bolton nhs foundation trust – board meeting october 31st 2013 · 2013-10-25 · 1 bolton nhs...

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Bolton NHS Foundation Trust – Board Meeting October 31st 2013

Location: Board Room Time: 0900 – 1300 hrs

Time Topic Lead Process Expected Outcome

0900 1. Patient Story verbal Patient story and learning points noted

0920 2. Apologies for Absence – Trust Sec. verbal Apologies noted

3. Declarations of Interest Chairman verbal To note any declarations of interest in relation to items on the agenda

4. Minutes of meeting held 26 September 2013 Chairman Minutes To approve the previous minutes

5. Action sheet Chairman Action log To note progress on agreed actions

6. Matters arising Chairman verbal To address any matters arising not covered on the agenda

0930 7.1 Chairman’s Report Chairman verbal to receive a report on current issues

7.2 Reportable issues log CEO verbal To receive a report on any reportable issues including but not limited to SUIs, never events, coroner reports and serious complaints

Safety Quality and Effectiveness

0945 8. Integrated Performance Report MD Report – enc To note and receive the integrated performance report

9. Mortality Report MD Report – enc To receive the regular mortality report

10. Pressure Ulcer Strategy DoN Report – enc To approve the new pressure ulcer strategy

11. Winter Plan COO Report – enc To approve the Winter Plan

12. Transparency in Care DoN Report – enc To approve involvement in the Phase 2 of the NHS North Transparency project

Strategy

11.00 13. Towards a digital trust CIO Presentation To approve the proposal for the development of EPR and EDMS

14 Timetable to communicate the new strategy Dir Strat & Imp

Briefing To note the proposed timetable for the communication of the long term strategy

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Time Topic Lead Process Expected Outcome

Governance

11.30 15 Board Assurance Framework Trust Sec Report – enc To receive the Board Assurance Framework and note the risks to the achievement of the Trust’s strategic objectives

16 Q2 Declaration to Monitor Trust Sec Report – enc To approve the Q2 declaration and note the introduction of the RAF

17 Changes to the Constitution Trust Sec verbal To consider a minor amendment to the constitution ahead of placing a formal proposal to the Annual Members meeting

12.00 18 Membership of AHSN Dir Strt and Imp

Report – enc To receive a six-month update on the benefits of AHSN Membership

Finance

12.15 19 Month 6 Finance Report DoF Report – enc To receive an update on the current financial position.

For Information

Chair reports of the following sub-committees will be noted – if any member of the Board wishes to raise a question regarding one of these items they should indicate this before the start of the meeting.

12.40 20 Finance and Investment Committee – Chair Report (meeting held -29th October 2013) – verbal

21 Quality Assurance Committee – Chair Report (meeting held 9th October 2013) – enclosure

22 Audit Committee – no meetings held during the reporting period

23 Charitable Funds Committee – enclosure

24 Any other business

Questions from Members of the Public 23

1250 25 To respond to any questions from members of the public that had been received in writing 24 hours in advance of the meeting.

Resolution to Exclude the Press and Public

To consider a resolution to exclude the press and public from the remainder of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted

1300 Lunch

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Part Two

Next meeting Thursday November 28th 2013

1330 1. Apologies for Absence Trust Sec To receive any apologies for absence

2. Declarations of Interest Chairman To receive any declarations of interest in items on the agenda

3. Minutes of the meeting held on 26th September 2013

Chairman Minutes To confirm the minutes of the previous meetings

4 Matters arising Chairman Verbal to address matters arising from the minutes

5. Mandatory Training – sanctions to address

Governance

1345 6.1 SUI – Bone cement DoN Report – enc To approve the final SUI report

6.2 SUI – wound packing DoN Report – enc To approve the final SUI report

Finance and Strategy

1400 7. Market share report DoF Report – enc

1410 8. Focus on SLR DoF Presentation

1510 9. Corporate CIPs CEO Presentation

Any Other Business

1530 Close

Board of Directors minutes - September 26th 2013 2013 Page 1 of 8

Meeting Board of Directors Meeting

Time 09.00 a.m.

Date 26th September 2013

Venue Boardroom

Present:- Abbv.

Mr D Wakefield Chair DW

Dr M Harrison Vice Chair

Mrs C Davies Non-Executive Director CD

Mrs G Ashworth Non-Executive Director GA

Dr E Adia Non-Executive Director EA

Mr A Duckworth Non-Executive Director

Mr J Scott Chief Operating Officer JS

Mr S Worthington Director of Finance SW

Mrs T Armstrong Childs Director of Nursing TAC

Mrs N Ingham Director of Workforce and OD NI

Mr S Hodgson Acting Medical Director

Mrs A Schenk Dir. Strategy and Improvement

In attendance:-

Mrs E Steel Trust Secretary ES

Miss K Bancroft HoD Family Division KB

Dr M Grey HoD Acute Adult Division MG

1. Patient Story

Deferred due to sickness

2. Apologies

Dr J Bene

3. Declarations of Interest

No additional interests declared

4. Minutes of The Board Of Directors Meeting Held on 1st August 2013

Approved subject to correction of a typographical error

5. Action Sheet

The Action Sheet Was Updated To Reflect Progress Against Agreed Actions.

FT/13/74 The HoD for the Family Care Division advised that the division have been

working to address the specific issues raised in the patient story heard at the

previous Board meeting including the management of transition from the


highest level of dependency as the baby improves. The action plan is

overseen by the Divisional Board [after the Board meeting a copy of the

action plan was circulated to Board members]

6. Matters Arising

No matters arising not covered elsewhere on the agenda

7 Chairman’s Report

The Chairman updated the Board with regard to the following:

Board Changes

Heads of Division have now been invited to join Board meetings as non-voting

members to support the Medical Director.

Welcome to new Governors; Governors were invited to remain for the private

session to observe discussions around the strategy for submission to Monitor

Last Board meeting for Nicky Ingham before her move to Blackpool and possibly

the last Board meeting for Jon Scott – both thanked for their contribution to the

Trust.

Performance

C. difficile – progress is being made but further work needed as there is still more

that should be done

CQC – following review inspection the Trust is now completely compliant with no

outstanding conditions

A&E – continues to perform well, unfortunately this means the Trust is not on the

list of Trusts who will get additional funding to support this areas Monitor – review

meetings now bi-monthly in London with a meeting by conference call on the

intervening months. The last call on Friday 20th September went well, the Trust is

on track with agreed actions to meet the enforcement notice. During the call

Monitor asked why the Trust does not do more to communicate about good

performance.

Winter – the winter plan will be brought to the October Board meeting – the Trust

must meet the challenge of maintaining performance and finding future savings.

18 weeks – continues to be delivered as an aggregate and is close to delivery in all

specialities.

Stroke performance has improved and is back on plan – this has been achieved by

ring fencing additional beds on the stroke unit. The TIA target has also been

achieved.

9. Performance Dashboard

The Medical Director highlighted the following areas of performance on the dashboard:

Mortality – remains green and is moving in the right direction. Board members

noted that although HSMR and SHMI had remained steady RAMI had increased.

An explanation of this change was requested – it was agreed that this could be

covered in the routine Mortality report due in October.

Appraisal performance improved but further work needed to achieve the mandatory


training target. Divisions are re-enforcing the importance of mandatory training and

are targeting areas of patient facing training.

The Board agreed to focus on the exception reports where issues/concerns had been

identified and to take other exception reports as read. Board members were reminded that

the new integrated performance report would replace the dashboard and exception reports

from October.

FT/13/88 Mortality report to October Board to include detail on work done to review notes of

unexpected deaths and exploration of increased RAMI SH

10. Exception Reports – Quality

Deaths following elective admission

All deaths following elective admission are reviewed by the Head of Division; any areas of

learning identified by this review are shared within the Division. The vast majority of

deaths recorded as being following an elective admission are in fact following an urgent

admission from clinic when a decision is made to admit the patient the next day, often in

patients with advanced cancer. The four patients in June/July came into this category –

the reviews did not identify any patient safety issues and concluded that all were cancer

patients who did not survive the post-operative period.

It has been agreed to move to a system of reviewing unexpected deaths defined as those

patients who had a low expectation of death but subsequently died. Board members

challenged as to whether unexpected death could be an objective measure – the Medical

Director advised that a validated scoring system gives a severity score which can be used

to compare performance – where the chance of death was felt to be low this should be

investigated.

Board members challenged whether intervention was appropriate in patients if death was

not unlikely; the Medical Director advised that no defects of care had been identified in the

cases reviewed, the risks had been explained to the patients and their families and on

balance it was right to give the patients a chance.

The Chair of the Quality Assurance Committee confirmed that the Committee had

discussed the peer review of case notes following an unexpected death.

Resolved: The Board noted the report and the reassurance that the patients reviewed had

received appropriate care.

Pressure Ulcers

The Trust report on all ulcers acquired in the care of the Trust with an aim to reduce

category two ulcers by at least 50% and zero tolerance for cat 3 and 4. An improvement

has been made on performance since 2012/13 but this is still not good enough and further

work is needed. A strategy is being formulated which is intended to equip staff and hold to

account – this will be brought for approval at the October Board meeting.

C difficile

At the end of August the Trust had reported 23 cases of C difficile against a target of no

more than 28 in the year. The two main issues identified through RCA are non-adherence

to the antibiotic policy and inappropriate sampling.

The new Consultant Microbiologist is now reviewing policies and working to make the

policy accessible following comments from junior doctors who have reported difficulty in

accessing policies.


The External Reviewer conducted a review of actions taken against the plan agreed

following the initial review and in a verbal debrief advised that positive improvements had

been made – a formal written report will be provided.

The issue of access to policies was challenged; Board members felt that rather than

developing an app for policies the challenge should be put back to consultants and their

teams to ensure that all members of the team take responsibility for compliance with

antibiotic stewardship.

Board members discussed the use of antibiotics, whilst it is accepted that their use saves

lives the policy for review of IV antibiotics after 48 hours must be followed. The Director of

Nursing confirmed that junior doctors are provided with feedback from the rcas.

The Director of Finance confirmed that a provision of £2m has been made in the financial

assumptions to address the financial penalty associated with failing this target.

Complaints

Performance against the target to respond to all complaints within the agreed timescale

deteriorated in July and August following a decision to give priority and focus to managing

the backlog of 137 complaints.

A new complaints policy was approved by the Executive Board and a system is now in

place to track and provide early warning of overdue responses. Performance is forecast to

be on track by November 2013.

Board members asked for assurance that in addition to responding to the complaints,

learning points were identified and communicated to teams. The Director of Nursing

confirmed that this is covered in the new policy

Staffing Incidents

All staffing incidents are reviewed on a daily basis with the majority being as a result of

staff being moved to provide cover in other areas. In August it was recognised that the

freezing of vacancies implemented as part of the original turnaround plan was causing

unacceptable pressure and the number of beds on one ward was temporarily reduced to

require fewer nurses and thus relieve this pressure.

Expenditure on wards was higher in August reflecting an increased spend on bank and

agency staff. It was accepted that once wards are at full establishment wards must

manage within this establishment through the planning of leave and the building in of

contingency for times of high pressure.

Staffing levels was one of the standards reviewed by the CQC; the CQC looked at the

systems to manage, risk assess and escalate staffing issues and triangulated this with

feedback from staff before concluding that the Trust was now compliant with this standard.

10 Falls Strategy

The Director of Nursing presented the Falls Strategy for formal approval from the Board of

Directors.

The strategy sets out a systematic proactive approach to falls prevention and includes the

role of a ward Fall Champion and Trust Fall Coordinator.

The Board discussed the strategy and requested further information with regard to

implementation and risk assessments. Board members asked for assurance that with a full


complement of staff wards would be able to implement the strategy and deal with the

management of patients identified as being at risk of falls. The Director of Nursing

confirmed that she was confident that the identification of high risk patients was improving

enabling “specialing” to be targeted at those identified as at risk.

A question was raised with regard to the management of falls in the community, the

Director of Nursing advised that there are community falls clinics to ensure possible actions

such as safe footwear and appropriate walking equipment is provided.

Resolved: the Board approved the Falls Strategy.

11. Exception Reports – Operational

Readmissions

The COO advised that the target of no more than 8% readmissions had been agreed on

the understanding that support/follow up services would be available to care for patients

after discharge. This target will be reviewed and based on available services following an

audit to be conducted with the CCG.

Non-Executives challenged this explanation on the basis of the dashboard showing an

increase in readmissions of approx. 1% month on month since September 2012 and asked

for assurance that patients were not being discharged before they are ready.

Resolved: Board members requested that a further report be provided in November after

the audit with the CCG.

FT/13/90 Report back on readmissions following audit with CCG COO

Diagnostic waits

Diagnostic waits were included on the dashboard from April following a recommendation

from the Intensive Support team. The majority of these were patients waiting for

endoscopy screening, this is being addressed by the mobile unit which came on stream in

August, was fully operational by the end of August and is on track to achieve the 1% target

by the end of November 2013.

There has been an increase in the number of patients waiting more than 6 weeks for an

MRI, this is as a result of the increase in activity following the end of additional CCG

funded provision in a mobile unit. Capacity to undertake this work within the Trust has

been increased and performance should be within tolerance for MRI scans by the end of

September 2013.

13. Quality Strategy

The Acting Medical Director presented on the development of the Quality Strategy setting

out the Trust’s commitment to ensure that quality principles, systems and processes are

adopted and embedded throughout the organisation. Meeting the challenge of improving

quality while reducing costs.

Board members agreed the importance of good consistent quality and asked for assurance

that the strategy would address the need for consistent 24/7 quality. The Acting Medical

Director confirmed that this has to be addressed, reducing the variation in quality at times

of day, across wards and between teams is one of the biggest steps to achieving the

overall quality goal. Board members agreed that ensuring a consistent approach to quality


is a key objective.

Board members supported the core goals in the strategy but felt the current policy was too

gentle in supporting the achievement of quality with no explicit detail on performance

management.

Resolved: The Board endorsed the further development of the Quality Strategy

14.1 Medical Staff revalidation

Board members were asked to approve the appointment of the Acting Medical Director as

the responsible officer for revalidation.

The Acting Medical Director confirmed that he had been revalidated and that there was a

good support structure in place to ensure the Trust is operating in line with the

requirements for medical staff revalidation.

Resolved: The Board approved the appointment of Steve Hodgson Acting Medical

Director as responsible officer for revalidation.

14.2 Norman Lamb letter re end of life care

Board members noted the letter from Norman Lamb regarding the phasing out of the

Liverpool Care Pathway and the requirement to provide assurance on the provision of end

of life care.

The Board noted the requirement for a clinical review to be undertaken by a senior

clinician. The Director of Nursing advised that the bereavement and palliative care team

would develop guidance for staff and audit practice, any complaints or concerns would be

escalated to the Quality Assurance Committee.

Board members asked if the change in practice and requirements has had any impact on

the Trust and if there were any financial implications of changes.

Resolved: The Board approved the appointment of the Director of Nursing as the Board

member with responsibility for overseeing complaints about end of life care and for

overseeing how end of life care is provided.

A report will be provided to the November QA meeting to provide assurance with regard to

the care of end of life patients.

On a separate but related issue the Board were advised that figures from CHKS show that

the trust has a higher than average number of end of life patients. A review of notes by a

clinical team including a GP has confirmed that these cases are being coded correctly

FT/13/91 Report to November QA Committee on end of life care

15. Month 5 Finance Report

The Director of Finance presented the key points of the month 5 Finance report, Board

members noted that this had previously been considered in the Finance Committee

meeting held on 18th September 2013.

The forecast shows that the Trust’s plan deficit of £7.8m is still achievable

The financial position for month 5 was a deficit of £ (1.4) m which is £ (0.9) m worse


than planned reversing the trend of the first four months. The year to date position

is better than planned at £ (4.7) m deficit compared to the planned £ (5.6) m.

Income has fallen this month due to a reduction in volume across most specialties.

Divisions are confident that they will catch up on the income shortfall.

Pay costs overall are in line with previous months. Although salaried pay costs

have continued to fall over the last 2 months, bank and agency spend has risen by

an identical amount resulting in no overall fall in pay costs

The increase in non-pay is driven by the temporary mobile endoscopy unit and

pass through drugs

Turnaround savings are below plan year to date. It is forecast that the full amount

of savings will not be delivered by the end of the year

The CCG remain very supportive for both the development of the long term

financial strategy and in supporting the winter plan. The CCG are considering

additional funding to support community services – a paper is due to be discussed

at the CCG Board.

In order to achieve run rate balance the corporate CIP is being brought forward.

Board members commented that although in the current position it is hard not to feel

nervous it does feel as though the financial strategy, clinical services strategy and quality

strategy complement each other in a logical manner to set out the future purpose and

direction of the Trust.

Concern was expressed that bank and agency spend had not yet been addressed, the

Director of Nursing confirmed that the Finance Committee had requested assurance that

controls were in place to manage this area of spend effectively and with regular monitoring.

Board members acknowledged the need to recognise improvement and to continue with

year on year efficiencies.

The Chairman reminded Board members that one of the key issues in addressing

performance for Monitor will be to put forward a plan to manage without funding from the

DoH.

16. Finance and Investment Committee Chair report (27/08/13 and 18/09/13)

The Chair of the Finance Committee provided his report on the business conducted at the

August and September 2013 meetings of the Finance and Investment Committee. The

September meeting had focused on a detailed review of the strategy papers with a view to

ensuring that plans were deliverable.

17. Quality Assurance Committee Chair report (07/08/13 and 11/09/13)

The Chair of the QA committee provided her report on the work of the QA Committee:

In future meetings the three Division quality reports will be reviewed in the same

meeting rather than one per meeting – this has been agreed to enable better

sharing of learning between divisions.

The Committee considered the process for reporting on and closing SUIs and

approved a proposal to support the timely sign off for SUIs by the Board with on-

going actions monitored through the QA Committee. It was also agreed that

although all efforts should be made to secure NED attendance on SUI panels the

preliminary meeting could go ahead without a NED in attendance and with an Exec


Director Chair.

The Committee approved the deferment of the CNST level 2 assessment, the Trust

will offer to be a pilot for the new NHSLA/CNST approach.

18. Audit Committee – Chair Report (17/09/13)

The Chair of the Audit Committee provided a report on the recent meeting of the Audit

Committee. The new external and internal auditors had now been appointed and had been

in attendance at the September meeting. Although it is early days the Committee felt

invigorated by the attendance of “fresh eyes”

The Committee had previously been concerned about the response to a no assurance

report on Medicines Management but had been assured by a report provided by the

Director of Nursing and now felt more confident that although not yet embedded actions

have been taken.

The Committee were concerned that the BAF had not been reviewed for some time, they

had accepted that the BAF was being reviewed but had set a deadline for the new BAF to

be received by the Board in October

FT/13/93 BAF to October Board meeting ES

19. Any other business

No further business

20. Questions From Members of the Public

No questions were received in advance of the meeting

Date And Time Of Next Meeting

31st October 2013

Resolved: that representatives of the press and other members of the public be excluded

from the remainder of this meeting having regard to the confidential nature of the business

to be transacted, publicity of which would be prejudicial to the public interest (Section 1(2)

Public Bodies (Admission to Meetings) Act 1960).

September Board actionsCode Date Context Action Who Due CommentsFT/13/74 01/08/2013 patient story - maternity Exec Directors to ensure issues raised in patient story are captured

and addressed

CEO Sep-13 working to address the specific actions -

KB to respond to further query on step

down once baby starts to recover

FT/13/84 01/08/2013 no smoking site update to solutions to address smoking around entrances JB Oct-13 matters arising verbal updateFT/13/73 04/07/2013 Market share report to be quarterly agenda item with information about potential

opportunities included

AMS Oct-13 agenda item

FT/13/76 01/08/2013 Pressure ulcers Paper to be provided on approach and measuring TA Oct-13 agenda itemFT/13/38 07/04/2013 Academic Health Science

Networks

Report to be provided on benefits being realised from membership

of AHSN

AMS Oct-13 agenda item

FT/13/60 06/06/2013 mortality regular reports through QA committee with quarterly Board reports -

next October

JB Oct-13 agenda item

FT/13/87 26/09/2013 Performance Winter plan to October Board meeting JS Oct-13 agenda itemFT/13/88 26/09/2013 Performance Mortality report to October Board to include detail on work done to

review notes of unexpected deaths and exploration of increased

RAMI

SH Oct-13 agenda item

FT/13/89 26/09/2013 Pressure ulcers Pressure ulcer strategy to October Board meeting TA Oct-13 agenda itemFT/13/93 26/09/2013 Audit Committee report BAF to October Board meeting ES Oct-13 agenda itemFT/13/94 26/09/2013 Mandatory training report on proposals to address mandatory training compliance NI Oct-13 matters arising verbal update

FT/13/95 26/09/2013 Authorisation of high level

contracts

SW to provide DW with breakdown of spend through the deanery SW Oct-13

FT/13/92 26/09/2013 Finance and Investment IT investment strategy to November 2013 Board meeting SW Oct-13 agenda item for OctoberFT/13/82 01/08/2013 Stroke clinical audit to validate provision of appropriate care to stroke

patients - report back to QA Committee

JB Nov-13 delayed to November to incorporate

latest census numbersFT/13/77 01/08/2013 Medication incidents QA Committee to receive detailed report on themes including

benchmarking if possible

TA Nov-13 delayed to November to incorporate

latest census numbersFT/13/61 06/06/2013 equality and diversity report to October Board to overlay staff data with patient data and

to correlate profile of patients and staff with population of Bolton

TA Nov-13 delayed to November to incorporate

latest census numbers

FT/13/78 01/08/2013 complaints complaints strategy to the Board TA Nov-13FT/13/90 26/09/2013 readmission report back to Board after audit with CCG JS Nov-13FT/13/91 26/09/2013 End of life care report to QA Committee in November 2013 to provide assurance

that palliative care patients have senior review and a responsible

clinician

TA Nov-13 scheduled for November to fit with

Committee cycle

FT/13/96 26/09/2013 Estates strategy Report back on possible solutions to lease the land to potential

developers

ST Nov-13

FT/13/97 26/09/2013 Estates strategy Outline plan with timescales for moves detailed within draft estates

strategy

ST Nov-13

Safe, High Quality Care, Fit for the Future

Quality and Safety

Valued Provider

Financially viable and sustainable

Great place to work

Fit for the future

Well Governed

Subject Integrated Performance Report

Prepared By

Approved By Executive Management Team

Presented By

Executive Summary

Please see the High level Executive Summary section at the beginning of the report

Key Recommendations

The Board are asked to receive the report and give approval.

Acronyms/Terms used in Report

TRUST BOARD

Trust Objectives

Purpose

This report sets out the Trust’s integrated performance against leading national and local targets and draws attention to key areas for specific review by the Trust Board. Driven by the Trust’s strategic objectives this report is underpinned by a strong platform of integrated governance and assured data quality controls allowing the Trust Board to make effective decisions and demonstrate its commitment to delivering high quality healthcare for the people of Bolton.

Report

Appendix A

Appendix B

Report change log


Executive Apex Reports High Level Executive Summary High Level Executive Dashboard • Monitor Governance Compliance Framework • Monitor Risk Assessment Framework • Mortality • Readmissions

Section 1 Improving the Quality of Care and Safety of our patients • Quality and Governance Scorecard • Quality and Governance Charts • Quality and Governance Report • Acquired Infection • Falls • Pressure Damage • CQUINS

Contents


Section 2 Valued provider of Integrated Services • Operations Scorecard • Operations Charts • Operations Report

Section 3 Financially viable and sustainable • Finance Scorecard • Finance Report Section 4 A great place to work • Workforce Scorecard • Workforce Charts • Workforce Report Section 5 Ward to Board Overview/Early warnings

Section 6 Fit for the Future Section 7 Well Governed

Appendix A Acronyms/Terms used in Report

Appendix B Dashboard Change log - in month

All measures are within confidence intervals.

Market share analysis

Electronic Patient Record

Monitor escalation

Run rate balance in March is not certain

Year to date deficit is £0.9m ahead of plan

September in month deficit of £0.7m is on plan

Forecast in year deficit of £7.8m is on plan

13.6 % of patients were re-admitted within 30 days against a target of 8%. Target level under current review with CCG.

Local induction attendance (starters in the last 12 months) has fallen to 59.5%

Mandatory Training compliance is 81% against a target 100%. This target has not been met in the last 18 months.

The number of staff absent for 3 months+ has risen to 79.

83.6% of staff appraisals are completed representing the highest figure in the last six months.

Local integration policy

The latest Mortality position is: SHMI - 1.01, RAMI - 85.0 and HSMR - 92.9.

79 patient falls in month is less than our threshold of 86. First six months data is on trend to achieve 13/14 year end target.

Acute Inpatient acquired pressure damage is above the monthly target at 8.

Infection Control (C.diff) reports 2 occurrences in month. This represents the lowest figure in the last six months.

A&E 4 hour target did not achieve in month at 94.4%.

18 week referral to treatment targets were achieved for admitted, non-admitted and incomplete pathways.

Significant improvement in Diagnostic waiting times for tests >6 weeks but still above National target of 1%.

Executive Summary

This executive summary provides an integrated overview of the Trust Board Performance Report. Supporting the Trust's Strategic Objectives it orientates executives quickly to the areas that have been escalated, are of particular note or political significance. The accompanying High-Level Dashboard and narrative gives further analyses. Compliance levels with the Monitor Risk Assessment Framework and CQC (Care Quality Commission) are also shown.

