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BOARD OF DIRECTORS

11th NOVEMBER 2015

Agenda

Meeting Title: Board of Directors

Date: Wednesday 11th November 2015 Time: 2.00pm

Venue: Education Centre, 1st Floor West Wing, 250 Euston Road Agenda item Attachment

1. Apologies for Absence and Declarations of Conflict of Interest

2. Minutes of the Meeting held on 9th September

A

3.

Matters Arising Report B

4. Other urgent matters not appearing on the Matters Arising Report

5.

Presentation: Focus on Safety World Health Organisation Safer Surgery Checklist Daniel Farrar, Consultant Anaesthetist & Oscar Fernandez-Saborit, Senior Matron, Theatres & Anaesthetics

6. Chairman’s Report

C

7. Chief Executive’s Report

D

8. Executive Board Report

E

9. Performance Report

F

10. Quality & Safety Committee Reports – September and October

G.1 & G.2

11. Finance & Contracting Committee Report H

12. Report of the Audit Committee Meeting held on 15th September

I

13. Minutes of the Audit Committee Meeting held on 21st July J

14. Any Other Urgent Business

15. Date of Next Meeting

Wednesday 9th December 2015

A

Agenda Item 2

Minutes of the Meeting held on 9th September 2015

Board of Directors Minutes of the Meeting held on 9th September at 2.00pm

Present

Richard Murley, Chairman

Harry Bush, Vice-Chairman David Lomas, Non-Executive Director Rima Makarem, Non-Executive Director Diana Walford, Non-Executive Director Caspar Woolley, Non-Executive Director Geoff Bellingan, Medical Director, Surgery & Cancer Board Jonathan Fielden, Medical Director, Medicine Board Gill Gaskin, Medical Director, Specialist Hospitals Board Neil Griffiths, Deputy Chief Executive Tim Jaggard, Interim Finance Director Robert Naylor, Chief Executive Flo Panel-Coates, Chief Nurse

In attendance Simon Knight, Director of Planning & Performance Ben Morrin, Director of Workforce David Probert, Director of Strategic Development Tonia Ramsden, Director of Corporate Services (Board Secretary) Annette Jeanes, Director of Infection Prevention & Control (for item 6)

Jocelyn Laws, Trust Administrator (Minutes)

Item Matters covered 9/1

Welcome, Apologies for Absence and Declarations of Interest The Chairman welcomed Professor David Lomas to his first meeting. Professor Lomas had replaced Professor Sir John Tooke as Vice-Provost (Health) at UCL and as the UCL nominee on the Board. The Chairman also welcomed David Probert who would be attending Board meetings routinely in future. Apologies were received from Tony Mundy and Kieran Murphy. Declarations of Interest Declarations made by David Lomas on appointment to the Board were included in the revised Register of Interests later on the agenda.

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9/2 Minutes of the Meeting held on 8th

July 2015 Alasdair Breckenridge pointed out that he had been omitted from the list of those present. The minutes were otherwise agreed to be correct.

9/3 Matters Arising Report The report was noted.

9/4 Chairman’s Report The Chairman drew attention to the forthcoming retirement of the Chief Executive who would be leaving the Trust at the end of March. A replacement was currently being sought and an appointment panel would be convened in November. The remaining items in the report were noted.

9/5 Presentation: A Patient Story Jonathan Fielden presented the key issues from a complaint arising from the treatment of a patient with long term cancer requiring surgery for the removal of a tumour, who also had a mental health condition. He provided background data on the incidence of mental health issues among our patients and advised that 46% of people with mental health problems also had long term physical problems. Mental health attendances comprised approximately 4% of Emergency Department (ED) activity and up to 12% of our elective patients had a mental health diagnosis included in their coding.

Complaints received from patients or family members related to the care environment, carer involvement, lack of empathy and understanding by individual staff, lack of knowledge about mental health conditions, and community support/links to partner organisations.

The patient in question had recovered well from the surgery but had suffered an acute deterioration in mental health in the immediate post-operative period. Their behaviour had ultimately led to the need for sectioning under the Mental Health Act and admission to a mental health facility once their physical condition improved.

The complaint from the patient’s family centred on lack of awareness or adequate training among staff to deal with mental health deteriorations, lack of holistic care relating to medication and environment, communication with the family over mental health interventions and lack of continuity of care with mental health provider colleagues. Following the initial response to the complaint which had not satisfied the family, they had met with key members of staff from both UCLH and Camden & Islington FT. This, too, had failed to address their concerns and the complaint was escalated to the CQC. The CQC had upheld several, but not all, aspects of the complaint.

Jonathan Fielden listed the actions we had put in place in response to the CQC’s feedback. These included education sessions for frontline staff on dealing with patients with mental health issues, and a masterclass on Deprivation of Liberty, the Mental Capacity Act and Mental Health Act for senior clinicians. We had appointed a mental health administrator covering all sites to improve the coordination related to sectioning and had introduced a mental health checklist to prompt staff to ensure correct processes were followed, including involving next of kin.

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There had also been a focus on ED, working with Camden & Islington FT and other colleagues to allow more rapid escalation of issues and improve responsiveness, and supporting a reduction in ED attendances and admissions through the formation of a mental health hub and more proactive crisis working. Across the Trust we were working to ensure that patients had their mental health needs appropriately met while being treated for their physical illness. The overall aim was to achieve parity of esteem but more needed to be done.

The Chairman said that during his visits to wards and departments sisters and charge nurses had raised the issue of treating patients with mental health problems as one of the biggest challenges. Jonathan Fielden said that a lack of appropriate mental health beds, and the fact that we treated patients from all over the country which meant we had to deal with numerous local authorities, made discharge arrangements very complex.

The Chairman proposed that the Board should have a further discussion on mental health issues in the future.

9/6 Focus on Safety: Infection Prevention and Control The Chairman welcomed Annette Jeanes who presented a summary of the annual infection control report which had been circulated with the Board papers. In 2014/15 the Trust had reported 109 cases of healthcare acquired Clostridium difficile of which 74 had been successfully appealed as not being due to lapses in care. There had been three cases of MRSA bacteraemia against a Monitor target of five, and 23 cases of MSSA bacteraemia against an internal threshold of 27. We had achieved 95.4% hand hygiene compliance, a significant reduction in surgical site infection and were one of the leading trusts in putting in place mitigating actions to control pseudomonas in tap water in high risk areas.

Root cause analyses were conducted in all cases of C.difficile and cases were reviewed by the CCG. 67% of cases had occurred in immunocompromised patients and were related to essential treatment. Examples of lapses in care were late stool sampling, delayed isolation (more than two hours), inadequate documentation and inadequate cleaning. A C.difficile reduction plan had been produced based on the findings of root cause analyses and learning from others. In the last year we had focused particularly on a deep cleaning programme, hydrogen peroxide vaporisation (HPV) decontamination and the introduction of microbiological testing of the environment for micro-organisms in the air.

With regard to MRSA and MSSA bacteraemias, approximately 60% were associated with patients’ skin and 20% with infections elsewhere in the body. A number of interventions to prevent harm had been introduced, including extensive training for all staff on intravenous line insertion and care, sterile techniques and sterile dressings to keep lines stable. Other interventions included reducing wound and urinary tract infection, improved documentation and monitoring, and removal of IV lines as soon as possible.

Improvements in the incidence of surgical site infection had resulted from a review of theatre practice, giving patients antibiotic prophylaxis, keeping patients warm while in theatre and through the use of impregnated sutures and vacuum dressings which formed a seal around the wound.

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Annette Jeanes outlined the key work areas planned for 2015/16 which included rolling out staff training in IV line care, cleaning, use of antibiotics and hand hygiene, setting up a C.difficile task force, continued surveillance, audit and feedback, and developing strategies for dealing with highly resistant micro-organisms.

The Chairman invited questions. Diana Walford asked whether any of the 35 cases of C.difficile classed as being due to lapses in care were preventable. Annette Jeanes said it was difficult to be certain; for example lapses due to delay in isolation would not have impacted on the patient who had the infection, but earlier isolation could prevent spread to other patients. Diana Walford also asked whether the testing used at UCLH was more sensitive and therefore we were penalising ourselves as we were reporting more cases. Annette Jeanes said this was absolutely the case; however, the Chairman said that doing what was best for patients was more important than meeting targets, a view the Board supported.

Rima Makarem asked about promoting hand hygiene to patients and visitors. Annette Jeanes replied that many patients and visitors understood the need to use hand gel or wash their hands but it was important to keep reinforcing the message.

In response to a question from Alasdair Breckenridge about the focus on C.difficile, Annette Jeanes said that several years ago we had had instances of patients becoming seriously ill from C.difficile, but because of more robust testing and changes in antibiotic prescribing etc. we had not had any patients requiring colectomies for many years. She felt that the situation had improved generally but assured the Board that this issue was still high on the agenda. The Chairman thanked Annette Jeanes for the presentation.

9/7 9/7.1

Chief Executive’s Report Chief Executive Transition This issue had been noted in the Chairman’s report.

9/7.2 Monitor Q1 Report The Chief Executive had intended to circulate copies of the Q1 Monitor before the Board meeting but it had not yet been issued.

9/7.3 Employment of Overseas Healthcare Professionals The report referred to the difficulty we have experienced in securing work permits for overseas nurses owing to immigration restrictions, and the fact that many of our nurses were paid below the salary threshold which entitled them to remain in employment in the UK. The Chief Executive said these issues affected a large number of trusts and NHS Employers was taking this up at national level.

9/7.4 RRO Rebranding The report updated on the issue of rebranding that had previously been discussed by the Board. Two concerns had been raised related to ownership of the new brand and the ability to distinguish it from that of the Australian partners’ brand - Everlight Radiology.

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The Chief Executive said that, following discussions, he believed these matters had been resolved and requested the Board’s endorsement of the proposal to rebrand the joint venture as Everlight Radiology UK. The brand would be fully owned by the LLP.

The Chairman felt we needed to further understand our rights if the parent company was sold or wished to buy us out. It was agreed that clarification on these points should be sought. The decision on the way forward was delegated to the Chief Executive, Chairman and Harry Bush.

9/7.5

EHRS – Visit to the US This item was noted.

9/8 9/8.1

Executive Board Report Nursing and Midwifery Biannual Staffing Report The biannual report was attached to the EB report. It provided an overview of nurse staffing capacity and compliance with the safe staffing standards set by the National Quality Board and NICE. The report also updated on recruitment and other initiatives aimed at ensuring we had sufficient nursing and midwifery capacity. Rima Makarem asked whether consideration had been given to allocating tasks currently undertaken by nurses to other staff groups. Flo Panel-Coates said we were focusing on making sure nurses spent more time on tasks only they could do and that where possible staff such as pharmacists could take over appropriate tasks. The Chairman commented that more use could also be made of volunteers.

9/8.2 Theatre Utilisation In response to questions raised by the Board about performance against the theatre utilisation metric, the EB had considered a report that provided an assessment of utilisation across all sites, how this was measured, and an overview of reasons for lost theatre time. The analysis had identified areas where improvements could be made so that productivity was increased. However, the Chief Executive stated that the improvements could only be delivered through adopting best practice across the Trust.

Geoff Bellingan would lead on drawing up a specific plan of action and report back to the Board in December, together with an update from Simon Knight on the development of metrics and improved reporting. Harry Bush said we must take a rigorous approach to maximising throughput.

Action: Medical Director, Surgery & Cancer/ Director of Planning & Performance

9/8.3 Summary Hospital Mortality Indicator (SHMI) Analysis

The report provided details of further analysis of the Trust’s performance against the external SHMI, following a review co-ordinated by Tony Mundy earlier in the year. The analysis had raised questions about the number of expected deaths used to calculate the SHMI as it was felt this should have increased in line with the growth in activity. The performance team were looking further at this and would share their findings with the Health and Social Care Information Centre which

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produced the calculation of the SHMI. The Chief Executive emphasised that in the last quarter of 2014/15 UCLH had been third best in the country for this measure and was consistently a top performer. However, we would continue to monitor our performance.

9/8.4 Recommendations Arising from the Jimmy Savile Inquiry/Fit and Proper Persons Test The report provided an update on actions arising from investigations into matters relating to Jimmy Savile. The EB had been advised that all actions had been completed with the exception of the recommendation concerning disclosure and barring checks for all eligible staff every three years. This would be given further consideration later in the year.

In line with the outcome of the Francis Inquiry, we had implemented the Fit and Proper Persons Test for Board members. All Board members had completed a self-declaration form and a full check would be carried out on each Board member every three years.

9/8.5 Facilities Management Following a discussion at the July Board, a report on cleaning standards, completion of maintenance and minor works requests and contract performance mechanisms had been presented to the EB and was attached to the report. The EB had felt that the report provided assurance that the required standards were being met and maintenance work was being completed within a reasonable timescale. The Chairman referred to the issue of timely access to clinical areas for essential works to be completed and said this required further consideration. The Deputy Chief Executive noted this issue.

9/8.6

Safeguarding Reports The annual reports on safeguarding children and safeguarding vulnerable adults had been circulated to the Board. The Board noted that safeguarding would be a presentation topic in the safety series. The annual infection control report had been included in the papers to support the presentation.

9/8.7 Communications and Public Relations The report provided details of the involvement of the Communications Team in various projects and events including the anniversaries due in the Autumn.

9/9 Performance Report Simon Knight presented the key issues. As at July the Trust remained non-compliant with all three cancer waiting time targets. The majority of breaches of the 31 day diagnosis to first treatment target were in urology; however Geoff Bellingan advised that we had been compliant in robotics for the last three weeks and were likely to achieve the recovery trajectory within the planned timescale.

There had been 29 breaches of the 62 day standard, 20 of which were due to late referrals from other Trusts. Barts Health had now made a commitment to refer by day 31 and we had almost reached agreement with the Royal Free, but we also had to make improvements to ensure we delivered the target. Simon Knight said

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the next step would be the introduction of a breach sharing arrangement and we would need to ensure we tracked information on administrative processes, diagnostic waits and other issues that could prevent the target being met.

The reduction in the number of pressure ulcers, and the improvement in complaints responded to within the target time (90% against a threshold of 85%) were noted. The Chairman said all three clinical boards should be congratulated.

In response to a question from the Chairman about progress on the duty of candour, the medical directors assured the Board that the need for transparency was being made absolutely clear to staff and that apologies were issued rapidly where appropriate. However, Gill Gaskin said the challenge was to ensure we recorded the actions taken.

Caspar Woolley asked what the key drivers were to the direct cost over-runs in the clinical boards. Tim Jaggard said the majority was due to under-performance on cost improvement plans which were built into budgets. Therefore the deficits were due to savings shortfalls rather than overspends. Gill Gaskin said there was some overspending owing to the need to employ agency staff in key areas which had been approved.

Harry Bush noted that the average time taken to recruit new staff had fallen to just over 13 weeks which was below the threshold of 14.6 weeks. He asked whether further improvement was possible. Ben Morrin believed it was but we needed to consider a sustainable model for recruitment.

9/10 Quality &Safety Committee Report The report of the July meeting was presented by Rima Makarem. The committee had received a report from the End of Life Care Team (EoLC) on the Trust’s response to specific areas of concern raised in a national review by the Parliamentary and Health Service Ombudsman into complaints about end of life care. Quality improvements in EoLC were being achieved and it was noted that UCLH Charity had recently agreed to provide further funding to support training.

The Committee had received updates on compliance with the Trust’s policy on consent, clinical effectiveness and clinical audit, and progress on the development of a nutrition & hydration strategy to be launched in September. They had also received the annual report on infection prevention and control prior to its submission to the Board. The QSC report also provided details of the preparations in place for the CQC inspection which included the reinstatement of specific Executive safety walk rounds and internal reviews of departments.

The Chairman thanked Rima Makarem for stepping in as chair of the QSC following John Tooke’s departure and prior to David Lomas taking over the role.

9/11 Performance Committee Report The report of the meeting of the Performance Committee held in July was noted. Diana Walford reminded the Board that there were now other systems for monitoring performance against the operational and strategic objectives and it had therefore been agreed to disband the committee. However, she felt its focus on RTT performance had been particularly helpful. The Chairman thanked Diana Walford for her contribution.

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9/12 Finance & Contracting Committee Report Harry Bush presented the report and said the position continued to become more challenging. As at the end of Month 4 there was a deficit of £15.7m before donation adjustments, and we were now forecasting a year-end deficit of £35m,

taking into account the release of £5m Board contingency. A number of additional controls had been put in place but more would need to be done to improve the I & E position in sufficient time to have an impact on the year-end outturn. However, it was likely that the pressures arising from contracting and commissioning issues would increase the deficit.

The Chairman asked the Chief Executive for his observations. The Chief Executive advised that he had attended a meeting of the Shelford Group CEOs the previous evening where they had shared financial information and UCLH was very much in line with others. Only one trust was predicting a break-even position and many had far greater deficits. The total deficit across all provider trusts this year was predicted to be in the region of £2bn and the situation was likely to be a focus of the Government’s forthcoming Comprehensive Spending Review.

The Chairman said the Board would be looking to the executive to do whatever it could to address the situation, not only for this year but for future years, which might include progressing ‘invest to save’ schemes.

Caspar Woolley raised a question regarding the Pathology division that was forecasting an adverse year-end position of £3.8m, following the introduction of the joint venture. Jonathan Fielden said we were working closely with Health Services Laboratories to ensure the benefits to UCLH from the joint venture were maximised.

9/13 Report of the Audit Committee Meeting held on 21st

July Rima Makarem presented the key issues. The Committee had reviewed the revised Board Assurance Framework and risk leads would receive training to ensure the new risk assessment tool was used consistently. The Committee had also noted progress on registering fixed assets with a value above £5000 and that tracking of lower value assets would be considered in conjunction with the EHRS business case. However, it was felt that some improvements in tracking should be implemented before EHRS came on stream.

The annual report on the work of the Audit Committee in 2014/15 was attached to the report and endorsed by the Board. It would be circulated to Governors. The Chairman thanked the members of the Committee for their work.

9/14 Minutes of the Audit Committee Meeting held on 21st

May The minutes were received. The Board noted that the Committee had reviewed the policy on engagement of external auditors for non-audit work and had agreed no change was required.

9/15 Entries in the Seal Register The report was noted.

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9/16 Revised Register of Board Members’ Interests The Register had been revised to reflect changes in membership of the Board and the other changes that had been notified. Diana Walford advised that she had been appointed as Chair of the Board of Trustees at Regent’s University London. This would be added to the Register.

9/17 Any Other Urgent Business There was none.

9/18 Date of Next Meeting The next meeting would be held on Wednesday 11

th November.

B

Agenda Item 3

Matters Arising Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

BOARD OF DIRECTORS

REPORT ON MATTERS ARISING FROM THE MEETING HELD ON 9th SEPTEMBER 2015

Minute no.

Issue Action

9/8.2 EB report: Theatre utilisation: Action plan to improve utilisation and throughput; Update on development of metrics and improved reporting for theatre utilisation.

A report on these two aspects of theatre utilisation will be presented to the Board in December.

Items from previous meetings brought forward - None

Items from previous meetings carried forward to future meetings - None

C

Agenda Item 6

Chairman’s Report

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CHAIRMAN’S REPORT TO THE BOARD OF DIRECTORS

11 NOVEMBER 2015

1. UCH AT WESTMORELAND STREET

On 24 September, I paid my first visit to the reconfigured UCH at Westmoreland Street (the old Heart Hospital) on a Governor walkabout with Claire Williams and members of staff. We were given a good insight into the progress being made with this new facility and had a useful discussion about some of the teething problems which have been encountered. On 13 October, the Chief Executive and I went with Professor Geoff Bellingan, Medical Director for Surgery & Cancer, to the formal opening of the facility.

2. MACMILLAN COFFEE MORNING On 25 September, the Chief Executive and I attended UCLH’s contribution to the Macmillan Coffee Morning in the Atrium of University College Hospital. We met Lynda Thomas, the Chief Executive of Macmillan who told us that they now have over 20,000 organisations around the country registered to participate in this very impressive event.

3. EGA HOSPITAL CHARITY 150TH ANNIVERSARY DINNER On 28 September, the Chief Executive and I attended a dinner at the Worshipful Society of Apothecaries to mark the 150th Anniversary of Elizabeth Garratt Anderson being admitted to the Society. This was a memorable event and was attended by a number of representatives of the Trust, the Society, senior female leaders in the NHS and descendants of Elizabeth Garrett Anderson. We heard about the struggles she faced to build a career in medicine in the mid-19th Century

4. INFECTION CONTROL On 2 October, I attended the Trust’s Infection Control meeting with Myriam Reidy, Infection Control Nurse. This was the first part of a shadowing visit which I have organised with Myriam. I look forward to a further session with her on the wards later this year.

