part 1

Annual Raising Concerns Report DoHR --- Apr/May Part 1

National Inpatient Survey Results DoN --- July Part 1

WODC Annual Report DoHR From 2014 May Part 1

QSPC Annual Report DoN From 2015 July Part 1

FIC Annual Report DoF From 2015 July Part 1

A&G Annual Report (part of the Annual Report)

CoSec From 2015 May Part 1

Annual Estates Report DoS From 2016 April Part 1

Quality Assurance for Responsible Officers and Revalidation

MD From 2016 July Part 1

GOVERNANCE REVIEW REPORTS Lead Annual Reports Part 1/2

Code of Conduct (5 yearly due 2018) CoSec/ Chairman November Part 1



Constitution (3 yearly due August 2017)(Note CoG Approval)

CoSec/ Chairman November Part 1

Scheme of Reservation & Delegation (Approve 3 yearly)

Co Sec/ CEO March 2017 Part 1

Standing Financial Instructions (Approve 2 yearly) last approved May 2016

DoF May 2018 Part 2

Annual review of the effectiveness of third party processes and relationships (Re Comply or Explain)

CEO/HoC February Part 1

Audit & Governance CommitteeTerms of Reference

Chair A&G/ DoF September 2016 Part 1

Finance & Investment CommitteeTerms of Reference

Chair F&I/ DoF September 2016 Part 1

Quality and Safety Performance CommitteeTerms of Reference

Chair QSPC/ DoN September 2016 Part 1

Workforce and Organisational Development Committee Terms of Reference

Chair WFC/DoHR September 2016 Part 1

Seal of Documents Register CoSec April Part 1

Gifts & Hospitality Register CoSec April Part 1

Annual Board Effectiveness Report Co Sec September Part 1

Independence of Non-Executive Directors Co Sec April Part 1

ANNUAL BUSINESS PLANNING/REPORTING Lead Annual Part 1/2

Strategic Plan (Approve)

Supporting Functional Strategies & Policy Intent (Approve)

CEO/DoS

Execs

(5 Year) TBA

(5 Year) TBA

Part 2

Part 2

Annual Operational Plan & Certification Receive Draft (BoD Pt 2)Approve Final (BoD Pt 2) Final Annual Operational Plan (BoD Pt 1) To receive

CEO/DoF CEO/DoFCEO/DoF

FebruaryMarchApril

Part 2Part 2Part 1

Approve Register of Compliance with Licence Conditions CEO/DoF March Part 1

Approve Register of Compliance with Code of Governance CEO/DoF March Part 1

Draft Sources of Assurance (Annual Corporate Governance Statement)

CEO/DoF May Part 2

Approve Annual Corporate Governance Statement CEO/DoF May Part 2

Annual Report:

Annual Governance Statement (previously Statement of Internal Control (Approve)

Accounts/Quality Accounts (Approve)

Audit Letter to Auditor (Agree)

Annual Membership Report

CEO/DoF/DoN

DoF/ HoC/DoNChairman

May

May

May

May

May

Part 2

Part 2

Part 2

Part 2

Part 2

Board Reporting Governance Cycle (Approve) Co Sec March Part 1

Annual Declaration of Interests (Receive) CoS/ Chairman April Part 1

Other Annual Certificates:Availability of Resources

Systems for Finance Compliance (condition G6)

DoF

DoF

May

May

Part 1

Part 1



Certification of AHSCs N/A and Governance – The Corporate Governance Statement

Training of Governors (S151 Act)

CEO

Chairman

May/June

May./June

Part 1

Part 1

BOARD ANNUAL OPERATIONAL BUSINESS Lead AnnualCommissioner Contract(s) (Approve) - Preliminary scrutiny by FIC

DoF/COO March/ April Part 2

Annual Budget/Capital Programmes DoF March Part 2

Annual CQC Report DoN July Part 1

Annual Staff Survey Report and Action Plan (Receive) DoHR April/ May Part 1

Annual Emergency Preparedness Report (Receive) COO May Part 1

Annual Clinical Excellence Awards (part 2 to approve) DoHR&OD May Part 2

Annual Clinical Excellence Awards(part 1 to note)

DHR&OD June Part 1

Annual Policy Review for Complaints MD July Part 1

Annual Policy Review for Claims MD July Part 1

Annual Health and Safety Report DoN Nov Part 1

POLICY

General Policies including Research Governance – via Strategic Intent

DoS TBA Part

KRNAugust 2016