Improving the Quality of Care and Safety of our patients A great place to work

Valued provider of Integrated Services Fit for the future

Financially viable and sustainable Well GovernedOur Patients

Finance Risk Rating

The Trust continues to be licensed to carry out regulated activities with no conditions imposed

on our registration status

Monitor Compliance Framework

Governance Risk Rating1Red

(To be Reported from October 2013)Governance

Monitor Risk Assessment Framework

CQC

Finance

Improving The Quality Of Care And Safety Of Our Patients

Plan 13/14

Plan YTD

Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Financially Viable And Sustainable

Plan 13/14

Plan YTD

Plan Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Well Governed Status

Total number of new SUIs received within the month 0 0 11 3 Forecast year end deficit – (full year) -7.8 -7.8 -7.8 -7.8 0 0 Monitor Compliance Framework Off Plan

Never Event 0 0 1 1 Forecast year end recurrent run rate - (full year) 0 0 -8.8 -8.8 0 -8.8Monitor Risk Assessment Framework Pending

All Patient Falls 1034 502 519 79 Forecast year end income and cost imp – (full year) 16.2 16.2 13 13 - -3.2CQC Essential Healthcare Standards (5) On Plan

Acute Inpatients acquiring pressure damage (grades 2+) 84 42 52 8 Actual position against plan - YTD -7.8 -6.3 -5.4 -0.7 0.5 0.9

CQUINS: National Clinical Quality Indicators (4) Off Plan

VTE Assessment Compliance 95% 95% 96.6% 96.7% Actual Income and Cost Improvement -YTD 14.6 5.6 5.4 0.8 0.7 -0.2 Report to prevent future deaths On Plan

Catheter Associated Urinary Tract Infection 95% 95% 94.6% 95.6% Capital Expenditure YTD -5.9 -3.2 -1.2 -0.3 0 2 Litigation On Plan

MRSA Bacteraemia Pre 48 Hours admission 0 0 0 0 Cash Position YTD 0.3 0.2 0.5 0.5 -0.1 0.3 Formal Contract Notices Off PlanMRSA Bacteraemia Post 48 Hours admission 10 0 0 0 Continuity of services rating 1 1 1 1 - - Formal Performance Notices On Plan

C Diff Hospital aquired 28 17 25 2 Contract Fines/Penalties Off Plan

CHKS RAMI (Rolling 12 months) 100.0 100.0 85.0 85.0

SHMI 1.000 1.000 1.015 1.015

Surgical WHO Checklist compliance 100% 100%

Formal complaints from patients n/a 325 43n/a Local Induction Attendance (starters in the last 12

months) 100% 100% 68.9% 59.5% The Trust Strategic Direction On PlanComplaints responded to within the time period % 95% 95% 73.8% 78.0% Number of staff absent for three months + n/a n/a 70 79 Local Integration Policy On Plan

Appraisals completed % 80% 80% 81.2% 83.6% Market Share Analysis On Plan

Sickness days % of days lost 3.75% 3.75% 4.7% 4.97% Winter Planning On Plan

Valued Provider Of Integrated ServicesPlan 13/14

Plan YTD

Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Mandatory Training Compliance % 100% 100% 79.6% 82.5% Electronic Patient Record On Plan

A&E 4 hour target 95.0% 95.0% 96.5% 94.4% Monitor Escalation On Plan

RTT Admitted Clock Stops % 90.0% 90.0% 95.1% 95.0%

RTT Non-Admitted Clock Stops % 95.0% 95.0% 96.7% 95.8% Performance improved but off target in month

RTT: Incomplete pathways within 18 weeks % 92.0% 92.0% 95.9% 94.9% Performance deteriorated and off target in month

Diagnostic waits >6 weeks % 1.0% 1.0% 9.7% 7.1% Performance improved and on target in month

% of patients who spend 90% of their stay on the stroke unit 80.0% 80.0% 82.7% 83.3% Performance deteriorated but on target in month

% Readmissions within 30 days of discharge 8.0% 8.0% 12.7% 13.6%The On Plan / Off Plan Columns represent a projected Year End position. The

status columns represents the current status of the initiative detailed

Status

High Level Executive Dashboard

Developing Our StaffPlan 13/14

Plan YTD

Actual YTD

Monthly Actual

Monthly Change

On Plan Off Plan Fit for the FutureTo be Developed

Area Indicator (All measured Quarterly) Threshold Weighting Oct-13 Nov-13 Dec-13

1

Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted 90% 1.0

2

Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted 95% 1.0

3

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway 92% 1.0

4

A&E: maximum waiting time of four hours from arrival to admission/ transfer/ discharge 95% 1.0

5 All cancers: 62-day wait for first treatment from:Urgent GP referral for suspected cancer 85%NHS Cancer Screening Service referral 90%

6

All cancers: 31-day wait for second or subsequent treatment, comprising:

Surgery 94% 1.0Anti-cancer drug treatments 98%

7

All cancers: 31-day wait from diagnosis to first treatment 96% 1.0

8

Cancer: two week wait from referral to date first seen, comprising:

All urgent referrals (cancer suspected) 93%For symptomatic breast patients (cancer not initially

suspected) 93%

14

Clostridium (C.) difficile – meeting the C. difficile objective DM* 1.0

19

Certification against compliance with requirements regarding access to health care for people with a learning disability N/A 1.0

20

Data completeness: community services, comprising:

Referral to treatment information 50%Referral information 50%

Treatment activity information 50%

Out

com

es

1.0

Acc

ess

1.0

1.0

Monitor Risk Assessment Framework 2013/14

Quarter 1 Actual

Quarter 2 Actual

Quarter 3 Actual

Quarter 4 Actual

High Level Executive Report

Improving the Quality of Care and Safety of our Patients

• 3 new Serious and Untoward Incidents have been reported in month. 11 incidents have been reported for the first six months of this year against a total of 9 for 12/13.

• There is one Never Event recorded for September 2013. This incident is currently being further investigated.

• 79 patient falls were reported in September with 4 sustaining a degree of severe harm. Three patients in the adult acute division each resulting in a fractured neck of femur and 1 in the elective care division resulting in a fractured shoulder.

• 8 Inpatients acquired pressure damage in September exceeding the monthly target of no more than 7. The table below shows both inpatient and community pressure damage incidents and their level of severity.

Performance Indicator Sept 2013

Hospital Pressure damage (grade 2) 5 Pressure damage (grade 3) 2 Pressure damage (grade 4) 1

Community Pressure damage (grade 2) 6

Pressure damage (grade 3) 2

Pressure damage (grade 4) 1

17

• VTE assessment and Catheter Associated Urinary Tract Infection indicators have both achieved. VTE has been compliant for the last six months.

• There have been no MRSA Hospital Acquired Infections in the last six months.

• In September C.Diff has seen the lowest number of incidents reported monthly this year at 2. Unfortunately we have still exceeded the quarterly target of 7 on the Monitor Compliance Framework returning a figure of 9. This area still remains a formal Monitor concern.

• There are currently two measures for mortality which are reported nationally for all NHS providers and across all specialties. They are both known by four letter acronyms HSMR and SHMI. Bolton also uses the CHKS mortality ratio known as RAMI. There are differences between all three measures. HSMR and RAMI consider deaths in Hospital whereas SHMI considers death in Hospital and deaths up to 30 days after discharge. Currently all three measures are within confidence intervals. SHMI at 1.01, RAMI at 85.0 and HSMR at 92.9.

• The World Health Organisation (WHO) Surgical Checklist has been introduced as a new metric for the organisation. It is a

patient safety alert and a tool for use in operating theatre environments. It is designed to help clinical teams improve the safety of surgery.

• 31 formal complaints have been received in September 2013. This represents the lowest number received in the last 3 months.

Valued Provider of Integrated Services

• The 4 hour A&E target has not been met in September achieving 94.4% against the 95% National Standard. This target has been achieved for the previous 18 months. There were 8,978 attendances with 503 patients breaching the 4 hour wait. The table below gives the breach reasons:

1. 226 of them were due to waiting for a bed, 2. 79 due to clinical need, 3. 77 were delays to be seen, 4. 64 were awaiting psychiatric review, 5. 43 waiting for surgical review 6. 14 due to other reasons.

Additional actions that are being taken by Divisions include working to improve discharges, monitoring patient flow and ensuring that capacity is available together with seeking to improve the delays in transfer of care.

• 18 week admitted, non-admitted and incomplete pathways were all achieved. Orthopaedics still remains a challenge at

specialty level.

• The stroke target of 80% has been achieved for the second month running with a delivery of 83.3%. Although not in the Compliance Framework Monitor still review this as a cornerstone target.

• Readmissions were 12% against an 8% target. This target is currently under review with the CCG. The chart below shows the CHKS National analysis for the year August 2012 to July 2013 and whilst the methodology is not consistent with the PBR rules it does give a like for like comparison with other Trusts. This analysis shows that we are in the middle of the pack and not an outlier.

Workforce

• Local induction performance has deteriorated (59.5%) partly due to a high number of Nursing staff and Health Care Assistants starting in month. The low attendance is of concern as the CQC review this area for assurance that all new staff have the basic safety, governance and mandatory training required to do their job.

• A verbal report is scheduled for October’s Trust Board on Mandatory Training. Medical and dental staff have the lowest rate of compliance at 73%. Out of 13 subject areas 11 improved in month with 2 slightly deteriorating. These two areas are infection control and moving and handling.

• The number of staff with more than 3 month’s absence has increased from 59 in July 2013 to 79 in September. The three major reasons are; stress and anxiety (28), back/musculoskeletal (18) and cancer (7).

• The sickness absence rate has increased in September to 4.97% from 4.86%. This is due to the increase in long term sickness absence particularly in the Adult Acute and the Elective Care Divisions.

Finance

• The forecast shows that the Trust’s plan deficit of £7.8m is achievable by utilising the £2.2m risk reserve that was set aside in the plan and by using non recurrent schemes of £1m to offset recurrent shortfalls.

• The Trust is currently not forecasting to achieve recurrent run rate balance by the end of the year. Action is being taken to secure run rate balance by the year end as follows:

1. Bringing forward of the corporate directorate CIP requirement for 2014/15 into 2013/14. 2. Work with Bolton CCG the community service model. £1.2m non recurrent support to community services has been

allocated by the CCG in this financial year. 3. Work with Bolton CCG on the “Making it Better” service specification 4. Other improvements in the clinical divisions cost improvement programmes. 5. Divisions with forecast underspends are being required to maintain these.

• The full year forecast for income and cost improvements is £13m v £16.2m plan. The shortfall is being covered by utilising

the £2.2m risk reserve that was set aside in the plan and by using non recurrent schemes of £1m.

• The financial position for month 6 was a deficit of £(0.7)m which is slightly worse than the £(0.6m) deficit planned. The year to date position is a deficit of £(5.4)m which is £0.9m better than the planned deficit of £(6.3)m.

• Income and cost improvements year to date at £5.4m are now £0.2m behind plan due to the Board decision to reinvest nursing savings on the wards and lower delivery rates in some other work streams than planned at the start of the financial year. This is being mitigated by additional CIP plans which are in place in the divisions and are part of the division’s financial recovery plans.

• The Trust capital plan as submitted to Monitor is £5.9m As at the end of September capital was £2m underspent. The underspend is in a number of areas of replacements, maintenance and enhancements.

• Cash has been managed effectively with a £0.5m cash balance at the end of September. The year-end position assumes support of £17.25m from DoH.

• Fit for the Future

• The Strategic Direction document 2013/14 – 2018/19 has just been completed in October and sets out a number of

strategies for the Trust. It gives clear direction of travel for the organisation for the next 5 years.

• The Trust is participating fully in the Health and Social Care Integration agenda by ensuring representation at the Integration Board, leading relevant work stream initiatives and participating actively in other work streams as appropriate.

• During Quarter 4 2012-13, Bolton NHS FT had 58% of all of Bolton PCT's elective admissions. Salford Royal is the next biggest provider of elective activity for Bolton PCT with 3144 spells; over 80% of these spells were for Nephrology, which is not a specialty that we would provide. The Trust has seen an increase in volume of elective spells and market share for Bolton PCT patients over the last 2 financial years. When comparing Q1 11-12 with Q4 12-13 there has been an over 5% increase in market share. The increases in market share have been seen in the Elective Surgical specialties of General Surgery, Urology, Orthopaedics and Plastic Surgery.

• The outline business case has been completed for an Electronic Patient Record (EPR) and an Electronic Discharge Monitoring System and an overview will be presented at the October board. Both projects are now expected to proceed to full business case. The outcome of the Department of Health funding bids made to the Safe Hospitals Safer Wards fund from NHS England should be known on the 31st October. Further benefits work is being undertaken to validate EPR benefits validation. A full EPR benefits model will be finished in November and integrated with the full business case.

• We are on track to address the recommendations in the KPMG and Deloitte reports by the end of October. We will then seek external assurance from PwC to assure the Board and Monitor that the recommendations have been addressed.

Well Governed

• At Quarter 2 we are not fully compliant with the Monitor Compliance Framework. Although the majority of our performance targets are met, C.Diff remains a concern together with our financial risk rating of 1.

• The new Monitor Risk Assessment Framework replaces the Compliance Framework from October 2013. A paper is

scheduled for discussion at the October Board.

• There are 5 Essential Healthcare Standards which have 17 outcomes for delivery. The Trust is currently recognised by the CQC as meeting the standards.

• The Trust is not meeting 2 of the 4 National Quality Indicators namely the Friends and Family Test and Dementia screening.

• There is one formal contract notice issued concerning 52 week performance.

• The table below shows the fines and penalties for current performance for month 6.

Plan Actual

Penalties (250) (115)

C‐Diff ‐ (800)

TOTAL (250) (915)

Agenda Item No 9

Meeting Trust Board

Date 31st October 2013

Title Mortality Report

Executive Summary

Why is this paper going to the Board

To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

Quarterly update of Trust’s mortality rate and factors affecting it Adverse movement of SHMI but still within expected parameters, explained by increased mortality over last winter period Favourable trending of more up to date RAMI and HSMR demonstrating improved performance since.

Next steps/future actions Clearly identify what will follow a Board decision i.e. future KPI’s, assurance requirements

Discuss Receive

Approve Note

Assurance to be provided by:

Positive trending of RAMI and HSMR

This Report Covers (please tick relevant boxes)

Strategy Financial Implications

Performance Legal Implications

Quality Regulatory

Workforce Stakeholder implications

NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Prepared by Dr Jackie Bene Presented by Dr Jackie Bene

MORTALITY UPDATE FOR BOARD OF DIRECTORS – 31st October 2013

Overview

The mortality rates at Bolton NHS Foundation Trust are monitored monthly by the Trust

Board within the Performance Board report. The programme of work around mortality

reduction and more detailed analysis of the mortality data are overseen on a monthly basis

by the clinically driven Mortality Reduction Group chaired by the Medical Director.

The Trust measures crude (actual deaths) and risk adjusted deaths by using the Risk

Adjusted Mortality Indicator (RAMI) and the recently developed national Summary Hospital

Mortality Indicator (SHMI).

Crude Mortality

The actual number of deaths in Bolton NHS FT has been reducing consistently over the past

few years and currently stands at 2.0.

Figure 1

Risk Adjusted Mortality

In the last quarter, the SHMI has moved adversely (Fig 2) but is still within the “as expected”

range. This metric is continuously rebased each quarter but the data period is always six to

nine months behind. The RAMI is rebased annually but it is more up to date, lagging by only

two months. The RAMI is useful to monitor trends but less useful as a benchmarked metric

given that peers are generally improving at similar rates. The RAMI is trending below peer as

shown in Figure 3. It is clear that the RAMI deteriorated over last winter trending very close

to the peer group between November 2012 and February 2013. The trend is shown over a

longer period in Figure 4 which covers the two previous SHMI periods. It is expected

therefore that as the RAMI has improved in more recent months that the SHMI will do so too.

2008/09

2009/10

2010/11

2011/12

2012/13

2013/14

Crude Mortality % 3.1% 2.9% 2.8% 2.6% 2.4% 2.0%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

Cru

de

Mo

rtal

ity

%

Crude Mortality Rates

CrudeMortali…

Figure 2 SHMI

Figure 3 RAMI

0.9

0.95

1

1.05

1.1

Jan 11 - Dec11

Apr 11- Mar12

Jul11 - Jun12

Oct 11- Sep12

Jan 12 - Dec12

Apr 12 - Mar13

SHMI

Figure 4

At the last Trust Board meeting it was reported within the Board Performance report that the RAMI

had jumped from 71 in June to 85 in July and was again 85 in August. It remains 85 as of September

2013. Over the previous 12 month period the RAMI had been fairly static around 70 to 73. The

reason for the sudden jump was the annual rebasing exercise undertaken by CHKS in July.

The Acting Medical Director updated the Board at the last meeting on the findings from surgical

elective death case reviews. He concluded that all were urgent admissions from clinic and were in

fact very ill patients rather than more healthy patients that one would expect in those undergoing

elective surgery. The Head of the Acute Adult Division reported within the quarterly Divisional

Quality Report to the September Quality Assurance meeting a case note review of ten patients with

the highest RAMI ie unexpected deaths. The outcome of the review is detailed in Appendix 1. It is

clear that most of these patients were equally very ill and would not be regarded as suffering an

unexpected death. This once again highlights the limitations of risk adjusted mortality data as a

reliable indicator of quality. However the review did highlight a potentially avoidable death and

lessons have been learned within the Division from this.

Benchmarking

The Trust monitors its mortality rate (RAMI) against a peer group of similar Trusts across the

country. The Mortality Reduction Group also monitors performance against a selection of North

West Trusts as shown in Figure 5 below. Bolton NHS FT has the second best RAMI in Greater

Manchester second only to Salford. Our HSMR is currently 92.9 which is in the middle of the pack

compared with other Greater Manchester Trusts. The most recent AQUA Mortality Report for Bolton

attached with this report gives further positive reassurances around Bolton’s mortality performance.

Figure 5

The main causes of mortality at Bolton NHSFT have remained fairly constant over the last three

years and the top five in terms of observed deaths currently are

Pneumonia

Septicaemia

Heart Failure

Aspiration pneumonia

Stroke

The main focus of mortality reduction work is around these conditions. The Mortaility Reduction

Group monitors the progress against the actions and the current RAG rated action plan which is

attached at the end of this report.

As well as the work focussed on specific disease groups there is also a significant amount of work

underway around the whole areas of acute illness management, end of life care and pathway work

in surgical areas. The work around enhanced monitoring in acute medical and surgical areas (Level 1

care) is progressing and the plan to co-locate ITU and HDU was discussed in the Estates Strategy at

the last Board meeting. Both require additional investment. In the meantime each Division has been

progressing seven day working and there is now weekend working by Consultants in all the major

specialities. In addition there has been an enhancement of the Hospital at Night Team. All this plus

the restructuring of acute medical pathways with the introduction of the Clinical Decision Unit last

winter has resulted in greater decision making by senior medical staff at night and at weekends. As

such, out of hours and weekend mortality is not significantly greater as demonstrated in Figures 6, 7

and 8.

0

20

40

60

80

100

120

0

600

1200

1800

2400

3000

BTH RBH LTH PAH SRFT SFT THFT UHSM WWL

RAMI Deaths 1,647 1,047 1,365 2,462 801 1,169 751 1,059 1,041

Exp Deaths 1,665 1,203 1,304 2,602 1,108 1,215 659 1,039 1,102

RAMI 98.9 87.1 104.7 94.6 72.3 96.2 114.0 102.0 94.5

RA

MI

Nu

mb

er

Of

Death

s

Deaths vs Expected Deaths using CHKS RAMI Spells

RAMI Deaths Exp Deaths RAMI

Figure 6

Figure 7

Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Deaths Between: 8am - 8pm 43 53 69 83 64 62 66 59 54 40 61 50

Deaths Between: 8pm - 8am 45 53 55 50 67 58 67 52 40 40 47 28

020406080

100

Nu

mb

er

of

De

ath

s

Deaths In/Out of Hours Trust Overall

704 54%

602 46%

Total Deaths In/Out of Hours

Deaths Between:8am - 8pm

Deaths Between:8pm - 8am

Figure 8

The current performance in terms of risk adjusted mortality for the main causes of death in the Trust

are shown in Appendix 2. It is clear that the work being undertaken is continuing to drive down

mortality in the main. The graphs show a deterioration in risk adjusted mortality over the winter

period and this is the most likely explanation for the adverse move of the SHMI and the RAMI. As the

overall Trust RAMI has recovered subsequently as has been the case in several disease specific

groups then it is likely the SHMI will recover too.

181 14%

197 15%

175 13% 212

16%

162 12%

203 16%

176 14%

Total Deaths per Day of Week

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Appendix 1

Appendix 2

Acute Adult Care Division – Overall Mortality

Elective Care Division – Overall Mortality

Trauma and Orthopaedics – Overall Mortality

Pneumonia

Heart Failure

Septicaemia

Stroke

Surgical Mortality

1

Overarching Mortality Reduction RAG Rated Action Plan- Jan 2013-Dec 2013

Work Stream Recognition and response to the physiologically deteriorating patient

Aim Implement and improve robust recognition / response systems to optimize clinical outcome Improve compliance with NICE CG50

Leads Jez Wood – Anne Gerrard – Bet Fox

No Key Aims Actions Who When Progress RAG

1

Improve /response system to NEWS

Consolidate outreach to provide robust 7 day 12 hour cover in line with H@N model

Information intelligence re outreach activity and future service planning - needs to be part of medium term trustwide IT strategy

JW/AG

Oct 2013

1.2 WTE shortfall in nurses identified, included into appropriate business case. Funding for MedICU’s outreach database no longer available. Dr wood to present NICE 50 results at November MRG

A

Audit NEWS impact Optimize response strategy

Re audit NEWS compliance - start data collection April 2013

Re audit NICE 50 compliance Aim to present MRG Nov 2013 Identify themes to support onward planning

AG/BF JW/AG/ DK

annual Nov 2013

Data collection completed and presented to MRG June 2013 Compliance improved to >60% - needs professional lead ownership/ accountability and feedback. Data collection complete – analysis in progress To gather themes from NEWS compliance/NICE 50 audit and RCA arrests and present to quality assurance/ trust board

A

2

2

Development / establishment of specialty based level one areas Future strategic planning

Discussion/agreement for model re Level 1 monitoring areas – workshop

Divisional / clinical leads/ out of hours working group

Oct 2013

Sept 2013

Target Oct 1st D2/ Nov1st D1 medical areas Business case for surgical areas being written – target Dec 1st 2013 Potential quality indicators for discussion LOS/ arrests/ level 0 HDU cases/ patient experience/delayed admissions/discharges Trish Armstrong-Child will continue the work around level 1 care commenced by Dr Bene

A

3

Operational model - Critical care/ critical care building infra structure

Development of upgraded level 2 - 3 areas Plans completed but currently on hold

Trust Board

Unable to agree as on hold

On hold due to financial imperative – timeline to be determined by trust strategic/ capital build priority

R

Development of operationally ‘closed’ critical care unit (ICU/HDU) in line with critical care network recommendation

Staffing expansion requirements quantified – need to be realised

Currently northwest outlier – GM critical care core specification mandates closed

units – new critical care CRG core specification currently in draft will also include and will influence future service

configuration/ commissioning

Trust Board

Unable to agree

as on hold

On hold currently due to financial constraints. Staffing requirements quantified – no funding agreed to date A risk escalation process to be included on the risk register

R

3

4

Improve compliance with Sepsis care bundles

Understand Trust sepsis incidence / outcomes / response

Forum considering lay member involvement

Dr Grey to identify acute division sepsis lead

Dr Wood to engage orthopaedics

Note international surviving sepsis day 13/9/13

Review of 2 x surgical cases from sepsis audit reviewed – enclosed

Sepsis Forum

JW/AG

JW

Discuss adaptation of arrest RCA process to cover sepsis so that all sepsis deaths are reviewed directed back to parent clinical team Recommendations from Sepsis audit incorporated into action plan. Rolling programme of audit on sepsis ongoing Mr. D Smith identified as surgical sepsis lead Educational event + local publicity including media coverage - next stage to embrace further community engagement Discuss availability of lactate testing on ABG Junior doctors have presented at the sepsis study day and shared learning with use of MDT. Sepsis form designed and will start using to improve screening for sepsis and encourage use of a similar process used in A/E. Community matrons have recently attended the sepsis study day and are looking into how they can support early recognition and response from a community perspective.

A

4

5

RCA arrests

Continue to embed into demonstrable clinical team learning

SJT

21/25 RCA returns received by clinical effectiveness, reflecting a good response. Dr Grey to take this back to clinical teams to discuss and encourage they continue to complete and return.

A

6

AKI pathway

Promote awareness of regional AKI pathway

Biochemistry automatic prompt introduced by Andrew Hutchinson

AH/KJ/AB Acute physicians to promote and include on acute medicine web page

A

5

Work Stream Heart Failure

Aim To ensure high quality care is achieved for patients with heart failure within the integrated organisation from diagnosis to end of life

Leads Dr Karen Lipscomb and Tracey Garde


3

Appropriate and safe management and treatment of Heart failure

Re structure/review of specialist nurses with defined roles and responsibilities to each team member and consideration to expanding service to 7 days a week.

TG

October 2013

Independent review to be conducted to look at the non ward based nursing strand. Awaiting a date for work to be commenced and completed.

A

Consultants buddy wards: PJS-B2, KL-B4, SL-B3, FK-C4, C2-on call consultant-in place since August 2012. Plans to extend the ward areas covered. Kay Lewtas to provide AQ data in a more up to date fashion to allow targeted management to ward areas failing on measures.

A

5 Outreach to respiratory wards

Specialist nurses to drive improvements and re-enforce adherence to NICE guidance. Cardiologists to deliver a sustainable outreach service to enable NICE compliance for medical review for heart failure patients during admission.

KL/TG Dec 2013 To reduce the ’breaches’ noted affecting NICE directives and AQ measures – Kay Lewtas provides monthly updates on breaches of care listing ward areas. AQ data being received 3 months retrospectively, rather than previous

A

6

6 months, allowing practice impact to be monitored more closely. E-job planning analysis to support delivering of a consultant outreach service

6 Re-creation of a heart failure care bundle

Re-design a heart failure care bundle to support new NICE directives and new AQ measures

KL/TG Nov 2013 Initial discussions within cardiology to commence before work can proceed further. Dr Bene requested that we hear at the next meeting from Dr Lipscomb on her plans to re-design HF care bundle to support new NICE and AQ measures

R

7

Work Stream Palliative and End of Life Care (EoLC)

Aim To support delivery of high quality care in the last year of life, including promoting and enabling patient’s choice and delivering of high quality care of the dying

Leads Dr Barbara Downes , Dr Kim Steel & Carmel Wiseman (Steven Wilson, Sharon France, Specialist Palliative Care Team, End of Life Care team)


2.

Explore & understand further the benefits and resource implications of implementing the Amber Care Bundle across RBH to improve earlier identification of those at the end of their life in acute hospital

Identify funding

BD/CW/KS

Sept 13 On track. Meeting held to discuss funding allocation. Proposing monies used to fund a project lead. Awaiting written confirmation of funding to be received.

A

Develop implementation plan

BD/CW/KS

Dec 13 CW & JS attended National AMBER care bundle workshop held in Manchester 18.7.13. learning from event has supported decision to appoint a facilitator to develop and lead on an implementation plan. Progress made in identifying suitable pilot areas for rolling out amber care bundle.

A

3.

Embed use of LCP within RBH

Review MDT decision making regarding the use of the LCP

BD/CW/KS

July 13 20 set of case notes audited 20th June and second set to be audited 17.7.13 to include surgical patients.

A

8

6.

To implement NHS North of England unified DNACPR policy and integration of Trust DNAR policy

Obtain update from NWAS regarding early implementer sites

Attend early implementers group meetings

Arrange steering group meeting to take implementation forward in Bolton

CW/JS March 2014

DNAR policy ratified at resuscitation committee and going to the CCG for feedback. Additionally awaiting regional feedback

A

7

During the phasing out of the LCP maintain and monitor standards of care in the last days of life

Complete data collection for national audit

BD/CW/KS

Dec 2013

Organisational & clinical data entry period (1st October - 30th November 2013). Bereaved Relatives Survey (1st October 2013 - 28th February 2014), questionnaires to be sent out to relatives by 31st October. February 2014 - organisations to upload the information from returned surveys.

A

Repeat case note audit on those supported by LCP and those not on LCP, in and out of hospital

Date to be confirmed following review of questions/standards and agreeing participants to undertake repeat audit.

A

8

Reconfigure Palliative and EofL Care Strategy groups

Identify and contact key people within divisions

Review and agree TOR’s

Agree interim action plan pending review of strategy

BD/CW/KS

Dec 2013

Reconfiguration of strategy group, currently identifying people to join the group and re-writing terms of reference. Following MRG in September team asked to contact HOD’s for divisional representation.

Action plan commenced, yet to be finalised and agreed.

R

9


1

Continued Enhanced Recovery integration within colorectal surgery. Seamless inclusion of new colorectal surgeon once appointed.

Formally integrate Enhanced Recovery to all colorectal consultants, one by one. Further develop Colorectal care pathway and launch ERAS branding Trust wide.