5. KAISER PERMANENTE FEDERATION On 13 October, I went to a reception hosted by Odgers Berndtson, to hear a talk from Dr Jack Cochran of the Kaiser Permanente Federation about some of the initiatives which that highly respected organisation has implemented to improve patient care. Dr Cochran covered a wide range of subjects including the benefits of clinical leadership and the advantages of fully integrated pathways of care. Both of these are clearly issues of great relevance to the NHS in general and UCLH in particular.

6. DR MIKE SHIPLEY On 15 October, the Chief Executive and I attended a function to mark the retirement of Dr Mike Shipley, Consultant Rheumatologist. Dr Shipley has had a long and distinguished career, first at the Middlesex Hospital and more recently at UCLH, which has included a number of senior management roles. We all wish him a long and happy retirement.

7. UCL INSTITUTE OF NEUROLOGY On 21 October, I attended the annual address at UCL Institute of Neurology, which this year was given by Professor Sir Paul Nurse, Nobel Prize winner and Director of the Francis Crick Institute. This was followed by a very enjoyable dinner with a number of colleagues at UCL.

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8. DR DENISE BAVIN On 30 October, I attended a function at Camden CCG to mark the retirement of Dr Denise Bavin from general practice and also from her role as a Governor at UCLH. Denise has been the best sort of critical friend to the Trust and we have profited greatly from her advice and support using her expertise as one of our local GPs.

9. MIDDLESEX ARCHIVE On 6th November, I am due to visit the Middlesex Archive located in the basement of 250 Euston Road with Penny McMahon whose position has been generously funded by The Middlesex Hospital Endowment Fund. There is much work to do to properly sort and record the significant archive we have for the Middlesex and the other predecessor hospitals to UCLH and the funding from the charity is much appreciated.

10. STAFF COLLEGE: PROFESSOR AIDAN HALLIGAN MEMORIAL LECTURE On 10 November, the Chief Executive and I will be attending the Professor Aidan Halligan Memorial Lecture which is being delivered by Brigadier Kevin Beaton OBE.

RICHARD MURLEY CHAIRMAN

D

Agenda Item 7

Chief Executive’s Report

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CHIEF EXECUTIVE’S REPORT TO THE BOARD OF DIRECTORS

11 NOVEMBER 2015

PART ONE 1. CQC INSPECTION

The Board will be aware that we have been given notice of a formal CQC inspection in the second week of March 2016. In preparation, the Trust has established a project group under the chairmanship of Professor Mundy, involving the Medical Directors amongst others. The project group has developed a plan to review the issues raised on the previous pilot CQC inspection and to address other issues arising since then. The CQC has recently inspected a number of similar teaching hospitals, most notably Cambridge, Guy’s and St Thomas’ and is currently inspecting the Central Manchester Teaching Hospitals. We are taking note of the outcome of these inspections in order to learn about the particular issues on which the CQC is currently focused. In preparation for our visit we have teamed up with Newcastle University Hospitals NHS Foundation Trust to undertaken reciprocal ‘shadow visits’ which should be a positive learning experience for both Trusts and those involved in preparing for the individual inspections.

2. FINANCIAL PERFORMANCE – MONITOR CHALLENGE

The Executive Board and Finance Committee continue to focus very closely on the financial performance of the Trust. In mid-October Monitor wrote to the Trust requesting a response in relation to two challenges – firstly to achieve our £20m deficit plan for 2015/16 and secondly to return to a break-even position on an ongoing basis by the end of this financial year. We are required to submit a formal recovery plan to Monitor by 20th November, the details of which will be prepared by the Executive Board following discussion at this meeting.

3. JUNIOR DOCTORS POTENTIAL INDUSTRIAL ACTION

The Secretary of State for Health wrote to all junior doctors on 4 November detailing a revised offer for a new employment contract, proposed to apply from August 2016. In response, the BMA announced that it remained intent to press ahead with a strike ballot for junior doctors. The BMA are balloting its junior doctor membership until 18 November. Over 380 junior doctors working at UCLH are BMA members. We are hopeful that the Government and BMA will reach an agreement. Yet since industrial action could follow in December or January we are putting contingency plans in place. Critical and emergency care would be exempt though any industrial action would undermine our ability to provide elective care.

4. UNIVERSITY COLLEGE HOSPITAL – 10 YEAR CELEBRATION

Last month the Chairman and I attended an excellent celebratory event to mark the ten year anniversary of the opening of the first phase of University College Hospital. The event was organised and funded by HMU (our PFI partners). The invitees to the event were largely those responsible for the planning, construction and commissioning of the new hospital and we were

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delighted to welcome back a number of key individuals who we had not seen over the last 10 years. The general feeling was that those present felt very proud to have been involved in such a successful landmark development. I had the pleasure of making a speech centered around a number of photographs taken before and at the time the hospital was opened. In particular I made the observation that the Trust as we currently know it may not exist if it were not for the visionary decisions made prior to the construction commencing in 2000. I hope perhaps that I may be invited to attend the 20 year celebration event in due course!

5. CURING CANCER

I am delighted to say that the UCLH documentary ‘Curing Cancer’, filmed over 12 months at the Cancer Centre in 2013, has won the prestigious Grierson Award. The Grierson Trust organises the annual British Documentary Awards and this documentary won the award for ‘Best Science of Nature Documentary’. The documentary was filmed by True Vision, under the directorship of Brian Woods who received the award. Brian said, “it was a huge team effort making this film, not only the production team and the patients, but all the many UCLH staff who took part”.

6. SENIOR STAFF CHANGES

The Board will wish to join me in congratulation Dr Jonathan Fielden on his new appointment to head up the specialist commissioning function at NHS England. He will also be a deputy to Professor Keogh, the NHS England Medical Director. Jonathan has been one of the three operational Medical Directors here for the last 3 years. He will take up his appointment in late March and I am currently in discussion with him as to how his role will be covered until a new substantive appointment is made.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

E

Agenda Item 8

Executive Board Report


Executive Board Report to the Board of Directors, November 2015

1. uclh future – Information Technology Developments As part of the Trust’s project to transform the way services are run, a programme of IT developments have been identified. The EB recently considered business cases for investment in a Pathology Order Communications System (OCS) and Single Sign-On system. Pathology is involved in 70% of all diagnoses made in the NHS; 95% of clinical

pathways rely on patients having access to efficient, timely and cost-effective pathology services, and test results influence diagnosis and management of disease. UCLH produces approximately 1m pathology diagnostic requests per year and currently utilises a paper-based system for ordering investigations. Paper-based requesting presents considerable potential for error and cannot provide demand control or management of investigation orders, which may result in over-requesting, under-requesting or inappropriate requesting. It is also subject to data quality issues.

The objectives of implementing an electronic OCS are to address the shortcomings of

the paper-based system by providing better management and control of pathology ordering and activity monitoring which will enable more effective utilisation management, improved service delivery and better patient care. OCS will also contribute to the preparedness of the Electronic Health Record System (EHRS) programme.

The Single Sign-On System (SSO) will be one of the first tangible technology

deliverables from the uclh future programme. The purpose is to streamline the log-on process used by clinicians and other staff to provide fast and efficient access to various electronic systems (Carecast, PACS etc), without the need to enter multiple log-ons which can adversely impact productivity. Other trusts that have implemented similar technology have seen reductions in calls to help desks and improvements in productivity and efficiency.

The EB approved investment in both of these systems. 2. “A Perfect Week” – Recalibrating Performance at UCLH The Board will be aware of the significant pressures on our services, in particular on

the Emergency Department. Urgent and emergency patients need to be seen and, if necessary, admitted promptly and improved patient flow through the hospital is key to achieving this. In addition, orthopaedic beds should be ring-fenced to optimise the outcomes for orthopaedic patients.

At the beginning of December we will welcome new haematology patients from the

Royal Free as part of the reconfiguration of specialist cancer services. However, this will place additional pressures on UCH. The EB considered a proposal from Jonathan Fielden and Charles House, Associate Medical Director for Tower Operations, to plan and run a ‘perfect week’ during which there will be a strong focus on performance, safety and maximising flow for all patients, particularly those within UCH. We have chosen the seven days from 19th November and will use a major incident approach during the period. The objectives are to prepare for the arrival of the Royal Free haemato-oncology patients, to ring-fence elective beds for orthopaedic patients and to

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recalibrate flow through UCLH for urgent care patients, thus improving urgent care performance.

During the week UCH will be run as optimally as possible; a control room will be

established with daily meetings held to review progress and clear measures of success identified against which to judge performance. This will help us to prepare for the challenges ahead and to sustain better ways of working to improve services for our patients. While the focus will be on UCH Tower we will share beneficial learning with our other sites.

3. CQC Inspection of Mental Health Provision Board members will be aware from the ‘patient story’ presented at the last meeting that

the family of a patient who had successfully undergone surgery for cancer at UCH subsequently made a complaint about the Trust’s handling of the patient’s mental health condition which had deteriorated during his inpatient stay. This had ultimately led to the need for sectioning under the Mental Health Act. The Trust’s response failed to satisfy the family who had escalated their complaint to the CQC. As advised at the last meeting, the CQC upheld some aspects of the complaint and the Trust put a number of actions in place in response to their feedback.

Following that, CQC inspectors visited the Trust at the beginning of October to look at

services for patients with mental health issues and our processes related to the application of the Mental Health Act (MHA). The inspectors felt improvements had been made but highlighted some further actions required. The next item refers to this issue.

4. Amendments to the Scheme of Delegation and Debt Write-offs The Scheme of Delegation is an appendix to the Trust’s Standing Financial Instructions

and may be varied from time to time by agreement of the Board. As referred to above, one of the immediate actions arising from the CQC inspection was to clearly identify within the Scheme of Delegation who can make decisions under the Mental Health Act and where duties are delegated out of hours, when a consultant is not present. These duties should be carried out by the most senior doctor on site in consultation with the consultant (and the Mental Health Liaison Team) who remains accountable and responsible for the management of the patient.

The EB considered a proposed additional section to the Scheme relating to powers

under the MHA. This sets out for each Trust site who has delegated authority to detain or discharge people admitted under the MHA. The powers relate to receipt and scrutiny of statutory documents and nearest relative order for discharge, duty of managers to give information to detained patients and patients’ nearest relatives in-hours and out of hours, and medical practitioner/approved clinician ‘holding power’.

The proposed additional section is attached at appendix A. The EB also considered a revision to section 2.2 of the Scheme of Delegation (capital

expenditure and disposals) which brings delegated decision-making authority for ICT-related capital approvals into line with those agreed earlier in the year for building infrastructure schemes. The EB supported a recommendation to approve the amendments to the delegated authority to enable capital schemes with a value up to £100k (and with no more than £50k of ICT or building infrastructure elements) to be approved by the Capital Works Committee and schemes with a value between £100k and £500k, or with more than £50k of ICT or building elements, to be approved by the Capital Investment Board. The proposed revisions are shown in appendix B.

3

The section will be supported by a flowchart illustrating the capital approval processes.

The Board is requested to approve the additional section and the revision to the Scheme of Delegation; once approved the changes will be made to the Scheme.

The EB received a report which proposed writing off non-NHS debts, incurred over

several years, which are deemed to be uncollectable. Details of the type of debtors and values by income stream are provided in appendix C, attached. In accordance with the section 4.9 of the Scheme of the Delegation, the Board is required to approve the write-off of bad debts above £100k. The total accumulated debt is £2.11m; all these debts are fully provided by the bad debt provision. The Board is therefore requested to endorse the EB’s recommendation that these debts should be written off.

5. Board Assurance Framework The Quarter 2 Assurance Framework was reviewed by the EB and was approved for

submission to the Board, following review by the Risk Coordination Board. It is attached at appendix D. Board members will be aware that the purpose of the BAF has changed to focus on monitoring the delivery of strategic, rather than operational, objectives.

6. Policy Approvals On the recommendation of the Policy Approval Sub-Group the EB approved three new

policies:

• Surgical Safety Policy and Procedure • Confirmation of Blood Group Sampling Policy • Starting at UCLH Policy.

The Surgical Safety policy establishes the process for implementing the ‘5 Steps to

Safer Surgery’. Every patient undergoing a surgical or invasive procedure in the Trust must have the 5 Steps applied to their pathway of care. This includes interventions in non-surgical areas such as imaging and endoscopy. The WHO Surgical Safety Checklist is a central part of the 5 Steps to Surgical Safety and has been shown to improve outcomes in surgery by standardising care, reinforcing safety processes and fostering open communication. Board members will note that a presentation on embedding the WHO Surgical Safety Checklist will be given at the meeting.

The objectives of the policy are to reduce surgery-related avoidable harm occurring in

UCLH operating theatres and to improve the reliability with which the 5 Steps are followed in surgical and other interventional areas. It incorporates new national standards for safety procedures that have recently been issued.

The purpose of the Blood Group Sampling policy is to implement best practice

guidelines to improve safety in transfusion and reduce the risks of transfusion of incompatible blood due to misidentification of patients at phlebotomy. It requires that a second confirmation blood group and screen sample be taken and sent to the blood transfusion laboratory before routinely requesting blood for any patients.

The Starting at UCLH policy sets out how we recruit and welcome new colleagues,

adhering to statutory obligations and best practice in recruitment and selection. The policy covers all staff including permanent, fixed-term, honorary and observer appointments. It also sets out the rules for ongoing employment checks monitoring of existing employees.

4

7. Research Update The EB received an update from the Biomedical Research Centre and on all other aspects of research activity at UCLH. The BRC continues to build towards the next funding competition round, the details for which will be released after the Comprehensive Spending Round on 25th November. Each of the 4 BRC Programmes has been developing strategy for the coming 5 years. Work is ongoing to define the cross-cutting themes and platforms that will further strengthen the BRC strategy and structure in the next round. The BRC is also in discussion with the other UCL NIHR BRCs at Great Ormond Street and Moorfields to calibrate strategies and identify opportunities for shared strategic objectives in the bid. The programme to relocate the Clinical Research Facility to 170 Tottenham Court Road is progressing well. The CRF currently has 134 active studies of which 53 are early phase clinical trials. In September the CRF dosed the first patient globally in a trial of a new drug for spasticity in patients with multiple sclerosis, which had been developed in UCL, and also consented the first patient in the world to a malignant haematology study sponsored by a small Swiss Biotech company. The CRF was chosen to conduct this study following the success of a previous trial run in the Unit. The Leonard Wolfson Experimental Neurology Centre CRF portfolio continues to grow,

with a total of 47 studies currently in set-up or ongoing. On 8th September the first dose for the LWENC’s first First-Time-In-Human study was successfully administered as part of the landmark gene-silencing study in Huntington’s disease. The first dose marked the first time an experimental drug was given by injection into the spinal fluid of patients at the NHNN.

A research performance dashboard is now included in the UCLH Quarterly Review

Board Pack. The Q1 report on performance in initiating and delivering clinical research shows that the performance of UCLH against the key metric of time taken from submission of a study for approval and the recruitment of the first patient continues to improve, and is currently at 85% which compares favourably with other Trusts.

Board members will be pleased to learn that UCLH’s performance in the recruitment of patients to NIHR Portfolio studies has recently been commended by the NIHR following the publication of the Guardian’s annual NHS trust research activity league tables. In 2014/15 UCLH was the fourth largest recruiter nationally to Portfolio studies and had the largest increase in the number of studies on the national Portfolio. This in part reflects concerted efforts to ensure that a higher proportion of new studies being approved at UCLH are adopted onto the national Portfolio. Among London’s NHS trusts only Guy’s had a higher number of recruits to NIHR Portfolio studies. UCLH was also fourth nationally in the number of interventional studies on the NIHR Portfolio. 8. Capital and Estates Issues On the recommendation of the Capital Investment Board, the EB approved an ICT

scheme enabling the implementation of supported self-management pathways for patients, following cancer treatment at the Trust. The scheme will allow cancer specialist teams to monitor surveillance tests using software.

The EB also endorsed the signing and sealing of a lease for part of ground floor east

wing at 250 Euston Road to Camden and Islington Council Social Work Department.

http://www.uclhospitals.brc.nihr.ac.uk/news/first-huntingtons-patients-dosed-gene-silencing-drug

5

9. Emergency Preparedness

In September the EB received the quarterly report from the Emergency Preparedness, Resilience and Response (EPRR) group. Key points from the report are as follows: Heatwave Response At the beginning of July, due to temperatures above 300 centigrade, service delivery at Queen Square and UCH theatres were impacted. It was not declared an incident but a number of learning points have been identified. UCH theatres were affected owing to a generator test held that morning which meant it took longer for theatres to reach the appropriate operating temperature which delayed theatre starts for several hours. Amendments have been made to the adverse weather procedure to ensure generator tests are not carried out on hot days; Infection Control will provide guidance on the fans that can be used and thermometers will be provided to areas without integral air conditioning to enable prioritisation of mobile air conditioning units. 2015/6 Assurance Process The Trust was advised of NHS England’s expectations for the 2015-16 EPRR

assurance process. NHS England undertake the process in order to be assured that the NHS in England is prepared to respond to an emergency and has resilience in relation to continuing to provide safe patient care.

The assurance process is based on the EPRR core standards and is divided into two parts: an audit of our Chemical, Biological, Radiological and Nuclear (CBRN) response procedures and an audit of our emergency preparedness, resilience and response procedures. Our written response and self-assessment for the CBRN audit has been completed and sent to NHS England. A site visit from NHS England the London Ambulance Service took place on 22nd September 2015. Our self-assessment response for the EPRR function was submitted on the 11th

September and NHS England, together with an independent peer reviewer, are due to conduct a site visit on 16th November 2015.

Policy and Procedure Reviews and Updates

As part of the update of our Major Incident Management Procedure all action cards are being reviewed by the relevant leads. The Gold Commander Action Card has been reviewed by the Chief Nurse and Director of Corporate Services, both of whom act as Gold Commanders. The EB approved the revised Gold Commander action card.

The CBRN procedure is currently being reviewed to provide clearer management processes depending on the nature of the incident.

Exercises and Training A flu pandemic exercise was held on 10th September. The aim of the exercise was to look at the impacts of a flu pandemic and to test our current response plans. This year’s flu campaign was launched several weeks ago; as at 5th November a total of 2001 staff have been vaccinated, compared with 1948 on the same date last year. SIR ROBERT NAYLOR CHIEF EXECUTIVE

Executive Board report to the Board of Directors Appendix A

Proposed Addition to the Scheme of Delegation: Ref Matter Delegated Delegated To Section 7 – Duties under the Mental Health Act Power to detain and discharge people who have been admitted under the Mental Health Act

7.1 Receipt and scrutiny of statutory documents (and nearest relative order for discharge under section 23)

• University College Hospital and University College Hospital at Westmoreland Street

• National Hospital for Neurology and Neurosurgery (NHNN)

• Royal National Throat Nose and Ear Hospital (RNTNEH)

• Eastman Dental Hospital (EDH)

UCH Site Co-ordinator & Independent Mental Health Administrator (MHA) Mental Health Team (Hughling’s Jackson Ward) & NHNN Site Team

UCH Site Co-ordinator & Independent Mental Health Administrator (MHA)

Inform Matron & Clinical Lead. A patient in an acute crisis should be transferred to UCH Emergency Department.

7.2 Duty of managers to give information to detained patients Duty of managers to give information to patient’s nearest relatives

In-Hours: Sister/Charge Nurse/Matron and RMN or Mental Health Advocate (supported by Site Team) Out-of-hours: Site Manager and RMN.