D Yates

Oct 2013

Enhanced Recovery uptake with 3 consultants in colorectal. Plans for 4th Consultant to adopt in October. ER is a turnaround workstream and therefore an ER steering group created to focus on Elective ER in areas of Urology, Breast and Gynaecology, Colorectal. End of October will see all colorectal surgeons adopting ER

A

2

Continue ERAS roll out and integration within Womens Healthcare Ward manager appointed for M1 Rollout to

Meet with Head of service and clinical leads to Identify self as ER lead nurse. Gain commitment form service. Set meetings and champions identified Care pathways Business case being considered to ensure permanent Enhanced recovery involvement. To ensure entrenching of Gynae and Brestcare ERAS Initial meeting with breast pathway team. Await

D Yates Jan 2014

ER in Women’s healthcare; Gynaecology component agreed and the procedures this will apply to, now need to clarify who will take follow up calls for these patients. Breast ER will be taken forward by an identified Breast Specialist Nurse as she has previous ER experience.

A

Work Stream Elective and Non Elective Surgical Workstream

Aim Safer elective surgery and better urgent care outcomes

Leads Daren Yates, Mr. Smith, Mr. Varghese and Dr Nethercott

10

Womens Healthcare-Breast

appointment of new nursing staff to support.

3

Roll out ER to Urology

Met with head of service. Miss Lee identified as clinical lead.

D Yates June 2013

Urology ER – first few patients are starting to go through pathway Mr Smith updated that a small team have commenced ER meetings to build on experience and expand ER into other services.

R

4

Roll out ER to MSK, initially # NOF BETTER URGENT CARE OUTCOMES

Met with Dr Darshan Assessment of how enhanced recovery principles could facilitate better outcomes for # NOF patients. Pilot on hold until Oct 2013 (due to staffing issues) Align and comply with national target of ERAS incorporation into #NOF from April 2013 Ortho # NOF ERAS discussion group meetings have finalised process and documentation.

D Yates/Dr Darshan/ Mr. Wykes/ Linda Woods/ Julie Pilkington/ Claire Bailey /Temp orthogeriatrician- name unknown.

Oct 2013

ER for #NOF Pilot delayed until October 2013 due to nurse vacancies. Process preparation completed with exception of education to new starters to be delivered when appointed.

A

5

SAFER ELECTIVE SURGERY-BETTER OUTCOMES Development of improved pre operative risk assessment methods to bring Trust in

Explore possible use of pre CQUINS qualification money for purchase of CPEX / CPET technology to enhance pre op risk assessment process.

D Yates/ Dr Nethercott / Dr Masheter

Jan 2014

Assistance required to move forward within division to obtain relevant funding to purchase a new CPEX service. Review of equipment requirements ongoing.

A

11

line with peer providers. Review of intra operative assessment technologies to bring Trust in line with peer providers.

Aim to use ODM with all high risk patients to improve outcomes and reduce risk by April 2013.CQUIN award potentially available. Roll out ODM training to all anaesthetists involved with Colorectal Enhanced Recovery and high risk patients. Seek board support for formal integration of ODM use within Anaesthetic pathways. - May 2013

ODM in use for all colorectal majors and P-Possum score >5%

7 Use of Risk Assessments in patients on Elective and Emergency Pathways

Formal integration of P-possum assessment in all general surgical in patients (excluding day cases):- Elective - part of pre assessment clinic Agreed with Mr. Varghese that all surgical emergencies (excluding O&G, Orthopaedic and Children) will have a P-possum score.

S. Leonard/ D.Nethercott/S. Corsan

Nov 2013

Sister Leonard is completing P-possum pre-operatively on colorectal patients. This is cross-checked with Anaesthetists. Ready to roll out to other pre-assessment nurses. Sometimes definitions of surgical grading and estimated blood loss differ, but otherwise going well. Agreement reached for a P-possum mortality score for referral to the Anaesthetic Clinic. Suggestion that this should be patients with a mortality risk of 5% that are referred to the Anaesthetic Clinic.

A

11 Audit and monitor use of P-possum scoring on patients

Audit and monitoring P-possum usage Audit tool to be designed, audit to be registered with Clinical Effectiveness and a surgical trainee to be identified and aligned to the audit.

J.Varghese/ nominated surgical trainee/ clinical effectiveness

Oct 2013

Dr Bene provided with the data from Mr Varghese on P-possum usage for emergency patients.

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12

12 Explore feasibility of acute surgical pathway

Emergency Laparotomy Pathway to be created and implemented Register in the National Emergency Laparotomy Audit (NELA)

Dr

Roberts/Mr. Smith

Nov 2013

Leads identified - Dr John Roberts(anaesthesia) Mr. Dave Smith (surgery) Dr Roberts has created an emergency laparotomy pathway. Prior to implementation discussions with surgical colleagues to be commenced. Hopeful that only minor adjustments required to pathway before using. Pathway will support the auditing of emergency laparotomy patients. Registered for NELA – to commence later this year. Mr Smith/Dr Price providing relevant information prior to project commencing.

A

13

Work Stream Respiratory

Aim Reduce mortality in COPD and Pneumonia

Leads Dr Ibrahim/M Bowden


2

Appropriate administration of Oxygen in ambulance/ Emergency care

Review current practice to include;

Oxygen prescribing/administration during interface/handover from GMAS to A/E staff

Establish a small working group to address these issues including GMAS

KI/MB October 2013 Meeting held with Matt Dunn (Advanced Practitioner, GMAS) and concerns expressed in relation to oxygen held in ambulances. Informed there is no space in ambulances to house any additional clinical equipment therefore an audit will need to gather supporting evidence that a change is required. Most patients in an ambulance receive oxygen at 6 litres as they are given a nebuliser in the vehicle and this is the minimum level required to deliver the nebuliser. Plan to audit patients and provide evidence (if found) that supports type 2 respiratory failure patients are compromised by not having smaller amounts of oxygen delivered during transit in an ambulance. Will also look at auditing oxygen usage once patient arrives in A/E. Additionally are looking into providing travel nebs for CO2 retainers if required in the ambulance. NWAS alert system – taking to clinical governance to

A

14

discuss how to incorporate into the alert system a notice to inform ambulance crew that someone from the address is likely to need controlled oxygen in the ambulance.

5

Early identification of EoLC in COPD/ Respiratory disorders

Discharge proforma

Work with palliative care team re best practice of GSF

Rapid Assessment tool i.e. COPD admission care bundle

Recognised trigger point - Implement Amber Care Bundle

Virtual ward concept for high risk patients – bronchiectasis & COPD EofLC

KI/MB October 2013 Meeting held with palliative care team and respiratory team have agreed to use the amber care bundle. Pilot to start in January 2014 for patients on virtual ward. Following pilot will meet and discuss themes with palliative care team. Dr Ibrahim and Michaela Bowden to attend training for advanced care planning.

A

6 Aspiration Pneumonia case note review

Need to interrogate data on aspiration pneumonia deaths further.

Contact Janet Heaton to look at data with increased RAMI

To review case notes of 20 identified patients of patients between Dec 12 –Jan 13

KI/MB October 2013 Case note review for aspiration pneumonia; proforma to be used has been agreed and case notes being pulled with a view to starting the audit

A

7 Reducing mortality in COPD through appropriate timely care

Design COPD admission care bundle Pilot bundle with respiratory nurse specialist – once agreed rollout/launch for D1, D2 and A&E as affects first few hours of care.

KI/Tina Dewhurst

Nov 2013 Tina Dewhurst leading on this piece of work. Working group convening to use COPD care bundle

A

KEY: Anne Gerrard (AG) Clare Blaydon (CB) Mr. Dave Smith (DS) Dr. John Roberts (JR) Dr Ambar Basu (AB) Dr Brian Bradley (BB) Tina Dewhurst (TD) Dr Kim Steel (KS) Dr Gary Saynor (GS) Dr Jackie Bene (JB) Dr K Ibrahim (KI) Anita Nasser (AN) Dr Karen Lipscomb (DrKL) Dr Kieran Moriarty (KM) Dr Steven Little (SL) Dr Owen McCormack (OM) Kay Lewtas (KL) Dr Power (SP)

15

Mr. Steve Hodgson (SH) Helen Clarke (HC) Lisa Woods (LiW) Beatrice Fox (BF) Michaela Bowden (MB) Natalie Speakman (NS) Helen Clarke (HC) Linda Woods (LW) Darren Yates (DY)

16

Completed Actions:

Work Stream Recognition and response to the physiologically deteriorating patient

Aim Implement and improve robust recognition / response systems to optimize clinical outcome Improve compliance with NICE CG50

Leads Jez Wood – Anne Gerrard – Bet Fox


1

Improve compliance with EWS recording

Audit compliance / PDSA improvement AG / BF / DP

annual Completed Feb – ongoing audits linking with Exemplar programme

G

H@N working vision development

Recruitment into team

CB May 2013

Nurse Practitioners recruited, waiting start date. Band 3 support worker re-advertised and shortlisted for. Work being undertaken with surgery/orthopaedics regarding level of support required out of hours

G

1

Optimize trust chosen `track and trigger ` system in line with national model

Development of Escalation Policy to support Exemplar Programme

Maria Sinfield

October 2012

Agreed at Professional Forum in September 12 the performance assurance framework to support nursing care indicators of which

clinical observations are an indicator

G

17

Improve compliance with EWS recording/ documentation

Review + implement electronic data/ alert systems – iBleep, Extramed, Patient track as feasible

HC / JB

Ongoing This piece of work has been incorporated into hospital at night/out of hours review and review relating to

hand held devices and completed from this workstream as review

occurring in aforementioned meetings

Implement National EWS score / chart trustwide including A&E (Exceptions paediatrics/ maternity)

Agree Clinical response algorithm via MRG

JW/AG/BF MRG

Jan 2013

National Score/Chart and Local Clinical Response Algorithm implemented trustwide January 14th 2013

G

Mandatory EWS training / awareness at Trust induction

Promote National E- learning package trustwide.

Carol LeBlanc

Feb 2013

AG /CLB to finalise clinical induction session for NEWS National e- learning training package to be promoted at Clinical Induction for medical and nursing staff All NEWS training to include reference to E-Learning website

G

2

Improve / establish robust response system to EWS H@N working vision development

Delivery of study day to support level 1 monitoring

AG/BF

Completed – 1st study day delivered Future study days to be delivered as level 1 areas identified

G

Repeat annual NICE 50 audit

JW Autumn 2012

G

Review of senior medical input model JB / DS

Dec 2012

Linked to workshops relating to hospital at night/out of hours service review therefore complete from this

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18

workstream

H@N service future model JB/NE Sept 2012

Action complete and removed from workstream as being addressed within

hospital at night/out of hours review

G

4

Improve compliance with Sepsis care bundles

Regroup sepsis forum

AG

Achieved G

Agree action plan to address key themes including: - standardising Trust sepsis audit form to

help collate numbers - develop and pilot sepsis proforma in

A&E - Continued delivery of sepsis study day - Increase education / awareness among

senior medical staff - Develop / offer sepsis education

sessions to individual specialties - Engage Director of Medical Education

in Sepsis Forum

Sepsis Forum

Ongoing

Sept 2012

Next Oct 2012

Achieved

CSQI presentation May 2012 AG-EW FY1/FY2 session June 2012/ Sept 2012- JW/AG - delivered O+G medical staff session Sept 2012- AG/JW – delivered Next full sepsis study day 18/10/12

G

Ongoing audits to identify key themes / issues impacting on compliance

Review new 2013 sepsis guidance

Trustwide generic Sepsis Audit form developed and being piloted by Junior Doctors

Sepsis Forum

CW

Ongoing

March

Audits to be completed on a quarterly basis and presented to MRG. Audit form re-designed and circulated for comments. Results of Audit to be presented at MRG in March 2013

G

5

Reduce avoidable cardiac arrest

Trust engagement in National Cardiac arrest audit

Resus Officer

Achieved G

19

Continue roll out of RCA of cardiac arrests within individual specialties

Defined need to involve specialty teams in addressing the findings – core independent team to undertake initial review and hand on to teams for emerging themes/ learning

Departmental Governance would be the appropriate forum for this

SJT to present latest RCA collated feedback June 2013 MRG

SJT / MT

July 2013

Targets set are: Reducing avoidable cardiac arrests by 10% per year and increasing RCA’s completed for Cardiac Arrests to >80% by June 2014 and >95% by 2015. Dr Thornton to present repeat audit in July 2013. CA RCA reviews not embedded into divisions, yet MDT review crucial to aid learning. HOD’s to discuss with clinical leads and incorporate RCA reviews within Mortality & Morbidity meetings identify nominated consultants to get behind undertaking CA RCA’s with divisional reviews occurring similar to CDiff/MRSA/HAVTE – currently poor clinician involvement in RCA’s so nominated clinicians to address RCA’s in context to these and not just CA RCA’s. CA review proforma to be circulated via Dr Thornton, but divisional dialogue to run alongside this. Dr Grey suggests that as Mortality and Morbidity reviews occur in all specialties then this is where they could start discussions and undertake reviews. Suggestions include that junior doctors can do a case review and share the learning within specialties.

G

20

Work Stream Heart Failure

Aim To ensure high quality care is achieved for patients with heart failure within the integrated organisation from diagnosis to end of life

Leads Dr Karen Lipscomb and Tracey Garde


1

Develop education for staff in Heart Failure and associated AQ measures

Develop education for the following staff groups to strengthen knowledge on heart failure and AQ measures:

Junior doctors (every 4 months)

Consultants

D1/D2 staff

Nursing (acute adult division)

Active case managers

KL/TG

July 2012

Education –plans for Friday lunchtime meetings with Elderly Care Consultants and junior doctors. Adopting a buddy system whereby each Cardiologist will ‘buddy’ an elderly care ward round 2-3 times a week. Meeting to finalise the division of elderly care wards amongst cardiologists to buddy. Carmel Wiseman to start GSF training for nursing staff. The HF monthly MDT Forum will also help to identify patients reaching ceiling treatment and end of life. Active case managers attending MDTs with linked person assigned to them. Will repeat this model in elderly care as a rollout.

G

21

Develop further and strengthen existing training in key areas to nursing staff (cardiology, assessment areas) for smoking cessation.

GB/TG

Oct 2012

Monthly MDT Heart Failure commenced August 2012 PJS and Steve Little to validate diagnosis in notes prior to submitting into AQ

G

Review clerking proforma in relation to smoking cessation screening questions

KL/AK May 2013 Smoking cessation screening questions now formulate part of the nursing and assessment care document

G

2

Effective and timely diagnosis of Heart Failure

Review the current system in place for accepting and prioritising echo requests for suspected new diagnosis of heart failure with detailed capture of clinical information required for decision making and prioritizing requests.

ST

June 2012

Echo request form re-designed and currently in printing. New forms in admission areas initially to aid prioritising echo requests.

G

ECHO requests: Timely requests for new inpatient diagnosis of heart failure

TG/ST June 2012

New ECHO cards are printed and placed in clinical areas/wards to allow ECHOs to be prioritorised.

G

22

3

Appropriate and safe management and treatment of Heart failure

Undertake a service improvement event with BICs department and key staff within specialty

KL/TG April-Dec 2012

RIE 10-13th April 2012 – action planned developed and in place. Heart failure pathways created, laminated and situated on notes trolleys. Same model will be adopted and go to complex care wards.

G

Re-organise Cardiologists on call schedule to allow set time to undertake consultant rounds in the assessment areas to identify and pull through heart failure patients.

KL

April-Dec 2012

Monthly Heart Failure MDT meetings for case reviews. Cardiologists will buddy wards.

G

BICs RIE planned for May 14th to look at Cardiology Rapid Access Clinics

KL/TG July 2012 Completed G

Monitor Heart failure emergency admission rates, re-admission rates and hospital bed day occupancy.

TG

April-Dec 2012

48 hour post discharge and diagnosis follow up phone call with use of a proforma being trialed to aid avoidance of re-admission. Established use of patient hand held records with patients being given supported control in condition management.

G

Participate in the National Heart Failure Audit; commences in April 2012

LW

Ongoing

Undertaking audit for past 6 weeks which is already highlighting where the problems lie. The themes encourage the continuation of plan to buddy elderly care wards. Has

G

23

been helpful in identifying that the primary diagnosis is not HF.

Advancing Quality Heart Failure Audit KL Ongoing Continuation of a perspective and prospective data collection. Awaiting results.

G

4

Raising awareness and recognition to End of Life Care for Heart Failure patients

Agree a pathway to support safe removal of an Implantable Cardioverter Defibrillator (ICD) in heart failure patients when identified as dying and commenced on the Liverpool Care Pathway.

PS/SL August 2012

Monthly forum has been launched and have an interim arrangement in place for ICD switch off at end of life. The Cardiac Network ICD Deactivation Policy will be formally endorsed at the Cardiac Network Board Meeting on 8th November. Dr Little is a member of the working group and attending the meetings.

G

To take forward High Impact Actions; Important Choices, identifying End of Life and communication of this with patient and family and facilitating patients to die at their place of choice.

KL/TG/ Palliative care team/JB

Nov 2012

GSF: discussions as part of the monthly forum re End of Life in place, proactive use of Specialist Palliative Care team for end stage heart failure certainly on C1 and recommendations going on ASCRIBE to GPs for GSF.

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24

Work Stream End of Life Care (EoLC)

Aim To support delivery of high quality care in the last year of life, including promoting and enabling patient’s choice and delivering of high quality care of the dying

Leads Dr Marion Lieth


1

Improve engagement and awareness of EoLC within trust

Expand membership of ‘Bolton Palliative Care and EoLC Strategy Group’ to strengthen representation from acute trust at strategic meeting

BD/ML May ‘12 May ’12 - Helen Clarke, Linda Woods and Anne Cleary now members of ‘Bolton Palliative Care and EoLC Strategy Group’

G

1.

Earlier identification of those at the end of life in primary care by supporting GPs to increase their awareness & sign up to the Dying Matters 1% Campaign

Undertake baseline assessment of practices who have signed up to the campaign

Undertake proactive visits to each GP practice

Work collaboratively with the Triple Aim team to support the EoLC project which incorporates the 1% campaign

CW

SF

BD/CW

March 13

Jan – Dec 13

Jan-Dec 13

Baseline assessment completed

Meeting with triple aim completed 4.2.13.

Practice visits have commenced

Earlier identification & 1% campaign is incorporated in Palliative & EoLC training

GP training event to be arranged May 2013 by Triple Aim team

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25

2.

Explore & understand further the benefits and resource implications of implementing the Amber Care Bundle across RBH to improve earlier identification of those at the end of their life in acute hospital

Attend regional workshops CW Jan-March 13 1st workshop attended 31.1.13 2nd workshop attended 21.3.13

G

2

EoLC developments thoughout divisions

Develop EoLC objectives for trust overall ML Mar ‘12 March ’12 – 1st meeting with HC, MS, AC, LW, CWi, Steve Wilson, ML; agreed to develop EoLC objectives for trust to support EoLC developments throughout divisions

G

3.

Embed use of LCP within RBH

Reduce missing data on LCP and improve documentation

ML/CW Jan 13 Facilitator project till end of Jan 13, 2 ½ days per week, extending to 3 further wards (D1, D2, C1) and continuing B3, B4, C3, D3, D4; final report early 2013

G

Review action plan for National Care of the Dying Audit Acute Hospitals

BD/CW

April13

Completed - Meeting with BD & CW 26.4.13. Action plan reviewed. Revised action plan completed G

26

Register for round 4 of the National LCP audit

JS Sept13 Registration for involvement in the National LCP audit completed. Data Entry period opens 1st Sept 2013 Data Entry period closes 30th Nov 2013 Bereaved Relative Survey 28th Feb 2014 Final Audit report 2014

G

7

During the phasing out of the LCP maintain and monitor standards of care in the last days of life

Complete registration on national LCP BD/CW/KS

Dec 2013 Registration completed

G

4. RBH staff appropriately trained in EoLC

Able to report attendance at Pall Care and EoLC training based on divisions/ professional groups

ML/ CW

July ‘12 Attendance database developed and has been in use since 1st September 2012

G

4.

Develop a training & education strategy which is consistent with the Network Education

Strategy

Bolton FT to have representation on the Network Education Strategy Group

CW

Feb 13

Completed

G

Cross reference Bolton FT training programme with network programme when final version released

CW

March 13

Completed

G

Review priorities for training & education as Palliative & EoLC educator has left the organization & agree membership of a group who will develop a local strategy

CW May 13 Meeting held 22.5.13 and priorities agreed until Dec13

Education Strategy group meeting arranged for 30.7.13

G

5. Support achievement of

Agree data collection & reporting requirements

CW/SW/BD

June 13

Meeting held 4.6.13 with contracts dept. Data collection & reporting requirements G

27

EoLC CQUIN agreed

Develop data collection & reporting systems

CW

July 13

Data collection & reporting systems developed further G

Arrange meeting with DN managers

SW/CW

July 13

Meeting held 10.6.13 & 26.6.13 with CW, SW & DN managers. Action plan developed and agreed with the DN teams involved.

G

Deliver training and education for the teams involved

SF June 13 Training programmed developed and delivery dates agreed

G

28

Work Stream Enhanced Recovery

Aim Integration of Enhanced Recovery as Standard Practice

Leads Daren Yates


5

SAFER ELECTIVE SURGERY-BETTER OUTCOMES Development of improved pre operative risk assessment methods to bring Trust in line with peer providers. Review of intra operative assessment technologies to bring Trust in line with peer providers.

Formal integration of anaesthetist assessment and presence as part of pre assessment clinic for all colorectal surgery.

D Yates/ S. Leonard

Ongoing

Achieved

G

Explore assessment tools. Explore and review NICE guidelines. Explore NICE guidelines. Explore and review professional bodies guidance. Explore and review possible use of pre CQUINS qualification money or other funding sources for intra operative technologies support. Increased the use of intra-operative oesophageal doppler monitoring.

Dr Nethercot/ Daren Yates

Ongoing 26/06/12

Compliant with NICE guidelines 2003 in pre-assessment clinic – full nutrition and skin integrity assessment completed so actions can be taken prior to surgery to optimize patients for surgery. Free loan of equipment agreed in principle. Regional Innovation fund money assured to purchase ODM equipment.

G

6 Use of Risk Assessments

Possum Scoring – discuss use of possum scoring with patients for Elective and Non

Daren Yates/Mr

P-possum incorporated into surgical clerking proforma. Communication

29

in patients on Elective and Non Elective Surgical Pathways

Elective patients Creation of a range of risk assessments for use in surgery with audit and monitoring of their usage.

Varghese/ Anaesthetist

on action being coordinated to surgical teams. Agreement reached that emergency surgical patients being booked into emergency theatres provide a P-possom score for patient on booking.

G

8 Agree a process to ensure all high risk patients are alerted to Anaesthetists

Devise a protocol/flowchart which enables those undertaking P-possum scoring to escalate ‘high risk patients’ to Anaesthetist. Alert of high risk patients to be identified on LE2.2 – agreement to highlight who will input the alert onto LE2.2

S. Leonard/ D.Nethercott/S. Corsan

April 2013

Team to incorporate into current process use of P-Possum. Alerts for high risk patients are now being inputted into LE2.2 by anaesthetic secretaries.

G

7 Use of Risk Assessments in patients on Elective and Emergency Pathways

Formal integration of P-possum assessment in all general surgical in patients:- Emergency – include into booking process for all emergencies

J.Varghese April 2013

Trial of P-possum scoring for all in-patients commenced in January. Piece of work being led by Surgeons who will be completing this assessment to identify high risk patients early and refer them as necessary. P-possum scoring to be included as part of booking process and checked when patients being placed onto emergency theatre list. Dr Corsan updated that since previous update, Mr. Varghese may have altered the remit of patients requiring P-Possum. Nashaba Ellahi to clarify with Mr. Varghese.

G

9 Improve Training and Education on use of P-possum for surgical

Include into specialty training programme for surgical doctors the use of P-possum and relevant understanding of undertaking. Encourage use of free website amongst surgical teams: riskprediction.org.uk Arrange desktop icon for risk scoring tool above


Matron within Elective care (Janet Howarth) is progressing with all surgical PC’s having icon for risk scoring – on target to achieve by February. Surgical Risk application to be applied to identified surgical

G

30

trainees to be available on PCs on surgical wards for ease of use by teams

PCs on 18/02/13. Nottingham Hip Fracture Score apps not required as Mr. Wykes has incorporated an appropriate scoring system into the Hip Fracture Care Pathway.

10 To closely observe and align clinical coding of co-morbidities in collaboration with coders

To encourage clinical engagement with coding, reviewing and validating coding of live patients but also of deaths. To identify a clinical coder and lead surgeon to take above forward.


Discussions of all mortalities take place in audit meetings. Further discussions to take place within division to agree a standard to identify deaths that require further validation. Mr. Varghese to discuss with Coding and Dr Ibrahim to explore if they can make any improvements.

G

31

Work Stream Respiratory

Aim Reduce mortality in COPD and Pneumonia

Leads Dr Ibrahim/M Bowden


3

Appropriate treatment pathway during in-patient stay of COPD

Early respiratory assessment 7days/week

Risk stratification

COPD care bundle/ICP

Liaise with palliative care team re early identification of patients

KI/MB/HO September 2012 onwards

Still reviewing risk stratification tools. 7day nursing service resumes Nov 2012. Consultant 7 day working due to start 13th October

G

1 Accurate reflection of current practice

Audit notes of deaths 2011

Live data collection at coding on a weekly basis

Share information with respiratory team and mortality reduction group

KI/MB/HO June 2012 onwards

This action to be monitored and tracked in Respiratory Governance Meetings with 6 monthly feedback on audit findings

G

4

Appropriate treatment pathway during in-patient stay of Pneumonia

Early respiratory assessment 7days/week

Risk stratification

Pneumonia care bundle/ICP

Education programme for assessment areas

Education programme for non-respiratory ward areas

BB/ October 2012 onwards

Education tool for pneumonia in place since October 12. Recent agreement that specialist nurses will have linked areas/wards where they will take forward training, education and audit.

G

Report prepared for Royal Bolton Hospital NHS Foundation Trust

by AQu.A Analytics

Page 1 of 24 FileName Version 0.4

5th

June 2013

Quarterly Mortality Report

Report No. 01

August 2013

Edition prepared for:

Royal Bolton Hospital NHS Foundation Trust

Author: Paul Hawgood

Version: 1.1

Contents Page AQuA Quarterly Mortality Report Issue 01

Version 1.1 5

th September 2013

Contents

INTRODUCTION ............................................................................................................ 1

SECTION 1 – The North West ..................................................................................... 2

1.1 Crude Mortality Rate .......................................................................................................... 2

1.2 SHMI .................................................................................................................................. 3

1.3 SHMI – proportion of deaths that occur in-hospital.............................................................. 6

1.4 SHMI – diagnosis groups ..................................................................................................... 7

SECTION 2 – Trusts in the North West ...................................................................... 8

2.1 Crude Mortality Rate .......................................................................................................... 8

2.2 SHMI .................................................................................................................................. 9

2.3 Palliative Care coding .......................................................................................................... 9

2.4 Signs and Symptoms coding .............................................................................................. 11

2.5 Co-morbidity .................................................................................................................... 13

SECTION 3 – Your Trust ............................................................................................ 14

3.1 Crude Mortality Rate ........................................................................................................ 14

3.2 SHMI ................................................................................................................................ 15

3.3 Palliative Care Coding ....................................................................................................... 15

3.4 Signs and Symptoms coding .............................................................................................. 17

3.5 Co-morbidity .................................................................................................................... 18

Appendix A: Differences between HSMR, RAMI and SHMI

Appendix B: Metadata

A


by AQuA Analytics

Page 1 of 18 AQuA Quarterly Mortality Report Issue 01

Version 1.1 5

th September 2013

INTRODUCTION

This is the first quarterly report on Mortality produced by AQuA Analytics for the benefit of its

members.

The report provides information on mortality rates, indicators of the quality of care and

system/process measures that may affect the quality of care. The report does focus on the

data, however, this is only one part of understanding the issues that may affect a Trust’s

mortality rate. They are an indicator, a sign-post, a prompt to looking at the wider system

issues; these issues and themes are explored in detail in AQuA’s Mortality Lessons Learned

publication (May 2013).

Many of the indicators contained within this report relate to Standardised Mortality Ratios.

There are several different methodologies available for the calculation of these ratios – see

Appendix A for a summary of the differences between the three main methodologies.

Throughout this report, data relating to the Summary Hospital-level Mortality Indicator [SHMI]

has been used. This is because this is the methodology used and published by the NHS

Health and Social Care Information Centre [HSCIC].

This report is set out in three sections:

Section 1 compares the North West with other regions of England.

Section 2 looks at the differences in data for the 22 Trusts in the North West for

which the NHS HSCIC produces a SHMI.

Section 3 provides more detailed information for your trust.

Some inferences and conclusions have been drawn from the data, however, this often needs

to be set in the context of the wider health-economy. AQuA has a rolling programme of

Mortality Reviews in order to support the understanding of issues surrounding mortality and

the quality of care provided in a Trust and the health economy that it serves. Detailed trust-

level analysis and inferences are best placed within this programme.

This report has been prepared following the publication of the SHMI for the period January to

December 2012; Appendix B details the metadata for the information contained within this

report.


by AQuA Analytics


Version 1.1 5

th September 2013

SECTION 1 – The North West

1.1 Crude Mortality Rate

The North West has the fifth lowest crude in-hospital mortality rate in England with a rate

that is similar to the overall rate for England – see chart 1. The rates for both England and

the North West have been reducing over the past four years – see chart 2.

Chart 1 – crude in-hospital mortality rate

Chart 2 – crude in-hospital mortality rate time series


by AQuA Analytics


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th September 2013

Across the former SHAs, crude mortality rates for non-elective [NEL] activity are between 5

and ten times higher than for elective [EL] activity; the crude NEL mortality rate for England

being 2.7% and the crude EL mortality rate for England being 0.4% (nearly 7 times higher) –

see chart 3. A similar pattern is seen for deaths occurring within 30 days of discharge. When

reviewing the underlying causes of high(er) mortality rates, it would, therefore, be beneficial

to explore pathways relating to emergency care.

Chart 3 – crude in-hospital mortality rate, NEL & EL split

1.2 SHMI

This report does not aim to describe the SHMI methodology in detail, nor to compare the

SHMI methodology to other methodologies e.g. HSMR. Appendix A shows a summary of the

differences between the three main methodologies and further information is available from

AQuA Analytics.

Although the North West has the fifth lowest crude mortality rate in England, it has the

highest SHMI – see chart 4. In essence, this means that the low crude mortality rate is to be

expected given our demographic make-up, the case-mix that we treat and the other illnesses

that our patients have. Indeed, our current SHMI of 1.07 means that it is expected that our

crude rate should be lower.


by AQuA Analytics


Version 1.1 5

th September 2013

Chart 4 – latest SHMI

The SHMI for the North West has been worsening since the indicator was first published for

the period Apr 2010 to Mar 2011. [The HED analytical tool re-creates SHMI to a high degree

of accuracy which does, therefore, allow for calculations to be made for periods prior to the

first publication – see chart 5.]

Chart 5 – NW SHMI time-series


by AQuA Analytics


Version 1.1 5

th September 2013

As was seen in chart 2, the crude mortality rate for the North West is falling but no faster

than it is for England. The SHMI is a relative-risk model centered around England having a

value of 1.00 for each publication. The fact that our SHMI is increasing over time [against a

back-drop of a reducing crude mortality rate] means that the SHMI-constructed risk model is

expecting relatively fewer deaths in the North West each time the SHMI is published and that

our reduction in Observed deaths is not keeping pace with this reduction in Expected deaths.

Factors that affect this risk model such as Signs and Symptoms coding and levels of co-

morbidity are described later in the report.

The impact of the modelling is illustrated further in chart 6. It shows that, for each SHMI

period apart from the latest publication, the number of Expected deaths has reduced.

Although our crude mortality rate has also reduced [as supported by the reduced number of

Observed deaths], this has not been at the same rate as the reduction in the number of

Expected deaths – indeed, there has been a small increase in Observed deaths in the three

most recent publications.

Chart 6 – NW SHMI Observed & Expected deaths time-series


by AQuA Analytics


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th September 2013

1.3 SHMI – proportion of deaths that occur in-hospital

The SHMI is calculated using deaths that occur in-hospital and those that occur within 30

days of discharge. Chart 7 shows the proportion of the total number of deaths that have

occurred in-hospital. Low levels of in-hospital deaths could be due to several factors

including patients being discharged too early and high levels of nursing, residential and

hospice care. The North West has a similar rate to the England average.

Chart 7 –% deaths in-hospital

Chart 8 – % deaths in-hospital time-series


by AQuA Analytics


Version 1.1 5

th September 2013

1.4 SHMI – diagnosis groups

For the purposes of constructing the SHMI risk model, the thousands of ICD10 codes are

grouped into 140 groups of similar conditions – these are known as CCS Groups*. The

number of Expected deaths is calculated for each CCS Group, compared to the Observed

number of deaths for that CCS Group and hence a SHMI calculated for that Group. CCS

Groups that have a high SHMI value may relate to conditions of low volume. It is, therefore,

more appropriate to be aware of the conditions that have the highest variance between the

number of Observed deaths and the number of Expected deaths (often referred to as the

number of Excess deaths) – see chart 9.

Chart 9 – excess deaths in NW by SHMI CCS Group

* CCS stands for Clinical Classification System. Each ICD10 code is mapped to one of 260

CCS Categories; these 260 Categories are then mapped to one of 140 CCS Groups. A full

list of the descriptions of each Category, of each Group and the related mapping is available

from AQuA Analytics.


by AQuA Analytics


Version 1.1 5

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SECTION 2 – Trusts in the North West


Based upon the latest published data, crude in-hospital mortality rates in North West

hospitals varies from 1.6% to 3.3% - a two-fold difference – see chart 10.

Chart 10 – crude in-hospital mortality rate by trust

There is a similar degree of variance for in-hospital deaths for non-elective admissions –

from 1.9% to 4.0% - see chart 11.

Chart 11 – crude in-hospital NEL mortality rate by trust


by AQuA Analytics


Version 1.1 5

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2.2 SHMI

Chart 12 shows the latest SHMI together with the range of the 95% Confidence Interval for

the 22 Trusts in the North West of England.

Chart 12 – latest SHMI by trust

2.3 Palliative Care coding

The Health and Social Care Information Centre publishes some contextual information for

domains that are not accounted for in the SHMI – one of these domains is Palliative Care. A

patient can be deemed to have received Palliative Care by virtue of Specialty Code 314

being present in any other their episodes or by having ICD10 Code Z515 in any diagnosis in

any episode. The charts below [13 and 14] show the rate of coding where either the

Specialty Code or the Diagnosis Code is present during the Spell; chart 13 is for all patients

and chart 14 is where the patient died.


by AQuA Analytics


Version 1.1 5

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Chart 13 – Palliative Care coding by trust, all patients

Chart 14 – Palliative Care coding by trust, patients died


by AQuA Analytics


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2.4 Signs and Symptoms coding

The level of Signs and Symptoms coding [R codes] is important because it has inferences

on the quality of care and has an impact on the calculations used to create the SHMI.

High levels of R codes may imply lower access to senior medical opinion and later

commencement of appropriate treatment. If R codes remain as the primary diagnosis

through the first few episodes of a patient’s pathway then this could be indicative of multiple

hand-overs within a short period of time i.e. during the period of diagnostic investigation.

R codes remaining as the primary diagnosis for the first 2 episodes affects the calculation of

the SHMI, usually in an adverse way. The SHMI uses the primary diagnosis of the first

episode to assign the CCS Group of that admission. If the primary diagnosis of the first

episode is an R code then the primary diagnosis of the second episode is used. However,

should the diagnosis of the second episode also be an R code then the SHMI will revert

back to the first episode’s primary diagnosis.

The CCS groups that R codes map to have relatively low mortality rates and, therefore, low

numbers of expected deaths. If a trust has a high level of R coding then it is more likely to

have a higher level of deaths with an R code as the primary diagnosis (first and second

episode). In turn, this will raise the number of excess deaths for that CCS group and,

ultimately, the total for the trust.

Chart 15 shows the general use of R Codes – there is a two-fold difference between the trust

with the highest usage of R codes in the primary diagnosis [24.6%] (all episodes of a Spell

where the first episode was non-elective) and the trust with the lowest [12.2%].

Chart 15 – Signs & Symptoms coding by trust, NEL, all episodes, all patients


by AQuA Analytics


Version 1.1 5

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Chart 16 shows the use of R Codes in the first episode – here, there is also a two-fold

difference between the trust with the highest usage of R codes in the primary diagnosis

[19.9%] and the trust with the lowest [9.7%].

Chart 16 – Signs & Symptoms coding by trust, NEL, first episode, all patients

As outlined above, the impact of high levels of R coding on a trust’s SHMI would be greatest

where a patient has died. The patients reported in chart 17 will also have been reported in

charts 15 & 16 so chart 17 focuses on the last episode. This highlights the incidence of a

definitive diagnosis not having been recorded by the time the patient has died. In this area, a

much greater variance between trusts is observed [from 5.5% to 0.4%].

Chart 17 – Signs & Symptoms coding by trust, NEL, patients died


by AQuA Analytics


Version 1.1 5

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2.5 Co-morbidity

Levels of coding are important for several reasons. Accurate and comprehensive recording

of co-morbidities will better reflect the state of health of the patients that the trust is treating.

Lower levels may be due to:

this information not being recorded by the clinician in the patient’s notes

this information not being recorded clearly enough

this information not being recorded fully on the Trust’s PAS

healthier patients

Levels of co-morbidity are used in both the SHMI and HSMR. A relatively high level of co-

morbidity increases the expected number of deaths in these calculations and so has the

effect of reducing the standardised mortality ratio.

Comparative levels of co-morbidity are arrived at using the Charlson Co-morbidity Index.

This Index assigns a weighting to 17 different conditions – the higher the weighting, the

higher the perceived impact of that co-morbidity on a patient’s risk of dying. A full list of these

conditions, their weighting and the underlying ICD10 codes used are available on request

from AQuA Analytics.

For non-elective episodes, there is a fair range of average Charlson values per episode

between trusts in the North West [from 3.3 to 5.8] – see chart 18. This may be a reflection of

the relative health of the population that each trust serves but it could also reflect more

comprehensive coding processes.

Chart 18 – Co-morbidity score by trust, NEL


by AQuA Analytics


Version 1.1 5

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SECTION 3 – Your Trust

This section shows information for your Trust. The North West edition of this report is not

specific to any particular trust; there is, therefore, no data to show in the “Trust” row of the

tables below.

The data relates to the same domains as in Section 2 but shows a time-series in order to

show whether areas are showing improvement or deterioration.

Trust Name Royal Bolton Hospital NHS Foundation Trust

Trust Code RMC


Fin. Year 2009/10 2010/11 2011/12 2012/13

Trust 2.85% 2.57% 2.39% 2.08% North West 2.68% 2.49% 2.36% 2.34% England 2.65% 2.41% 2.34% 2.28%

Chart 19 – trust crude in-hospital mortality rate time series

2.0%

2.1%

2.2%

2.3%

2.4%

2.5%

2.6%

2.7%

2.8%

2.9%

2009/10 2010/11 2011/12 2012/13

Pe

rce

nta

ge o

f d

isch

arge

s

Crude in-hospital Mortality Rate

Royal Bolton Hospital NHS Foundation Trust North West England

Source: HED


by AQuA Analytics


Version 1.1 5

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3.2 SHMI

Period Apr 10 - Mar 11

Jul 10 - Jun 11

Oct 10 - Sep 11

Jan 11 - Dec 11

Apr 11 - Mar 12

Jul 11 - Jun 12

Oct 11 - Sep 12

Jan 12 - Dec 12

Trust 1.05 1.05 1.04 1.07 1.06 1.03 1.01 1.01 North West 1.05 1.06 1.06 1.05 1.05 1.06 1.07 1.07

Chart 20 – trust SHMI time-series

3.3 Palliative Care Coding

The first table and chart relate to all patients admitted; the second table and chart relate to

patients that died.


Jul 10 - Jun 11

Oct 10 - Sep 11

Jan 11 - Dec 11

Apr 11 - Mar 12

Jul 11 - Jun 12

Oct 11 - Sep 12

Jan 12 - Dec 12

Trust 0.9% 0.9% 0.9% 1.0% 1.0% 1.0% 1.0% 1.0% North West 0.89% 0.87% 0.88% 0.95% 0.92% 0.95% 1.00% 1.04% England 0.89% 0.88% 0.91% 0.95% 0.99% 1.02% 1.04% 1.06%

0.90

0.95

1.00

1.05

1.10

Apr 10 -Mar 11

Jul 10 - Jun11

Oct 10 -Sep 11

Jan 11 -Dec 11

Apr 11 -Mar 12

Jul 11 - Jun12

Oct 11 -Sep 12

Jan 12 -Dec 12

Ind

ex

SHMI


Source: HED


by AQuA Analytics


Version 1.1 5

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Chart 21 – trust Palliative Care coding time-series, all patients


Jul 10 - Jun 11

Oct 10 - Sep 11

Jan 11 - Dec 11

Apr 11 - Mar 12

Jul 11 - Jun 12

Oct 11 - Sep 12

Jan 12 - Dec 12

Trust 16.5% 16.8% 17.2% 17.4% 18.9% 19.0% 19.7% 20.3% North West 16.4% 15.9% 15.7% 15.8% 16.7% 17.1% 18.1% 18.7% England 16.6% 16% 16.4% 17.2% 17.9% 18.4% 18.9% 19.1%

Chart 22 – trust Palliative Care coding time-series, patients died

0.8%

0.9%

1.0%

1.1%

Apr 10 -Mar 11

Jul 10 - Jun11

Oct 10 -Sep 11

Jan 11 -Dec 11

Apr 11 -Mar 12

Jul 11 - Jun12

Oct 11 -Sep 12

Jan 12 -Dec 12

Pe

rce

nta

ge o

f d

isch

arge

s

Palliative Care Coding: All Patients (Combined: Diagnosis and Specialty)


Source: HSCIC

14%

16%

18%

20%

22%

Apr 10 -Mar 11

Jul 10 - Jun11

Oct 10 -Sep 11

Jan 11 -Dec 11

Apr 11 -Mar 12

Jul 11 - Jun12

Oct 11 -Sep 12

Jan 12 -Dec 12P

erc

en

tage

of

de

ath

s [i

n/o

ut

of

ho

spit

al}

Palliative Care Coding: Patient Died (Combined: Diagnosis and Specialty)


Source: HSCIC


by AQuA Analytics


Version 1.1 5

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3.4 Signs and Symptoms coding

All non-elective FCEs.

Fin. Year 2008/09 2009/10 2010/11 2011/12 2012/13

Trust 21.1% 15.5% 16.8% 15.9% 13.0% North West 18.6% 18.1% 17.8% 17.3% 16.2% England 16.1% 15.8% 15.6% 15.1% 14.8%

Chart 23 – trust Signs & Symptoms coding time-series, NEL, all patients

First Episode of the non-elective Spell.

Fin. Year 2008/09 2009/10 2010/11 2011/12 2012/13


Chart 24 – trust Signs & Symptoms coding time-series, NEL, all patients

12%

15%

18%

21%

24%

2008/09 2009/10 2010/11 2011/12 2012/13

Pe

rce

nta

ge

NEL FCEs with an R Code as the primary diagnosis


Source: HED

12%

14%

16%

18%

20%

22%

2008/09 2009/10 2010/11 2011/12 2012/13

Pe

rce

nta

ge

NEL FFCEs with an R Code as the primary diagnosis


Source: HED


by AQuA Analytics


Version 1.1 5

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Last Episode of the non-elective Spell where the patient has died.

Fin. Year 2008/09 2009/10 2010/11 2011/12 2012/13


Chart 25 – trust Signs & Symptoms coding time-series, NEL, patient died

3.5 Co-morbidity

Fin. Year 2008/09 2009/10 2010/11 2011/12 2012/13

Trust 2.5 2.9 3.4 3.3 3.4 North West 3.1 3.4 3.8 3.9 4.1 England 2.9 3.2 3.5 3.8 4.1

Chart 26 – Charlson Co-Morbidity Index time-series, NEL

0%

2%

4%

6%

8%

2008/09 2009/10 2010/11 2011/12 2012/13

Pe

rce

nta

ge

NEL FFCEs with an R Code as the primary diagnosis of the last Episode - patient died


Source: HED

2

3

4

5

2008/09 2009/10 2010/11 2011/12 2012/13

Ave

rage

Sco

re p

er

Epis

od

e

Charlson Co-morbidity Index - NEL episodes


Source: HED

Appendix A: Differences between HSMR, RAMI and SHMI

Hospital Standardised

Mortality Rate (HSMR)

Risk Adjusted Mortality

Index (RAMI)

Summary Hospital-level

Mortality Indicator (SHMI) **

Observed

All spells culminating in death

at the end of the patient

pathway, defined by specific

diagnosis codes for the

primary diagnosis of the spell:

uses 56 diagnosis groups

which contribute to approx.

80% of in hospital deaths in

England*

Total number of observed in-

hospital deaths

Number of observed in-

hospital deaths plus deaths

out of hospital within 30 days

of discharge

Expected

Expected number of deaths Expected number of deaths Calculated using a 10 year data set (as of 2012) to get the risk estimate

Expected number of deaths Calculated using a 36 month data set to get the risk estimate

Adjustments Sex Age in bands of five up

to 90+ Admission method Source of admission History of previous

emergency admissions in last 12 months

Month of admission Socio economic

deprivation quintile (using Carstairs)

Primary diagnosis based on the clinical classification system

Diagnosis sub-group Co-morbidities based on

Charlson score Palliative care Year of discharge

Sex Age Clinical grouping (HRG) Primary and secondary

diagnosis Primary and secondary

Procedures Hospital type Admission method

Further detailed methodology

information is included in

CHKS products, or specific

enquiries to CHKS

www.chks.co.uk

Sex Age group Admission method Co-morbidity Year of dataset Diagnosis group

Details of the categories

above can be referenced

from the methodology

specification document at

http://www.ic.nhs.uk/services/

summary-hospital-level-

mortality-indicator-shmi

Exclusions Excludes day cases and

regular attendees

Excludes mental illness,

obstetrics, babies born in or

out of hospital, day cases,

and patients admitted as

emergencies with a zero

length of stay discharged

alive and spells coded as

palliative care (Z515)

Specialist, community, mental health and independent sector hospitals.

Stillbirths Day cases, regular day

and night attenders

Whose data is

being compared

and how much data

is used for

comparison e.g. all

trusts or certain

proportion etc.

All England provider trusts via

SUS

Data attributed to all Trusts

within a ‘super-spell’ of

activity that ends in death

UK database of Trust data

and HES

Data attributed to Trust in

which patient died

All England non-specialist

acute trusts except mental

health, community and

independent sector hospitals.

Data attributed to Trust in

which patient died or was

discharged from

*HSMR does not exclude 20% of deaths, it looks for the diagnosis groups that account for the majority

of deaths, and the figure of 80% is quite variable dependent on the case mix of the trust. HSMR

could just as easily cover 100% of activity. It covers 80% of activity mostly for historical reasons and

the fact that you get little extra value from the other 20%.

** The HSCIC publishes the SHMI indicator as observed, expected, denominator, value, upper control

limits, lower control limits and banding. The term numerator is not used in the publication.

http://www.chks.co.uk/

http://www.ic.nhs.uk/services/summary-hospital-level-mortality-indicator-shmi



Appendix B - Metadata Page i of iii AQuA Quarterly Mortality Report Issue 01

Version 1.1 5

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Annex B: Metadata

Resource type

Title Description Coverage Numerator Denominator Date Publisher Source Status

Mortality Charts 1 & 10

Crude in-hospital mortality rate

142 SHMI Trusts

Discharge Method = 4

All discharges Latest published SHMI (12 month period)

HSCIC HED Published



142 SHMI Trusts (22 in North West)


All discharges 1.4.2009 – 31.1.13

HSCIC HED Published



142 SHMI Trusts



HSCIC HED Published

Split as per Appendix B.3 of the SHMI Indicator Specification i.e. Elective = Admission Method 11, 12, 13 Acute [NEL] = 21, 22, 23, 24, 28, 31, 32, 81, 82, 83, 84, 89, 98

Mortality Chart 4 SHMI 142 SHMI Trusts

Observed deaths Expected deaths Latest published SHMI (12 month period)

HSCIC HED Published

Mortality Charts 5, 12 & 20

NW SHMI 22 Trusts in North West

Observed deaths Expected deaths Latest published SHMI (12 month period)

HSCIC HED Published

Mortality Chart 6 Observed and Expected deaths

22 Trusts in North West

N/A N/A October 2009 – December 2012

HSCIC HED Published

Appendix B - Metadata Page ii of iii AQuA Quarterly Mortality Report Issue 01

Version 1.1 5

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Resource type


Mortality Chart 7 % Deaths occurring in-hospital

142 SHMI Trusts


Discharge Method = 4 plus deaths from the HES-ONS linked mortality data file

Latest published SHMI (12 month period)

HSCIC ONS

HED Published

Mortality Chart 8 % Deaths occurring in-hospital

142 SHMI Trusts (22 in North West)



October 2009 – December 2012

HSCIC ONS

HED Published

Mortality Chart 9 Excess deaths by CCS Group


The sum of Observed deaths minus Expected deaths where this is >0 for a Trust.


HSCIC HED Published

Clinical Coding

Chart 13 & 21

Palliative Care coding


Patients with ICD10 Code Z515 in any position of any episode or Specialty Code 315 in any episode


HSCIC HSCIC Published

Clinical Coding

Chart 14 & 22

Palliative Care coding


Patients with ICD10 Code Z515 in any position of any episode or Specialty Code 315 in any episode (where Discharge Method = 4)



HSCIC HSCIC Published

Clinical Coding

Charts 15 & 23

Signs & Symptoms coding


ICD10 “R” code in primary diagnosis of any episode. Admission Method

Number of episodes

Latest FY for which data has been published

HSCIC HED Published

Appendix B - Metadata Page iii of iii AQuA Quarterly Mortality Report Issue 01

Version 1.1 5

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Resource type


= 21 – 28, 31, 32, 81 – 89, 98.

Clinical Coding

Charts 16 & 24



ICD10 “R” code in primary diagnosis of the first episode. Admission Method = 21 – 28, 31, 32, 81 – 89, 98

Number of first episodes [i.e. Spells]


HSCIC HED Published

Clinical Coding

Charts 17 & 25



ICD10 “R” code in primary diagnosis of last episode. Admission Method = 21 – 28, 31, 32, 81 – 89, 98 (where Discharge Method = 4)

Number of last episodes [i.e. Spells] Discharge Method = 4


HSCIC HED Published

Clinical Coding

Chart 18 & 26

Charlson Co-morbidity Index


Total co-morbidity score for all relevant codes in Diag02 – Diag20 for each episode

Number of episodes


HSCIC HED Published

1 See Appendix D.1 of SHMI Methodology

1

Agenda Item No: 10

Meeting Trust Board Meeting


Title Pressure Ulcer Prevention Strategy

Executive Summary



Despite pressure ulcer prevention and management being one of the Trusts top three objectives for 2013/14 there is currently no evidence to suggest that the organisation had a systematic approach to understanding why pressure ulcers are still occurring and what standards need to be met to ensure improvement in occurrence happens. Over recent months the clinical and corporate teams have developed an improved and proactive approach to challenging why pressure ulcers are occurring. The attached strategy has been developed to clearly outline the approach the Trust is taking towards the management and prevention of Pressure Ulcers. A zero tolerance of grade 3 and 4 hospital/community acquired pressure ulcers will be enforced through the delivery of the strategy.

Delivery of the Pressure Ulcer prevention strategy is key for the organisation in its aim to provide Harm Free care, and provide patients with positive experiences of the care delivered.

19

12

29 27

13 15

0 0 0 0 0 0

-10

-5

0

5

10

15

20

25

30

35

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Nu

mb

er

of

Cas

es

Pressure Ulcer Total (2,3 and 4) 2013 -2014 (All Areas)

Total Target Linear (Total)

2


The Strategy will be launched in November 2013 across the organisation.

Discuss Receive

Approve * Note



Strategy * Financial Implications

Performance * Legal Implications

Quality * Regulatory


NHS constitution rights and pledges

Equality Impact Assessed


Prepared by

Beverley Tabernacle, Deputy Director of Nursing. Jacqui Ashton, Nurse Consultant Tissue Viability

Presented by Trish Armstrong-Child, Director of Nursing

3

Pressure Ulcer Prevention Strategy Bolton NHS Foundation Trust October 2013 – October 2014

4

Contents

1. Executive Summary ………………………………………………………. 4

2. Background ………………………………………………………………... 5

3. Introduction………………………………………………………………… 7

4. Pressure Ulcer Risk……………………………………………………… 8

5. Risk Factors …………………………………………………………………... 8

6. Reduced Mobility/Immobility…………………………………………………. 9

7. Lack of Sensation…………………………………………………………….. 10

8. Skin Marking………………………………………………………………….. 10

9. Compromised Vascular supply……………………………………………… 10

10. Nutritional Status……………………………………………………………... 10

11. Continence…………………………………………………………………… 10

12. Extremes OF Age…………………………………………………………….. 11

13. Patient Refusal……………………………………………………………….. 11

14. End Of Life…………………………………………………………………… 12

15. Communication………………………………………………………………. 12

16. Moving,Handling,Positioning………………………………………………... 12

17. Pressure Ulcer Care Plan…………………………………………………… 13

18. Trust Wide Responsibilities…………………………………………………… 14 19 Holistic Assessment………………………………………………………… 15

19. Incident form completion…………………………………………………… 15

20. Root Cause Analysis (RCA)………………………………………………. 15

21. Dissemination of Learning from RCA panel……………………………… 15

22. Summary ……………………………………………………………………….. 16

23. References……………………………………………………………………… 17

5

Appendix 1 Waterlow Risk Assessment...................................................................18 Appendix 2 Community/ Hospital Care Plan............................................................19 Appendix 3 Root Cause Analysis Tool.....................................................................20 Appendix 4 Turning Clock........................................................................................21

6

1. Executive Summary This strategy will set out the approach that must be taken by all members of Bolton NHS Foundation Trust to undertake effective pressure ulcer prevention in either an in-patient setting or a community setting for patients in receipt of health care. This strategy underlines the change in culture required to that of zero tolerance and where staff consider pressure ulcer prevention 24 hours a day throughout the care delivery cycle. Pressure ulcers are rarely due to one factor alone and by considering all possible risk factors and addressing each identified risk for patients via a multidisciplinary approach the patients risk of developing a pressure ulcer can be reduced. Communication of risk to the wider team on a regular basis will ensure that all staff is aware of every patient’s pressure risk. Figure 1 Classification of Pressure Sores

7

2. Background Bolton has a population of approximately 276,800, an increase of 15,763 (6%) from the 2001 census. The most significant change in Bolton’s age structure was the increase in the very elderly (aged 85+). Bolton continues to have an ageing population, as does the rest of the country as a whole. In particular there has been a significant increase in the population aged 85+, which has increased by 20% in the past years. There are 5,500 over the age of 85 living in Bolton. This is significant as this group has an increased level of social need in areas of health care, accommodation and other types of social care support. By 2085 it is predicted that there will be 11.5 million people aged 80 or over (ONS, 2012) With the elderly population growing and life expectancy increasing, many individuals now face the challenge of caring for a growing number of elderly patients who are sick and vulnerable. The changes in the skin that occur as an individual ages affect the integrity of the skin, making it more vulnerable to damage. The epidermis gradually becomes thinner, making the skin more susceptible to damage from mild mechanical injury forces such as moisture, friction and trauma. Around 412,000 people in the UK are likely to develop a pressure ulcer (PU) every year (Bennett et al, 2004), including 4-10% of patients admitted to hospital (RCN, 2005). The financial cost of pressure ulcers cannot be underestimated as they are postulated to be the single most costly chronic wound to the NHS (Posnett and Franks,2008).The cost of treating a category 3 pressure ulcer is between £363,000-£543,000 and a category 4 between £447,000-£668,000 (Department of Health (DOH),2010a). The large numbers of patients affected and high cost associated with pressure ulcers means that they have become a key quality issue for the NHS. Zero tolerance to avoidable pressure ulcers is being implemented widely as a Quality of Care indicator. The main focus of this strategy will therefore be on prevention of pressure ulcers within the in-patient and community environment. Work has already begun with the harm free care panels but the organisation is taking a zero tolerance to pressure ulcers developing in our care setting. Therefore practice has to change immediately for further reduction/prevention of pressure ulcers. This must be achieved and sustained.