7.3

Medical Practitioner/approved clinician ‘holding power’ under section 5(2)

Consultant in charge (Responsible Clinician) or the doctor’s nominated deputy. (The duty senior Doctor on the on-call rota is considered a responsible nominated delegate)

Executive Board Report to the Board of Directors

Appendix B

Proposed Changes to the Scheme of Delegation

The following are extracts from the Scheme of Delegation as they currently are with the relevant sections proposed for change highlighted, followed by the relevant sections with the proposed amendments. Current:

Ref Matter Delegated Delegated To

Section 2 – Approval of Business Cases and Service

Developments (setting of pay and non-pay budgets as part of setting annual financial plans to deliver organic growth within financial targets is outside the scope of these approval limits and subject to a separate process)

2.2 Capital expenditure and disposals (see appendix 4 for more detailed information on approval thresholds and process) • Up to £100,000 (if no ICT or building/infrastructure works) • Up to £100,000 (if no ICT or building infrastructure works > £50,000) • £100,000 to £500,000 (if no ICT) • £500,000 to £1,000,000 (or if scheme requires ICT), or up to £5,000,000 where the Finance Director determines that the business case is considered “business as usual” rather than “novel or contentious” • Over £1,000,000 (or over £5,000,000 where the Finance Director determines that the business case is considered “business as usual” rather than “novel or contentious”)

Executive Director and Head of Finance Capital Works Committee Capital Investment Board Executive Board Board (via Investment Committee)

Proposed:

Ref Matter Delegated Delegated To

Section 2 – Approval of Business Cases and Service

Developments (setting of pay and non-pay budgets as part of setting annual financial plans to deliver organic growth within financial targets is outside the scope of these approval limits and subject to a separate process)

2.2 Capital expenditure and disposals (see appendix 4 for more detailed information on approval thresholds and process) • Up to £100,000 if no ICT or building/infrastructure

works • Up to £100,000 where scheme includes ICT or

building infrastructure works < £50,000 • £100,000 to £500,000 or where scheme includes

ICT and building infrastructure works £50,000 to £500,000

• £500,000 to £1,000,000, or up to £5,000,000

where the Finance Director determines that the business case is considered “business as usual” rather than “novel or contentious”

• Over £1,000,000, or over £5,000,000 where the

Finance Director determines that the business case is considered “business as usual” rather than “novel or contentious”

Executive Director and Head of Finance Capital Works Committee Capital Investment Board Executive Board Board (via Investment Committee)

Executive Board Report to the Board of Directors Appendix C

Proposed Bad Debt Write-off – Summary

The table below summarises the values by income stream and the financial year in which the revenue was recognised.

Total £000

2014/2015 £000

2013/14 £000

2012/2013 £000

Prior to 31/3/2012

£000 Overseas Visitors 1,935 80 590 539 726 Private Patients 120 - 34 61 25 Non NHS Organisations 36 - 5 1 30

Individuals 20 - 9 3 8 Total 2,111 80 638 604 789

Detailed analysis of reasons for debt write-off:

Overseas Visitors: £1,935K 203 transactions have been undertaken. • Debtors cannot be traced in their home countries despite the involvement of local debt

collectors and embassies, mostly due to a lack of local infrastructure (£1,404K) • Patients have died during their treatment or after they returned to their home country. In

the proposed cases attempts to receive payments from their estate were unsuccessful (£445k)

• Patients gave insufficient address details to trace them (£86K). In accordance with DoH and UK Board Agency (UKBA) guidelines, Overseas Visitors with outstanding debt more than £5,000 and over 3 months old are reported to the UKBA. In such cases future visas or entry will be denied until the balances are settled. This has provided some success collecting outstanding amounts.

- Private Patients £120K • Debt collection agencies have exhausted all available sources to trace the individuals

£119K (112 individuals) • Patient has subsequently died (£1K)

- Non NHS Organisations £36K • Company struck off by Registrar of Companies – no accounts filed. Invoice was for a

promised donation which was never paid. There is no contract, this would not be enforceable. (£30K)

• Uneconomic to collect (£6K, 67 transactions)

- Other Individuals £20K • Ex Staff - 12 accounts where debt collectors exhausted all available sources to trace the

individuals and are recommending write off. • 57 transactions totalling £10K - uneconomic to collect.

BOARD ASSURANCE FRAMEWORK, QUARTER 2 2015/16

Page 1 of 11

UCLH strategic theme: Provide the highest quality of care within our resources Responsible monitoring committee: Quality and Safety Committee (QSC)

PRINCIPAL RISKS Description of risks

LEAD

Which director leads on

manage-ment of this risk

KEY CONTROLS What controls / systems are

already in place to manage the risk

ASSURANCES ON CONTROLS

What evidence can be used to show that our controls

are working

CONTROLS AND ASSURANCE GAPS AND ACTIONS What controls should be in place to manage the risks

but are not?

What evidence should be in place to show the controls are working / or effective but is not currently in place

Risk rating

Likelihood x impact = risk

Gap Date Current Target

Weaknesses in tracking patients requiring review or treatment could lead to failures to provide best care

Operational medical directors

Administrative processes in divisions for booking and tracking patients after A&E attendance, outpatient or inpatient stay

Patient administration system booking lists and waiting times reports

Report functionality now available to track whether future bookings have been provided to patients marked as needing an appointment, but needs to be made part of an agreed business as usual process

Our Clinical Data Repository has been updated so that we can flag abnormal results helping to reduces the risk of missing important findings in diagnostic tests, Work is underway to embed this change through the organisation

None Control gaps

Business process and business as usual reporting needed to track whether future bookings have been provided to patients marked as needing an appointment

Documentation of current and proposed patient referral channels from external organisations is underway to inform the development of our Interoperability Framework, which in turn should help to fill this gap. The trust’s Chief Clinical Information Office (CCIO) is in the process of producing the trusts integration strategy which will explain how we plan to connect and share data with our external stakeholders.

Build mechanisms for results review and oversight of long term patients into UCLH Future programme workstreams

Assurance gaps

No high-level indicators demonstrating to senior managers that booking and tracking systems are operating appropriately: need to generate performance indicators for key management reports

Dec 15

Sep 15

Oct 15

Sep 15

5 x 3 = 15

3 x 3 = 9

Executive Board Report to the Board of Directors

Appendix D


Page 2 of 11

Delivering required levels of financial savings / efficiency in our long term financial model or tactical responses to deficits reduce the quality of care delivered

Medical directors / deputy chief executive

Quality impact assessment of savings schemes prior to acceptance into the programme Use of safer nursing care tool to determine ward staffing levels UCLH Future emphasis on targeting waste and improving patient experience through greater efficiency.

Quality and Safety Committee review of quality indicators Monitoring of complaints and patient experience surveys Improving care walk rounds Reporting of actual staffing vs desired staffing

Control gaps

[Not considered a material gap]

4 x 3 = 12

3 x 3 = 9

State of disrepair on older parts of the estate has an impact on provision of high quality services for patients [Source: risk register analysis]

Director of Estates and Capital Investment

Planned preventative maintenance regime, enhanced checks and (re)validation of areas

Capital programme in place and project works being undertaken

Replace and refresh programme

Backlog maintenance contribution from Ifm

Annual condition survey

CIF-D engineers audit schedules and programmes

Surveys and risk assessments of existing infrastructure

The Capital Investment and Facilities Division are monitoring the relevant service provider to ensure checks and monitoring is taking place as required

This strategic backlog maintenance risk is reviewed every year alongside the condition B survey and planned preventative maintenance programme

Audit on Backlog maintenance and management found no gaps / issues

None noted 3 x 4 = 12

1 x 4 = 4


Page 3 of 11

Insufficient capacity to deal with the number of patients referred to the Trust means that UCLH doesn’t meet access targets. Direct access diagnostic growth may be a particular risk

Deputy chief executive

Demand and capacity modelling Ongoing relationships with commissioners Modelling and planning for strategic building projects, and subsequent delivery of new capacity Development of new models of care UCLH Future plans to improve pathways and reduce length of stay

Performance against waiting times standards

Performance against other access and flow metrics including mixed sex breaches; cancelled operations

Reports on referral numbers and market share

Control gaps

More detailed modelling to assess whether sufficient capacity to meet RTT standards, using Intensive Support Team tool

Sophisticated modelling needed to deliver greater grip on demand pressures in short, medium and long term, to be delivered through clinical coordination centre under the UCLH Future programme

Complete

tbc

4 x 3 = 12

2 x 3 = 6


Page 4 of 11

UCLH strategic theme: Support the development of our staff to deliver their potential Responsible monitoring committee: Picked up in relevant Board committees as needed


LEAD

Which director leads on manage-

ment of this risk





are working

CONTROLS AND ASSURANCE GAPS AND ACTIONS What controls should be in place to manage the risks but

are not?


Risk rating



Lack of trained nurses nationally and restrictions on agency / immigration controls lead to ongoing high nursing vacancy rate, with impact on quality and financial position

Director of workforce

Retention and recruitment plan in place including national and international recruitment drive National lobbying on training places Workforce forecasting and modelling over next five years

Vacancy figures and quality metrics reported monthly Quarterly reporting to Executive Board informed by weekly review by retention and recruitment group

Control gap Action with Department of Health and NHS England to encourage more effective national planning and procurement strategy for permanent and temporary supply

4 x 3 = 12

3 x 2 = 6

Lack of a long term Organisational Development plan to support the continued effectiveness and viability of the organisation


Director of organisational development appointed and in post

Organisational development is one of the four pillars of the UCLH Future programme, and will be delivered through its structures

Reports to the Board on progress of UCLH Future with evidence of progress against milestones and indicators

Assurance gap

Board approval of Organisational Development vision and strategy

Dec 15

3 x 4 = 12

2 x 4 = 8


Page 5 of 11

Loss of accreditation for junior doctors training posts as a result of national changes on education, impacting on availability of junior doctors for service provisions / rota coverage

Director of workforce

The Medical and Dental Education Team work with departments to monitor feedback and develop and implement training action plans

Improved General Medical Council survey results.

Control gaps

There is a lack of transparency and clarity regarding the allocation of funding for training posts.

Lack of clarity and transparency as to whether Consultants have sufficient time in their job plans for supervision, delivery of training and attendance at external training-related activities (such as Annual Review of Competence Progression panels and recruitment events).

Lack of contingency plan at service level in the event of loss of trainees

Note: there is currently no imminent threat of this happening for the remainder of this financial year, but it could affect us from the next recruitment round which starts early 2016 for a start date of August 2016. It is difficult to quantify the risk as the posts for the next year have not yet been announced. as a trust we need to plan clinical services so that they are less reliant on junior doctors. We can’t start planning mitigations until we are clearer on the specific nature of the risks.

3 x 4 = 12

2 x 4 = 8


Page 6 of 11

UCLH strategic theme: Achieve financial sustainability Responsible monitoring committee: Finance and Contracting Committee


LEAD


ment of this risk

KEY CONTROLS What controls / systems are already in

place to manage the risk


What evidence can be used to show that our controls are working

CONTROLS AND ASSURANCE GAPS AND ACTIONS

What controls should be in place to manage the risks but are not?


Risk rating



Unachievable efficiency targets greater than those assumed in the UCLH long term financial model (LTFM) are imposed upon acute providers

Finance Director

UCLH looking at partnerships and pathways which make more efficient use of acute provider capacity Shelford Group & NHS Providers lobbying Monitor & NHSE for consultative approach to efficiency. Monitor commitment to review specialist tariffs for 2016/17 Maximising cost savings potential through UCLH future programme CEO-chaired financial performance group to focus on returning to at least run-rate balance against plan. New Cost Improvement Programme Director appointed

Annual financial planning

In-year financial reporting and forecasting

Monitor’s review of financial planning and in-year position

Recovery plan monitored through fortnightly CEO-chaired meetings

Control gaps

Further development of LTFM target metrics, as requested at the October Board seminar.

Robust forecasting and reporting process for financial performance.

Nov 15

4 x 5 = 20

3 x 5 = 15

Commissioner-driven changes in models of care and tariff structures lead to lost income / contribution for trust

Finance Director

UCLH looking at partnerships and pathways which make more efficient use of acute provider capacity Use of Local Hospital Strategy to ensure engagement with local CCG commissioners together with



Reporting to Finance Committee

Control gaps

Need to confirm governance framework for negotiation and management of proposed changes to service models

Need to confirm management resource available to manage changes

Dec 15

tbc

3 x 4 =12

2 x 3 = 6


Page 7 of 11

other local providers. New partnership board set up between UCLH and the Royal Free.

on key service developments

Specialist tariff continues to underfund complex specialist treatment below level assumed in UCLH long term financial model

Finance Director

Shelford group & NHS Providers lobbying on appropriateness of specialist tariff. Monitor commitment to review specialist tariffs for 2016/17 UCLH patient costing data is used as part of benchmarking group and is externally recognised as strong




Control gaps

Extend usage of PLICS data by clinical boards to effect change, looking at detailed comparisons within divisions and broader comparisons with other organisations

Assurance gaps

Difficulty of gaining assurance around fairness of national policy on tariff setting, particularly for specialist work, in relation to whether higher costs demonstrate complexity or inefficiency.

Dec 15

4 x 5 = 20

3 x 4 = 12

Commissioners cannot afford to pay for the growth assumed in UCLH long term financial model

Finance Director / Director of Commissioning

High-level review of all capital schemes adding new capacity

UCLH future programme develops new pathways

Relationships / formal governance and negotiation frameworks between UCLH and commissioners, helping mould fair contract and tariff models

Contract negotiations framework ensures rigour in assessing and mitigating impact of alternative tariff frameworks


In-year financial and contractual reporting and forecasting


Control gaps

Identify and agree split of growth between transfers from other providers (centralisation) and own growth, as service rationalisation plans progress

On going

4 x 4 = 16

3 x 3 = 9

UCLH Future programme does not generate enough savings to meet the Trust efficiency requirement in the long term financial model


Board review of the UCLH long term financial model for realistic future efficiency requirements Board review of the UCLH future programme performance against the requirement

Reports to the Board on progress of UCLH Future and cost improvement programmes / financial position.

Internal / external

Control gaps

UCLH Future and cost improvement plans to be provided at more granular level to demonstrate delivery of required levels of savings.

Sep 15

Com-

plete

4 x 5 = 20

3 x 3 = 9


Page 8 of 11

Metrics and productivity measures in UCLH Future tracker

audits on progress against efficiency programmes

Budget holders unable to manage to their establishment budgets and deliver efficiency savings due to poor data quality and lack of clarity

Director of Workforce / (with Finance Director)

Project to create ‘One version of the Truth’ has been undertaken, with a clear definition of authorised establishment

Internal Audit reports on budgetary control

Reporting on levels of discrepancies between ESR and the general ledger

Control Gaps

An ESR/Finance Alignment project has been initiated and is now in progress. A list of system recording issues and operation practices that may need to be modified have been identified and solution are being worked through. Reconciliations meetings with Workforce and Finance are underway to align both systems. Work to re-engineered joint processes will commence shortly. This is anticipated to take several months to complete. Application of consistently applied definition of establishment, for example to specials, maternity, etc.

Mar 15

Mar 15

4 x 3 = 12

3 x 3 = 9

Material decline in London property values or other disposal restrictions leads to failure to deliver assumptions on disposal values in long term financial model

Finance Director (with Director of Estates)

Board reviews the LTFM when making capital commitments. LTFM has sensitivities around the value of asset disposals.

Discussion at Board and Treasury Advisory Group to ensure the timing of asset disposals is optimised

Control gaps

Proposal to mitigate financial risk to be discussed and agreed by Investment Committee and Board of Directors

Dec

3 x 5 = 15

3 x 3 = 9


Page 9 of 11

UCLH strategic theme: Improve patient pathways through collaboration with partners Responsible monitoring committee: Strategic Programme Board


LEAD


ment of this risk





are working


are not?


Risk rating



Commissioners delay / block cancer moves as a result of concerns raised through the gateway process PROPOSE REMOVAL OF THIS RISK

Surgery and Cancer Medical Director

Local Clinical Commissioning Group and NHS England endorsement of the cancer-cardiac business case

Business planning process with London Cancer, commissioners & North East London trusts.

Regular cross sector meetings – medical director-led with senior engagement from the above.

Cancer programme action plan led by Jonathan Gardner

Cancer waiting times improvement plan

Commissioner-led gateway review and assurance processes

Internal audits on cancer management / waiting times issues

External audits on cancer waiting times as part of Quality Account audit

Control gaps

None: at the Joint Programme Board, Commissioners have now formally approved the transfer of 4 of the 5 specialist cancers to transfer (with only Brain remaining). Therefore this risk is now negligible. This position is strengthened by winning the Vanguard bid. The remaining risks are operational delivery to the expected timeline which are being managed through the cancer unification board risk register.

Sep 15

2 x 3 = 6

2 x 3 = 6


Page 10 of 11

Risk to the ability of the Trust to develop and increase its role in the local health economy and beyond because of lack of engagement with the integrated care agenda

Medicine Board Medical Director

Integrated Care Division

Local Services Strategy

Urgent care steering group

System redesign group

Local service strategy agreed by Executive and Board October 2015

Agreement to explore Accountable Care options October 2015

Improving relations with Local CCGs

Joint working on system leadership projects as both system leader, partner or contractor

Control gaps

Move to working as accountable care network/partnership working now need to be developed

Jan 2016

4 x 3= 12

2x4=8

Risk that in negotiations for reconfiguration and mergers across London we lose opportunities to develop critical mass and world class services in our strategic service areas, leading to strategic weakening and loss of income

Director of Strategic develop-ment

Engagement with Camden CCG at regular monthly meetings to discuss strategic planning and strategic opportunities

Ad hoc meetings with NHSE (London) reviewing UCLH strategic development in line with commissioner plans

All cancer reconfiguration plans monitored through gateway process with all commissioners and providers across north-east London

Founding membership and participation at all major UCLP events

Minutes and associated action tracker for Cancer Gateway reconfiguration plans. All plans on target.

Acknowledged engagement of commissioners in strategic intent document and annual planning process

Minutes and clear documented engagement with UCLP of all reconfiguration discussions

None noted at this stage

3 x 4 = 12

2 x 4 = 8


Page 11 of 11

UCLH strategic theme: Generate world-class research Responsible monitoring committee: To Be Confirmed


LEAD

Which director leads on

manage-ment of this risk





are working


are not?


Risk rating



Strategic, reputational and financial risk of losing the 'Big' or 'Comprehensive' Biomedical Research Centre (BRC) status as a result of the transfer of cardiovascular services to Barts Health and the Trust's strategic focus on just Neurosciences and Cancer

Corporate medical director

Consideration and planning by the BRC Strategic Board

Metrics consistently demonstrate strengths across multiple scientific and clinical areas

Research groups working on research in areas outside Cancer and Neurosciences

Control gaps

Develop strategy for cardiometabolic experimental medicine programme

Programme Directors to consider how best to align their strengths with Neurosciences and Cancer priorities

Develop strategy for BRC Big Questions that emphasises UCLH/UCL breadth of strengths

Develop strategy for bidding for +50% in the next BRC bidding round

Dec 15

Dec 15

Dec 15

Dec 15

3 x 4 = 12

2 x 3 = 6

F

Agenda Item 9

Performance Report

Board of Directors Performance Report – November 2015

Current issues Action Month first raised

A&E (Page 7) The Trust was below the threshold for A&E patients being seen with 4 hours. This is the first time we have breached this threshold since February. The worsened performance reflects increased attendances and increased bed capacity pressures at UCH in month.

August 2015

Diagnostic waits

(Page 7)

The Trust missed the target for diagnostic waits within 6 weeks in September. Performance is improving month on month since January but we are still below the threshold. MRI and endoscopy continue to be the most challenged modalities. Endoscopy is projecting compliance by December. This has been pushed back following delays implementing schemes to increase capacity. MRI at the UCH site is now compliant, however there remain breaches at Queen Square. The department are looking to source additional capacity through outsourcing.

December 2014

Cancer waits

(Page 8)

Breast symptomatic performance is challenged due to two team members taking leave unexpectedly. The service are managing this as closely as they can but the issues will continue into October and November.

For the 31 day standard, most of the breaches continue to be in urology and relate to robotic surgery capacity pressures. The service have now increased surgical capacity and we are projecting achievement of this standard from October onwards. Non-compliance with the 31 day subsequent ‘other’ standard were primarily due to capacity pressures on the HIFU pathway for prostate cancer.

We also failed the 62 day standard, with 19.5 patients breaching. Of these, 8.5 were urological, 5 were haematology and 3.5 were gynaecology. 12 of the breaches were caused by factors outside of the trust’s direct control, primarily late referrals.

July 2013

eVTE Risk Assessments completed (Page 10)

The trust was narrowly under the 95% standard of patients being assessed for VTE in September. This was due to Specialist Hospitals Board not achieving target; paediatrics, women's health, Queen Square, and RNTNE were worse than threshold.

September 2014

Falls with harm (Page 11)

There were 5 falls with moderate harm, spread across 5 clinical areas within all three Boards. Each fall had an RCA and although no consistent themes were identified, there were learning points from each which have been fed back to staff locally, and Trust-wide via the Harm Free Care Group. This was a high number of falls with moderate harm in one month. We undertook a review of other nurse-sensitive indicators across our wards during this period, which concluded that other key indicators were within expected parameters.

January 2015

Complaint responses (Page 13)

The Trust was under the threshold for complaints response time in September, a 14.2% decrease from August. There were different reasons behind this disappointing performance across each division.