8

Pressure ulcers have a profound negative effect on the physical, social and financial realms of people’s lives and are also distressing for their carers. Subsequently the National Institute for Clinical Excellence (NICE, 2005) produced clinical guidelines “The management of pressure ulcers in primary and secondary care. A Clinical Practice Guideline” (CG7) which set the main aims of:-

“To reduce the occurrence of pressure ulcers by providing guidance on the early identification of at risk patients, the provision of preventative interventions and by identifying practice that may be harmful or ineffective.” “All individuals on admission to a healthcare setting, hospital should have an appropriate pressure risk assessment within six hours of admission to an acute setting. All individuals admitted onto a community nurse caseload should have a pressure ulcer risk assessment performed at the first visit and at regular intervals thereafter dependent on clinical need”.

Failure to perform an appropriate risk assessment and act to protect a patient constitutes neglect by the omission of care (Nursing and Midwifery Council 2008). By following these guidelines, adhering to evidence based practice and creating a culture that addresses pressure ulcer prevention all day every day Bolton NHS Foundation trust can successfully achieve a significant reduction in pressure ulcers.

3. Introduction Pressure ulcer prevention is the responsibility of every member of staff that comes into contact with our patients, from those involved in direct patient care to support staff whose input is more distant. Figure 2 Key Elements of the Strategy:

Assessment

• Does the Patient have a pressure sore?

• What is the Patients Risk?

Cause

• How, Where and Why did the Pressure ulcer occur?

Zero Tolerance

• Strategy

• Training

• Transparency

9

This requires the implementation of appropriate screening and assessment of at-risk patient’s (including vulnerable adults). Protection of the individual patient from pressure damage is a fundamental aspect of nursing care. Pressure ulcer risk assessment using an appropriate tool is intrinsic to that care. Bolton requires a change in staff culture that considers that all patients to be at risk of pressure damage until deemed otherwise 24 hours/day. This will enable the trust to prevent all avoidable pressure ulcers by considering each individual’s risk within 6 hours of admission or initial admission to caseload. There is much that can be done to reduce the risk of pressure damage and therefore minimise harm whilst in our care. To achieve this means involvement from a wide range of staff, particularly nurses, doctors, healthcare assistants, therapist and pharmacists. This strategy therefore outlines the best practice approach to prevent pressure ulcers. The greatest success will be achieved when all aspects are implemented and all staff from management through to support staff are committed to 24 hour pressure ulcer prevention.

4. Pressure Ulcer Risk Protection of the individual patient from pressure damage is a fundamental aspect of nursing care. Pressure ulcer risk assessment using an appropriate tool is intrinsic to that care. Healthcare professionals require specific training in pressure ulcer risk assessment appropriate for the group of individuals within their care. Various groups have particular needs which their pressure ulcer risk assessment tool should reflect in order to highlight the risk:

Paediatric patients

Orthopaedic patients

Older people

Adults

Adults with mental health issues

Critical care patients.

5. Screening and Assessment of Pressure Risk/ Ulcers For all patients this should begin with a risk assessment. Risk assessment tools have been developed to help identify those patients most at risk (Waterlow). Recognising which patients are at risk of developing pressure ulcers early on is an essential part of the prevention care pathway. However, all risk assessment tools are limited and therefore should be used within the context of a holistic assessment, and include a full skin assessment using the trust risk and skin assessment (Appendix 1).

10

Waterlow Pressure Ulcer Risk Calculator (Appendix 1) The Waterlow Pressure Ulcer Risk Calculator and skin assessment should be performed on every individual patient at the initial assessment. Below 10+ = At risk 15+ = High risk 20 + = Very High risk The Waterlow score and skin assessment combined with clinical judgement should be used to determine the treatment plan for the patient. All patients should have a pressure ulcer risk assessment immediately upon entry to an episode of care. For all patients identified as ‘at risk’ initial screening should lead to further holistic assessment. Although an assessment may take time to complete, it should be commenced within six hours for ’in-patients’ and during the first visit for patients under the care of the Community Nursing Service.

6. Risk Factors Risk assessment is not exclusive to the prevention of pressure ulcers, it is used in many aspects of life and healthcare. The Health and Safety Executive (2011) States “that it helps to focus on the risks that have the potential to cause harm”. These risks need to be identified and processes initiated to reduce the likelihood of harm occurring. Each identified risk factor needs to be considered. For instance, a patient with dementia may have both an intact sensory pathway and be able to move. What this patient may lack is the cognitive ability to recognise the pain signal associated with the beginnings of pressure damage (EPUAP&NPUAP2009).This would normally trigger movement, sometimes subconsciously. Some patients in pain may stay still because moving increases discomfort, they may be taking analgesics, sometimes opiates. Pain is an early warning signal for pressure damage and the use of strong analgesics may diminish this, which delays a trigger to move.

7. How do Pressure Ulcers develop? Pressure ulcers normally occur due to a combination of extrinsic and intrinsic factors. Extrinsic factors are those that can be controlled or altered by clinicians. Intrinsic factors include those inherent patient-related features that may predispose them to developing pressure ulcers, such as previous or chronic conditions that may leave them susceptible to injury.

8. Reduced Mobility or Immobility (Appendix 4 Turning Clock)

11

The longer pressure is exerted over a bony prominence, the higher that pressure will become. This results in an increased period of reduced or occluded blood flow to the tissue, which results in tissue hypoxia leading to tissue death. Pressure ulcers may first present with blue/black or purple discolouration of intact skin this is often a sign of deeper tissue damage. Patients who are undergoing surgery requiring them to be immobile for long periods may be at increased risk of pressure damage therefore preventative measures should include actions that can be taken to reduce pressure, shear, friction and moisture build-up. Assessment of mobility should include all aspects of independent movement including walking, ability to reposition, bed to chair. All patients at risk of pressure damage need to reviewed minimum every six hours within the acute setting and at each domiciliary visit. Figure 3 Actions that can be taken to reduce pressure, shear, friction and moisture build-up

9. Lack of sensation

If pain signals are absent because of a lack of sensation, patients will not be aware that damage is occurring and will not realise they should move. This increases the risk of pressure ulcer development in those with, cerebrovascular accident, multiple sclerosis, spinal cord injury and neuropathy. Health professionals should consider other medical conditions that may impair sensation, as well as temporary sensory loss due to unconsciousness, spinal anaesthesia or analgesia, or alcohol or substance use. A source of pain elsewhere may distract from the pain associated with pressure, reducing the likelihood of the patient responding to this pain trigger.

•shearing refers to the pulling of the skeleton (normally by gravity) downwards, while the skin adheres to the surface of the bed, trolley or chair. This results in the tearing of capillaries and can increase the severity of pressure ulcer when shear and pressure forces are present. During surgery, certain positions that are necessary in order to gain access to the affected area may also leave the patient at risk of shearing forces.

Shear

•Describes the forces at play when two surfaces rub across one another. If this persists, patients can develop friction ulcers. Friction may compound the effects of pressure and shearing and potentially lead to loss of dermis.

Friction

•moisture is implicated in the development of some pressure ulcers due to the effect of the skin being over-hydrated, whether due to incontinence, excessive perspiration and/or wound exudate. If the skin is excessively moist, the epidermis becomes weaker and more fragile. This can lead to skin breakdown in the presence of pressure, shear and/or friction.

Moisture Da

ma

ge

12

10. Skin marking The change of colour in the skin associated with pressure damage is an early warning sign of risk. In pale skin a visible circular pink/red blanching mark known as blanching erythema (the area of redness blanches white when pressed lightly with a finger),over a bony prominence is an indication that pressure is starting. If this is not noticed and continued pressure is sustained, the discolouration will become darker until it is purple/black. Identifying skin colour changes can be difficult in patients with darker skin colours, as areas of redness are neither visible nor blanch white. This means these patients may be at increased risk of pressure damage. It is essential that the pressure is removed and the skin is inspected at regular intervals. Erythema may also be masked by physiological illnesses that alter the skin colour. This includes cellulitis, necrotising skin infections, bruising disorders and incontinence-dermatitis.

11. Compromised vascular supply An already compromised vascular supply will be further hampered by pressure, resulting in a more rapid deterioration of skin. Patients with peripheral arterial disease may be at risk of damage to their heels. Patients who experience events such as cardiac arrest or hypovolaemic shock may be at increased risk of skin damage because the blood supply to the skin is diminished by a sudden drop in blood pressure.

12. Nutritional status There is a significant link between poor nutritional status and pressure ulcer risk. Undernourished people are at increased risk of pressure ulcer development (EPUAP and NPUAP(2009)Patients who have chronic disease prior to surgery may be at risk of malnutrition and this risk could be reduced with appropriate preoperative nutrition. Also consider hydration. Nutritional support should be given to patients with an identified nutritional deficiency. Nutritional support/supplementation for the treatment of patients with pressure ulcers should be based on:

Nutritional assessment (MUST Tool 1999)

General health status

Patient preference

Expert in put supporting decision-making (dietician or specialist).

Professional judgement

13. Continence Urinary and faecal incontinence can have a detrimental effect on skin integrity and are considered to be a risk for pressure ulcer development. The cause of the

13

continence problem must be explored, for e.g. factors such as Chron’s disease, ulcerative colitis, impacted faecal load, antibiotic use and bacterial infection should be considered. In urinary incontinence, the ammonia produced by the urine raises the pH balance of the skin on contact, making it permeable. It is essential that the underlying cause of the urinary incontinence is explored to prevent skin breakdown.

14. Extremes of age Neonates and very elderly people have more fragile skin. In the elderly, several changes occur in the skin and its supporting structures, which may predispose their skin to pressure, shearing and friction related ulcers. Pruritus is common in the older person. Dry skin is itchy skin. Once identified patients should have a frequent skin assessment to prevent breakdown. Neonates are a group vulnerable to pressure ulcer risk given the immaturity and underdevelopment of the epidermis and the dermis of a baby born before 28 weeks of gestation (McGurk 2004).For children who are at risk of developing pressure ulcer they require vigilant regular monitoring.

15. Patient refusal On occasion, patients may not wish to change their position as often as needed to protect their skin, or they may refuse to use a pressure-relieving mattress/cushion. In such instances, nurses should first consider patients’ mental capacity) Mental Capacity act, 2005). If they are deemed to have capacity then the patients decision must be respected and documented. Some patient’s may have fluctuating capacity and this must be taken into consideration when the patient is refusing to change position. Some-times the explanation given to the patient is not always fully understood, therefore the nurse/health professional must ensure that they have explored every avenue to explain how important pressure relief would be of benefit. Review of the patient is essential, if the patients risk of pressure damage is high the review gives the health care professional the opportunity to explore why the patient is refusing equipment.

16. End of life The dying process compromises the homeostatic mechanism of the body, which may lead to a number of vital organs becoming compromised. This can lead to skin complications, including gangrene, infection and pressure ulceration. Specific attention should be given to bony prominences and skin areas with underlying cartilage. When delivering care to patients on the end of care pathway it is essential that pressure care is maintained. The patient should be kept comfortable and pain free when repositioning, pressure areas and skin changes must be monitored closely. Skin changes at life’s end may well be an inevitable event that cannot be averted despite all preventative measures being implemented.

17. Communication Good communication between healthcare professionals and patients and carers is essential. It should be supported by evidence-based written information tailored to the patient’s needs. Treatment and care, and the information patients are given

14

about it, should be culturally appropriate. It should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Moving,Handling,Positioning and Re-Positioning

Skin damage can be minimised by using correct positioning, transferring and repositioning techniques and the use of aids.

Hoist slings and sliding sheets should be removed from underneath the patient after repositioning.

Where possible patients should be taught to reposition themselves and carers should be shown how to assist.

Repositioning should be performed in such a way as to minimise the impact on bony prominence.

Whenever possible avoid positioning patients directly on a pressure ulcer or directly on a bony prominence unless this is contra-indicated by the general treatment objectives.

Using the 30 degree tilt can increase the range of positions available (Appendix 2)

Moving and handling should be in accordance with European and trust manual handling regulations.

The patient’s need for repositioning should be assessed, planned, auctioned, evaluated and documented with evidence of ongoing re-assessment. The frequency of repositioning is determined from individual assessment.

A repositioning plan should take into consideration, existing/potential tissue damage, medical condition, comfort, patient preference, support services and overall plan of care.

18. Pressure ulcer and risk care plan (Appendix 2)

This should be completed as soon as a pressure ulcer is identified. Whilst the pressure ulcer care plan may be initiated by nursing staff, all staff involved with the patient should be aware of its individualised content. If the patient transfers ward/unit the pressure ulcer must be re-assessed and have regular on going assessments. Figure 4 Key Assessment Priorities for Care plan must include:

Assessment

•Cause of ulcer

•Site/location

•Dimensions of ulcer

•Depth of pressure ulcer is measured by identifying the category of the ulcer using the EPUAP tool.

•Level of risk –from holistic assessment

•Previous pressure damage

•Exudate amount and type

•Local signs of infection

•Pain

•Wound appearance in the ulcer i.e black, grey, yellow, red, pink or green.

•Surrounding skin

•Undermining/tracking(sinus or fistula)

•Smell/odour

•Tracing and or photography(calibrated with a ruler)

•Pressure relieving support surface/cushion

•Re-positioning regime using Bolton Turning Clock

•Monitor closely skin changes

15

The ward/unit/caseload teams Must involve the clinical specialist - Tissue Viability Team if a pressure ulcer is failing to improve. Pressure ulcers should not be reverse graded (retrograding).A category 4 pressure ulcer does not become a category 3 as it heals. As the ulcer heals it should be described as a healing category 4 pressure ulcer showing signs of granulation tissue at base/edges of wound etc.

19. Education & Training All staff who care for patients with or ‘at risk’ of developing a pressure ulcer Must ensure that their knowledge is current and evidence based. All staff must attend a yearly pressure ulcer prevention and management course. This will be held by the tissue viability service and will cover:

Pathophysiology of pressure ulcer development

Risk factors and risk assessment tools

Positioning/repositioning

Selection, use and maintenance of support surfaces and equipment

Incident reporting

Pressure classification

Please contact the Tissue Viability Service for further details 01204 463823/9.

20. Trust wide responsibilities The following points are the responsibility of the Foundation Trust and all staff working with patients at risk of pressure damage.

All staff in regular contact with patients should undertake pressure ulcer prevention training, to ensure all are familiar with risk factors and their role in prevention.

All clinical staff must re-assess and evaluate effectiveness of interventions at specified intervals to identify any potential changes in risk.

Pressure relieving equipment should be provided appropriate to the individuals’ needs without delay.

Adequate staffing levels should be provided at all times to meet the number and level of dependent patients at any point. Unfilled shifts are not acceptable and should be escalated immediately.

21. Trust acquired pressure ulcers

16

All preventable pressure ulcers acquired in Bolton must be reduced to zero. If a pressure ulcer occurs we should learn from it and the following measures should be taken and evidence of such recorded. Pressure ulcer acquired protocol

Full holistic clinical assessment, when the pressure ulcer developed, risk of patient, type of pressure relieving equipment.

Complete on line incident form and include any actions taken. The relevant manager must be informed immediately of all pressure ulcers acquired within the trust. All category 3 and 4 pressure ulcers acquired in hospital or community ensure the Tissue Viability Consultant Nurse is made aware of the incident at the earliest available opportunity. All category 2, 3, and 4 pressure ulcers acquired within Bolton will be subjected to a full Root Cause Analysis.

Review pressure ulcer care plan to reduce the risk of further deterioration.

If the patients pressure ulcer deteriorates seek advice/review from Tissue Viability Team, Medical / Surgical review.

22. Incident Form Completion When completing the incident form give as much detail as possible about the development of the pressure ulcer.

When the pressure ulcer developed and in which environment, home, ward A&E, theatre, residential home or nursing home.

Give details of pressure ulcer wound assessment, size, depth, position and details of frequency of treatment.

Document any issues that may have significantly contributed to the patient developing the pressure ulcer.

If the patient developed the pressure ulcer having sustained a fall document how they fell and if found on the floor how long the patient was on the floor.

Include the patient’s opinion regarding what happened and record their answer.

Include any contributing factors, general health condition, environmental factors.

23. Root Cause analysis (RCA) (Appendix 3)

As indicated in the pressure ulcer protocol all pressure ulcers should have a RCA completed whereby the staff member(s) involved and the manager should look at the pressure ulcer(s) in detail considering all factors that may have contributed to the pressure ulcer developing and whether or not sufficient measures had been taken to pre-empt and prevent the pressure ulcer. It may be beneficial to bring fresh eyes in to help complete the RCA. Details of the RCA should be communicated to the wider

17

team, in particular any lessons learned and recommendations as a result. The RCA will then be discussed at the next harm free care panel when other areas can also learn from the outcome and prevent further pressure ulcers in other areas.

24. Dissemination of learning from RCA panel The learning gained from all cases discussed at the Pressure Ulcer RCA panel must be cascaded to staff from the same and other areas to ensure any measures identified that may prevent future pressure ulcers are shared. This can be done by staff involved feeding back directly to the rest of the MDT in the area. The pressure ulcer RCA panel should be seen by all staff as an opportunity to learn, to enable improved patient care across the organisation. This can only be achieved if the learning at the panel is disseminated effectively.

25. Summary

Figure 2 MDT Collaborative approach

Pressure ulcer prevention is everyone’s job and should be considered 24 hrs a day for all patients. Preventing pressure ulcers in patients at risk requires a multidisciplinary collaborative approach from many members of the multidisciplinary team and only when this is executed correctly and efficiently will pressure ulcers be reduced to zero. Patients and their relatives also have a responsibility to work with health professionals to minimise the risk ensure of pressure ulcer damage when in our care.

18

References Department of Health (2011) Safe care. Department of Health undated defining avoidable and unavoidable pressure ulcers. Health and Safety Executive (2011) Five steps to Risk Assessment. McGurk V et al (2004) Skin Integrity assessment in neonates and children,Paediatric nursing,16,3,15-18. Mental capacity Act (2005) Mental capacity. Moore Z,Van Ettan M (2011) repositioning and pressure ulcer prevention in the seated individual. Wounds UK 7 (3):34-40. National In statute for Health and Clinical Excellence (2008a) Surgical site infection. Prevention and treatment of surgical site infection. NICE, London. Available at:www.nice.org.uk/CG74. National Institute for Health and Clinical Excellence (2005) CG29 Pressure ulcer management: Quick reference guide. NICE, London. Available on line at htpp://guidance.nice.org.uk/CG29/QuickRefGuide/pdf/English. National pressure Ulcer Advisory panel (2010) Not All pressure Ulcers are Avoidable. Washington, DC: NPUAP. North West Tissue Viability Nurses.Guidelines for classification of pressure ulcers (Adapted from EPUAP 2009) Nursing and Midwifery Council (2008) The Code: Standards of conduct, Performance and Ethics for Nurses and Midwives. NMC. London. Office of National Statistics (2012) Results, 201-based NPP reference Volume. Available from:www.ons.gov/ons/dcp 171776_253934.pdf. Posnett j,Franks p (2007) The Costs of Skin Breakdown and Ulceration In the UK.In Pownall M (ed|) Skin breakdown:the silent epidemic.London.Smith&Nephew. Royal College of Nursing (RCN) (2005) The management of pressure ulcers in primary and secondary care. A Clinical Practice Guideline. Available from: http: /www.rcn.org.uk.

19

Appendix 1 WATERLOW ASSESSMENT (J. Waterlow 2005)

Score

Date Date Date Date Date Date

Build/ Weight for Height

Average (BMI = 20 - 24.9) 0

Above average (BMI = 25 – 29.9) 1

Obese (BMI = > 30) 2

Below average (BMI= < 20) 3

Continence

Complete/ Catheterised 0

Urinary incontinence 1

Faecal incontinence 2

Urinary and faecal incontinent 3

Risk area, visual skin type

Tissue paper/ Dry/ Oedematous/ Clammy, pyrexia (score 1 for each) 1

Discoloured (grade 1) 2

Broken/spots (grade 2 – 4) 3

Mobility

Fully 0

Restless / Fidgety 1

Apathetic 2

Restricted 3

Bedbound / Traction 4

Chairbound e.g. wheelchair 5

Sex

Male 1

Female 2

Age

14 - 49 1

50 - 64 2

65 - 74 3

75 - 80 4

81+ 5

Appetite

Patient eating poorly or lack of appetite 1

Has patient lost weight, if yes weight loss score:

0.5 - 5kg 1

5 - 10 kg 2

10 - 15 kg 3

> 15 4

Unsure 2

Tissue Malnutrition

Terminal Cachexia 8

Multiple organ failure 8

Single organ failure (respiratory, renal, cardiac) 5

Peripheral vascular disease 5

Anaemia (Haemoglobin < 8) 2

Smoking 1

Neurological Deficit

Diabetes, MS (Mulitiple Sclorosis), CVA (Cerebral Vascular Accident) 4-6

Motor/ Sensory 4-6

Paraplegic (max of 6) 4-6

Major Surgery or Trauma

Orthopaedic/ Spinal 5

On table > 2 hours 5

On table > 6 hours 8

Medication

Cytotoxics, long term high dose steroids, anti- inflammatory (max of 4) 1-4

Total Score

Risk Level

Signature

20

Appendix 2 Care Plan – Hospital

CARE PLAN NUMBER …………….. BOLTON NHS Foundation

Trust

CARE PLAN TITLE: Patient at Risk of Developing Pressure Ulcers

PATIENT’S NAME ………………………………………………RMC/ NHS NUMBER…………………….. WARD ………

Plan commenced by ………………………………………… Date…………………………………….

Problem: Patient is at risk of developing skin / tissue damage.

Goal (s): To prevent tissue damage.

Summary of problems in relation to Waterlow assessment:

Provide patient / carer with a copy of pressure ulcer prevention information / leaflet

Date

Signature

Assess following risk factors and devise individual plan of care

Assess if patient needs assistance to alter position and frequency of position changes

State frequency of Waterlow assessment as an intervention below

Date: Intervention commenced

Signature Individual Interventions: Date: Intervention Discontinued

Signature

Score Risk Level

Actions

10 +

Implement for ALL

risk groups below

Provide patient information leaflet and commence repositioning chart.

Advise patient to move from side to side in bed and stand every 15-20 minutes when sitting out. If unable to alter position independently reposition the patient at regular intervals in accordance with response to pressure.

Reassess Waterlow score in accordance with the patient’s individual needs or as changes to clinical condition.

All grade 2 pressures sores must be recorded as a clinical incident.

10+

At risk

Skin intact/ grade 1 or 2 and good mobility – Static cushion and pressure reducing static mattress

Grade 3/4 pressure ulcer and average or poor mobility – Dynamic cushion and dynamic mattress

15+

High Risk

Skin intact & good mobility - Static cushion and pressure reducing static mattress

Skin intact or grade 1 or 2 & poor mobility - Static cushion and dynamic overlay

Grade 3 or 4 and poor mobility – Dynamic cushion and dynamic mattress replacement

20+

Very High Risk

Skin intact & good mobility - Static cushion and pressure reducing static mattress

Skin intact, grade 1 – 4 & poor mobility - Dynamic cushion and dynamic mattress

21

Document date of discontinuation of plan and rationale for discontinuing

Date:

Signature

22

Community CARE PLAN NUMBER ……………..CARE PLAN TITLE: Patient with Pressure Ulcer BOLTON NHS Foundation

Trust

PATIENT’S NAME ………………………………………………RMC/ NHS NUMBER…………………….. Date Of Birth ………

Plan commenced by ………………………………………… Date…………………………………….

Problem: Patient has a pressure ulcer on -------------------------------------- category -------------------------------

Goal (s): To facilitate healing and minimise risk of infection and further tissue damage.

Pressure Ulcer History:

Hospital Acquired (3 days after admission) Community Acquired (on admission or within 3 days)

District nurse input Nursing home Residential Home

Provide patient / carer with a copy of pressure ulcer prevention information / leaflet

Date

Signature

Assess following risk factors and devise individual plan of care

Surface: Need for pressure relieving equipment

Skin: Frequency of skin inspection

23

Keep Moving: If patient needs assistance to alter position and frequency of position changes

Incontinence: Urinary / faecal incontinence

Nutrition: Nutrition and hydration needs

Date: Intervention commenced

Signature Individual Interventions: Date: Intervention Discontinued

Signature

Community: Plan of care discussed and agreed with patient

Patients Signature

Document date of discontinuation of plan and rationale for discontinuing

Date:

Signature

24

Appendix 3 RCA Tool

Pressure Ulcer Root Cause Analysis (RCA)

Data Gathering Tool (For patients who acquire category 2/ 3/ 4 Trust acquired pressure ulcer complete within 5 working days)

Stage 1: React – What were the critical problems

Patient Name: DOB:

RMC/NHS Number:

RCA Completed by: Date :

Designation:

Date Incident Reported Incident Number

Past Medical History:

Current Medical History:

Date and time admitted to hospital/Dept /DN Caseload:

Were there any transfers/moves after admission? Give details:

Date pressure ulcer was identified:

Category of Pressure Ulcer:

Site of pressure ulcer/s please state category and site of each pressure ulcer?

Sacrum Left heel Right heel Right ischium Left ischium Left hip Right hip Other (Specify)

Where did pressure ulcer develop?

Give Details (ward name/district nurse team/other)

Was patient identified as at risk of pressure ulcers on admission Yes /No

Was the six hour skin inspection completed Yes/No Date & Time: Completed on transfer Yes/No Date &Time

What was the Waterlow score on admission(i.e. to ward/District Nurse Team)

List all dates and scores of completed Waterlow

Was the patient incontinent Yes/No Was the patient immobile describe Bed Bound Yes/No Chair Bound Yes/No

Was the patient meeting their nutritional needs Yes/No What was the nutritional score?