February 2015

September 2015

Month 6 - September

Board of Directors Performance Report

Month 6 - September

1. Executive summaries

2. Finance 3. Delivery of QEP

4. Access

5. Patient Safety and Quality metrics

6. Workforce

7. Externally Reported Frameworks

8. Research and Development

9. Appendix A: Quarterly review of top 10 objectives

Page Con

Board of Directors Performance ReportContents

Month 6 - September

Board of Directors Performance Report

Data quality score:

√√ high data quality

√ sufficient data quality

x not sufficient data quality

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% Elective variance -14.0% 0% 35.6% -12.2% -17.4% -5.8% 50.1% -5.4% -8.0% Number of MRSA Bacteraemias 0 0 0 0 0 2 0 2 0

% Daycase variance -2.0% 0% 6.5% -4.3% -0.4% 1.6% 4.8% -0.5% 4.1%

Number of clostridium difficile

cases reported (excluding

successful appeals) 37 15 13 9

% Non-elective variance -15.2% 0% 4.3% 0.6% -28.7% -13.7% 4.0% -4.3% -24.4% % Hand Hygiene Compliance94.1% 95.0% 91.9% 96.7% 93.8% 95.1% 92.1% 96.4% 95.1%

Outpatient Variance -2.5% 0% -1.3% -2.7% -2.8% 2.6% 1.5% 2.6% 3.0%Number of MSSA Bacteraemias

(Trust Attributable) 3 2 1 0 2 15 2 2 11

Discharge rate from outpatient

attendance (for target clinics)20.5% 25% 25.4% 8.2% 26.8% 19.5% 22.7% 7.9% 25.7%

Tower elective theatre utilisation 71.6% 85% 72.9% 68.4% 74.1% 12.2% 74.4% 73.9%All Pressure Ulcers Acquired at

UCLH 5 6 0 4 1 33 10 13 10

Queen Square theatre utilisation 78.7% 85% 78.7% 70.0% 70.0% Inpatient falls with serious harm0 0 0 0 0 1 1 0 0

Percentage of Completed eVTE

Risk Assessments 94.5% 95.0% 94.2% 96.0% 92.5% 95.5% 96.3% 96.2% 94.3%

% Non-admitted closed pathways

under 18 weeks96.8% 95.0% 99.8% 91.9% 96.9% 96.9% 99.3% 92.8% 97.0%

Complaints responded to within

target time 59.2% 85.0% 66.7% 53.8% 61.1% 75.3% 92.1% 70.9% 69.1%

% Admitted closed pathways under

18 weeks93.2% 90.0% 100.0% 91.2% 93.4% 92.1% 99.2% 88.9% 93.1%

Friends & Family Test (IP survey)

New 97.2% 96.0% 98.7% 96.7% 96.8% 97.0% 97.8% 97.1% 96.6%

% incomplete pathways < 18 weeks 93.7% 92.0% 95.1% 91.8% 94.1% 94.3% 96.7% 92.7% 94.5%

A&E attendances within 4 hours 92.8% 95.0% 92.83% 96.3% 96.3%Average time to recruit (request

pack - start date)14.3 14.6 13.1 15.2 14.4

% Diagnostic waiting list within 6

weeks97.2% 99.0% 98.9% 98.3% 94.4% 96.3% 92.5% 96.6% 95.1%

% Statutory and mandatory training

compliance83.0% 90.0% 84.0% 84.0% 81.0%

Appraisal Tier 3 - All remaining staff

at Band 7 and above30.6% 90% 33.4% 28.8% 31.7%

Cancer 62 Day GP referral to

treatment 68.8% 85.0% 100.0% 61.0% 80.0% 79.8% 95.1% 73.3% 90.1% Vacancy Rate (Trust Rate)

10.3% NA 9.3% 13.2% 9.2%

Cancer 62 day referral from

screening to treatment100.0% 90.0% 100.0% 74.6% 69.2% 78.4%

Cancer 31 Day Subsequent

Surgery Treatment87.8% 94.0% 100.0% 78.6% 100.0% 87.6% 100.0% 76.8% 100.0%

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Chemotherapy Treatment98.7% 98.0% 97.9% 100.0% 99.4% 99.2% 99.8%

HEADLINE FINANCIAL

PERFORMANCE (Overall Rating) 2

Cancer 31 Day Subsequent:

Radiotherapy96.0% 94.0% 93.3% 98.2% 97.7% 100.0% 97.1% 98.6%

1. Operational Performance (Debt

Service Cover) 1

Cancer 31 Day Subsequent: Other 52.8% 98.0% 18.2% 100.0% 57.9% 44.8% 100.0%2. Cash and Balance Sheet

Performance (Liquidity) 4

Cancer 31 days from diagnosis to

first treatment89.4% 96.0% 100.0% 81.2% 97.9% 89.4% 97.9% 85.4% 97.6%

Income and expenditure plan and

CIP delivery

Cancer GP referral to appointment 86.8% 93.0% 82.6% 90.6% 82.8% 91.4% 90.0% 91.5% 92.7%

Cancer 14 day wait from referral

(symptomatic breast)72.8% 93.0% 72.8% 90.4% 90.4%

* The trust threshold is an aggregate of individual clinical board thresholds

This month Year to date

Month 6 - September

Efficiency

and

productivity

Page 7

Cancer

Page 9

18 weeks and

other access

indicators

Page 8

Infection

Page 10

1.2 Executive summary: board performance

This month Year to date

Activity

Page 4

Finance

Page 2

Workforce

Pages 14 - 16

Quality and

safety

Pages 11 - 13

2. Financial Performance2.1 Financial Performance Summary

Month 6 - September

2. Financial Performance2.2 Service lines summary

Month 6 - September

Month 6 - September

2. Financial Performance2.3 Clinical income summary

Month 6 - September

3. Delivery of CIP3.1 CIP update

3. Delivery of CIP3.2 Efficiency and productivity

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Tower elective theatre utilisation 85% 71.6% 72.9% 68.4%

Queen Square theatre utilisation 85% 78.7% 78.7%

Discharge rate from outpatient

attendance (for target clinics)25% 20.5% 25.4% 8.2% 26.8%

DNA rate 8% 11.9% 14.2% 11.9% 11.2%

Average length of stay for key

specialties- elective admissions3.3 3.6 2.6 4.5 3.0

Average length of stay for key

specialties- Non elective admissions5.1 4.9 5.0 8.1 3.6

Page 6

This month

Month 6 - September

Theatre Utilisation - Tower theatre utilisation has decreased by 3.1% in the month to 71.6%. Queen Square has increased by 5.2% for the month, which is an improvement from the previous two months. Measurement of session length for Queen Square has now been adjusted to make it consistent with the Trust. A lack of beds lead to a number of cancellations within GI which affected their utilisation. Queens Square are working to fix data recording issues to bring them in line with rest of trust. LOS – The trust has committed to an 11% LOS reduction (based on the 14/15 out-turn) by year end. This is being profiled across the year with a target of 4% reduction in September. CHKS, our benchmarking supplier, have developed an expected LOS metric which takes account of the HRG and patient condition. In order to take account of case mix changes, we are monitoring improvement against expected LOS each month. This means that the target changes each month according to case mix, and we expect a % improvement in relation to the expected LOS. In this way we can monitor real LOS improvements rather than just case mix changes. The expected LOS has some exclusions, including day case, maternity, transfers and cancelled operations. Therefore we have applied the same exclusions to the actual LOS presented here.

60%

65%

70%

75%

80%

85%

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

Percentage trust theatre utilisation - All Services

Tower elective theatre utilisation - total elective time utilised Queen Square theatre utilisation

4. Access4.1 Access Targets - Referral to treatment

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% incomplete pathways < 18 weeks 92% 93.7% 95.1% 91.8% 94.1%

Patients waiting > 52 weeks 0 0 0 0 0

Patients waiting 40-52 weeks 33 9 6 18

Measure of Tip-in rate/numbers

% data quality issues on waiting list 5% 7.6% 10.6% 11.6% 6.7%

% cases not validated > 14 weeks tbc 28.4% 43.8% 21.1% 29.8%

% Diagnostic waiting list > 6 weeks 99% 97.2% 98.9% 98.3% 94.4%

% Last Minute Cancellations to Elective

Surgery0.6% 0.4% 0.0% 0.7% 0.0%

% Cancelled Operations Readmitted

Within 28 Days95.0% 97.7% 100.0% 50.0%

A&E attendances within 4 hours 95% 92.8% 92.8%

Page 7

This month

Month 6 - September

89%

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%


A&E attendances within 4 hours

A&E attendances within 4 hours Target

We achieved all three 18 week targets in September and reported no 52 week waiters. At specialty level, GI surgery and urology were both non-compliant with the 92% standard. We missed the target for diagnostic waits within 6 weeks in September. Performance is improving month on month since January but we are still below the threshold. MRI and endoscopy continue to be the most challenged modalities. Endoscopy is projecting compliance by December. This has been pushed back following delays implementing schemes to increase capacity. MRI at the UCH site is now compliant, however there remain breaches at Queen Square. The department are looking to source additional capacity through outsourcing. Medicine Board were non-compliant due to small numbers of breaches in neurophysiology. The service are projecting sustained compliance from October. We were below the threshold for A&E patients being seen with 4 hours. This is the second time we have breached this threshold since February. The worsened performance reflects increased bed capacity pressures at UCH in month and increased attendances. This has also highlighted the need to tighten operational processes in A&E and the UCH Tower in periods of increased attendances. There were 43 last minute cancellations for September, 0.4% of elective surgery which is better than threshold of 0.6%. There was one patient that was not readmitted within 28 days of their cancellation which meant 97.7% of patients were seen within 28 days which is better than threshold. As part of our contract we do not receive payment for patients re-booked outside of 28 days after an on the day cancellation.

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Referral to treatment % incomplete pathways under 18 weeks

% incomplete pathways < 18 weeks

Target

Will be available for October reporting

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Two week wait from referral to date first seen93% 86.8% 82.6% 90.6% 82.8% 97.9%

Two week wait from referral to date first seen: breast symptoms 93% 72.8% 72.8% 90.3%

31-day wait from diagnosis to first treatment 96% 89.4% 100.0% 81.2% 97.9% 89.4%

31-day wait for second or subsequent treatment: surgery94% 87.8% 100.0% 78.6% 100.0% 87.8%

31-day wait for second or subsequent treatment: drug treatments98% 98.7% 97.9% 100.0% 98.7%

31-day wait for second or subsequent treatment: Radiotherapy94% 96.0% 93.3% 98.2% 96.0%

31-day wait for second or subsequent treatment: other98% 52.8% 18.2% 100.0% 52.8%

62-day wait for first treatment from urgent GP referral to treatment85% 68.8% 100.0% 61.0% 80.0% 88.0%

62-day wait for first treatment from screening service referral90% 100.0% 100.0% 100.0%


Page 8

Month 6 - September

This month

4. Access4.2 Access Targets – Cancer

This month, we have presented both the externally reported cancer performance, and also the performance when we exclude those breaches that are outside of the trusts direct control, such as late referrals (this impacts 62 day only), patient choice delays or unavoidable delays due to medical complexity of the patient’s condition. Looking at performance in this exposes the internal issues that need to be addressed: Breast symptomatic performance is challenged due to two team members taking leave unexpectedly. The service are managing this closely but the issues will continue into November. For two week wait, we are looking at increasing the number of appointments available so that we reduce the number of patient DNAs and re-arrangements which drives most of the breaches. For the 31 day standard, most of the breaches continue to be in urology and relate to robotic surgery capacity pressures. The service have now increased surgical capacity and we are projecting achievement of this standard from October onwards. Non-compliance with the 31 day subsequent ‘other’ standard were primarily due to capacity pressures on the HIFU pathway for prostate cancer. We were also below the 62 day standard, with 19.5 patients breaching. Of these, 8.5 were urological, 5 were haematology and 3.5 were gynaecology. 12 of the breaches were caused by factors outside of the trust’s direct control, primarily late referrals.

0%

10%

20%

30%

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50%

60%

70%

80%

90%

100%

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15 Aug-15

Sep-15

Cancer 62 day referral targets

Target (GP referral to treatment)

Cancer 62 day referral from screening to treatment

Target (screening to treatment)

70%

75%

80%

85%

90%

95%

100%

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15 Aug-15

Sep-15

Cancer 2 week referral targets

Cancer GP referral to appointment

Cancer 14 day wait from referral (symptomatic breast)

Target

5. Quality5.1 Infection

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Number of MRSA Bacteraemias 3 2 0 2 0

Number of clostridium difficile cases

reported (excluding successful

appeals)

49 37 15 13 9


due to lapses in care12


under review25


successfully appealed15

Number of MSSA Bacteraemias 14 15 2 2 11

% Hand Hygiene Compliance (this

month)95.0% 94.1% 91.9% 96.7% 93.8%


Page 9

YEAR TO DATE

Month 6 - September

We have so far reported 52 cases of C diff as at the end of September. 15 of these cases have been successfully appealed as not being lapses in care. 12 cases of C diff have been found to be a lapse in care by the Trust. 25 cases are still under review. Therefore, our worst case position currently is 37 cases against the September year to date threshold of 49. There were two cases within GI. Root cause analysis (RCAs) were completed but no consistent themes or strains were identified. There are 15 cases of MSSA year to date against a threshold of 14 cases. An RCA for medical specialties, where there was one case, shows this was due to Percutaneous Endoscopic Gastrostomy (PEG) insertion and has been discussed at the daily huddle where the importance of documentation around visual infusion phlebitis scores was reinforced. There was one MSSA case within Queen Square for September. The plan is to investigate if this is a training issue or a compliance issue. The infection control nurse is happy to support training on IV devices at Queen Square and run training on the use of the new cannula. Paediatrics also had one case. The infection control team will carry out training for all ward areas and the RCA has been shared with the ward team at the safety huddles. Hand Hygiene compliance was marginally below threshold. RNTNE have highlighted their under performance at the Divisional Governance Meeting and at the local SpR induction session. There is now a daily walkaround with challenges to any non-compliant staff.

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Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

MRSA bacteraemia / infections - All Services

MRSA actuals monthly MRSA threshold monthly

MRSA actuals YTD MRSA threshold YTD

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Clostridium difficile infections post 48 hrs - All Services

CDiff Actuals Monthly excl. successful appeals CDiff Threshold Monthly

CDiff Actuals YTD excl. successful appeals CDiff Threshold YTD

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% Harm free care (National Safety

Thermometer)95.0% 96.3% 89.6% 98.9% 97.9%

% Harm free care (Hospital acquired

only)95.0% 98.3% 95.6% 99.6% 98.8%

Patients with preventable dose

omissions10.0% 8.4% 8.8% 7.3% 9.2%

% eVTE Risk Assessments completed 95.0% 94.5% 94.2% 96.0% 92.5%

The trust threshold is an aggregate of individual clinical board thresholds

Page 10

5. Quality5.2 Safety

This month

Month 6 - September

We were above threshold of 95% for the National Safety Thermometer harm free care indicator. However the medicine board are not achieving compliance within emergency services, infection, and critical care. The low performance is reflective of a number of falls in ED as well as patients that acquired issues in the community. (Further detail on falls on next page). We were narrowly worse than the 95% standard of patients being assessed for VTE in September. This was due to SHB not achieving target; paediatrics, women's health, Queen Square, and RNTNE were below threshold. Turnover of junior doctors led to a lower performance. Divisions will seek to give more training on this to new juniors. Paediatrics are seeking to update cohorting criteria to make their performance more accurate.

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Patients with preventable dose omissions- All Services

Preventable dose omissions Target

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VTE risk assessment - All Services

Percentage of Completed eVTE Risk Assessments Target

5. Quality5.3 Safety

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Inpatient falls with serious harm 0 0 0 0 0

Inpatient falls with harm 21 24 6 6 12

% of Serious Incidents (SI) reports

submitted within the designated

timescale (60 working days)

94.0% 75.0% 100.0% 50.0%

All Pressure Ulcers Acquired 6 5 0 4 1

Number of Grade 3 Pressure Ulcers

Acquired1 1 0 1 0

Number of Grade 4 Pressure Ulcers

Acquired0 0 0 0 0


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This month

Month 6 - September

Two inpatient falls with harm were under UCLH@Home and therefore has not been allocated to a board but has

been accounted for in the overall Trust figure

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Patient falls per 1,000 bed days and Overall - All Services

Inpatient falls with harm Patient falls Falls per 1000 beddays

There were 24 reported falls, five with moderate harm and the remaining with low harm. The five moderate harm falls constituted four fractures and one laceration. These were spread across five clinical areas within all three Boards. Each fall's RCA showed no consistent themes, however there were learning points from each. The newly appointed Darzi Nurse for Falls will prioritise quality improvement in the five highest risk areas. It's important to note that four fractures in one month is an unusually high number, prompting a review of other nurse-sensitive indicators across our wards during this period. The review was conducted by the Clinical Governance Team and concluded that other key indicators were within expected parameters during this period. The month of October has seen no fractures reported. There was one SI report not submitted within 60 working days in women's health. The case was very complex and required extensive conversations with all involved. It has since been reclassified as not being an SI. The numbers of pressure ulcers remain low across the Trust, with five reported. One grade 3 was reported in the Cancer Division. This case related to a complex palliative care patient who was not compliant with treatment. There were learning points from this incident, including earlier escalation to senior and expert staff, completion of documentation, and timely ordering of equipment. The Charge Nurse & Matron from this area have presented the case for learning to the senior team and locally. The number of complex patients ‘admitted with’ grade 2,3 and 4 pressure ulcers remains high. In October we met with our community and CCG colleagues to review clusters and hotspots across the health economy. We are conducting a Trust-wide annual audit of Pressure Ulcer Care with our partners Medstrom.

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Pressure Ulcers acquired at UCLH split by Grade/Category - All Services

Grade 4 Grade 3 Grade 2

5. Quality5.4 Outcomes

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Emergency readmissions within 30

days (with PbR exclusions)3.1% 3.2% 7.4% 3.0% 1.3%

A&E to admission conversion rate 20.0% 10.6% 10.6%

Cases of harm in theatres 11 4 7

Sepsis cases 46 23 22 1

% Complete Vital Signs collected 96.0% 96.6% 98.4% 98.6% 95.3%

% deteriorating patients escalated

according to protocol90.0% 94.7% 95.2% 86.7% 97.9%

Local SHMI (1 yr rolling data) 0.55 0.51 0.71 0.48


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This month

Month 6 - September

We were compliant in achieving the threshold for vital signs observations in September. Women's Health were not compliant due to non-submission for the Antenatal Care Unit and T06 (gynaecology). This has been escalated to matrons in all non-compliant areas. Within Paediatrics T11N submitted 5 out of 10 submissions, although they were 100% compliant for all submissions. Due to data issues the emergency readmissions performance was obtained late. Therefore, the current underperformance is still being investigated. Further detail will be given to November Quality and Safety Committee

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90%

95%

100%


% Complete Vital Signs collected - All Services

Percentage of Complete Vital Signs New Target

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1.0%

2.0%

3.0%

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7.0%

8.0%

Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15

Emergency readmissions within 30 days (with PbR exclusions)

Emergency readmissions within 30 days (with PbR exclusions)

5. Quality5.5 Patient Experience

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Complaints responded to within target time 85.0% 59.2% 66.7% 53.8% 61.1%

Friends & Family Test (IP survey) 96% 97.2% 98.7% 96.7% 96.8%

Friends & Family Test (AE survey ) 95% 95.1% 95.1%

Friends & Family Test (OP survey) 93%

% of hospital appointments postponed by

hospital4.8% 4.0% 6.8% 4.0%

Page 13

This month

Month 6 - September

We were worse than threshold for complaints response time in September, a 14.2% decrease from August. The division of cancer had a higher compliance than stated due to extensions from management team not reaching complaints team in time. Surgical specialties are receiving very high volumes of complaints, including large numbers from ophthalmology patients relating to their care being transferred to the Royal Free. At Queen Square the division has received a sharp increase in the number of clinically complex complaints, which require investigation (or at least agreement/sign off) by the appropriate Associate Clinical Director. At RNTNE there were two complaints, both dealt with informally within time but not closed down punctually on formal reporting. At EDH two complaints were not updated whilst complaint lead was on holiday; a system is now in place to cover leave. The medicine board had an issue with data being double counted which has been corrected now. We continue to improve on the friends and family test (IP Survey) with 97.2%. Response rates has also continued to improve. Friends and family test for A&E has also improved after being non compliant last month.