What pressure relieving equipment is in place? (E.g. Mattress and/or cushion). Date Implemented

Reposition chart commenced Yes No Date:

Is this completed appropriately Yes No

Date care plan commenced

Is this completed appropriately Yes No

Pressure Ulcer Photographed Yes/No Patient informed and given explanation Yes/No.

25

Patient Consent sought Yes/No If so, state date. (check if information leaflet given)

Who has the pressure ulcer been reported to(i.e. TVN/Matron)

Date:

Any Vulnerable Adult Concerns: Describe:

Stage 2: Record - Complete a timeline from the patient’s records review

What actually happened (timeline of events include dates & frequency of skin inspections)

What should have happened

Stage 3: Respond – What needs to be done to reduce the chance of another pressure ulcer developing?

Recommendations: Actions to be taken

By who and by when

RCA Panel Review Meeting Date:

Recommendations from Panel & Outcome:

26

Appendix 4 New Turning Clock Documentation

1

TRUST WINTER PLAN

2013/2014

2

CONTENTS

Page

1. Introduction

3

2. Learning from Previous Years

3

3. Capacity 2013/14

5

4. Planned Demand (RTT)

6

5. Norovirus and Infections

6

6. Social Marketing

7

7. Risks

7

8. Hospital Plan 8.1 Emergency Demand/Capacity Modelling 8.2 Using Planned Capacity to Meet Demand 8.3 Improved Discharge Policy 8.4 Weekend Discharge Team 8.5 7-day Woking 8.6 CDU 8.7 BCU 8.8 Winter Ward B1 Ward 8.9 Surgical 8.10 Elective Bed Capacity 8.11 Families 8.12 Integrated Rapid Response Team and A&E 8.13 Intermediate Care 8.14 3rd Party Providers 8.15 Impact of Actions taken to Meet Demand

8

9. Workforce Issues

11

10. Escalation Process

12

Appendices

Health Economy Plan

Trust Escalation Plan

Critical Care Escalation Plan

NHS North West – Major Contingencies – Guidance for Critical Care Escalation

14

3

1. INTRODUCTION

The Trust Winter Plan addresses specific conditions related to winter which impact on:

Emergency Department capacity

Bed capacity

Critical care services

Communications including cross-party working with partnership agencies

Business continuity, ensuring that the Trust maintains essential services and, where relevant, returns to normal operating capacity as quickly as possible

Ambulance turnaround times

The plan outlines the principles of response to be adhered to when pressures are identified which are likely to put at risk the Trust’s ability to deliver acceptable levels of patient care and services.

There are a number of factors that are particular to winter and which result in increased demand for healthcare services:

Length of stay for many patients increases, driven by increased acuity and more complex needs. This is particularly relevant in the care of the elderly and respiratory patients.

Closure of capacity due to infection which limits the supply of usable beds. Norovirus is significantly more prevalent in winter and this can result in temporary closure of affected wards thus reducing bed capacity.

Intermediate care capacity comes under increased pressure during winter, with demands from both the community and primary care as well as “step-down” patients from hospital. This can contribute to increased lengths of stay in hospital, leading to challenges regarding staffing in all areas.

Unplanned staff absence increases in winter months, particularly due to increased infections, leading to challenges regarding staffing in all areas.

The Winter Plan aims to meet the need of the Trust during these pressures as it is essential that the Trust is able to continue to provide high quality, safe and effective patient care throughout the winter period. It is also important that care is delivered in a timely manner so that the Trust continues to achieve against performance measures in both urgent and elective care.

2. LEARNING FROM PREVIOUS YEARS

Winter 2012/13

Last winter the Trust increased the medical bed base to 362, by opening 14 beds on CDU on 26th November 2012 and 25 beds on B1 on 3rd December. The beds on B1 were not fully utilised until after Christmas, due to staffing shortages.

Accident & Emergency Type 1 performance against the 4-hour target was above 95% every month between November 12 and March 13, with the exception of January when it was 94.5%.

Attendances at Accident & Emergency for the period Nov-Mar 12/13 were 46,857 compared to 46,591 (+0.6%) the previous year. Emergency admissions were 14,550 and 14,145 (+2.9%) for the same period. In January, emergency admissions were 10.5% higher than the previous year.

4

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Acute Adult non-elective admissions

2011/12

2012/13

2013/14

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

Acute Adult Non-elective LOS

2011/12 2012/13 2013/14

0

2000

4000

6000

8000

10000

12000

41000 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 41365 May Jun Jul

Occupied bed days - Acute Adult - Available Against Actual

Available Actual

5

Daily conference calls with the PCT and Social Services were instigated in December and continued throughout the winter months. This assisted in identifying any delayed discharges and where possible these were expedited with the support of other agencies. The following areas of focus that in previous years have been beneficial to this and other organisations:

Expanding bed complement from November 13

Introduction of a weekend discharge team

Increased medical cover in A&E during peak times

Additional 15 bed capacity in Intermediate Care (Darley Court = 5 & Laburnum = 10)

Maximising the efficiency of bed utilisation

7-day working across medical specialties in order to increase weekend discharges and give earlier senior review to optimise the length of stay

Daily liaison with Social Services to expedite discharge where social care is indicated

Ensuring prompt discharge before 10:00am wherever possible

Patient flow meetings are held at least four times per day, enabling close monitoring, real-time communications and assisting decision making

Measurement of daily discharges by ward to involve clinicians

Conference calls with CCG to ensure delays in transfer of care and escalated to start in November 13

Infection Control measures 3. CAPACITY 2013/14

3.1 During 2013-14 the number of attendances at A&E has reduced by 1,714 from April to September. However,

the number of majors patients rose by 1,028 in the same period. Majors patients are more likely to require beds than other A&E patients. Admissions via A&E for the period increased by 1,496 whilst ALOS reduced from an average of 4.9 to an average of 4.5 days.

3.2 Medical beds & Clinical Decisions Unit (CDU)

The medical bed base usually stands at 305 plus 14 CDU beds; the CDU beds will support avoidance of admissions.

3.3 Surgical beds Surgery has 176 beds excluding Day Care and Critical Care beds

3.4 Paediatrics There are 38 Paediatric beds which include 7 beds dedicated to assessment and observation and 3 beds dedicated for High Dependency.

3.5 Gynaecology Ward M1 There are 15 beds on this ward and 2 assessment areas.

3.6 Intermediate Care Beds There are 30 beds at Darley Court, which are for patients requiring rehabilitation or sub-acute nursing care. In addition Labernum lodge provide capacity for intermediate care patients.

6

4. PLANNED DEMAND (RTT)

Planned patient activity (daycase procedures) will be delivered alongside RTT activity. Private providers and LLP will be utilised if necessary.

5. NOROVIRUS ANDINFECTIONS The Trust has developed robust plans to deal with infection control and is mindful of the likelihood of

increased prevalence of Norovirus, Clostridium Difficile and flu in the coming months. The Trust is proactively promoting flu vaccinations for staff as well as at risk groups in the community. 5.1 Norovirus

Norovirus is highly infectious and spreads easily from person to person. It is the most common cause of infectious diarrhoea and vomiting in the UK. It is also known as winter vomiting disease. It can be spread by contact with an infected person, consuming contaminated food or water or by contact with contaminated surface of objects. The virus can survive in the environment for many days.

Washing hands with soap and water, prompt disinfection of contaminated areas and isolation of those infected for 48 hours after their symptoms have ceased can minimise transmission. There is no specific treatment for Norovirus apart from letting the illness run its course and drinking plenty of fluids to prevent dehydration.

To ensure staff comply with hand washing standards, hand washing audits are carried out in clinical areas on a weekly basis and compliance is also recorded with Exemplar reporting. Performance is currently at 85% with actions to improve and this will be maintained during the winter period.

Vigilance on the part of nursing, medical and other staff can lead to early identification of a problem. The Norovirus Policy details control measures to be taken within affected clinical areas, dealing with prevention of spread to unaffected area and environmental decontamination during and post outbreak.

As Norovirus is often brought into the hospital environment by someone incubating the infection, the No to Noro campaign/Norovirus-Stop the Spread is being run throughout the whole health economy. The infection Prevention & Control Team (IPCT) have designed posters to distribute throughout the Trust and in the community and GP premises to raise awareness about the dangers of the spread of Norovirus to patients and staff.

The IPCT include Norovirus in mandatory training sessions and the Norovirus policy is available on the Trust Intranet. Further information/leaflets can be obtained from the HPA website. Hospital is closed to visiting during periods of infection outbreak. Ward A4 will be available to decant wards for fogging during the winter period.

5.2 Seasonal Flu

The Trust takes the prevention of seasonal flu very seriously. There is a Flu Strategy in place and the Steering group meets on a monthly basis the whole year round in order to plan, deliver and review the Flu Programme. The programme reflects a whole systems approach to planning and delivery of the programme – everything from ordering vaccine, training staff, promoting the campaign, undertaking the vaccinating and reviewing the programme prior to planning for the next season.

7

Promotion will be ongoing and this will include informing staff how and when they can access their jab, success stories and stories and news articles to generate interest and motivate staff to attend.

There is potential for an infectious disease outbreak affecting patient care and Trust operations in a similar way to the pandemic influenza outbreak. The health response to such an outbreak would be led nationally and via the regional / local command and control mechanisms. The Trust maintains a strategic plan outlining the process and actions to be taken in the event of this type of outbreak.

This plan is held in readiness by the Emergency Planning department.

6. SOCIAL MARKETING The Trust will work with the CCG and Local Authority on any Social Marketing campaign which aims at

reducing pressure on acute hospital beds. 7. RISKS

The key risk that the Trust will face over winter is greater demand on critical services leading to reduced capacity. This will arise from:

Increased emergency patient admissions

Longer length of stay due to increased complexity and acuity

Increased demand for intermediate and other care outside the hospital

Higher levels of infection resulting in closed wards

Staff absence through sickness, including seasonal flu and norovirus

Reduced staff attendance due to adverse weather

BCU patient pathways are being redesigned at present with plans for closure. Therefore, dependant on the success of these pathways and the impact of winter pressures, for approximately 3 months during the winter months there will be no BCU for admissions.

Risks associated with the above are: a small number of sub-acute patients who cannot be turned around by the rapid response team at the front door will have to be admitted. This has been calculated at about 3-4 patients per month.

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8. HOSPITAL PLAN 8.1 Emergency Demand/Capacity Modelling

The Trust has commissioned a bed modelling exercise for the last 2 years. This gives an analysis of the number of inpatients in hospital throughout the year by specialty. From this bed model, demand can be estimated using this historic data. The following key points have been drawn:

350-360 acute medical beds are needed in the winter months

Surgical bed capacity is adequate to meet elective and non-elective demand

8.2 Using Planned Capacity to meet demand The Trust uses a predictor tool which compares predicated admissions against current admissions, planned discharges and bed availability. The outcome of this is then fed into an escalation tool with 16 other metrics and then informs level of escalation. Escalation triggers are in place and discussions are taking place to agree more explicit thresholds for incorporation in to the revised escalation plan. Bed meetings are held at least 4 times per day. Capacity Management systems data is also in place. The HERD data will also be used at bed meetings to understand the whole health economy pressures and support predicted demands on the whole system. The Trust has used the predictive tool to anticipate demand on a daily basis. This is largely reliable and generally predicated activity is manageable. Surges of activity are dealt with in specialties’ escalation plans. There is some flexibility between surgical and medical beds depending upon demand. Extramed is used on a daily basis.

8.3 Improved Discharge Policy

In preparation for the winter the Joint Trust and Bolton Council Adult Hospital Discharge and Transfer of Care Policy has been updated and following final approval on 13th December 2012 will be implemented across hospital wards, intermediate care facilities and community services. A weekly Delayed Transfer of Care meeting will be held with Council representatives from Bolton, Wigan and Salford to performance manage and improve the discharge process for patients. Information will be given to patients and/or relatives/carers to ensure they are clear about discharge dates and expectations to avoid undue-delays in choice and decision making which may include interim alternative places of care if necessary. Matrons will review any delays in their areas daily and take actions to mitigate the delays and ensure that patients are discharged before lunch. If appropriate actions for discharge are not being processed this will be escalated to the Director of Operations or the COO of the relevant organisation.

8.4 Weekend Discharge Team During the winter period an additional weekend discharge team will be available. This team made up of

physician, therapy, pharmacy and discharge co-ordinator will focus on discharging patients during the winter period to prevent delays and contribute to better bed utilisation.

9

8.5 7 Day Working From October 1st 2012 a new structure of weekend working for consultant physicians commenced. In November 13 the weekend discharge team will be in place junior doctors, physiotherapists, occupational therapists and pharmacists to support the consultant to prevent delays for those patients who are medically fit for discharge. The discharge team will be reviewing patients to ensure decision for discharge has been determined and all the actions required to enable the patient to be discharged will be put in place.. There will be a consultant rota in place to manage the winter ward.

8.6 CDU/ Integrated Rapid Response Team

The Clinical Decisions Unit (CDU) opened on 26th November 2012. The unit comprises 14 beds and this, along with regular attendance in A&E by acute physicians will support admission avoidance wherever possible. The working day of acute physicians has been extended to cover 8.00am to 8.00pm to increase senior review of medical admissions. It is anticipated that the CDU will negate the need for 14 patients per day to be admitted to assessment wards within the hospital, freeing up capacity on wards D1 and D2.

8.7 BCU Plans are in place for BCU patients to have alternative pathways. Eventually some patients will be diverted to CDU, others to F3 and all sub-acute patients will be turned around from A&E by the Acute Rapid Response team into the care of Community rapid response team. Currently BCU is used as destination for patients who are awaiting transport etc. to support A&E flow. Due to the risk to winter capacity it is not expected that BCU will reduce capacity until April 2014..

8.8 Winter Ward The Trust will open winter ward to provide additional capacity. This will be B1 with 26 beds and will be opened in November 13.

8.9 Surgical The Elective Care Division currently has 9 beds on F5. It is intended that these beds will be transferred to the Family Division for Elective Paediatric Surgery. (please see 3.3.) F6 will be used flexibly and will convert to male or female as demand requires. A pilot study is underway to facilitate rapid assessment of Gynaecology patients presenting at A&E or referred from their GP. This pathway enables patient’s attendance at the ward where assessment by a specialty doctor will be undertaken to determine the best course of action for these patients. This will be under constant review during the winter. It is envisaged that if successful this will reduce the number of admissions to M1.

8.10 Elective Bed Capacity Review and balance elective and urgent bed demands. Will create additional paediatric capacity between

Oct 13 to Mar 14. Build flexibility around trauma capacity. Trial SAU beds in F3 to improve flow. Open additional beds to cope with winter pressure.

8.11 Families There is capacity to increase 9 beds in Ward F5 to help manage a peak in paediatric attendance over the winter period to reduce the likelihood of cancellation of paediatric elective surgery cases when paediatric medical activity is high. The 9 beds on Ward F5 will assist in managing the continued flow of paediatric elective surgery patients at times of high paediatric medical demand. This will reduce the likelihood of treat and transfer for children being initiated and help keep paediatric A&E breaches to a minimum.

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8.12 Integrated Rapid Response Team & Additional A&E Senior Staffing This year there will be a front end rapid response team delivering assessment and admission avoidance or early supported discharge to medical patients in the sub-acute phase. This will be delivered by an MDT team of nursing and therapy staff with the support of social workers where required. This rapid response will act to avoid admission and to also support early discharge from D1 and D2 the medical assessment bedded area by signposting to, arranging for, or delivering, care in the community. There will be an increase in support in the referral and assessment team and core districting nursing services to support these patients at home. In addition to this front end team there will be increased medical cover at consultant and middle grade level to support times of increased demand in A&E during this winter period. This will also be supported by senior advanced nursing both for adult and paediatric patients in A&E.

8.13 Intermediate Care As last year demonstrated, increased intermediate and community bed capacity supports patient flow through the acute hospital. Darely Court capacity will be expanded by additional 5 beds with 10 beds additional beds at Laburnum Lodge from November to March.

8.14 3rd Party Providers Capacity at 3rd party providers such as the Beaumont and the Spire Manchester Hospitals will be utilised to reduce the impact of required RTT activity. The Elective Care Division has arrangements in place to utilise capacity at the BMI Beaumont Hospital and Spire Manchester Hospital. Where possible this capacity will be utilised to deliver planned care for patients both on the RTT pathway and those awaiting repeat procedures.

If cancellation of elective work at the RBH site is necessitated due to winter pressures all attempts should be made to provide this activity elsewhere within the 18 week RTT pathway. Bolton NHS FT has an agreement with N.W.S.S. (North West Surgical Solutions). Member consultants access the Beaumont Hospital, Spire Manchester Hospital and Bolton NHS FT. The Elective Care Division will seek to utilise this company to deliver planned orthopaedic surgery both at a 3rd party provider or at weekends at the RBH site in order to deliver to the 18 week RTT standards.

8.15 Impact of the Actions Taken to Meet Demand The Trust has a medical bed base of 305 beds and 14 CDU. The following actions have been implemented in order to meet the expected demand based on the bed modelling described above. Medical bed base 305 beds CDU opened 26th November 14 beds Winter ward capacity opened 2nd December 26 Darley Court additional step down beds (to open December) 5 beds Laburnum Lodge 10 beds _______ Total 360 beds ________

In winter a small percentage of beds are frequently unavailable because of infection control measures. Given the above capacity it is anticipated that the 360 beds estimated to be needed in the winter months will be available in order to maintain occupancy at appropriate levels and thus facilitate effective patient flow.

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9. WORKFORCE ISSUES 9.1 Adverse Weather Conditions

Adverse weather conditions may make it difficult for staff to attend work as normal due to school closures, poor driving condition etc. In the event of adverse weather conditions, the following provisions should be adhered to:

All user email

Staff should make contact with their ward/department as soon as possible if they are experiencing difficulty.

Staff who are delayed or need to leave earlier than normal will be required to make up the lost time as agreed with their line managers.

Staff who are unable to attend work at all may take annual leave, accrued flexi-leave or unpaid leave.

Staff who live within a reasonable distance and safe walking distance from the hospital are expected to make their journey to work on foot.

Staff should only leave their shift with the agreement of their manager after a handover has taken place to ensure patient care is not compromised.

All staff and managers are requested to be as flexible as possible in order to ensure that essential services are delivered and maintained during such unusual circumstances.

9.2 Access to Trust and Non-Trust 4x4 Vehicles/Drivers

During severe weather, in order to maintain patient care to vulnerable patients in the community it is sometimes necessary to request the services of a voluntary team within the North West who can provide drivers with 4x4 vehicles as well as considering Trust staff who have offered their services as owners of 4x4 vehicles. If deemed necessary by service managers, access to the North West 4x4 service is achieved by contacting a designated number which is on constant relay and will divert to all members of the group until answered. It should be noted however there is likely to be a high demand for this service should the severe weather be spread across a large area or for a prolonged period. The service is voluntary, will have operational limitations and will require mileage to be covered at a rate of 65p per mile. When requesting assistance contact details must be provided for the correct person to receive the invoice from North West 4x4 – such invoices should receive prompt attention to reflect the fact that this is a voluntary service and reliant upon goodwill and reimbursement. The service should only be considered for critical staff and services in adverse conditions and it must not be advertised in any way outside of the normal command and control structures. The contact details for the North West 4x4 service and a list of Trust staff with 4x4 vehicles plus additional information are available to all senior managers on call via the Network Drive (J:) – Major Incident – Majax Control – Winter Plans.

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10 ESCALATION PROCESS 10.1 Response Flow Chart

CMS – updated 2-4 hourly by Emergency Department and Bed Management teams to reflect current capacity status

Unify 2 – Winter reported mechanism compiled by Trust informatics teams to indicate to commissioners overall Trust status across a number of data sets

Exception Reporting – required by SHA (NHS North West) in event of Trust experiencing serious operational difficulties

Emergency Planning Generic In-Box – e-mail in box accessible by all senior managers on call, used by Greater Manchester NHS Resilience Team to notify Trust of key information out of hours.

Winter Related Service Delivery Issue

Local/Service Winter Business Continuity Issue?

Minimum Impact

Resolve Issue at service level using exiting winter Business

Continuity procedures

Report/Update using existing divisional structure

Return to Normal Service Provision Continued Monitoring at Service Level

Report Actions/Requests to Commissioners and Health

Economy partners

C.O.O. Set up Control to manage

response at Trust

Trust Wide Winter Service Delivery Issue?

Serious Impact

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10.2 Command and Control:

The suggested Command and Control structure for the Trust when responding to incidents during winter is outlined below.

As identified in the command and control structure above, most incidents resulting from winter pressures i.e. patient care issues, reduced staffing numbers, short term loss of supplies etc. will be managed at service level using existing resources policies and business continuity procedures. Wider ranging, serious or protracted incidents that may affect patient care, service delivery or have a negative effect on performance targets will need to be managed via an Operational Control Group. The group, chaired by the Chief Operating Office, with representation from all affected services and all staff that will be required to respond will be required to attend the meetings to discuss immediate priorities and allocate appropriate actions. Liaison with all health economy stakeholders should be initiated in line with the current Borough Escalation Plan.

“Bronze Control” will be provided by Service Level operational and clinical staff. This group of staff will lead the operational response to winter pressures using identified Business Continuity arrangements

Bronze Control: Service Level Managers

and Teams

“Silver Control” will be provided by the “Operational Control Group” (O.C.G). This group made up of senior managers and matrons and bed managers and clinicians will convene as a response to the Trust experiencing winter pressures that cannot be addressed at service level using existing operational Business Continuity arrangements

Silver Control: Operational Control

Group

“Gold Control” will consist of the Chief Executive Officer, the Chairman and Medical Director. They will co-ordinate the Trust’s strategic response to winter pressures.

Gold Control:

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APPENDICES

Bolton Health Economy and Social Care Resilience Plan The Health Economy Escalation Plan has been produced to assist in the management of the health and social care economy across Bolton during periods of surge or pressure.

The Bolton Health Economy and Social Care Resilience Plan is separate from each organisation’s Major Incident Policy.

Trust Escalation Plan

The Urgent Care Escalation plan has been designed to reflect the needs of Bolton Foundation NHS Trust and the fluctuating demands frequently seen in such a busy general hospital.

Critical Care Escalation Plan

NHS North West – Major Contingencies – Guidance for Critical Care Escalation The Trust has drawn up contingency plans for its response to a possible influenza pandemic but the actions and principles contained in the Critical Care Escalation Plan are appropriate for any emergency surge in critical care capacity regardless of cause.

Additionally, the Major Contingencies – Guidance for Critical Care Escalation document provides a framework for the development and implementation of the critical care response to contingencies, including influenza or mass causality events, within the North West.

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BOLTON HEALTH & SOCIAL CARE ECONOMY

RESILIENCE PLAN

2013/14

16

CONTENTS

Introduction……………………………………………………………………………………………………………………………………………. 3

Planning Assumptions and System Capacity …………………………………………………………………………………………….. 4

Information Management ………………………………………………………………………………………………………………………. 6

Communications ……………………………………………………………………………………………………………………………………. 8

Delegated Authority ………………………………………………………………………………………………………………………………. 8

Awareness Training ………………………………………………………………………………………………………………………………… 9

Health Economy Resilience Leads ………………………………………………………………………………………………………….. 9

Escalation Plan ………………………………………………………………………………………………………………………………………. 11

Appendices ……………………………………………………………………………………………………………………………………………. 23

Signed Agreement …………………………………………………………………………………………………………………………………. 24

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INTRODUCTION

This document has been produced to assist in the management of the health and social care economy across Bolton

during periods of surge or pressure.

The document has been branded as a Bolton Health Economy and Social Care Resilience Plan and is separate from

each organisation’s Major Incident Policy.

The document and plan are subject to continuous improvement and evaluation and as such is a ‘working document’.

This 2013/14 plan builds on the 2012/13 plan and sets out the steps to be taken across the Bolton Health and Social

Care Economy to ensure that appropriate arrangements are in place to provide a high quality and responsive service

through the winter period and beyond.

A system was established in 2011/12 to provide daily capacity and performance monitoring of providers and this will

continue in winter 2013/14.

Significant changes for 2013/2014 to be acknowledged as part of this plan are:

The establishment of Bolton Clinical Commissioning Group

Risk sharing agreements between the FT, Bolton Council and Bolton CCG for additional

Intermediate Care bed costs over Winter 13/14

Integration of the hospital discharge team and the Intermediate Tier Home Services

The monitoring of capacity and demand for 2013/2014 will continue to be through the Bolton NHS Foundation

Trust Urgent Care Group, which has the remit to develop robust demand management strategies, promote best

practice and ensure that the whole system is aware of changes to the levels of predicted activity, enabling the

system to respond accordingly. A key element of this plan is each organisations response to escalation. An escalation

plan has been developed to align partner agency trigger points and action plans.

The Borough-wide resilience planning approach builds on the whole system approach, which acknowledges the usual

peaks in demand over the Christmas and New Year period, plus unusual peaks in demand for other reasons, eg., as a

result of adverse weather conditions. Our commitment is to ensure that we have an adequate ‘system wide’

resilience plan, to respond to operational pressures in parts of the system, such as delayed transfers of care, waits

for Intermediate Care, waiting times in accident and emergency, ambulance delays, unplanned ward or

nursing/residential care home closures.

The resilience plan seeks to ensure:

Clear identification of the escalation process with defined escalation levels and triggers;

That key organisational contacts are identified;

Potential risks have been identified and contingencies have been put in place;

That the provision of high quality services are maintained through periods of pressure;

That the impact of pressures on the levels of service, national targets and finance are managed;

That process is in place to meet the winter reporting requirements of appropriate Boards and the GM

Cluster;

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This escalation process defines stages of potential increasing pressure that would trigger defined actions so the

ability of the BNHSFT, Adult Social Care services and Practices within the Borough to manage patients / service users

in a timely manner.

Winter 2013/2014

Additional anticipated pressures:

ANTICIPATED ADDITIONAL PRESSURES/RISKS SYSTEM IMPACT

Seasonal holiday and spread of seasonal holiday - Increased pressure on GP Out Of Hours, ED services

Patients not accessing timely care/crash-landing

Increasing number of patients presenting with drug/alcohol related conditions

Potential industrial action Insufficient resource to provide all services

Workforce, it is as crucial as ever for employer organisations to offer and promote the seasonal flu vaccine to their frontline healthcare workers and eligible patients

Robust locality sickness management/prevention strategy in place

Adverse weather Rise in specific conditions, falls, COPD etc. Transport/mobility restrictions.

Rising fuel costs and changes to eligibility criteria for patient transport

Older, frail and elderly may be affected. Impoverished families, and people with one or more long term condition may struggle to fund the cost of keeping sufficiently warm/attend appointments.

1. PLANNING ASSUMPTIONS AND SYSTEM CAPACITY

Each Health and Social Care organisation in Bolton has its own internal arrangements for capacity management and

escalation to meet surges in demand. This is a contractual requirement. This plan recognises the need for capacity

management as a co-ordinated model across the Health and Social Care economy.

NHS Bolton, BNHSFT, GMW and Bolton Council continue to work jointly to review, co-ordinate; monitor and update

resilience plans.

A Winter Assurance Checklist has been completed and provided the GM Cluster (September 2013), which illustrates

our level of preparedness across a number of areas. It will be the responsibility of Bolton Clinical Commissioning

Group as the lead commissioner to ‘declare’ the health and social care economy status.

It is an inherent understanding in this plan that no action should be undertaken by one constituent part of the

system, which may undermine the ability of other parts of the system to manage their core business, without prior

consultation / discussion.

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1.1 BOLTON NHS ACUTE FOUNDATION TRUST

As part of resilience planning BNHSFT has its own detailed plans for service development plan and capacity. This

includes details of inpatient beds required during the year, associated theatre sessions and outpatient capacity.

When bed occupancy exceeds normal operational levels, timely, daily discharges procedures will be in place to

maintain system safety and efficiency. The system will increase or re-allocate staff to key areas to ensure that the

daily discharge targets are achieved.

2013/14 DEVELOPMENTS to strengthen Winter Plans:

Escalation plans have been further developed for 2013/14 based on those of 2012/13. Services within the scope of

the escalation plan include:

Intermediate Care services, providing both increased bed based and integrated domiciliary care directly from

the community and the acute trust; an increased emphasis on home based reablement.

Develop a “Take Home and Tuck Up” service

An Active case management service targeting very high intensity users of unscheduled care services in

conjunction with primary care clinicians and the NHS Bolton Clinical dashboard; this is aimed to reduce

admission or expedite the discharge process.

A Rapid Response team (to include a Social Worker) with a 1 hour response, managing patients in the

community from primary care, nursing and therapy services.

Bolton Community Unit, providing step up care for community patients to assist avoiding acute admissions

and enhancing the flow of patients through the A+E department at RBHFT

Acute medical Consultants are providing a rapid assessment to support GP’s in managing Care closer to

home. They are also in-reaching very frequently into the A&E dept to ensure that high level assessment is

given early in the patient’s journey. This is aimed to reduce admission and shorten length of hospital stay.

1.2 PRIMARY CARE

46 practices offer extended hours opening for access to GP appointments in the Borough equating to 92% of all

practices. Risk stratification in liaison with practices will identify vulnerable patients who may be at risk to co-

ordinate any additional support, care plans will be developed in liaison with community services.


For Primary Care, these include:

The development of a data set to monitor urgent care in general practices thereby enabling the

health economy to have advanced warning of surges in demand in practices which would alert to

potential surges across the system and allow time to plan for this

Continued development of the QBiT (Quality Business Information Tool) and HERD (Health Economy

Resilience Dashboard) to support Primary, Secondary and Intermediate care. (see attachment for

details of QBiT and HERD)

20

1048_systems_overview.docx

A step up over the winter months in the regularity of communications to practices to keep them

informed on changes in system pressures – weekly newsletter escalating to daily related to alert

status

Under QOF Quality and Productivity initiative, practices will carry out a pre-winter review of all COPD

Severe and very severe and all Heart Failure on the QoF registers. The review will include proactive

review, meds review, flu vaccination, care planning including a self-care plan/ rescue meds /

education.

Project work with Practices to improve individual practice management of demands for urgent care.

1.3 SOCIAL CARE –


Social worker to be integral part of Integrated Discharge Team

Altered working patterns of staff to ensure cover from 8am to 7pm

Integrate social worker into the Rapid Response Team

Refocused all social work and Reablement services to prioritise BCU, Hospital and Intermediate Care

Discharges

Integrate Home Support Reablement team with Intermediate Care at Home team

Specific project work with care homes

Jointly funded Intermediate Tier Service Manager post

1.4 MENTAL HEALTH

Jointly funded Intermediate Tier Service Manager post

1.5 AMBULANCE TRUST (NWAS)

NWAS has its own escalation plan including Resource Escalation Action Plan (REAP) arrangements currently under review) and Clinical Escalation Plan all underpinned by Major Incident Plan and On Call Procedures and Deployment Plan, Regional Operational Coordination Centre and Urgent Care Desk monitoring activity and performance.


RAID to be fully staffed and operationalised

Section 136 Suite opened and fully staffed

Integrate member of RAID team into Integrated Discharge Team

Return Crisis team to community to prevent known individuals in crisis getting to A&E

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The REAP, is an integral part of the NWAS Business Continuity management strategy and is in operation at all times. It enables NWAS to ensure that its service can respond to challenges in the local environment, such as increased activity, significant loss of staff, buildings and resources, or pressures within the wider NHS. The health economy will continue to work with the NWAS in reporting escalation and local pressure status on the Capacity Management System and working to the Gold Control and SHA diversion process and policy. To meet national indicators for the Ambulance Service patient response and turnaround times, standard operational guidelines are in place to support minimal delays in emergency response times and hospital turnaround times.

2. INFORMATION MANAGEMENT

All Provider organisations are responsible for reporting their performance through various systems. These include a Capacity Management System and ExtraMed which provide operational information systems that supply information to the CCG Data Warehouse that “feeds” the Health Economy Resilience Dashboard (HERD). Emergency Pressures Reporting: This is managed by the GMCSU Utilisation Management Team (UMT). This report is provided by all acute trusts and collaboratively provides the UMT with a region wide picture of demand/capacity and this is fed into the GM Gold Command emergency planning process. Information provided by the Bolton NHS Foundation Trust will be used by commissioners to gain assurance that all effective measures are being implemented. Where assurance cannot be provided, or actions are not resulting in solutions, then the Urgent Care Operational Board will open communication channels to co-ordinate a solution. Escalation and reporting timescales are as figure 1. 2.1 ESCALATION

For 2013/14, escalation will monitored daily through local HERD report and a minimum of twice weekly health economy conference calls, operational intelligence, SIT REP and breach reports. HERD details differing levels of capacity availability and trigger indicators. Operational intelligence will be provided by senior managers and clinicians involved in the delivery of day to day services and members of the BNHSFT Urgent Care Group. Below is a list of the escalation levels to be adopted; for the purposes of this plan taken from the Greater Manchester Command and Control Framework;

Fig 1. Levels of Escalation for Winter Plans

Level(s) Colour Level Characteristics Impact Reporting Timescales

1 Green Individual organisations manage their own pressures within normal capacity planning parameters, liaison between commissioners and providers, and provider to provider within the economy will be standard practice

No impact on service

delivery

Monday – Friday only by 1030 daily across 5 days

2 Yellow Low surge effect activity increasing impacting

on service delivery

Monday – Friday only by 1030 daily across 5 days

3 Amber Medium surge effect moderate to severe

effects on services

All Health Economies reporting across 7 days, real time information.

22

delivery

4 & 5 Red Major disruption to services high impact on service

delivery

All Health Economies reporting 7 days as required by DH/ NHS NW.

The Escalation Plan is at section 7 of this plan.

3. COMMUNICATIONS

During usual daytime working hours each organisation will have communication arrangements in place, (both internal and external) to manage escalation within and across the health and care economy. Out of hours the Bolton CCG Director on-call arrangements will have responsibility for leading escalation and necessary communications including declaring the health economy status with NHS England and provider organisations. During winter and other pressure periods communications will be mobilised appropriate to the level of escalation. See attached Winter Escalation plan. 4. DELEGATED AUTHORITY This Resilience Plan will be taken for agreement through NHS Bolton and partner organisations as follows: Bolton CCG Urgent Care Operations Board August 2013 Bolton CCG Executive September 2013 RBHFT Executive Board October 2013 Bolton Council Portfolio Board October 2013 Executive Briefing October 2013 Committee Admin October 2013 GMW Executive Board October 2013 Bolton CCG is the lead for managing the Bolton health economy alert status. In alert status individual organisations will be responsible for cascading and managing internal processes. The BNHSFT Urgent Care Group will meet weekly and more frequently when necessary to monitor and identify capacity/demand and ensure the appropriate escalation level is recommended and activated as appropriate, within agreed timescales and triggers of Escalation. In the event that any pressures identified outside of the routine winter monitoring arrangements, the BNHSFT Urgent Care Group will be an informing and co-ordinating group (as indicated by the Tactical Response plan appendix F) responsible for the activation of escalation, de-escalation and lead communications between the Health Economy organisations. The BNHSFT Urgent Care Group reports to the Urgent Care Operational Board which has overall accountability for delivering resilience.

23

The use of trigger indicators to activate actions across organisations, as set out in the plan will, to an extent, result in ‘automatic’ corrective action being undertaken to respond to pressures in one or more parts of the system. However, individual resilience leads with delegated authority will be provided with the necessary information set out within the Borough-wide escalation plan, in order to respond appropriately to escalation or alerts. All provider organisations will ensure the explicit responsibility for who can decide on a change of escalation level in an organisation is in place, this is evidenced in the individual’s plans and on call responsibilities. Our system ensures that organisations do not automatically escalate if just one trigger is tripped, and therefore it has been agreed that the duty manager or director on call for the individual organisation will consider triggers and issues pertinent at the time to inform the escalation alert status. 5. AWARENESS RAISING AND TRAINING A programme of training and development is in place to ensure individuals, departments and organisations are aware of obligations, processes and individual responsibilities regarding the escalation process. Desktop exercises have been undertaken throughout 2013; including Winter Debrief, Winter Planning, Resilience Testing due on the 9th of October 2013.

6. HEALTH ECONOMY RESILIENCE LEADS

The following is a list of those personnel from the principal members of Bolton’s health economy who would input to and aid the tactical support function of the Urgent Care Operational Group in the decision process.

Bolton Clinical Commissioning Group

TITLE NAME CONTACT DETAILS

Clinical Director Barry Silvert 01204 462012

Chief Executive Officer Su Long 01204 462110

Major Incident Planning

Greater Manchester Gold Emergency Planning

Peter Heijstraten 0161 212 4834

07749684166 (emergency only)

Head of Communications Lucy Ettridge 01204 462026

Senior Commissioner Jackie Bell 01204 432100

Bolton NHS Foundation Trust


Chief Executive Officer Jackie Bene 01204 390808

Director of Operations Jon Scott 01204 390390 x3803

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Clinical Lead Acute Adult Division Adam Robinson 01204 390390 x3726

A&E Clinical Lead Owen McCormack 01204 390381

Director of Nursing, Patient Safety and

Infection Control

Trish Armstrong-Childs 01204 390390 x3650

Divisional Director of Operations for

Acute Adult Care Division

Michelle Redgard 01204 390822

Bolton Council – Social Services


Director of Adult and Children’s

Services

Margaret Asquith 01204 ******

Assistant Director Rachel Tanner 01204 ********

Assistant Director of Health and Adult

Social Care, Integration and Providers

Services

Adrian Crook 01204 334175

Infection Control Nurse Julie O’Malley 01204 462538

07918619122 (emergency only)

Director of Public Health Wendy Meredith 01204 462009

Greater Manchester West


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7. ESCALATION PLAN 2011/2012

Area Bolton Clinical

Commissioning

Group

Foundation Trust Primary care (FHS

Contractors)

Adult Social Care

Volume &

Capacity Monitoring and

responding to

Urgent Care

dashboard, GM

Gold command

and NHS NW as

required.

No weather

alerts.

All providers have

BCUs in place

Bed availability within normal range

Clinical activity within normal range

National bed utilisation optimal threshold

85%

Intermediate bed utilisation at normal

level of 89%

12 spare beds out of 80 available in IMC

GP Out of Hours demand as predicted for

time of year.

DISCHARGES WITHIN EXPECTED RANGES

(NEED TO AGREE THRESHOLDS)

GP Activity /Consultations

and spotter practices within

normal range.

Seasonal influenza

vaccinations proceeding

against plan

Referrals for assessments and unscheduled reviews are

within are at or below 10% of hospital population.

No delays in assessments. Referrals to Reablement

Home Support Team are within normal seasonal levels

and there is capacity to meet demand from assessment

areas and complex ward(s).Referrals to Independent

sector Domiciliary Home Care Services are within

normal seasonal levels and there is capacity

Capacity available in 24 hour care including residential,

EMI and nursing sectors.

Requests for admissions to permanent residential care

within normal seasonal levels.

Staffing Staff absence levels normal across the organisations

Infection

management Infection control status normal (no significant containment issues)

Critical Care Availability / Capacity within Unit and / or North West Critical Care Network

26

ACTIONS L1 GREEN

Bolton Clinical Commissioning

Group Foundation Trust Primary care (FHS Contractors) Adult Social Care

Communications

PCT lead communicators

identified and trained in

resilience planning and

escalation processes GBCCG01

Monitoring and responding to

Urgent Care dashboard, GM Gold

command and NHS NW as

required. GBCCG02

Maintain daily monitoring using

CMS/HERD/Sit Reps/GM

Utilisation reports/Breach

Analysis and 2 weekly Health

Economy conference calls

GBCCGO3

Normal local admission criteria apply

Monitoring against 21/2-hour internal

targets - Monitoring of trigger measures

at Bed Meetings. GHOS01

Ward managers identifying and reporting

gaps in staff cover;

Hospital data reporting through SITREPS

and CMS. GHOS02

HR / WorkforceNormal monitoring

activities in relation to staff attendance

Daily communication of status to partner

organisations.

Business continuity plans are in place and

tested. GHOS03

Normal local admission and referral

criteria apply. GHOS04

Co-ordinate established whole system

approach through weekly sit-rep

reporting agreed across all providers.

GHOS05

Vaccination programmes have

commenced for staff GHOS06Infection

notifications levels manageable

Primary Care

Practices on a day to day basis flex capacity

to meet peaks in demands GPC01

Business continuity plans (BCP) are in place

with triggers alerting the PCT of any

unplanned reductions in service (or

undefined timescale) GPC02

Since 2011/12 winter period, daily

monitoring of demands for urgent care

have been in place, to prompt advance

warning to other parts of the Health and

Social Care Economy GPC03

Vaccination programmes have commenced

for staff and patients GPC04

Usual Business processes apply

Hospital and Intermediate care discharges

prioritised GLA01

Routine monitoring of activity in the

independent domiciliary home care sector

GLA02

Weekly monitoring of capacity in the

Residential/Nursing Care Home sector GLA03

Weekly Acute/non acute care SITREP

reporting to monitor and respond to

blockages in the system. GLA04

Business Continuity Plans in place GLA05

HR/Workforce

Flu vaccines available for staff GLA06

Infection control risk assessments in place for

staff working in high risk areas. GLA07

Routine monitoring activities and protocols in

place in relation to staff attendance. GLA08

If capacity or operational effectiveness is being stretched beyond existing capability out lined above consider this a trigger INFORM PARTNER

ORGANISATIONS to move to next level.

27

WINTER ESCALATION PLAN 2011/2012

L2 YELLOW Description

Low surge effect – activity increasing impacting on service delivery

Area Bolton Clinical

Commissioning

Group

Foundation Trust (including the new

integrated PCT Provider Arm)

Primary care (FHS

Contractors)

Adult Social Care

Volume &

Capacity

Dashboard

monitoring

identifies Adult

Social Care or

Acute Trust or

Primary Care

escalating beyond

Green

Increasing activity

in practices and

consultations

Weather alerts

reported

Bed availability issues but within

acceptable limits

Clinical activity increased in ED/D1/D2

Demand for community services beginning

to out strip capacity in CRT / RRT / IC /

Nursing beds/ IC@home /

IMC Bed utilisation now at 95% (only 4 of

the 80 beds vacant)

OOH showing increasing activity –

thresholds to be identified

Some delays accessing social care

packages

DISCHARGES WITHIN EXPECTED RANGES

(NEED TO AGREE THRESHOLDS)

Increasing activity in

practices with low surge in

consultations within normal

range – external reports and

spotter practices

Number of all GP contacts

increasing

Referrals for assessments and unscheduled reviews are

slightly above normal seasonal levels and are 11% or

above of the hospital population

No delays in assessments.

Increase above anticipated seasonal levels of referrals

to independent sector domiciliary care

Additional capacity planned to be provided by

Independent sector Domiciliary Care Services

Requests for admission to permanent residential care

within seasonal levels

Temporary residential/nursing homes affected by

infection and not able to accept new placements.

Staffing Staff absence levels have exceeded normal levels and managers are reporting staff shortages impacting on services. Flu vaccination

rates not being achieved Put in %. All data too retrospective and there are no systems in place to reflect real time status

Infection Infection control outbreaks causing concern and impacting on transfer issues and are just containable within increased Infection

28

management control measures operating procedures daily IC report required Flu vaccination rates below plan -

Critical Care Capacity within critical care / regional availability may be compromised. Regional escalation may be actioned.

ACTIONS L2 YELLOW

Bolton Clinical Commissioning

Group

Foundation Trust Primary Care (FHS Contractors) Adult Social Care

IN LINE WITH GM GUIDANCE REQUEST INFORM TACTICAL RESPONSE GROUP. ANY ORGANISATION MOVING TO YELLOW MUST INFORM TACTICAL RESPONSE GROUP BY E-MAIL TO TRIGGER APPROPRIATE LEVEL OF CROSS DEPARTMENTAL OR CROSS ORGANISATIONAL DISCUSSIONS

PCT consolidates plans to identify a

pool of GP locums; nurse and admin

staff for access by Practices as

necessary for maintenance of core

services YBCCGO1

PCT trouble shooting team identified

in readiness to mobilise on Amber

alert YBCCGO2

PCT lead communicators sends alert

to partner agency leads of change in

status YBCCGO3

Public/patient communications re-

enforced on self care and advice on

health protection/promotion

delivered through media, practices

and pharmacies. YBCCGO4

Continue with normal local admission criteria

or review with the potential to fast-track

admissions and investigations YHOS01

Emergency Department

Monitoring against 21/2-hour internal targets –

Monitoring of trigger measures at Bed

Meetings x 5 daily. YHOS02

HR / Workforce

Ward managers identifying and reporting gaps

in staff cover; YHOS03

Normal protocols in place around sickness

reporting/agency/bank staffTrust wide skills

audit refreshedReview workforce business

continuity plans including collation of

volunteer lists YHOS04

Practices continue to flex capacity to

meet peaks in demand. YPC01

Identify patients with chronic problems

for review. YPC02

Reinforce messages on self-care,

supported by PCT borough wide

communications plan YPC03

Identify at risk patients cared for in

community and ensure care plans are in

place YPC04

Create capacity in Reablement Home

Support to support prioritisation of

Hospital and Intermediate Care

discharge. YLA01

Continue routine monitoring of activity

in the independent domiciliary home

care sector YLA02

Double the levels of weekly monitoring

of capacity in the Residential/Nursing

Care Home sector Mondays and Fridays

mornings YLA03

Continue weekly Acute/non acute care

SITREP reporting to monitor and

respond to blockages in the system.

YLA04

29

Information

Monitor and responding to Urgent

Care dashboard, GM Gold command

and NHS NW as required.

PCT to respond to queries and

report YBCCGO5

Elective Services

Consider/review suspension of elective major

adult non-oncology surgery Consider

identifying patients with chronic problems for

review in collaboration with GPs Low

DISCHARGES (NEED TO AGREE THRESHOLDS)

YHOS05

Consider pooling of GP locums YPC05

ACM/DN. In liaison with Practices start

to identify vulnerable patients in

readiness to mobilise emergency care

plans in case of transition to amber alert

YPC06

Business Continuity Plans in place YLA05

HR/WorkforceFlu vaccines available for

staff YLA06

Infection control risk assessments in

place for staff working in high risk areas.

Continue Routine monitoring activities

and protocols in place in relation to staff

attendance. YLA07

L3 AMBER Description: Medium surge effect –

Moderate to severe effects on services

Area Bolton Clinical Commissioning

Group

Foundation Trust Primary care (FHS Contractors) Adult Social Care

Volume & Capacity In a defined geographical area,

25% of the practice(s) have

alerted the PCT that part of

their BCP has failed e.g. owing

to inability to secure locum or

staff cover and inability to

mobilise buddying

arrangements

Increasing Urgent Care activity

across the system

Bed availability minimal put in %

Low DISCHARGES (NEED TO

AGREE THRESHOLDS)

Significant reliance on GP Out of Hours & NHS Direct services. (OOH plan at appendix G)

Clinical activity disrupted.

Demand for provider services

has out striped capacity in CRT /

Increasing GP Activity

/Consultations outside normal

range.

Serious delays accessing social

care packages

Referrals for new

assessments/unscheduled reviews

well above normal seasonal levels 15%

or >15%

Delays in new assessments/

unscheduled reviews being completed.

Severe delays in non urgent new

assessments/unscheduled reviews

being completed.

If capacity or operational effectiveness is being stretched beyond existing capability outlined above. Regional response would be implemented.

INFORM PARTNER ORGANISATIONS

30

Increased reliance on Out Of

Hours GP Service & NHS Direct

Weather alerts

RRT / IC / Nursing beds/

IC@home

IMC Bed utilisation now at 100%

(No beds available] and zero

patients waiting

Serious delays accessing social

care packages

Some independent Domiciliary Care

Services no longer able to accept

referrals

Delays in transferring work from home

support reablement to the

independent sector due to the above.

Home support escalation plan on

amber.

Some problems with capacity in the

residential/nursing home sector

Requests for admissions to residential

care for permanent and emergency

short term care are well above normal

seasonal levels.

Some problems making placements.

Staffing Staff absence levels across the organisations beginning to place a strain on service delivery

Data is too retrospective to establish – need to identify proxy to measure

Infection management Infection control issues escalating and requiring implementation of special measures

Critical Care Critical care capacity compromised. Local / Network escalation required

31

ACTIONS L3 AMBER

Bolton Clinical

Commissioning Group

Foundation Trust Primary Care (FHS Contractors) Adult Social Care

IN LINE WITH GM GUIDANCE REQUEST INFORM TACTICAL RESPONSE GROUP. ANY ORGANISATION MOVING TO AMBER MUST INFORM TACTICAL RESPONSE GROUP BY E-MAIL TO TRIGGER APPROPRIATE LEVEL OF CROSS DEPARTMENTAL OR CROSS ORGANISATIONAL DISCUSSIONS

Team mobilised to support practices approval/advice on temporary suspensions ABCCGO1

Co-ordinated comms with public/patients, LA and health partners ABCCGO2

Co-ordinated plans for media

management ABCCGO3

Information to practices from

Urgent Care Clinical Lead on

alert status to activate plans

as necessary ABCCGO4

Normal local admission criteria still apply AHOS01

Bed Management

Identify/expedite potential discharges;Review

all patients for Rehab / home; Review

diagnostic delays; AHOS02

Prepare bed escalation capacity; AHOS03

Consultant review of all patients; AHOS04

Review elective priority list; AHOS05

Constant monitoring and increased

assessment of demand AHOS06

Liaise with identified Bolton Council Senior

Manager over escalating planned discharges.

AHOS07

Start deferral of non-essential or elective

work to generate staff capacity for re-

location. AHOS0

Practices, in accordance with their BCP,

defer non essential tasks and mobilises

workforce plans. APC01

Sit Reps from Practices at critical status

co-ordinated with other parts of the

system eg OOHs/walk in centre APCO2

ACM/DN’s in liaison with Practices

develop emergency care plans for

identified vulnerable patients APC03

Continue to create capacity in Reablement Home Support to support prioritisation of Hospital and Intermediate Care discharge. ALA01 Continue routine monitoring of activity in the independent domiciliary home care sector ALA02

32

The Response to notification

with demand reduction

measures includes:

Reinforce infection control

advice and procedures in

consultation with health

departments of the devolved

administrations ABCCGO5

Reinforce self-care and how to

protect and look after yourself

ABCCGO6

Co-ordinate established whole

system approach through weekly

Urgent Care ops meetings/

increasing the frequency

including meeting face to face

ABCCGO7

Community services

Infection Prevention

Reinforce Infection prevention advice

Reviewing threshold on Emergency

Admissions criteria because trolley waits will

increase due to patient acuity and an increase

in clinical exceptions. AHOS09

Increased reliance on Out Of Hours GP Service

& NHS Direct services. See GPOOH plan

appendix G.

Liaise with Bolton Council Senior Managers to

request action to prioritise support through

home care services to the BCU and IC Nursing

beds in order to escalate appropriate

discharges. AHOS10

Review at risk patient emergency care plans ready

to implement if needed. AHOS11

Weekly sickness absence monitoring to move to

daily AHOS12

Continue weekly monitoring of capacity in the Residential/Nursing Care Home sector Senior Manager to attend weekly acute/non acute SITREPS to monitor and respond to delays/blockages in the system ALA03 Suspend routine review activities, identify staff to transfer to manage areas of high demand specifically BCU, hospital and Intermediate Care discharges. ALA04 Notify all independent sector providers regarding escalation status. ALA05 Escalate planned discharges

HR/Workforce

Non mandatory staff training cancelled. ALA06 Offer part time staff extra hours ALA07 Review Infection control risk assessments ALA08 Senior management on call arrangements in place, ALA09

33

L4/RED Desctipgtion

Major disruption to services – high impact on service delivery

Area Bolton Clinical Commissioning

Group

Foundation Trust Primary care (FHS Contractors) Adult Social Care

Volume & Capacity In a defined geographic area,

50% of the practice(s) have

alerted the PCT that part of

their BCP has failed e.g. owing

to inability to secure locum or

staff cover and inability to

mobilise buddying

arrangements and 25% of

practices at risk of temporary

closure or suspension of

services

Weather alerts

Bed availability – None

Low DISCHARGES (NEED TO

AGREE THRESHOLDS)

Significant reliance on GP Out

of Hours & NHS Direct

services. (OOH plan at

appendix G)

Clinical activity – Severely

disrupted

No IMC beds available and

patients waiting

Increasing urgent care activity in

practices surged to the extent of

major disruption to the service

requiring advice/support from

the PT C Troubleshooting team

Referrals for urgent new assessments

/unscheduled reviews severely above

normal seasonal limits.

Severe delays in completing urgent

assessments

No routine assessments being done

No capacity in Reablement home support

Limited capacity in the independent

domiciliary care sector serious delays in

accepting work.

Severely limited capacity in the

Residential Nursing care Home sector.

Some homes closed to admissions. (eg.

due to Noro virus)

Severe problems making placements for

permanent and emergency short term

care.

Staffing Serious Staff absence levels creating service delivery issues Economy-wide

Demand for support is outstripping capacity. Practices alert NHS Bolton of specific difficulties in accessing

34

other patient support and treatment services et access to community/inpatient services

Infection management further escalation of infection control issues implementation of special measures

Critical Care No Availability / Capacity. Full local escalation required

ACTIONS L 4/5 RED

PCT Bolton Clinical

Commissioning Group

Foundation Trust (includes the

Integrated PCT Provider Arm)

Primary Care (FHS Contractors) Adult Social Care

IN LINE WITH GM GUIDANCE REQUEST INFORM TACTICAL RESPONSE GROUP. ANY ORGANISATION MOVING TO YELLOW MUST INFORM TACTICAL RESPONSE GROUP BY

E-MAIL TO TRIGGER APPROPRIATE LEVEL OF CROSS DEPARTMENTAL OR CROSS ORGANISATIONAL DISCUSSIONS

Notification of demand

reduction measures by the

Tactical Response Group

includes: RBCCGO1

Ensure all provider BCPs are

activated including FHS

contractors RBCCGO2

Increase frequency of co-

ordinated pandemic

conferences both telephone

and face to fact RBCCGO3

Anti-viral collection centres

open and fully operational

Joint working to minimise

At the earlier stage of the surge:

Staffing Business continuity plans

activated. RHOS01

Cancel clinics, elective surgery and

inpatient admissions where no severe

adverse effect anticipated RHOS02

Essential care only when required

As the surge increases:

Defer some services/treatment for non-

life threatening conditions RHOS03

Clinical care practices to maximise

capacity

Defined non-essential services suspended across

practices (within DH guidelines – Aug ’09) ensuring

continuity of care for vulnerable patients and

essential screening/patient reviews maintained

RPC01

Practices co-operate with process for phased

response to demands for access to secondary care

(new integrated provider) balance of probability

for urgent referrals shifts from possible to

probable eg overt cancer signs RPC02

End of Life care services continue to be supported

and expanded if possible and feasible RPC03

Practices support secondary care plan to manage

Suspend all non urgent work and

undertake only urgent/emergency work

that contributes to an agreed system wide

approach to manage demand and capacity

across the whole system.RLA01

Suspend services where appropriate RLA02

Suspend any non urgent activity and

transfer staff to areas of high demand.