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Patient experience - Complaints received

Number of Patient Complaints Complaints responded to within target time Target

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50%

60%

70%

80%

90%

100%


Patient Experience - FFT scores and response rate (IP & AE)

Friends & Family Test (IP survey) New FFT AE scoreFriends and Family - IP Response Rate FFT AE response rate %

6. Workforce 6.1 Performance indicators

Month 6, 2015/16

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Staff in Post (WTE)NA 7381.0 1514.7 2130.7 3072.7 663.0

% Temporary staffing filled via BankNA 89.1% 93.1% 79.5% 92.6% 97.1%

Vacancy Rate (Trust Rate)NA 10.3% 9.3% 13.2% 9.2% 7.5%

Staff Turnover Rate (excluding:

internal rransfers, FTCs, bank staff,

honoraries, junior doctors and NEDs)

12% 14.8% 15.8% 12.5% 15.0% 19.6%

The Trust threshold is an aggregate position of indvidual clinical board thresholds

Page 14

Month 2- May

Temporary staffing: We no longer rely upon agency staff for

administrative and clerical or nursing assistant roles. In M5 we applied

new controls to initiate ‘agency free zones’ across most wards and

departments. Our relative and actual reliance on agency staffing

continues to decrease. Our bank fill rates are the highest reported for

an acute teaching trust in London.

Vacancies: The Trust’s vacancy rate continues to fall. The nursing

establishment has grown to reflect Westmoreland Street’s gradual

reopening. The overall nursing vacancy rate is 12.2% though vacancies

in the Medical, Surgery and Cancer and Specialist Hospitals Boards

are now below 12%.

Turnover: Turnover has remained steady between month 5 and 6. We

are continuing our efforts to focus on retention initiatives for clinical

staff, especially in hard to recruit areas.

Staff in Post: The establishment was stable in M6 though reductions

were agreed for M7 onwards that will show in following reports. As part

of the Workforce/Finance Alignment Project, we are reviewing the way

we record Honorary Contracts on ESR. The solution we shall apply

from M7 reporting shall show that we have overreported vacancy rates

in our corporate nursing divisions from M1-M6.

6. Workforce 6.2 Performance indicators

Tru

st

thre

shold

Tru

st

actu

al

Me

dic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

Corp

ora

te

Fu

nctio

ns

Sickness absence rate (%) 4.0% 3.1% 3.4% 3.1% 3.3% 2.0%

Appraisal Tier 3 - All remaining staff at

Band 7 and above

90% (by the

end of

October)

30.6% 33.4% 28.8% 31.7% 23.3%

% Statutory and mandatory training

compliance90% 83% 84.0% 84.0% 81.0% 76.0%

Average time to recruit (request pack -

start date) (weeks)14.6 14.3 13.1 15.2 14.4 12.8

Average time to recruit (request pack

received - unconditional offer) (weeks)N/A 10.0 7.9 9.8 11.4 9.3

Page 15


Month 2- May

This month

Nursing and Midwifery Detailed Workforce Dashboard

Key Workforce Metrics &

Indicators

NA 2-4 RN 5-7 RN 8a+ NA 2-4 RN 5-7 RN 8a+ NA 2-4 RN 5-7 RN 8a+ NA 2-4 RN 5-7 RN 8a+ NA 2-4 RN 5-7 RN 8a+ All

Establishment FTE 157.4 552.5 24.1 262.4 848.7 29.3 235.2 1195.1 50.6 9.0 100.2 16.5 664.0 2696.4 120.5 3480.9

Staff in Post FTE 143.0 485.6 23.5 218.1 766.2 27.9 220.1 1039.6 50.3 5.8 68.0 7.0 587.0 2359.4 108.7 3055.1

Vacant Posts FTE 14.5 66.9 0.6 44.3 82.6 1.4 15.1 155.4 0.3 3.2 32.2 9.5 77.0 337.1 11.8 425.9

Starters FTE 10.0 13.0 0.0 22.0 20.0 0.0 11.4 11.2 0.0 0.6 0.0 0.0 44.0 44.2 0.0 88.2

Leavers FTE 3.0 4.6 0.0 4.0 2.2 2.0 6.0 19.2 1.0 0.8 0.0 0.0 13.8 26.0 3.0 42.8

Vacancy Rate 9.2% 12.1% 2.7% 16.9% 9.7% 4.6% 6.4% 13.0% 0.7% 35.6% 32.1% 57.6% 11.6% 12.5% 9.8% 12.2%

Turnover Rate 23.1% 24.8% 21.9% 20.6% 23.2% 16.7%

Temp Staffing Usage 34.2% 8.3% NA 23.4% 12.7% NA 26.5% 10.4% NA 0.0% 2.0% NA 27.3% 10.5% NA 14.0%

Sickness Absence 5.9% 2.7% NA 2.6% 3.0% 3.0% 4.5% 2.8% 3.2% 2.1% 1.9% NA 4.1% 2.8% 2.1% 3.0%Right Staffing Level by

Shift104.4% 89.7% NA 129.2% 89.0% NA 132.8% 91.0% NA NA NA NA 121.7% 90.2% NA 97.9%

Page 16

Month 2 - May

23.3%15.9%13.2%17.8% 15.6%

Medicine Board Surgery & Cancer Board Specialist Hospitals Board Corporate Board UCLH Trust

Notes: Turnover is ca lculated as a 12-month rol l ing average over the preceding year. It excludes FTC and transfers of s taff. Temporary staffing usage is the temporary staff

used as a proportion of the total s taff (temporary plus substantive). The vacancy and establ ishment data for this report rel ies upon the GL data for M4 (July) 2015/16. Our vacancy projection reflects our assumptions of the impact of

our nurs ing recruitment campaign for the ful l year. The projection was set before the new government announced changes in the visa system for migrants from outs ide the EU.

As part of the Workforce/Finance Al ignment Project, we are reviewing the way we record Honorary Contracts on ESR. Currently, we have no way of quanti fying the contribution to service that this component of the workforce makes.

A solution to this identi fied issue wi l l be in place by the time of the next CEO Performance Pack for M7. This wi l l have a s igni ficant corrective impact on the staffing numbers and vacancy rates for the vacancy rate in Corporate

Nurs ing.

Estimated riskThresholds Weighting Sep 15 Q1 Q2 Comments

49 1.0 37 29 37

25 cases still

under review, 12

lapses in care

92% 1.0 93.7% 94.3% 93.8%See page 8 for

detail.

85% 68.8% 70.1% 67.9% See page 15 for

detail.

90% 100.0% 74.6% 100.0%See page 9 for

detail

94% 87.8% 87.6% 91.1%See page 9 for

detail

98% 98.7% 99.4% 99.7%See page 9 for

detail

94% 96.0% 97.7% 97.4%See page 9 for

detail

96% 0.5 89.4% 89.4% 88.8%See page 9 for

detail

93% 86.8% 91.4% 90.6%See page 9 for

detail

93% 72.8% 90.4% 86.1%See page 9 for

detail

95% 1.0 92.8% 96.3% 95.0% See page 8 for

detail

Green Green Green

Page 17

31 day wait for second or subsequent treatment: Surgery

1.031 day wait for second or subsequent treatment: anti cancer drug treatments

31 day wait for second or subsequent treatment: Radiotherapy

Incidence of Clostridium difficile year to date

Maximum time of 18 weeks from point of referral to treatment - incomplete pathways

7. Externally Reported Frameworks 7.1 Monitor Indicators – Compliance Framework

Indicators

62 day wait for first treatment from urgent GP referral

1.0

62 day wait for first treatment from consultant screening service referral

Month 6 - September

31-day wait from diagnosis to first treatment (all cancers)

Two week wait from referral to date first seen: all cancers

0.5

Two week wait from referral to date first seen: symptomatic breast patients

A&E: Maximum waiting time of four hours from arrival to admission/ transfer/ discharge

Overall governance rating / Monitor RAF assessment

7. Externally Reported Frameworks 7.2 CQUIN and financial penalty summary

Month 6 - September

Financial Penalties

Financial Plan

assumptions

MRSA £ -

C. Difficile £ -

RTT penalties £ -

RTT 52+ penalties £ -

Cancer waits £ -

A&E £ -

Diagnostic waits £ -

LAS 30 & 60 Minute handover £ -

VTE risk assessments £ - Mixed sex accommodation

breach £ -

Total penaties £1,000,000 £0 £0 £0 £0 £0

Non-reimbursed activity -

Contract metrics

Financial Plan

assumptionsQ1 Q2 Q3 Q4

Emergency readmissions TBC

Emergency readmissions First / follow up ratios (full year

projection)TBC

Total non-reimbursed

penalties£0 £0 £0.00 £0 £0 £ -

Overall penalty / risk /

non-reimbursement£0 £0 £0 £0 £0

The level of LAS breaches remains an estimate at this time as there are many cases being reviewed and challenged by the A&E department

Will be finalised once contracts are signed off

The level of LAS breaches remains an estimate at this time as there are many cases being reviewed and challenged by the A&E department

Will be finalised once contracts are signed off

1. Referrals and activity

2. Access

3. Patient safety and quality metrics

4. Data Quality

5. Research and development

6. Average Length of Stay

Page 19

Quarterly review slidesContents

Month 6 - September

Month 6 - September

Quarterly Review1. Referrals and activity

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

Number of referrals to UCLH per Quarter (RNTNE included from Apr-12)

GP Refs Non GP Refs Total Refs

210,000

215,000

220,000

225,000

230,000

235,000

240,000

245,000

250,000

255,000

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

All Outpatient Attendances (RNTNE included from Apr-12)

Total Attendances

24000

25000

26000

27000

28000

29000

30000

31000

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

Daycase and Elective Inpatients (RNTNE included from Apr-12)

Total DC & ELIP

11500

12000

12500

13000

13500

14000

14500

15000

15500

16000

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

Non Elective Inpatients (RNTNE included from Apr-12)

Non Elective

Quarterly Review2. Access Targets

Page 21

Month 6 - September

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

62 day from GP referral target (without reallocations)

Performance Threshold

29500

30000

30500

31000

31500

32000

32500

33000

33500

34000

89%

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

2013-14 Q22013-14 Q32013-14 Q42014-15 Q12014-15 Q22014-15 Q32014-15 Q42015-16 Q12015-16 Q2

A&E 4 hour wait target

A&E Performance Threshold A & E Attendances

0%

20%

40%

60%

80%

100%

120%

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

62 day screening target

Performance Threshold

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2013-14 Q22013-14 Q32013-14 Q42014-15 Q12014-15 Q22014-15 Q32014-15 Q42015-16 Q12015-16 Q2

Switchboard calls answered within 30 seconds

Calls answered within 30 seconds Threshold

No Data

Page 22

Quarterly Review3.1 Infections

Month 6 - September

0

1

2

3

4

5

6

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

MRSA - All Trust reported cases to HPA (including community acquired)

UCLH All MRSA (incl community acquired) MRSA Peer average

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

MRSA cases per 10000 bed days UCLH Vs London Peers

UCLH MRSA bed rate London peers MRSA bed rate

Linear (UCLH MRSA bed rate) Linear (London peers MRSA bed rate)

0

5

10

15

20

25

30

35

40

45

50

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

C. Difficile - All Trust reported cases to HPA (including community acquired)

UCLH All C-diff (incl community acquired) C diff Peer average

0

1

2

3

4

5

6

7

8

9

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

C. Difficile cases per 10000 bed days UCLH Vs London Peers

UCLH Cdiff bed rate London peers Cdiff bed rate

Linear (UCLH Cdiff bed rate) Linear (London peers Cdiff bed rate)

Month 6 - September

Quarterly Review3.2 Other Quality issues

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

Last minute cancellations to elective surgery

Cancellations to Elective Surgery Threshold

0

500

1,000

1,500

2,000

2,500

3,000

3,500

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

Number of Incidents

0

50

100

150

200

250

300

350

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

Inpatient Falls

Falls with no harm Falls with harm (w/o serious harm) Falls with serious harm

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Local SHMI 0.52 0.52 0.52 0.53 0.52 0.53 0.53 0.52 0.53 0.52 0.53 0.48 0.53 0.52 0.52 0.52 0.51 0.53 0.51 0.51 0.53 0.53 0.57 0.56 0.55

External SHIMI 0.71 0.74 0.75 0.80 0.78 0.79 0.78

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1.3

1.4

Rela

tive R

isk (

Index 1

00 <

Bett

er

Ris

k, >

Wors

e

Ris

k)

Mortality - SHMI Relative Risk, 1 year rolling data

Appendix 1

Page 24

Quarterly review3.3 Other Quality issues

Month 6 - September

- The HSMR indicator has been replaced with the new SHMI indicator. The Trust remains

0

10

20

30

40

50

60

70

80

90

100

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

Emergency Readmissions with Complications Within 30 Days- All Services

Emergency Readmissions with Complications

3 per. Mov. Avg. (Emergency Readmissions with Complications)

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

0

100

200

300

400

500

600

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

30 Day Readmissions following elective admissions - All Services

External readmissions - Elective 30 Day Readmissions - Elective % 30 Day Readmissions - Elective

8.5%

9.0%

9.5%

10.0%

10.5%

11.0%

11.5%

0

100

200

300

400

500

600

700

800

900

1000

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

30 Day Readmissions following non-elective admissions - All Services

External readmissions Non-Elective 30 Day Readmissions - Non-Elective

% 30 Day Readmissions - Non-Elective

0

50

100

150

200

250

300

350

400

450

500

2013-14 Q2 2013-14 Q3 2013-14 Q4 2014-15 Q1 2014-15 Q2 2014-15 Q3 2014-15 Q4 2015-16 Q1 2015-16 Q2

7 Day readmissions - All Services

7 Day readmissions - All Services 3 per. Mov. Avg. (7 Day readmissions - All Services)

Quarterly review3.4 New CQC Risk Summary May 2015

Month 6 - September

Month 6 - September

4 Data quality reporting

Research and Development Directorate5.1 Research Activity Performance UCLH: September 2015

Month 6 - September

Studies approved (NHS permission) UCLH by calendar year and phase (n) This shows the number of studies approved each year, by study type. Early phase is considered to be drug trials which are Phase 1 and 2 (the earliest stages of trials in humans) The goal is to see growth in the number of these trials. Other study types are all studies excluding clinical trials.

Studies approved (NHS permission) UCLH by calendar year and Study type (n) This shows the number of studies approved each year, by study type. The goal is to see sustained growth.

Recruitment to UCL BioResource. August 2013 – September 2015 (n). BioResource target is 10,000 DNA samples and phenotype information from patients /volunteers from UCLH and other UCLP hospitals. This data shows the different sources from which participants have been consented (UCL bioresource or via other studies).

Studies approved (NHS permission) by calendar year and study type

Studies approved (NHS permission) UCLH by calendar year and study types (n)

Research and Development Directorate5.2 Research Performance UCLH: July 2015

Month 6 - September

Number of studies initiated within 70 calendar days

NIHR Initiation Performance Targets (interventional and Ctimp portfolio only): Percentage of studies obtaining NHS Permission and recruiting first patient within 70 days of submission to R&D. The Department of Health had set a target for all Trusts to demonstrate dramatic and sustained improvement in the initiation target. The numbers on in the bar chart shows the % performance against this standard each quarter for each board. The total number of trials is written under the bar chart.

Interventional studies recruiting first patient within NIHR 70 day target Q4 (13/14) – Q1 (14/15) by comparable Trusts (%)

Research and Development Directorate5.3 Clinical Research Facility (CRF) Activity: March 2015

Month 6 - September

Booked attendances by type – This data has been extracted from the CRF’s booking system (CRF Manager). It shows the number of attendances booked into a clinical space in the CRF each month. Day patients will be in the unit for the whole day and inpatients may be in the CRF until 11pm if blood samples are require d post treatment on a trial. Number of trial participants – This graph shows the number of individual trial participants seen in the CRF each month. This does not equate to participants on trial at any given time as a participant may not be required to attend every month. Participants are only counted once in each month. The data has been taken from the CRF Manager system. This activity data is provided to give context on the volumes of patients going through the CRF. Patient experience – This data has been extracted from the Meridian system dashboard (Patient Experience Questionnaires). The UCLH bar relates to the combined results of all questionnaires submitted across the Trust.

Research and Development Directorate5.4 UCL/UCLH Biomedical Research Centre (BRC) Activity trends: July 2015

Month 6 - September

Number of Commercially sponsored Trials Approved to begin at UCLH, 2013/14,

2014/15 and Q1&2 2015/16. The goal is to achieve sustained growth of commercially sponsored studies active at site. Number of Early Phase Trials Approved to begin at UCLH 2013/14 – 2015/16 (Q1&2)(commercial and non-commercial). Early phase is considered to be drug trials which are Phase 1 and 2 (the earliest stages of trials in humans) The goal is to see growth in the number of these trials BRC Cited academic papers 2012/13 and 2013/14 and 2015/5 (n) and total citations (summary numbers). The BRC publications is an indicator of both quality as represented by the H-index [e.g. 67 papers have been cited 67 times] and both quality and quantity by the number of papers and citations, all with an upward trend.

Number of commercially sponsored trials approved Number of early phase trials approved

Number of BRC cited academic papers 2012/13 – 2015 (Q1)

6.1 Average length of stay

Actual ExpectedExtra bed

days used

Monthly LoS

TrendActual Expected

Extra bed

days used

Monthly LoS

Trend

Critical Care Critical Care Medicine 13.8 12.3 9

Emergency Services Accident & Emergency 1.6 3.1 -182

Infection Infectious Diseases 4.4 6.9 -12 6.3 6.5 -9

Clinical Pharmacology 23.4 7.9 140

Rheumatology 1.2 1.9 -14 10 8.3 7

Respiratory Medicine 1.3 4.3 -38 13.3 11.1 50

Geriatric Medicine 11.1 11.6 -37

General Medicine 5.6 5.3 3 4.6 6.1 -501

Haematology (Clinical) 14.1 12 165 13.7 13.3 13

Medical Oncology 5.3 5.5 -17 10 9.6 22

#Month 6 - September

S&C Cancer

Quarterly Review

Elective Risk Adjusted AvLOS: Month 6 Non-Elective Risk Adjusted AvLOS: Month 6

Med

Medical Specialties

Rather than use peer comparisons, which do not account for risk adjustments, this calculation uses a methodology that looks at each individual patient and benchmarks their spell with similar cases nationally.

Each spell starts with a value of zero – the predicted length of stay is then calculated by looking at a number of fields within the spell, and adding or deducting a number of days based on the model coefficients. The final predicted length of stay is the sum of the values applied. The factors that contribute to the risk score are age, gender, primary and secondary diagnoses, most significant surgical procedure, HRG and discharge status.

6.2 Average length of stay

Actual ExpectedExtra bed days

used

Monthly LoS

TrendActual Expected

Extra bed days

used

Monthly LoS

Trend

General Surgery 3.8 3.8 -8 4.6 4.9 -34

Gastroenterology 3.5 3.4 7 10.4 6.2 132

Gynaecological Oncology 6.5 5.7 36 11.3 8.1 12

Thoracic Surgery 5.6 5.5 7 4.5 7.7 -6

Urology 2.8 3 -48 4.4 5.8 -67

Trauma & Orthopaedics 3.9 4.2 -38 5.8 7.2 -74

EDH Oral Surgery 2.8 2.7 4 1.8 2.8 -14

Paediatrics 3.6 3.7 -7 2.2 2.6 -56

Paediatric Surgery 0.9 0.8 1

Neurosurgery 4.4 4.5 -29 10.3 11 -37

Neurology 2 1.8 144 3.9 7.4 -341

RNTNE ENT 1.1 1.6 -42 2.8 3.1 -8

Obstetrics 2.3 2.2 50

Gynaecology 2.2 2.3 -13 2.2 2.2 0

Page 35Month 6 - September

Quarterly Review

Elective Risk Adjusted AvLOS: Month 6 Non-Elective Risk Adjusted AvLOS: Month 6

S&C

SpH

Paediatrics

Queen Square

Women's Health

Surgical Specialties

[Type text]

1

Appendix 1: Tracking delivery of the2015/16 top 10 operational objectives

Top ten objectives Lead director Measurement / target Q2 score/ RAG

Q2 Score – overall objective RAG

Reason for score Forecast year end position (RAG)

1. Improve patient safety

1. Achieve hospital acquired infection targets

Jonathan Fielden

No cases of MRSA 2 cases

No more than 97 C-diff 52 cases ytd

No deterioration in C-difficile lapses in healthcare 12 cases ytd

2. Deliver “Sign up to Safety” campaign

Sandra Hallett

Reduce number of sepsis cases 139 Q2 (138 Q1)

90% patients escalated to PERT using agreed tool 94.1%

96% of vital signs taken in Q4 of 2015/16 97.0% Reduce the number of cases of harm in operating theatres 67 Q2 (70 Q1)

3. Deliver progress towards 24 / 7 working

Ben Morrin

Agree with commissioners areas requiring further development by end Q1.

Areas for further development sent to Commissioners 25 Sept 2015. Agreeing clinical standards with commissioners overtaken by NHSE determining 4 priority standards with new timetable for delivery

Implementation assessment / plan in place by end Q2

Baseline assessment completed 25 September. Next steps highlighted by assessment agreed by Medical Directors Paper to go to EB to agree next steps November: Amber due to later delivery of paper to EB than originally planned (mitigated by change to NHSE timetable and targets)

Implement according to plan

Implementation plan will be agreed in line with new NHSE timetable. Baseline assessment demonstrates this is achievable.

2. Deliver excellent clinical outcomes 1. Maintain upper decile SHMI results

Sandra Hallett

In upper decile of trusts for SHMI Latest SHMI shows UCLH as 3rd in country

[Type text]

2




2. Agree a joint approach to integration with CCGs

Jonathan Fielden

Integration strategy document agreed with Camden CCG by end Q2

Strategy signed at October board. Written support from Camden CCG

Deliver 2015/16 milestones

3. Avoid increase in levels of emergency admissions

Jonathan Fielden

Maintain 30 days emergency readmission rate of 3.05% 2.5%

Maintain conversion rate for A&E to admission at <20%

10.6%

3. Deliver high quality patient experience and customer service

1. Maintain patient survey satisfaction ratings

Flo Panel-Coates

Maintain overall scores in inpatient, outpatient and cancer surveys

From Meridian data the inpatient overall experience remains static around 92%. Responses remain low for cancer and outpatients however overall experience remains static around 90%.

Maintain scores on Friends and Families test

97.1%(inpatients) 94.7% (A&E) FFT scores remain high

2. Reduce the number of outpatient cancellations

Gill Gaskin

Reduce hospital outpatient cancellation and postponement rate to 10%

4.7%

3. Avoid increase in the number of inpatient cancellations

Geoff Bellingan

Maintain current last minute elective cancellation rate of 0.6%

0.3%

4. Enable staff to maximise their potential

1. Reduce the level of nursing vacancies

Ben Morrin

Reduce the nursing vacancy figure to 11% by end December and 7.5% by end March 2016

12.2% (at end M6)

Nursing vacancies are decreasing in line with trajectory. We are confident we shall meet the M9 target and M12 targets.

Reduce staff turn-over to 12%

Though reducing, our overall turnover at M6 was in excess of 15%. Our turnover position per month is a 12 mth rolling mean average for the preceding year thus action taken to incentivise retention shall only impact on that with a lag.

[Type text]

3




2. Maintain/achieve improvements in staff satisfaction survey

Ben Morrin

Maintain results for the annual staff survey reported in March 2016

3. Improve the effectiveness of performance appraisals for all staff

Ben Morrin

90% staff with appraisals by end December 2015

Improvement in staff survey results around appraisal 90% of consultants have a job plan by the end of Q4 2015/16.

5. Reduce waiting times

1. Achieve the 18 week RTT targets

Neil Griffiths

Trust compliance with the three RTT waiting targets

Specialty level compliance by end of March 2016

2. Meet cancer waiting times targets

Geoff Bellingan

Delivery of reduced 62 day breaches in line with the Trust’s trajectory

Breaches reduced from 78 to 60.5, but this is still above our trajectory.

3. Achieve the 95% 4 hour A&E standard

Jonathan Fielden

Compliant performance against A&E 4 hour wait standard across 2015/16.

95.02%

6. Achieve sustainable financial health

1. Agree contracts with commissioners

Mike Foster

Contracts signed by end April 2015 or entered disputes process

Contract baseline values and terms and conditions have been agreed with NEL CCGs and NHSE. We are now confirming baseline values for the associates to the NEL contract and the plan is to move to contract signature on both contracts by the 30 October

Reduce by 10% (compared to 2014/15) levels of challenges unresolved 3 months after challenge period

As reported in quarter 1 - Very good progress has been made in reducing challenges, however work on the baseline needs to be finalised once contracts have been agreed.

2. Deliver cost improvement

Tim Jaggard

Achieve budget targets (including cost improvements)

Financial position significantly behind plan, and under review by Monitor

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programme agreed by EB and FCC Cash targets are in place and a target has been set for reducing outstanding debt – however, to date cash is behind plan largely due to poor operational financial position. Outlook for the end of the year is better.

3. Improve cash-flow performance

Tim Jaggard

Quarterly cash and outstanding balance targets established by June 2015 and then achieved

7. Develop and implement year 1 milestones of our transformation strategy

1. Standardise and improve patient pathways

Neil Griffiths

Set criteria for which pathways will be standardised and Increase volume of patients going through standardised pathways

There has been progress against the urgent care work-stream to identify and standardise pathways. There has been less progress in the planned care work-stream.

Length of stay reduced in key specialties according to agreed targets

The trust has seen a reduction in LOS against the 2014/15 baseline, however, further work is required to identify more pathways to deliver this standard.

2. Agree preferred option for future IT infrastructure

Director of ICT

Plan to go to Board in April 2015


ITO Strategy agreed Project initiated and discovery phase commended Procurement resources engaged High level milestones agreed Amber based upon the need to define and secure resources for delivery

3. Agree strategy for organisational development

Ashvin Sharma

Organisational development priorities agreed by May 2015

OD priorities agreed with CEO and are included in OD charter for UCLH future Priorities for leader and change capability on track Capability assessment process for top 80+ on plan

Board of Directors approve organisational development strategy by December 2015 NB first scoping discussion

This needs sponsorship from trust chairman and CEO, plan to obtain this in order to take to November Board. NB this is paused pending new CEO

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completed in July 2015

8. Develop the research agenda 1. Increase the number of participants in clinical trials

Bryan Williams

Increase number of clinical trials participants by 5% by March 2016

2. Move the Clinical Research Facility to new premises

Tony Mundy

CRF in new facilities by September 2015

3. Progress clinical academic appointments with UCL

Ben Morrin

Delivery in line with plan agreed with UCL, with plan to be agreed by end October

Progress is on track against our renewed plan. 9. Develop education

1. Develop plans for the UCLH Institute

Ben Morrin

Board of Directors approve plan for UCLH Institute by September

The Board’s session is now timetabled for November.


The 2015/16 milestones for integrated induction are on track though the quality improvement element of the Institute’s first phase work programme has been constrained by delayed recruitment

2. Improve staff compliance with mandatory training

Ben Morrin 90% compliance by year end

Compliance at end Q2 reached 84%. Work is in play to improve compliance and review TNA and model of provision for key mandatory training.

3. Improve satisfaction with medical education programmes

Emma Taylor

Improve overall postgraduate medical training satisfaction ratings

A HEE led review of our postgraduate medical training was carried out in June and positively assessed UCLH provision. Junior doctor satisfaction had improved on GMC/HEE benchmarks. The Education Director is taking forward action on specific issues where improvements were encouraged.

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10. Progress service developments

1. Progress phase 4/5 developments

David Probert

Ensure full contractual sign off of Phase 4 (July)

Phase 4 contract sign off agreed for July 2015 with full Government approval now received.

Begin full construction of Phase 4 (July)

Phase 4 early works underway with demolition complete and planned main works on time to commence.

Gain Full Business Case Approval for Phase 5 (July) Phase 5 FBC approved by Trust Board in July

2015. Begin construction process for Phase 5 (November) On target for November/December demolition of

site

2. Implement cardiac/cancer strategy

Gill Gaskin

and Geoff Bellingan

Cardiac services move to Barts

Haematology service move to UCLH – autumn 2015

Specialist cancer services to UCLH – autumn 2015

3. Continue Emergency Department expansion project

Jonathan Fielden

Completion of ED road-works phase by September 2015

Complete by November 15, this will not delay the overall programme

Completion of next phase of majors cubicles expansion by December 2015

Completion of key milestones according to agreed plan

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Agenda Item 10

Quality and Safety Committee Report September 2015


September Quality and Safety Committee report to the Board of Directors, November 2015

1. Morecombe Bay report- Lessons learned QSC received a report from Women’s Health. Analysis of the recommendations arising from the Morecambe Bay report against current UCLH Maternity Services showed that 15 of the 18 recommendations were fully met with three remaining recommendations partially met. These relate to duty of candour, the culture within maternity services and appropriate clinical escalation. The three outstanding recommendations are to be fully implemented and reported to the QSC in three months. Children’s Inpatient and Day Case Survey 2014 Overall the findings of the survey were positive although there was some disparity between the national and Picker findings (which tended to show UCLH in a slightly better light). No areas were scored in the category of ‘worse than other trusts’. The relatively low response rate of 27% was also noted which is, however, in line with the national rate. 2. Duty of Candour (DoC) compliance report QSC received the compliance report as recorded on Datix. Whilst there is overall improvement in recorded compliance, there is still a long way to go. A case note audit has started which will show actual compliance. Two key messages are that actions must be recorded on Datix and there is a need to address front line knowledge and understanding for which plans are underway. 3. Annual Patient Safety report 3.1 QSC received the annual report; the report provides an overview of safety in 2014/15 with a focus on incident reporting including serious incidents and the DoC. It includes more detail on some of the top safety concerns such as falls and pressure ulcers and medicines. It also covers briefly the Trust governance structure and describes in more detail the role of the Patient Safety and Risk Steering Group. The Trust’s commitment to the Sign up to Safety initiative is noted and plans for next year. Learning from complaints and claims is addressed in other relevant reports.

3.2 DoC was discussed including the difficulty associated with the fact that, under current guidance some clinical conditions (e.g. neutropenia in cancer patients) have to be classified as causing ‘moderate’ harm and which then fall into the DoC protocol. The guidance is still evolving and it was agreed that UCLH should play a key leadership role in the national debate.

3.3 The national Sign up to Safety initiative was discussed. It incorporates five key pledges: to put safety first; continually learn; be honest; collaborate and support. The Trust’s three safety improvement projects are to reduce surgical harm, to reduce sepsis and to reduce harm from deterioration. 4. Adult Safeguarding Committee quarterly report QSC received the quarterly report. There has been over a doubling of deprivation of liberty (DoLs) applications between 2014/5 and 2015/6. Safeguarding alerts have increased by 33% (from 61 to 92) in Quarter 1 2015/16 compared to Quarter 1 in the previous year. Whilst Level 1 & 2 training had been achieved Level 3 was not yet achieved, actions are in hand to address this. Further update will be provided at the next QSC. QSC discussed whether the rise in alerts was due to a rise in incidents of safeguarding or a rise in reporting. It is difficult to be entirely clear on this an example was provided – that of five alerts raised against staff none had been substantiated. It is clear that the landscape is changing and a joined up process with our partners is needed. 5. CQC inspection preparedness update Current position: The pilot inspection November 2013 resulting in four compliance actions relating to WHO safer surgery checklist, capacity and paediatrics in ED, nursing assessment documentation and security of medical records. The Trust is now the highest priority banding for inspection on the CQC’s Intelligent Monitoring Report and will be inspected by April 2016 in order to be given a rating.

The Inspection will be of “core services” i.e. urgent & emergency, medical services, surgical services, critical care, maternity & gynaecology, children & paediatrics, end of life, OPD & imaging.

Improving Care walk rounds (ICRs) Multidisciplinary ICRs using the CQC inspection frameworks have been in progress since April 2014. They assess the five domains of care (Safe, Caring, Well Led, Responsive and Effective).Feedback and reports are provided to the division who then develop action plans. Revisits indicate some improvements.

Inspection preparation: Priorities and concerns identified from ICRs, previous inspection, IMR & horizon scanning have been established and the CQC Executive Steering Group re-established to oversee preparation. The first cycle of ICRs in maternity, cancer centre, medical services is now complete with a second follow up visit (to check on progress) is due to start in October. Communications plans are underway. A Mock external inspection by a team from Newcastle UHT is planned for October with a reciprocal visit to Newcastle in November.

Concerns & Priorities: Estates and Facilities, storage, cleaning & PPM; C.Difficile (numbers & learning from RCAs) & IC; Duty of Candour compliance; Consent & Mental Capacity Act; Staffing; Capacity and flow (impact of winter pressures); ED patient experience during re-build; Learning from incidents, serious incidents & Never Event and DNACPR documentation. Residual risks associated with the four compliance actions arising from the 2013 visit are being followed up.

The CQC Executive Steering Group (CQCESG) will oversee progress on actions and ensure new actions on emerging issues. CQCESG will provide monthly update to the Executive Board. EB will report to the Board and there will be monthly update to QSC, for assurance. 6. Trust Quality & Safety performance Book

Three items were highlighted for comment: C difficile numbers (and that a single case is likely to be successfully appealed); reduction in the divisional submission of hand hygiene audit data and the tailing off of response rates on the Friends and Family test (FFT). FFT response rate overall is 23% and 19% for the Emergency Department. Whilst this is comparable with other Shelford group trusts, QSC considered it too low and requested that the target response remain at 40% and ward areas be given targets to achieve. 7. Infection Scorecard

7.1 C.difficile There are 38 C. difficile cases year to date, 9 cases have been successfully appealed, 7 cases are deemed to be a lapse in care and a further 22 cases are pending.

QSC questioned whether the Trust is learning from investigation of these cases and heard that there are themes relating to the prescribing of antibiotics, issue relating to rapid stool sampling and isolation. The relatively small number of side rooms is deemed to be a contributory issue. QSC were satisfied that learning is taking place.

Hydrogen peroxide vapour (HPV) cleaning was discussed and noted that its use (it is used after routine cleaning and takes a further five hours to carry out) is a balancing act between the additional time a room is out of commission/ keeping a patient waiting in the ED Department. HPV cleaning is always used in high priority cases.

QSC noted the need to ensure a clear narrative on the Trust’s approach to C. difficile including the high reported levels and that hard indicators on the cleanliness of the environment need to be established. All agreed that the low threshold for reporting have eradicated some morbidity and mortality and that the right thing is being done for patients. QSC also noted that there has been no reported outbreak of C.difficile. 8. Patient Safety & Risk Steering group quarterly report Two issues were highlighted. 8.1 Misconnection of medical devices is a known risk that has led to patient injury and death e.g. connecting a blood pressure machine to an IV line. To reduce risk a series of new standards for small bore connectors in a range of medical devices has been introduced. These will provide a physical barrier to making mistakes. The first devices to be fitted with the new connectors will be

enteral feeding tubes. Giving sets will be introduced from October 2015 and feeding tubes and enteral syringes from March 2016 onwards. The Medical Devices Committee has formed a multidisciplinary sub-group to oversee the safe implementation of the new devices. Initially this group will focus on the enteral feeding connectors. The group will need support from relevant clinical areas to safely and effectively implement the new devices.

8.2 The national Medication Safety Thermometer has recently been implemented. As part of this the method used to measure and report on dose omissions in the trust has change from ‘the % of all doses that are omitted’ to ‘the % of patients with at least one preventable dose omission in the preceding 24 hours’. One impact of this is that the absolute number reported is likely to be higher. For UCLH however the number of dose omissions occurring in the trust continues to fall. Early indications suggest that dose omission rates are lower in wards where e-prescribing and administration (EPMA) has been implemented. 9. QSC Terms of Reference The ToR were endorsed subject to the inclusion of reference to the cross committee function in relation to the work of the Audit Committee and the Risk Coordination Board. The QSC Chair and Director of Quality and Safety will further review the ToR and ratify on behalf of QSC prior to submission to the Board. The new ToR will be reviewed again in June 2016 to allow the new QSC Chair to make changes as required. There will be increased focus on learning. ACTION: The QSC recommends the ToR (attached) to the Board for approval. 10. Patient Experience QSC received Patient Experience papers. As part of reviewing patient experience at UCLH a draft proposal to change the structure and reporting have been presented to both the Patient Experience Committee (PEC) and the Making a Difference Together (MaDT) Steering Group. The proposals describe strengthening the PEC and aligning a number of other groups to this, including combining the MaDT governance with a monthly reporting group below the PEC – the proposed Improving Experience Group (IEG). A new quarterly experience report has been developed to facilitate discussions through the new structure. QSC approved the direction of travel and requested further update in three months.

Sandra Hallett

Director of Quality and Safety

QUALITY & SAFETY COMMITTEE

Terms of Reference

Objectives

1. The Quality & Safety Committee (QSC) functions as the Trust umbrella quality governance committee. It is responsible to the Board of Directors (BoD) for:

1.1 monitoring and ensuring that appropriate arrangements are in place for measuring &

monitoring quality 1.2 escalating issues & determining which need to be drawn to the Boards attention 1.3 identifying potential risks to quality and propose mechanisms to improve quality 1.4 learning from mistakes for all staff.

2. The committee is responsible for providing assurance to the Board of Directors by:

2.1 Ensuring that strategic priorities are focused on those which best support delivery of the Trust priority objectives in relation to

the patient experience

the safety of patients and service users

effective outcomes for patients and service users

2.2 Scrutinising monthly quality & safety performance including:

Quality & Safety Performance Book

Serious Incident reports for actions completed (individual & Incident trend analysis) and for endorsement of sign-off

Clinical complaints & claims trends

Reports from sub committees

Patient survey results

2.3 Overseeing development of the annual Quality Account 2.4 Reviewing the annual corporate clinical audit programme and ensures it supports

national and Trust priorities 2.5 Reviewing progress against Quality Priorities 2.6 Reviewing compliance with regulatory standards (CQC & Monitor Quality

Governance Framework) 2.7 Receiving reports following CQC visits & ensuring any necessary action 2.8 Receiving reports from notable national bodies (Ombudsman, National Enquiries) &

reviewing local assurance Procedural notes 3. The Quality & Safety Committee is a sub-committee of the Trust Board and accountable to

it. The committee will:

3.1 Provide a monthly report on quality & safety to the Executive Board and Board of Directors through the Corporate Medical Director

3.2 Provide an annual Quality Account through the Quality & Safety department 3.3 Address quality improvement issues 3.4 Provide a quarterly report and update to the Risk Coordination Board (RCB) 3.5 Receive a quarterly report from the RCB 3.6 Provide assurance to the Trust Audit Committee on specific matters at their request.

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4. Quorum - Chair and 60% of members. 5. Frequency of attendance - Delegated attendance is not encouraged but exceptionally an

appropriately qualified and experienced substitute can be agreed with the Chair. When attendance falls below 75% over an annual period the issue will be raised with the individual by the Chair and any steps taken to improve attendance.

6. Membership 6.1 Non-executive Director (Chair)

Three non – executive Directors (NEDs) including the Trust Chairman Medical Director (Corporate Board) Medical Director (Specialist Hospitals Board) Medical Director (Surgery & Cancer Board) Medical Director (Medicine Board) Chief Nurse Director of Quality & Safety Director of Performance Director of Research & Development / alternative responsible officer Council of Governors Representative

In attendance:

Director of Education Deputy Director of Quality and Safety

Head of Quality and Safety department Quality and Safety manager

6.2 Divisional Clinical Directors / Divisional Managers & Clinical experts may be invited to attend specific meetings.

6.3 The Directors for the relevant area will present committee reports and invite subject experts as required.

7. Frequency Monthly, at least 10 times a year. The committee will not meet in August. 8. Reporting Committees Child & Adult Safeguarding Committees Clinical Effectiveness Steering Group CQC Compliance Steering group Patient Safety & Risk Steering group Nutrition & Hydration Steering group Patient Experience Committee Clinical audit & Quality improvement committee report Complaints Monitoring group Revised September 2015 Next review due: June 2016 Approved by Board of Directors

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Agenda Item 10

Quality and Safety Committee Report October 2015


October Quality and Safety Committee report to the Board of Directors November 2015

1. Quality Account Report QSC received the report and discussed responses to the question ‘Did you get enough help from staff to eat your meals’ and noted that whilst the score improved during Quarter 2 (89%) it remains below the target of 95%. The chief nurse reported that other data suggests that the group of patients reporting a lack of help are not the ‘red tray’ or vulnerable patients. Work is ongoing to clarify the interpretation and meaning of the data and to raise the profile of the issues it raises. QSC discussed the process for setting targets noting that whilst a target should be aspirational it also needed to be realistic. In the past the Trust set targets by looking at high performing trusts and often deliberately pushed the bar high. Further work to clarify the position of other trusts in the Shelford group is to be undertaken. 2. Sign Up to Safety campaign report QSC received the Quarter 2 report. The NHS England ‘Sign up to Safety’ Campaign has invited healthcare organisations to make a public commitment to play their part in reducing avoidable harm in the NHS by 50 per cent and saving 6,000 lives. Sign up to Safety aims to deliver harm free care for every patient, every time, everywhere. It champions openness and honesty and supports everyone to improve the safety of patients. UCLH joined the campaign in October 2014 and has committed to: listen to patients, carers and staff, learn from what they say when things go wrong and take action to improve patients’ safety. We have also committed to turn our actions into a safety improvement project plan and provide an improvement trajectory over the next three years. QSC noted progress with the three areas (reducing harm from surgery:’ reducing harm from deterioration and reducing harm from sepsis) for safety improvement within the campaign: A project manager has been appointed for nine months from September 2015 to May 2016 and an oversight steering group convened with executive leadership. Membership includes the Corporate Medical Director (Chair), the Director of Quality and Safety and the chairs of the three task and finish groups for the safety work streams. Detailed project plans are in place for each work stream and are available upon request from the Project Manager. 3. Sharing learning from serious incidents QSC received the Learning from Serious incidents report. Mechanisms for ensuring that information on learning was disseminated and cascaded appropriately were discussed i.e. what messages does the Trust want to get out and what is the best way of doing this. The role of the Quality and Safety Bulletin, the Trust website and the Performance pack in conveying learning were discussed as well as the type of language which will best convey learning and key points. Principles of transparency, appropriate confidentiality and easy access to information were confirmed. Pages on learning from SIs within the report will be included in the QSC performance pack for now and a more detailed proposal for communications on learning / SIs is to be submitted to the Nov QSC. 4. Policy compliance - plan for improvement QSC received the report, which outlined a proposal for managing issues related to policy work rounds. Common high risk high frequency policy ‘work rounds’ from adverse incidents/near misses and complaints and the ‘Safety and migration from policy compliance’ Quality Forum (held in February ‘15 have been identified. . A list of approx. 18 policies and procedures was identified. In addition a review of Issues arising in red and amber 4 complaints and serious incidents linked to policies and guidelines identified a further 14 areas to consider. The paper proposed and QSC agreed that the Patient Identification policy should be used as pilot work to see how we can improve. The aim is to design ‘work rounds’ out by making the policies realistic and deliverable and emphasise the key safety components.

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QSC also discussed medication errors and noted that this is on balance a well-controlled area which has strong monitoring and review mechanisms. External consultants had reviewed this area in the past and had little to add to current practice. It was also noted that work rounds are not necessarily negative and may on occasion be reflective of better or safer practice and so should be incorporated into policy. New practices such as eg electronic prescribing would not necessarily solve all issues and other unknown problems may occur with the introduction of a new system. 5. Patient Experience committee report QSC received the report which summarised topics covered by the July and September 2015 meetings. A new approach to the patient experience structure and reporting were discussed at the July meeting and subsequently approved at September QSC. This included PEC moving to quarterly meetings and a new supporting structure through the Improving Experience Group (IEG) and site specific experience groups. The first IEG took place on 13th October, with the next PEC meeting in November. A non-executive member of the Trust Board will take the chair of the PEC early in 2016. The discharge policy and procedure, the carer’s policy and the patient and public involvement (PPI) policy approved for submission to the Policy Advisory Sub Group. An updated version of the PPI Toolkit was also approved. To support the carer’s policy, the carer’s card pilot was discussed, with PEC supporting the continued roll out. The annual review of Governor walk rounds was considered and supported to continue 6. Risk Coordination Board (RCB) report

QSC received and noted the RCB report which covered meetings held in July and August. Corporate risks under review in Q1 were: delivery of the UCLH future programme and risk of non-payment of over performance by commissioners. Risks downgraded from a rating of 16 or more were: Insufficient bed, theatre, outpatient & endoscopy capacity across sites and risk to patient safety, high quality care and staff experience due to nursing vacancies. 7. Research governance report

Professor Yousry presented the 2014/15 Clinical Research Centre Quality & Safety unit report. Key developments in 2014/15 were: Establishment of a JRO Quality and Safety Unit and appointment of a Director; Revision of UCLH portfolio structures and policies; Oversight of the introduction of the new HRA requirements for sponsorship and hosting studies; Revision of policies on consent for and suspension of studies; Establishment of Joint Senior Pharmacist post and a joint UCLH/UCL initiative, in which the Q&S unit will coordinate the development of enhanced systems for peer review and devolved research governance at UCL Institute of Neurology. Research incidents and complaints: The rate of incident reporting has increased since 2010 and is currently at a rate of 1 incident for every 14 research studies. Ongoing monitoring will take place. A senior pharmacist post (joint between pharmacy and the joint research office) has been created in response to a review of medication incidents. Plans for future development include enhanced systems for peer review, the assessment and recording of adverse incidents and joint UCLH/UCL approaches to information governance adverse were detailed at the end of the report. 8. Guidance for local quality and safety groups

QSC were informed that guidance for local / governance/ quality and safety committees is currently being updated and will be reissued shortly. MDs were asked to remind DMs and DCDs of the importance of ensuring local meetings are recorded accurately and that actions are documented. 9. Trust Quality & Safety Performance Book The performance book was noted including a decrease in performance for some indicators. There has been a slight improvement in the response rate for friends and family test but this remains below target. Overall inpatient experience has steadily improved. Performance of the complete vital signs audit during August was also good at 98.5%.

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In relation to pressure ulcer data the chief nurse reported there were no specific trends or themes and that work is underway to understand the data more fully. There is a focus on reducing harm from falls and a Darzi nurse has been appointed to take this work forward. QSC acknowledged the need to keep a clear focus on venous thromboembolism. QSC discussed the medications security audit and the need to understand the level of risk. Locks on fridges are a consistent theme. QSC agreed that funding for locks for all relevant areas must be found. Sandra Hallett Director of Quality and Safety

H

Agenda Item 11

Finance and Contracting Committee Report

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UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST FINANCE & CONTRACTING COMMITTEE REPORT TO THE BOARD OF DIRECTORS

1. Introduction 1.1 This report updates the Board of Directors on the issues considered at the meeting of

the Finance and Contracting Committee (FCC) on Wednesday 4th November 2015, relating to the financial performance and contracting position of the Trust as at 30th September 2015.

A brief update is also provided on issues discussed at the FCC meeting of 7th October 2015, which have not been previously reported to the Board of Directors.

1.2 The Board of Directors is asked to: • Note the financial performance for the first six months of the 2015/16 financial

year, and that a separate report is also being taken to the Board providing an update on the work that is being done to improve the current year-end outlook and underlying run-rate position,

• Note the other financial issues discussed, including the updates on Surgery and Cancer Board financial performance and enabling services transformation provided to the Committee,

• Endorse the governance declaration, which was submitted as part of the Quarter 2 financial return to Monitor (as set out in section 4, below),

• Note the contracting update, and • Note the issues discussed at the previous FCC meeting of 7th October 2015.

2. Financial Performance 2.1 The Trust’s month 6 year-to-date income and expenditure position, as shown in table 1

below, when reported prior to donation-related adjustments and exceptional items, was a deficit of £24.4m which was £13.7m worse than the planned position. This position included the release of £3.3m from the Trust’s £10m Board contingency

2.2 The Committee noted that within the Quarter 2 financial return to Monitor; the Trust reported a financial sustainability risk rating (FSRR) of 2, in line with plan, as part of Monitor’s new risk assessment framework.

Table 1 – 2015/16 month 6 financial position

2.3 The Interim Finance Director informed the Committee that following the normal quarterly review of provisions and central budgets, the reported financial position in the month

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(prior to donations and donated asset adjustments) was £0.7m worse than plan. This included adjustments in respect of:

a) The conclusion of 15/16 contractual discussions with commissioners, b) The recognition of the Trust’s share of profits from the pathology joint venture,

and c) The recognition of some upsides on central reserves, particularly following the

restriction of corporate spend this year.

2.4 The Interim Finance Director also pointed out that the latest forecast of the 15/16 outturn position showed the Trust potentially delivering a year-end deficit of £32.5m before donations (£12.5m adverse variance to plan), which assumed the release of £5m of the £10m Board contingency. The Interim Finance Director informed the Committee that this latest forecast showed a £3.3m improvement compared to the month 5-based projection, which was due to the conclusion of contractual discussions along with the impact of the standard detailed quarterly review. The Committee noted that as the Executive Board had been able to review the latest set of projections in advance of the Quarter 2 submission date, the month 6-based forecast had been used in the latest financial return to Monitor.

2.5 The Interim Finance Director also mentioned that a newly established process for activity forecasting had been put in place in month 6, and a comprehensive review undertaken to ensure the Trust was adopting a robust and consistent forecasting methodology across all clinical boards and corporate directorates.

2.6 The Committee also discussed the development of a UCLH recovery plan that was designed to provide a response to a request from Monitor for the Trust to submit two separate recovery plan challenges by Friday 20th November:

a) To achieve the original planned 2015/16 deficit position of £20m, and b) To return to a break-even run-rate by the end of 2015/16 such that the Trust is in

a position to plan for surpluses on an on-going basis. The Interim Finance Director informed the Committee that a Recovery PMO had been leading on the development of the recovery plan and, aligned to this, the Executive Board had also agreed an approach to increased levels of assurance, with the introduction of Special Measures and Enhanced Reporting regimes for the most challenged clinical divisions. The Committee noted that a separate report on the UCLH financial recovery plan was being taken to the Board.

3. Other Financial Issues 3.1 The month 6 CIP position showed that the Trust had delivered year-to-date savings of

£16.1m, a shortfall of £2.8m against the planned target of £18.9m. The current forecast year-end CIP position, based on schemes identified to-date, was £41.4m savings (96% of the annual target of £43m), with full year equivalent savings of £47.7m.

3.2 The Trust’s cash balance at 31st October 2015 (month 7) was £65m (£26m behind plan). The Interim Finance Director informed the Committee that the shortfall on cash continued to relate to outstanding debt with commissioner debt; however he was hopeful that the recent conclusion of contractual discussions would now result in increased cash flow from current year SLA payments. The Interim Finance Director also mentioned that the Trust had drawn up an improvement programme of work to review and enhance local credit control processes and address any underpinning system issues, which included the appointment of a senior interim resource to provide the required short-term capacity.

The Committee asked the Interim Finance Director if he could provide a more detailed report to the next FCC meeting on cash management issues, including progress in recovering outstanding debt and other actions to improve cash flow in general.

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3.3 The Deputy Director of Strategic Development presented the Committee with an update on the work taking place on assessing the opportunities for the transformation of enabling services, i.e. those corporate services that enable the delivery of clinical care, rather than front line clinical services and pathways.

The Deputy Director of Strategic Development outlined the current opportunity against a number of enabling service areas where specific costs saving estimates exist. The Committee noted that the Enabling Services Transformation team would now focus on monitoring and supporting delivery against these business cases/developments to ensure clear fiscal and quality opportunity was maximised and achieved on time.

The Committee also noted that a further piece of work was being done, with a view to completion by the end of November, to move other areas of corporate savings into schemes of delivery.

The Committee asked for an update to be presented to the next FCC meeting on the corporate partnership work taking place in North Central London, and how this work could be applied in future to assess areas of common interest and potential opportunity between UCLH and other organisations.

3.4 The Medical Director for Surgery and Cancer Board presented the Committee with an update on the financial performance of the board and details of recovery actions to address the financial position, particularly in Gastrointestinal (GI) Services.

The Medical Director pointed out that the board was currently reporting a £3.7m year-to-date adverse variance to plan, of which poor financial performance of the GI Services division, mainly relating to non-achievement of activity targets, contributed £3.4m of the shortfall.

3.5 The Medical Director mentioned that a number of recovery actions had been implemented to improve the Surgery and Cancer Board’s financial position, including:

a) A further review of vacancies which would enable the board to deliver over 93% of its additional headcount reductions target of £2m by year-end,

b) A review of theatre flows in the UCH Tower and Westmoreland Street, and c) A formal recovery plan for GI Services, which focussed on the division delivering

its planned levels of activity and maximising contribution. The Medical Director informed the Committee that as a result, the board was currently

estimating a forecast outturn position that was £4.7m adverse to plan, which represented a £1.8m improvement on the month 5-based forecast outturn.

3.6 The Medical Director also drew the Committee’s attention to the significant number of service changes, particularly across the next couple of months, due to the transfer of London Cancer activity into the Trust. The Medical Director pointed out that whilst there were a number of risks to the successful delivery of all the transfers, there could also be further benefits for the Trust, including:

• Patients who have their cancer surgery at UCLH choosing to continue to have their chemotherapy or radiotherapy treatments in the Trust, and

• Opportunities resulting from the Trust being awarded Vanguard status in the latest round of bids in relation to the Acute Care Collaboration new model of care.

4. Quarter 2 Finance Declaration to Monitor 4.1. The Committee noted the financial and governance narrative that formed part of the

Trust’s Quarter 2 report to Monitor, as submitted on 30th October 2015, which highlighted three key statements included in the governance declaration.

4.2 Maintenance of a risk rating of at least 3 The Committee also noted that following the introduction of the new financial sustainability risk rating (FSRR) the Trust was also unable to confirm the statement

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that "the Board anticipates that UCLH will continue to maintain a FSRR of at least 3 over the next 12 months”.

The Committee noted that if the Trust was rated as 1 on any of the individual measures of the FSRR, the risk rating would be subject to an override and capped at a 2. The Committee noted that the Trust’s current 15/16 forecast outturn would need to improve by c. £30m for the override measure to no longer apply; at which time the Trust would return an overall rating of 3.

4.3 Delivery of capital expenditure in line with forecast The Committee noted that the Trust was able to confirm a new declaration that was required on the follow statement: "The Board anticipates that the Trust's capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return". The Committee noted that a latest forecast, endorsed by the Director of Estates, Capital Investment & Facilities, estimated that the Trust would incur capital expenditure of £113m in 2015/16, which was £45m less than the 15/16 plan of £158m. The key areas of delay were within the strategic projects element of the capital programme.

4.4 Compliance with targets & indicators The Committee noted that as a result of issues concerning delivery to-date against

cancer waiting times, the Trust was unable to confirm that it was satisfied that plans in place were sufficient to ensure on-going compliance with all existing targets (after the application of thresholds), as set out in appendix A of Monitor’s risk assessment framework, and a commitment to comply with all known targets going forwards. The Chief Executive informed the Committee, however, that NHS England was looking to implement a revised breach reallocation policy for the 62 day wait target for first treatment from urgent GP referral. The Committee noted that this was in line with what the Trust had been pursuing for a number of years, and would have a positive impact in future on the Trust’s performance against this target.

4.5 The Board of Directors is asked to provide their formal endorsement of the full in-year governance declaration, which covers the three statements, as above.

5. Contracting Update 5.1 The Associate Director of Contracts was pleased to inform the Committee that the Trust

had agreed the terms and conditions of the 15/16 Camden CCG contract, as well as agreeing the contract baseline values for the other CCGs in North East London.

The Associate Director also mentioned that on the back of agreeing the terms and conditions with Camden CCG the Trust had also issued revised contract baseline offers to the other 81 associate CCGs.

5.2 The Associate Director informed the Committee that the Trust had also now agreed a contract baseline and terms and conditions with NHS England for specialist services activity.

5.3 The Associate Director pointed out that in parallel to issuing the offers; the Trust was working with commissioners to ensure that all contract documentation was accurate and complete.

5.4 The Associate Director provided an update on work that was being done to plan for the 2016/17 contracting round, which included the following key areas of focus:

• Developing the Trust’s engagement strategy with all commissioners, • Reviewing the timing of the Trust’s contract offers, given that there may be an

expectation that contracts should be signed by the end of February 2016, • Developing an approach to pricing that reflects the clinical priorities of the Trust

and responds to national tariff changes, and

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• Identifying common ground between commissioner efficiency expectations and the UCLH Future work.

5.5 The Committee thanked the Associate Director for his update, and for the work of the Director of Commissioning and the contacting team in agreeing 15/16 contract baselines, particularly when the difficult economic climate across the NHS, pressures on commissioner spend, and the issues with the 2015/16 draft tariff made planning, engagement and negotiation more difficult than in previous years.

6. Summary of issues discussed at the FCC meeting of 7th October 2015

6.1 This section summarises the discussion at the previous FCC meeting, which due to the absence of a formal Board meeting in October has not yet been reported to the Board.

6.2 The UCLH Research Director provided the Committee with an update on Research and Development financial issues, including:

• A summary of Research and Development income received by the Trust, • The Biomedical Research Centre (BRC) and its preparedness for the application

for new monies for the 5 years commencing 2017/18, and • The relationship between UCLH/UCL and benefits that accrue to both as a

consequence of BRC and other research investments. The Research Director provided the Committee with examples of the BRC’s success in

leveraging external funding and increasing the levels of collaborative contracts, particularly as a result of the development of its research infrastructure. The Research Director also emphasised the importance of the annual impact statements in demonstrating the return on investment made by the spin-out activity, particularly via the partnership in place with UCL.

6.3 The Committee also discussed the process for inclusion of research-related programmed activities in consultant job plans. The Committee also noted that as part of the process of improving consultant productivity there was a need to ensure there was clarity in defining the content and output of both supporting professional activity and additional programmed activities.

6.4 The Committee noted that the Trust’s month 5 year-to-date financial position was £13.0m behind plan. The Interim Finance Director informed the Committee that the in-month position, which was £3.4m adverse to plan, was a continuation of the significantly adverse trend seen in the previous four months. Of particular concern were continued activity shortfalls particularly at Queen Square and GI Service.

6.5 The Committee was concerned that despite the inclusion of further financial recovery actions, particularly savings from the additional headcount reductions, the Trust’s year-end forecast (£15.7m adverse to plan) remained broadly unchanged from the previous month’s estimate.

6.6 The Interim Finance Director mentioned that following the submission of the month 5 results to Monitor he had been asked to attend monthly meetings with the regulator, and to provide them with a more formal set of financial recovery actions as to how the Trust was aiming to return to plan as well as get to a position of break-even income and expenditure at the earliest opportunity.

The Interim Finance Director informed the Committee that in the context of the challenging financial position, the enhanced scrutiny from Monitor and the increased internal review, there needed to be greater visibility on the underlying assumptions underpinning the monthly forecasting process, therefore he would be liaising with the Director of Workforce, Director of Performance and Planning, as well as Heads of Finance to discuss improving the ways in which workforce, activity and CIP information fed into the divisional forecasts. The Interim Finance Director was confident that an

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improvement in the methodology used for activity forecasts would provide him with greater degree of assurance on the month 6-based forecast.

6.7 The Committee noted that under Monitor’s risk assessment framework published in August 2015, from Quarter 2 onwards, the old continuity of service risk rating would be replaced by a financial sustainability risk rating.

The Committee noted that that the change in risk rating regime now made it far more difficult for UCLH to deliver an overall risk rating of 3, and therefore as part of the Quarter 2 return to Monitor the Trust would no longer be able to declare that it anticipated maintaining a risk rating of 3 or higher for the next 12 months.

6.8 The Committee also received updates from the three medical directors on year-to-date financial performance within their clinical boards, and efforts being made to return to balanced run-rate positions against plan by year-end.

6.9 The Committee noted that Medicine Board’s latest forecast indicated a run-rate position that was broadly achieving plan by year-end; however this was largely dependent on turning around the financial performance of the Medical Specialities division. The Committee was also hopeful that the Pathology division’s forecast position would improve as result of the series of further recovery actions in the division, including the resolution of outstanding contractual issues.

6.10 The Committee noted that whilst Specialist Hospital’s latest forecast anticipated the board returning to a positive run-rate against plan in the second half of the year, there were concerns over the scale of turnaround that would be required to deliver the forecast, which was significantly greater than in the other two boards.

6.11 The Committee noted that Surgery and Cancer Board’s forecast still indicated a shortfall against planned run-rate at the end of the year, however the board’s forecast in general appeared cautious, particularly as a result of the significant uncertainty resulting from the thoracic activity move to Westmoreland Street, transfer of haematology services from the Royal Free London and head and neck cancer services from Bart’s Health.

The Committee was hopeful that potential further upsides in cancer activity and workforce savings would improve the board’s forecast position.

6.12 The Director of Performance and Planning was pleased to inform the Committee that, following a series of recent meetings held with Camden CCG, a scenario to close the financial gap between contacting positions had now been agreed.

The Committee also noted that following an escalation meeting held with NHS England in early September, agreement had been reached on activity volumes and quality issues; therefore the time since then had been spent on resolving a remaining pricing gap. As a result of this work, overall agreement had now also been reached with NHS England on the 15/16 contract position.

6.13 The Director of Performance and Planning presented the Committee with a paper outlining the mechanisms that would be used to monitor the benefits of the UCLH Future programme. The Committee asked if this information could be presented to FCC on a quarterly basis, with the inclusion of additional narrative to explain performance.

The Interim Finance Director also informed the Committee that further work would be undertaken to align financial productivity measures with the work that had been carried out by Lord Carter to-date to review the productivity of NHS hospitals.

Dr Harry Bush Tim Jaggard Chair of FCC Interim Finance Director 5th November 2015

I

Agenda Item 12

Report of the Audit Committee Meeting 15th September 2015

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Report to Board of Directors – 11 November 2015

MAIN POINTS FROM THE AUDIT COMMITTEE

The Audit Committee (AC) met on 15 September to consider the following important matters. 1. Internal Audit (IA)

- IA Assurance Reports AC reviewed a progress report noting that IA had two draft reports, Estates & Management Review and the Central Alerts System due for sign off; these would come to the next meeting. IA advised they were issuing planning memorandums to managers for Q3 & Q4 this would enable them to better plan the audits for the rest of the year.

AC noted the potential for slippage in the IA workplan and asked TIAA to present an early draft audit plan setting out the timetable of work for next year to assure AC that the plan would be managed evenly across the year. This would come to the November meeting.

IA reported that they had followed up the outstanding unimplemented recommendations from the past audits (transferred from 2014/15). AC was pleased to note these had reduced from 155 to 39.

- IA Charter AC reviewed the IA Charter, which is the terms and responsibility of internal audit activity and reflect best practice. The Charter included KPIs and an escalation process to deal with sign off of IA reports. AC approved the Charter which is available to board members for the Director of Corporate Services.

IA agreed to produce a briefing note on the role of both IA and UCLH managers in the audit process. AC asked that this be provided to the EB and to audit leads for new reports, this was agreed.

- Research and Development Audit Nick McNally, Divisional Manager for R&D presented a follow up report on how R&D administration operated more generally. This followed an amber/red IA report. It advised that the department had in place sound systems to monitor research grants and that the department had been subject to a DH/NIHR audit in 2014 which had a favourable outcome. The report included a table which set out the system controls in place.

2. Counter Fraud

AC reviewed the Local Counter Fraud Specialist’s (LCFS) quarter 1 report. LCFS drew particular attention to the potential emerging risks including illegal working and conflicts of interest linked to procurement. The new risks would be discussed at the UCLH quarterly fraud meetings.

LCFS also provided an update on the Fraud and Bribery assessment confirming that actions had been completed. AC noted that LCFS had reviewed the fraud policy.

3. External Audit plan and Q1 report Craig Wisdom, Deloitte presented their audit plan which set out the key areas of work that would be monitored during the year including capital plans and progress against cancer plans.

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Deloitte also confirmed they had completed their Q1 planned fieldwork. AC and Deloitte advised on key changes expected to the auditing requirements which included a greater focus on value for money auditing; both parties await the publication of the Annual Reporting Manual which may require a change to the accounting of business combinations. A workshop for AC members would be arranged.

4. Procurement Report

Pia Larsen, Director of Procurement presented a report on contract management which included recommendations to improve the current approach. AC noted that contracts were managed within the operational divisions/departments but that the procurement team was providing support and expertise to improve service benefits.

The report set out the next steps which included reducing variation by introducing procurement principles and formalising the contract management approach for high value contracts. AC noted that a number of the procurement actions had been adopted by the EB but asked that the EB consider establishing a contract database; TJ would highlight this for discussion at the EB.

5. Policy Review

AC noted the main changes to the expenses policy which it had previously reviewed. The policy had been updated to make it clearer that the line manager was responsible for checking and approving claims including ensuring receipts were provided. Once approved the policy would be communicated via Insight.

AC reviewed a new anti-fraud and bribery policy which provides comprehensive advice and information on all aspects of fraud and bribery in one place. It replaces the previous counter fraud policy and sections of the code of conduct and conflict of interest policy. A new code of business conduct will be presented to the AC in January.

AC noted a new policy on the disposal and condemnation policy which set out how UCLH will dispose of capital assets. This was required under SFIs. AC asked how small personal items were tracked. For staff leaving the Trust this was included on the leaver’s checklist.

6. Other assurance matters AC discussed a regular paper on waivers. This showed an increase over the previous year largely due to waivers associated with the transfer of services to Westmoreland Street and the revision of the SFIs in December 2014 which had reduced budget holders’ procurement approval levels. AC noted that this would reduce as contract management improved although there would always be some level of waivers required.

Prepared by Tonia Ramsden for Rima Makarem

Audit Committee Chair

J

Agenda Item 13

Audit Commitee Minutes

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AUDIT COMMITTEE (AC)

Minutes of the meeting held on Thursday 21st July 2015

Present: Audit Committee Members Rima Makarem Non-Executive Director and Chair (RM) Diana Walford Non-Executive Director (DW) Kieran Murphy Non-Executive Director (KM) Harry Bush Non-Executive Director (HB) Non-Members Tonia Ramsden Director of Corporate Services (TR) Dominic Firth Deputy Director of Finance (Interim) (DF) David Foley Counter Fraud, Baker Tilly (DFo) Hannah Wenlock Counter Fraud, Baker Tilly (HW) Paul Grady Internal Audit, TIAA (PG) Clive Makombera Baker Tilly (CMak), Internal Audit, For Item 5 Jonathan Gooding Deloitte (JG), External Audit Liz O’Hara Head of Workforce (LOH) For Item 4.2 Jennie Friswell Head of Medical Workforce (JF) For Item 4.3 Dipak Chauhan Trust Risk Manager (DC) For Item 7.2 Paul Sutton Treasury and Accounting Manager (PS) For Item 4.5 Simon Knight Director of Planning and Performance (SK) For Item 7.1 Catherine Mooney Deputy Director of Quality & Safety (CM), For Item 4.41 Mairi Bell Chief Accountant; Minutes Item Matters Covered

1. Apologies for Absence

Apologies received from Tim Jaggard (TJ), Neil Griffiths and Nick Atkinson. 2. Minutes of the Meeting held on 21st May 2015

The minutes were agreed, subject to a note from TR that the issue of tax compliance on Page 7 had been addressed.

3.

Matters Arising AC agreed to close the following MA items as completed: MA 271, MA 272, MA 276.

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4. 4.1 4.2

Other Reports

Fixed Assets Update DF provided an update on this long-standing item, proposing to AC that a decision on Asset Tracking be put on hold pending wider decisions on the EHRS solution, which would be likely to include asset tracking, even if as As Is + option was chosen. RM noted the different reasons for keeping good track of assets – primarily maintenance and patient safety, and asked two questions about the proposal: Will Medical Physics be able to track assets? How long will it take, and is there an interim solution? DF confirmed that tracking would be possible, but the timeframe was uncertain, noting that a decision on EHRS was likely within a year, but the wider programme would take up to 5 years to implement. RM recommended postponing further discussion until the Board had discussed EHRS in October with an update to come to November AC. HB asked about the risk in delaying this. DF agreed to include this in the update. ACTION Update to November AC on Asset Tracking (DF) Whistleblowing Annual Update LOH presented the annual update on Whistleblowing, firstly reminding AC of the two ways to log whistleblowing; via the Employee Relations team or via CQC. LOH advised that the whistleblowing policy had been updated, with the new name ‘Raising Concerns’ proposed, with the new policy accommodating recommendations from the Francis report. LOH noted that consideration was being given to whether an independent guardian was needed at UCLH. LOH highlighted the 13 cases of whistleblowing outlined in an appendix to the report, comparing this to 18 cases from the previous year. LOH further noted that cases would be expected to increase in the current year with a forthcoming CQC inspection. DW commented that ‘whistleblowing’ was the standard term used at UCLH and that any change would need to be cascaded through other documentation. RM commented on the time taken to complete some investigations and also asked how anonymous queries were followed up. LOH replied that, having

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4.3

recently taken over the role, these were under review to establish how to conclude them, and advised that investigations should normally be concluded within an agreed timeframe. LOH further noted that where possible follow up was done within 1 to 2 months. AC discussed benchmarking and LOH advised that other Trusts reported higher levels of whistleblowing. AC discussed some of the detail from the staff survey, noting some inconsistencies in how questions on whistleblowing had been answered. DFo provided an alternative view of benchmarking, noting that within the client base for Counter Fraud services, numbers reported were lower than UCLH. DFo also commented that visibility of feedback was important, even for anonymous concerns. PG noted that within the Internal Audit client base, numbers were usually higher. HW asked if Counter Fraud could review the new policy and this was agreed by LOH. ACTION CF to review the new policy on whistleblowing. UCLH Appraisals Process JF attended to present a paper outlining the UCLH appraisals process, with particular focus on Medical Appraisals and Job Planning, an area in receipt of a critical internal audit report from 2014-15. JF gave some background information, including the requirement for doctors to be revalidated every 5 years and confirming that job plans were expected to set out how clinicians should perform their duties. JF confirmed the process should flow as: Job Plan Appraisal Revalidation RM reminded AC of the Red rated audit report, noting significant concerns around the timing of job planning, which should take place before the start of the year, and should include discussion on private work to be undertaken. RM noted that clinicians may view appraisals as a ‘tick-box’ necessary for revalidation. JF advised that she was new to the post but set out her upcoming objectives, including set up of an electronic job planning system, recruitment of a senior medical workforce manager and in depth work with Medical Directors to understand blockages to time. JF advised the likely implementation time for all the changes would be for 2016-17. JF also confirmed that job descriptions of Divisional Clinical Directors would be reviewed to ensure this responsibility was clearly stated.

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4.4

4.5

KM asked about the conflict between revalidation and organisational requirements. JF noted that the language linking job plans and appraisals had been strengthened in the policy. DW noted that objectives from job plans needed to be in place before appraisals because there was a PDP (Personal Development Plan) requirement which was essential for revalidation. DW added that the current job planning process was out of sync with the appraisal / revalidation process, noting that if appraisals were approached appropriately, revalidation would follow without additional input required. RM asked about the 16-17 timeframe, and if every clinician would have a job plan in place for April 16. JF replied that it may depend on links to the Trust top 10 objectives, and that any delay there would have a delaying impact on job planning. RM asked for a further progress update to the November AC. HB asked whether clinical excellence points were cumulative. JF agreed to check this. DW commented that awards withheld due to job plans should not be available retrospectively. JF replied that this was been proposed, but legal advice was that it was not possible. AC asked JF to review the legal status. ACTION Update November AC on Job Planning and Appraisals (JF)

Check if points awarded are cumulative (JF)

Review the legal status on withheld CE Awards (JF) Quality Governance Framework CM attended to present a brief update on the Quality Governance Framework, giving a description of the process and noting that it had been discussed at QSC. CM confirmed that the Trust had taken Monitor best practice and assessed whether the standards had been met or identified areas for improvement. CM fed back up QSC’s comments, asking if AC were happy with the proposed actions and asking when updates to AC would be required. RM and CM agreed updates would be provided to AC every 6 months. DW provided CM with a list of suggested updates (hard copy). Debt Write-Off Update PS attended to present an update on proposed debt write-off. PS outlined the reasons for write-off, primarily deceased patients, untraceable debtors and failed court judgements. PS confirmed that debts to be written off were Private or

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Overseas patients.

5.

AC discussed the figures and RM asked what proportion of the write-offs related to emergency admissions, and how much was within control of private patients admission processes.

KM asked how much overseas income the Trust received. PS replied about £1m, and that provision against this debt was made at 100% when invoiced, although collection was around £0.5m.

DW asked if any improvements had been seen since the IA review. CMak replied that the follow up work showed poor progress on work to implement PP improvements. DW noted that the Trust couldn’t afford to lose money on this scale. HW suggested drawing on good practice from other Trusts, noting a recent overseas visitors advisory event, attended by HW.

KM asked whose role it was to collect the money. CMak replied that the private patients business team would speak to each overseas visitor, and collect information on which to bill, noting that there were several teams across the Trust reporting into Finance.

KM asked about timing, noting the ages of the debts. PS advised there was a process to work through in attempting to collect monies, but suggested that twice yearly updates to AC would be beneficial.

ACTION

Confirm the proportion of write-offs relating to emergency admission (PS)

Finance to review the private patients billing process (TJ)

Further update on write-off to come to Jan AC (PS)

Internal Audit

Internal Audit Final Progress Report 2014/15

CMak presented the final progress report from Internal Audit for 2014-15 reviews. CMak highlighted 11 completed reports, noting particularly two Amber-Red rated reports, Consent, and R&D.

CMak also noted two reports in draft requiring closure, where requests for management comments had been escalated.

Regarding the Consent report, CMak drew attention to three key issues; poor record-keeping, unreadable forms and use of private mobile phones. CMak noted this had been raised in the Head of Internal Audit Opinion. RM added this had been raised at QSC.

KM asked if the files weren’t there, or couldn’t be found. CMak replied that this was not known, and that repeated requests for information had been made.

Regarding the R&D report, CMak commented on a lack of evidence and documentation, with conclusions drawn based on the limited information seen. DW commented that this was not acceptable from the Joint Research Office.

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CMak added that this had been escalated via TJ. TR suggested that the administration lead, Nick McNally should come to Audit Committee and explain the non-compliance.

CMak noted that R&D had said some items were implemented, and this would need to be tested by TIAA during follow up in 2015-16. PG noted the risk of clawback within R&D and KM asked about admin controls.

CMak also discussed the Paying Patients follow up, following a red rating in the previous year. CMak noted Joe McElligot had taken over, and had provided comprehensive responses, but recommended an update to a later meeting.

RM asked about payroll controls, noting a doubling of overpayments in the last two years, and asked CMak if the response was really sufficient. CMak agreed that it was not strong enough and a more robust response would be requested.

KM asked about sponsorship compliance (page 35) and what level of risk was actually being run. CMak replied that the employer could lose their licence if found to have poor controls, and that the wrong people could be sponsored. CMak added that issues with the licence could make things difficult for the Trust. RM requested that PG follow this up in the current year. PG agreed that a mini re-audit could be done in the current year. RM thanked Baker Tilly’s team for their hard work over 6 years. ACTION R&D to explain Audit Non-Compliance to Audit Committee and admin controls in R&D (Nick McNally)

Update on Private Patients to a future meetings (TJ)

Request additional response on payroll overpayments (CMak/TIAA)

Follow up on Sponsorship compliance (PG)

Internal Audit Plan 2015/16

PG introduced the finalised Internal Audit plan for 2015-16, noting that the plan had now been to EB and was back at AC for formal ratification. PG noted this ratification had been assumed in the progress report.

Internal Audit Progress Report 2015/16

PG then introduced the Internal Audit progress report for 2015-16. RM commented on 51 overdue recommendations on page 5, and asked if some had potentially been closed off. TR asked about access to TIAA’s system. PG replied that the data was being cleansed first.

RM commented on the proposed timing of Procure to Pay. PG replied that the date would be checked, and that a meeting with procurement had taken place on 6th July.

HB asked why safeguarding was on the plan again. PG replied that it was a different area within safeguarding. TR added that there were specific elements within Trust policy where Internal Audit review was required.

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6.

AC discussed the plan to audit IT strategy. PG advised this review would seek to give assurance as to whether the strategy was robust enough with effective implementation processes outlined. HB suggested it would be more effective to focus on skills and processes for implementation. DF noted this would be covered within the audit IT Project Management Delivery (page 11). PG confirmed he would liaise with David Hill to review the scope. RM asked if AC could see the scope prior to the audit. HB added that a decision on EHRS would be needed in advance of this.

RM noted the forthcoming CQC inspection, scheduled for Dec-Mar and asked if there was a chance to do a mock CQC rather than walkrounds. PG replied that more days would be needed, and suggested doing a mini review on identified risk areas. RM highlighted Queen Square as an area of concern. DW suggested that clinical pathway transformation would be better done internally by clinical audit people, and that it was asking a lot of internal audit. PG agreed that it was a stretch to find someone with clinical knowledge as well as project skills. DW suggested the Trust should provide clinical input to joint working.

RM asked if page 9 should show NG as the sponsor rather than JF. PG agreed to check. RM confirmed the plan was formally approved. AC suggested some further areas for consideration including the Joint Research Office, the Pathology Joint Venture and the developing financial position. JG noted the potential impact on VfM and resilience. ACTION PG to confirm start date for P2P audit. (PG) PG to check sponsor (page 9) (PG) Counter Fraud Progress Report DFo presented the Counter Fraud (CF) progress report, noting that there was now active involvement from the new Internal Audit team at monthly and quarterly CF meetings. DFo noted that a self-review tool was still outstanding and needed management completion, and requested confirmation that this would be done. DFo highlighted the reactive work, noting 7 referrals in the current year, and the focus on this area in monthly meetings. RM asked about the recurring theme of lack of, or delay in, management responses. RM asked if the reason was managers were too busy, or not taking the issues seriously. DFo replied that managers were generally very busy, and that the debrief process was important to get buy-in to the findings. DFo added that CF and Internal Audit were working together to develop a single escalation process to deal with lack of response.

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7.

7.1

HW noted that management responses had been improving for CF with the escalation process to be ratified at the quarterly meeting. RM asked for escalation to AC if this was not working. DFo noted that very significant breaches would be escalated immediately. RM asked about IT risks, including hacking. DFo replied that discussions had been had with the Head of IT, and that this area was robustly managed with up to date controls and firewalls in place. RM asked if CF were satisfied with this assurance. DFo noted this was an area of specialist IT audit. HB suggested a paper on cyber security from IT would be helpful. AC discussed the format of the CF progress report, noting an improved format, but also suggested opportunities for further improvement. HB noted that key findings and emerging issues would be valuable to every AC, but a shorter more focussed report would be good, with a longer annual report. KM asked about delays in cases, and when cases would be handed back to internal investigators. HW noted that a specific delayed case had already been escalated to Chief Executive level, and the monthly meeting was taking a more robust and timely view around hand back of cases which couldn’t be progressed by CF. ACTION To confirm completion and submission of self-review tool (TJ) TR to arrange a deep-dive session on Cyber Security for AC and IT. (TR)

Risk

Board Assurance Framework (BAF) Update SK introduced a report on the BAF, summarising changes since the last presentation, and noting a first attempt at populating the new format with risks and mitigations. SK asked for AC feedback. RM commented that AC’s role would normally be to review the process undertaken, with the Board to review the detail every 4 to 6 months. SK noted the BAF would be refreshed quarterly, with a specific request for review annually. SK added that risks would come from Board and Sub-Committees and that the BAF would be presented quarterly to the Board. RM asked about sources of assurance, including Counter Fraud and Internal or External Audit work, noting that consideration of external risks and influences could further improve the BAF. HB commented that the BAF was coming on well, but requested track changes to be used to keep track of variations from previous versions seen. SK agreed to do

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7.2

this. RM suggested including a column to show trend in risk rating. KM asked about the monitoring committee, and SK replied that there was not always a clear home, and suggested maybe inclusion at Board Seminars would be an option. AC noted that this currently was not considered at either QSC or FCC. RM led a detailed page turn review and fed comments back to SK on the BAF content. DW suggested that the Board should have a half hour brainstorming session to identify risks. TR suggested using the NED only risk training session to do this. ACTION Arrange a risk brainstorming session for NEDs (TR). Review of Risk Matrix DC and CM attended to present an overview of the Risk Matrix. CM advised that DC had refreshed the risk severity descriptions, with some flexed for UCLH. CM also noted the subjective nature of risk assessment. CM advised that risks rated > 16 should go to Risk Coordination Board (RCB) but that there were > 100 and this was not possible for one Board to review. DC added that risk leads were being trained, and that automatic alerts would be used to highlight any risks entered with a red rating, and any risks not being reviewed. DC further noted that red risks would be challenged and rationalised. RM asked if DC agreed with the 100 recorded. DC responded that this was not the finalised version, and some still needed further review. DC noted that a number of risks were being rated by gut instinct rather than appropriate tools, and that some were assessed in order to show a red rating. DC also noted some ‘risks’ were issues which had gone wrong. CM added that some risks were being overstated to draw attention, or potentially to seek funding. RM commented that the Risk Matrix looked good, but was too complex for a lay person. DC replied that a robust structure was being developed with knowledgeable people acting as risk champions to support it. HB asked about the grading, noting that a 2% budget loss would be seen as ‘catastrophic’. DC noted this was taken from NPSA guidance, which was given to all NHS bodies to use, and that this had been modified with input from the Finance Director. RM asked about risks which crossed domains, e.g. where both financial and service loss were possible. DC replied that where there were cross-cutting risks, all scores would be reviewed, with the highest one taken.

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TR commented that the risks needed to be considered from a corporate perspective. CM replied that this was one of the greatest challenges, with RCB also looking at aggregation of risks. CM noted that the Board would have to agree on descriptions. RM asked for a further update in 6 months. ACTION Update on Risk Matrix to Jan AC (DC)

8. Audit Committee Work Programme Noted.

9. Any Other Business None.

10. Date of Next Meeting

9am, Tuesday 15th September 2015,

Chairman/CEO Meeting Room , 2nd floor central

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