RLA03

Escalate planned discharges form Hospital

and Intermediate Care. RLA04

Operate at critical FACs criteria only.

RLA05

35

referrals and maintain

patients in a community

setting across all services, eg,

GPs, Intermediate Care at

Home and Referral and

Assessment teams to prevent

admission

Increase BCU capacity with

additional beds/ chairs

RBCCGO4

Ensure rapid discharge RHOS04

ED/Medicine

Consultant recall to wards; RHOS05

Opening available escalation capacity

i.e. use of Out patients RHOS06

Notifications to GPs/PCT/Social

Services; RHOS07

Start implementation of plans around

patient classification of emergency

management priorities RHOS08

Critical Care/Paediatrics

SHA May implement of NHS North

West Critical Care Operational Policy

Use alternative settings for critical care

Increase stringent criteria for critical

care beds

Restrict treatment options in ICU

RHOS09

Consider implementation of the reverse

triage methodology RHOS10

Paediatric referrals for critical care

should follow current practice e.g.

Paediatric ICUs. if not possible

Paediatrics may have to be cared for on

patients where possible in community settings

RPC04

Practices support plans for managed early

discharges RPC05

Manage patients within the community setting

including: RPC06

Trauma cases

Cardiac arrest – not responsive to electrical

therapy

Known severe, progressive baseline cognitive

impairment requiring respiratory support

known advanced, untreatable neuromuscular

disease requiring respiratory support

Known advanced metastatic malignant disease

Known advanced, irreversible

immunocompromised requiring respiratory

support

Severe & irreversible neurological event or

condition

Elective palliative surgery

Continue to create capacity in Reablement

Home Support to support prioritisation of

Hospital and Intermediate Care discharge.

RLA06

Advise independent sector organisations of

escalation status. RLA07

Continue routine monitoring of activity in

the independent domiciliary home care

sector RLA08

Twice weekly monitoring of capacity in

independent residential/nursing care

home sector RLA09

HR and Workforce

Advise trade unions of escalation status.

RLA010

Senior management on call arrangements

in place, RLA11

Offer staff additional hours to facilitate 7

day services in high demand areas and all

staff training cancelled RLA12

36

adult wards RHOS11

Elective Services

Gradual increasing suspension of all

elective major adult surgery RHOS12

Infection Control

To increase their level of input,

focussing on limiting the spread of

infection within wards and more

generally across the hospital RHOS013

HR / Workforce

Implement plans to transfer staff into

non-specialist areas (created through

closure of Out patient services, wards

and other non-essential corporate

services) RHOS14

Clinical care practices maximised –

removal of all non-essential clinical

involvement across the Trust RHOS15

Senior manager to attend RBH bed

meetings RHOS16

Senior manager included in RBH control

Team RHOS17

Referral and assessment team member

37

L 4/5 RED

based in BCU RHOS18

Deploy consultant of the day to BCU

RHOS19

If capacity or operational effectiveness across the health and social care economy (ie there is a risk to borough

wide provision of care) this should be escalated to GM Gold Command so that a regional response could be

implemented. INFORM PARTNER ORGANISATIONS

38

7. APENDICES

Appendix A: Bolton Health and Social Care Economy Organisational Response Pathway

Appendix A operational reponse pathway.doc

Appendix B: Winter Assurance Checklist, providing a Summary of readiness of components of the

Borough health economy providers

Appendix C: Emergency Pressures Health & Social Care Tactical Group Terms of Reference

appendix C tactical response.doc

Appendix D:

NWAS Winter capacity plan 2013/2014

NWAS Strategic Winter Capacity Plan 2011 12 .pdf

NWAS Winter Assurance Checklist 2013 (FINAL inc NHSE REVISIONS 2013-09-19).docx

Appendix E: NWAS Hospital Arrivals policy 2011/2012

Appendix E Hospital Arrivals Policy 2011 12.doc

Appendix F: Greater Manchester Command and Control Framework 2011/ 2012

FINAL - GM NHS CCFramework Winter 2011-12 (2).doc

Appendix G: Arriva Winter Plan

ATSL Winter Plan .docx

39

Bolton Health and Social Care Economy Resilience Plan - AGREEMENT

This joint plan has been produced by the Health and Social Care Economy. Individual organisations are responsible

for ensuring that appropriate training and communications systems are in place to deliver the actions required in the

Resilience Plan and in particular the Escalation Plan at Section 7.

Name: Su Long

Signature: …………………………..

Organisation: BOLTON CLINICAL COMMISSIONING GROUP Date: ………………………………..

Name: Margaret Asquith

Signature: …………………………..

Organisation: Bolton Council Date: …………………………………

Name: Jackie Bene

Signature: ………………………….

Organisation: Bolton NHS Foundation Trust Date: ………………………………..

Name: Bev Humphrey

Signature: ………………………….

Organisation: Greater Manchester West Mental Health NHS FT Date: ………………………………..

Agenda Item No : 12

Meeting Board of Directors


Title Phase 2 Transparency Project NHS England

Executive Summary



• “Transparency in Care” aims to be a programme of improvement in culture and care.

• Publishing data on harm, experience and staffing that supports patient choice and enhances staff knowledge, leading to empowerment to change practice.

• By participating in “Transparency of Care”, the Board of Directors is agreeing to the Compact agreement and ownership of the ‘concept’


Discuss Receive

Approve Note


Bev Tabernacle, Deputy Director of Nursing


Strategy * Financial Implications


Quality * Regulatory




Prepared by Bev Tabernacle, Deputy Director of Nursing

Presented by Trish Armstrong-Child, Director of Nursing

BOARD – 31st October 2013

Phase 2 Transparency Project NHS England 1. PURPOSE

Inform the Board of the organisation involvement in the Phase 2 of the NHS North Transparency project and to present the Board Compact which has been issued through the Chief Nurse for the North of England.

2. BACKGROUND

In September 2011 Nursing Leaders from 8 Acute NHS Trust in the

North West came together as members of the “Transparency Project”

to see if they could learn more about the PU and Fall harms that occur

in their Organisations. They jointly had a shared passion to progress

and improve the experience of both patient and staff and to work

closely with patients to learn what needs to change in order to improve

future patient care.

This work was completed with a view to the expansion of the project to

include further indicators, and enable roll out across all areas of the

NHS. Phase 2 of this work began in August 2013 with 35

organisations being invited to participate in the further development of

the work completed in 2012.

The Phase 2 Transparency data will be undertaken in the following

areas;

1. Classic Safety Thermometer results

2. Friends and Family Test

3. Pressure Ulcers grade 2-4 and unclassifiable ( pre and post 72 hour)

4. Falls moderate harm and above

5. Staffing levels/skill mix (when harm occurred)

6. Staff and Patient Experience information

7. Patient story of harm

8. Improvement story

Bolton Royal NHS Foundation Trust is one of the 35 organisations

involved in the Phase 2 Transparency project.

3. CURRENT POSITION Bolton Royal FT was involved in the Phase one work in relation to transparency, currently data is not being submitted. A review of the process used will be undertaken by the Deputy Director of Nursing to ensure that the system going forward is inclusive of the new areas of information and fit for purpose.

4. PROPOSAL

The Board Compact is outlined in Appendix 1. The Transparency project working group have agreed the following measures, and upload of this information is supported by a purpose built web module to enable easy upload of the information required.

1. Trust level data on MRSA, C Diff, Safety Thermometer and FFT ( NHS North are currently working on a solution that will extract this data from the current systems)

2. Pressure Ulcers (2 and above) and Falls (moderate and above) – Actual numbers for each month and a trend line of rates/1000 occupied bed days. PUs by pre 72 and post 72hr.

3. Staffing levels, this will have to be at ward level for each harm. So will look like: PU or fall, the shift on which it was identified (E, L or N) then the preceding 3 shifts: Planned RN vs. Actual RN, Planned Non-RN vs. Actual Non-RN for each shift.

4. The mini RCAs will be completed electronically BUT will not be displayed on the front page for publication – that information is for the Trust to use.

5. Staff experience – 3 questions to be asked at the time or the harm to 5 staff members (a range of staff). The results will be displayed as a net promoter score.

6. Patient experience questions – 7 questions; to be included as part of the Trust monthly survey, not specifically patients who have been harmed. Again, the results will be presented as a net promoter score. For those trusts that cannot include them in their regular surveys, for whatever reason, this section will be left blank.

7. A patient story 8. The improvement story – this is what you have seen from the month’s

data and what improvements you are making, written in language that the public and all staff groups will understand.

5. CONCLUSION Although some of this data collection and publication will be challenging, it is important that the organisation continues to participate in the Transparency work in a shared learning environment with other organisations. The publication dates for this information are yet to be confirmed, however currently the project is looking to publish in the New Year. Work will be done between now and the first data collection to ensure that processes are in place to support this work in the long term.

6. RECOMMENDATIONS

The Board are asked to agree with the ongoing participation in this work and endorse the Board Compact in Appendix 1.

NHS | Presentation to [XXXX Company] | [Type Date] 1

Transparency in Care

The Board Compact

September 2013

Transparency in Care

• “Transparency in Care” aims to be a programme of improvement in culture and care.

• Publishing data on harm, experience and staffing that supports patient choice and

enhances staff knowledge, leading to empowerment to change practice.

• By participating in “Transparency of Care”, the Board of Directors is agreeing to the

Compact agreement and ownership of the ‘concept’

Transparency in Care – Background & Context

• Phase one: 8 Trusts in NW agreed and started to publish harm and experience data in

February 2011. (Pressure ulcers, falls, patient and staff experience)

• There were two key principles: to improve experience and reduce harm; to be open

and honest with the public.

• The programme was not formally evaluated; however the majority of Trusts did

demonstrate improvements and have continued to publish their data and information.

• So why spread the programme further?

Compassion in Practice

Francis Report: “Duty of Candour” and “Openness”

Keogh Reviews: Ambition Two and Three

Berwick Report

The Board Compact

• Board endorsement of organisation’s involvement and commitment to openness

• Utilisation of common data definitions, reporting templates, PR/media etc. Trusts can

add to the data set if they so wish, but the core must be agreed.

• Publication of data in agreed formats at agreed times and proactively shared with

stakeholders (internal and external). Will form part of routine quality reporting in Part

One of Board of Directors.

• Commitment to publish further metrics as developed and agreed

• Focus on the capacity and capability for improvement, not to apportion blame

• Mentoring organisations new to transparency as their own experience and confidence

grows

Metrics and narrative for publication

The metrics for publication will grow over time. In the first instance, we will publish actual

numbers and trends (annotated with improvement work):

1. Classic Safety Thermometer results

2. Friends and Family Test

3. Pressure Ulcers grade 2-4 and unclassifiable ( pre and post 72 hour)

4. Falls moderate harm and above

5. Staffing levels/skill mix (when harm occurred)

6. Staff and Patient Experience information

7. Patient story of harm

8. Improvement story

Publication

• The metrics and narrative will be published monthly on the Trust internet and intranet

(within two clicks) and on NHS Choices. Internally, wards and teams will be able to

view both their local data and Trust data.

• Trusts will establish a regular feedback mechanism with staff, patients and families to

ensure the publication is understandable and meaningful.

Agenda Item No : 15



Title Board Assurance Framework (BAF)

Executive Summary

Why is this paper going to the Committee

To summarise the main points and key issues that the Committee should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

The BAF is designed to focus the Board on controlling principal risks threatening the delivery of objectives. The BAF aligns principal risks, key controls and assurances on controls alongside each objective. Gaps are identified where key controls and assurances are insufficient to reduce the risk of non-delivery of objectives.

Board members are asked to note the significant risks to the achievement of the Trust’s objectives and consider the mitigations and assurances. We are continuing to review and refine the BAF to ensure it best meets the needs of the organisation.

Next steps/future actions Clearly identify what will follow i.e. future KPI’s, assurance requirements

The development of the BAF will continue with oversight from the Risk

Management Committee

Discuss Receive

Approve Note



Performance

Legal Implications

Quality

Regulatory

Workforce

Stakeholder implications



Prepared by Esther Steel Trust Secretary

Presented by Esther Steel Trust Secretary

BOARD ASSURANCE FRAMEWORK

1. INTRODUCTION

The Board Assurance Framework (BAF) is a tool which sets out the significant

risks for each strategic objective, along with the controls in place and

assurances on their operation. The BAF is used by the Board of Directors to

ensure that all significant risks have been identified; information on control,

performance and assurance is timely and relevant; and to provide leadership on

risk management.

2. DEVELOPMENT OF A NEW BOARD ASSURANCE FRAMEWORK

Although the format previously used for the BAF was in line with Department of

Health guidance it was felt that the format and content could be improved to

provide a more effective framework.

In developing the new BAF advice has been sought from other Trusts and

companies recognised for their expertise in this area. The BAF policy is being

updated to reflect the changes.

2. 2013/14 ASSURANCE FRAMEWORK

The Board of Directors agreed the following corporate objectives in March

2013:

Improved care

To be financially strong

To be well governed

To be a great place to work

To be fit for the future

The BAF sets out the significant risks to the achievement of these objectives as

agreed at the Risk Management Committee (October 16th 2013)

3. NEXT STEPS

The new BAF is still a work in progress and will be subject to further review and

refinement before being presented to the Audit Committee on 21st November

2013.

Summary of Risks October 2013

= risk increased = risk decreased = new risk = no change

Im

pact

Likeliho

od

score

A1 Failure to reduce the number of cases of CDT 4 5 20

A2 Failure to provide appropriate skill mix 3 4 12

A3 Failure to provide timely response to deteriorating patient 4 4 16

A4 Failure to comply with CQC standards 4 4 16

A5 Failure to meet the criteria for meeting needs of people with learning disability 3 2 6

A6 Failure to continue to meet the A&E target 4 4 16

A7 Failure to continue to meet the RTT target 4 4 16

B1 Failure to achieve the planned deficit 5 3 15

B2 Failure to achieve run rate balance 5 4 20

C1 Failure to address compliance requirements 5 2 10

C2 Failure to ensure safe management and learning from incidents 4 4 16

C3 Failure to comply with information governance 3 3 9

D1 Failure to reduce sickness absence 4 4 16

D2 Failure to strengthen communication and engagement 4 4 16

E1 Healthier Together 5 3 15

E2 Failure to achieve integrated care

E3 Failure to provide adequate IT infrastructure 20

E4 Failure to provide an efficient fit for purpose estate 4 4 16

Risk Assessment Process

RISK = Impact x Likelihood

A simple approach to quantifying risk is to define measures of the Impact and

Likelihood should an identified hazard materialize as an accident/ incident.

Examples of qualitative measures of Impact

Level Descriptor Examples of the Impact of outcome/s

1 Insignificant Unsatisfactory patient experience not related to patient care. Short term low staffing

with no effect on service. No obvious/small financial loss.

2 Minor Unsatisfactory patient experience related to patient care but readily resolvable.

Ongoing staff shortage reduces service. Minor environmental implications. Minor

financial loss (<0.1%). Local media short term interest.

3 Moderate Some short term physical harm. Mis management of patient care leads to short term

effects. Lack of staff leads to late delivery of service. Moderate financial loss (0.1%-

0.5%). Long term local media attention. Moderate business interruption up to 2 days

4 Major Major injuries or long term incapacity. Uncertain delivery of service due to staff

shortage. National adverse publicity. Major financial loss (over 0.5% of turnover loss).

5 Catastrophic Death caused by accident, exposure to toxic substance or through serious

unsatisfactory patient care and outcome. None delivery of key services due to lack of

staff. Over 1% of turnover loss. International media interest. Major loss of life/property

after fire.

Examples of qualitative measures of Likelihood

Level Descriptor Examples of how often it may occur.

1 Rare Will only occur in exceptional circumstances

2 Unlikely Unlikely to occur in most circumstances.

3 Possible Reasonable chance of occurring.

4 Likely Likely to occur under most circumstances.

5 Certain More likely to occur than not.

QUALITATIVE RISK ASSESSMENT MATRIX –

Impact Likelihood

Rare 1 Unlikely 2 Possible 3 Likely 4 Certain 5

Insignificant – 1 1 2 3 4 5

Minor – 2 2 4 6 8 10

Moderate – 3 3 6 9 12 15

Major – 4 4 8 12 16 20

Catastrophic -5 5 10 15 20 25

Low Moderate Significant High

Strategic Objective A

Improved Care – improved outcomes for patients – Reduction of C Difficile cases Lead Director Director of Nursing

Risk to achieving objective 1

Failure to reduce the number of cases of CDT caused by inadequate compliance and/or insufficient operational control could lead to harm to patients. Extended stay, financial penalty and further intervention by Monitor

Date added to BAF 1st

April 2013

Date of last update 16th

October 2013

Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales

What controls/systems are in place to assist in securing delivery of objective and managing principal risks?

Where we can gain evidence that our control/systems, on which we are placing reliance are effective

Where are we failing to put controls /systems in place? Where are we failing in making them effective?

current I L

• Ratification and launch of new C Difficile policy

• Development of diarrhoea assessment tool

• New policy and assessment tool incorporated into all training

• Weekly CDT RCA strategic reviews • IPCT close monitoring of admission

areas for patients admitted with diarrhoea

• Alerts implementation on Extramed for patients previously identified with CDT and risk assessed.

• Monthly divisional report sent out to divisions

• CDT workshops held across Trust for Staff

• Trust wide mattress audit – replacement of mattresses

• Introduction of sporicidal wipes for CDT/GDH cases

• New handwashing posters launched • Commode audit • Introduction of hydrogen peroxide

fogging of all side rooms after CDT cases • Upgrading estates programme to

improve facilities (floor signs, doors on bays, sinks at ward entrances)

• External follow up review requested by Trust to provide assurance.

• Trialling of ATP machine to identify areas to be cleaned

• Two permanent Microbiologists employed by Trust

• Cases reducing month by month • More divisional accountability • Improved staff awareness around CDT • Improved attendance at strategic reviews • External reviews note tangible improvements • Infection Control Committee

• Inappropriate testing • Antibiotic management • Handwashing • Gaps in environmental audits • Linked resource within IPC team and

microbiology

4 5 20 • On-going upgrading works. • C Difficile action plan developed for 12 months (need to embed). • Function of antimicrobial stewardship committee. Timescale – November 2013. • Review current antibiotic policy. Timescale – December 2013. • Develop business case for increased IPC support. Timescale – December 2013.

Position at date: Comments I L Comments

Currently on 25 cases against an annual trajectory of 28 cases for acute Trust (therefore likely to go over trajectory in the financial year). Severe implications for quality of patient care and also financially due to penalties imposed on Trust for exceeding trajectory.

Strategic Objective A Improved Care Lead Director Director of Nursing


Failure to provide the appropriate skill mix and establishment for “safe and suitable staffing” could lead to compromised patient safety and patient experience leading to potential adverse incidents and complaints and potential regulatory or reputational damage


April 2013


October 2013





current I L

• Ward staffing establishments agreed at July Board of Directors meeting

• Recruitment to agreed staffing levels

• Implementation of E-Rostering system to facilitate monitoring of KPIs for safe staff Rostering

• Rostering Policy developed incorporating escalation process for unsafe staffing incidents

• Staff encouraged to use incident reporting system to highlight incidences of unsafe staffing-exception reports to Board when number of incidents exceeds agreed threshold

• Rostering KPIs

• Incident reporting of unsafe staffing levels

• CQC Inspection Reports

• Recruitment process not yet completed

• Ward managers need to be empowered to sign off rosters that prioritise patient safety at all times ensuring school holidays and unpopular shifts are covered first

• Timeliness and senior level scrutiny of Roster sign-off needs to be strengthened

• Safety walk rounds provide the opportunity to triangulate

• Work to date has mainly focussed on ward nurse staffing-further work needed to look at the wider workforce, including Community Nursing teams , AHPs and medical staff.

3 4 12 • Review current rostering policy . Timescale – November 2013.

• Establish monthly e rostering forum to review current levels.

Timescale – November 2013. • Explore upgrade of e rostering software. Timescale –

December 2013. • Development of the integrated pathways that will include

staffing and skill mix. To ensure services are fit for purpose. Timescale – commenced December 2013

Position at date: Actions taken I L Comments


Improved Care – improved outcomes for patients – recognising and responding to the deteriorating patient

Lead Director Medical Director


A failure to provide an adequate timely response to the deteriorating patient could impact on mortality and length of stay


April 2013


October 2013





current I L

• Yearly NEWS audit

• Monthly Audit via Nursing care Indicators (NCI’s); section criteria –’Patient Observations’

• Expansion to the Nurse Practitioner and Critical Care Outreach Teams

• iBleep cover on days and nights each Wednesday and at weekends

• Critical Care outreach response dovetailing with the hospital at night team

• Planned introduction of level 1 care areas

• Limited resuscitation service

• Advanced Nurse Practitioners augmenting senior review

• Divisional Action plans for aiding improvement in NEWS in place - for divisions to take appropriate ownership of the issues faced and report/update at the Trust Mortality Reduction Group

• Minimum yearly presentation of Cardiac Arrest reviews sharing findings and themes from RCA’s to act upon

• Educational initiatives – AIM, Sepsis, Junior doctor rolling programme

• Benchmark mortality data with peers via Mortality Board Report/CHKS data (Crude/RAMI/SHMI)

• Monthly audit of NCI’s

• Cardiac arrest reviews – data shows year on year reduction

• Annual NEWS audit – 2013 compliance of 61.5%

• Using the NEWS system and following the graded response algorithm

• Escalation process for wards not achieving Green RAG rating on NCI’s not yet agreed

• Critical Care Outreach team yet to recruit to capacity.

• No iBleep surgical cover for bank holidays

• Shortfall in funding to ensure consistent 7 day dovetailing with hospital at night; limited critical outreach medical cover (only 5 mornings)

• Funding to rollout level 1 care

• Shortfall in provision of resuscitation training

• Need for an operationally closed unit for critical care

• Advanced Nurse Practitioner are limited in Surgery

• Divisional Action plans may not be reviewed frequently at Divisional Board Meetings.

• Lack of on site senior surgical, orthopaedic & medical personnel out of hours

• Ownership at a divisional , ward and team level for monitoring improvement over time and acting on findings.

4 4 16 Much work been completed to date and this continues to remain a top priority within the mortality reduction group. There is a workstream which forms part of the mortality 5 point plan; the leads track and monitor movement against key actions and report into the mortality reduction group bi-monthly.



Improved Care Lead Director Director of Nursing


Non-compliance with CQC standards could lead to poor patient care and poor patient experience and could affect Monitor compliance rating; CCG contract; Trust reputation and NHSLA cover.


April 2013


October 2013





current I L

• regular monitoring of the CQC quality and risk profile at the QAC.

• monthly meetings with the CQC local inspector.

• early reporting of SUI’s to CQC and CCG.

• reporting to the Board of all CQC inspection visits.

• learning from incidents/SUI’s and reviews.

• Excellent QRP.

• Internal audit reports.

• Dashboard performance monitoring.

• No enforcement action by CQC.

• significant assurance on QRP report.

• significant assurance on CQC process.

• mid table performance when

• benchmarked against other trusts in

• NRLS report.

• poor implementation of learning from incidents.

• poor response to patient complaints.

• Feedback from divisions on implementation of learning from SUI’s and Divisional reviews to QAC.

• Monthly incident reporting of category 3 and 4 pressure ulcers

• Reduction in falls but not harms from falls

4 4 16 • New complaints policy. Timescale – launch October 2013. • Develop patient experience strategy. Timescale – launch November

2013. • Review current incident reporting policy to include process and

audit. Timescale – draft November 2013. • Develop and introduce ward risk registers. Timescale launch

December 2013. • Launch of falls strategy. Timescale November 2013. • Develop PO strategy. Timescale launch October 2013.


Need to embed new complaints policy, falls strategy, pressure ulcer strategy.

Strategic Objective A Improved Care Lead Director Director of Nursing

Risk to achieving objective

5

Failure to comply with the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH, 2008) as a result of lack of cover for the service during long term absence of the LD nurse could lead to poor patient experience and impact on the Monitor RAF rating


April 2013


October 2013





current I L

• All patients admitted with LD are seen by the LD Liaison Nurse if necessary. Ward staff are all aware of how to contact the nurse if required.

• Community teams contact LD Nurse to inform her of any admission.

• Information page on the Trust intranet provide guide for staff to identify patients who may have LD, with a variety of accessible information on various procedures which staff can download.

• LD Nurse aware of patients and can evidence seeing them

• The quarterly Safeguarding Adults report presented to Clinical Governance provides updates on national reports and recommendations in relation to LD.

• From Complaints from families and patients not aware that patients with LD are not do not feature.

• One recent clinical incident identified issue with patient not having nutritional needs managed over a week end.

• LD Nurse has developed a matrix to

evidence how reasonable

adjustments have been made.

• Cover for absence of LD Nurse

• No cover when the LD Nurse is on leave or off sick. Community LD Nurses can help with complex problems but are not able to cover all the work during periods

• No cover at week ends and out of hours.

3 2 6 LD Nurse has developed a matrix to evidence how

reasonable adjustments have been made.


Strategic Objective A Improve care - Improved patient experience Lead Director COO


A failure to continue meeting the A&E target caused by increased attendances or insufficient operational control could lead to poor patient experience and escalation of intervention by Monitor


April 2013


October 2013





current I L

• Weekly SITREP

• Urgent care board

• Bed flow meetings (4 * daily)

• Analysis of breaches

• Winter plan

• Discharge planning

• ECIST

• PAF

• Reports to Board

• CCG contract monitoring

• LOS in medical wards

• Delayed discharges below 20 a month

• CHC process

• GP referrals to A&E for primary care issues

• OOH primary care patients attending A&E

• Trust Board sign off of Winter Plan

• CCG agreement for co-location of GPOOHs

• There has been a sustained rise in admissions since July which is affecting bed capacity – analysis is being undertaken to determine the root cause.

4 4 16 • Sign off and funding of Winter Plan

• Development of Primary Care treatment on site for GP referrals for primary care treatment.

• Co-location of GPOOH service under discussion with CCG


Strategic Objective A Improve Care - Improved patient experience Lead Director COO


A failure to continue meeting the RTT access targets as a result of increased referrals or insufficient operational control could lead to poor patient experience and experience and escalation of intervention by Monitor


April 2013


October 2013





current I L

• PTL

• Daily monitoring

• Sustainability tool

• Elective care programme board performance management

• Reduction in new to follow up ratios

• Sustainability tool

• Reporting to Monitor

• Performance report

• PAF

• Reports to Board

• CCG contract monitoring

• Demand management

• Trauma capacity

• Plan for management of trauma to ensure sufficient theatre and bed capacity to deliver 18 weeks RTT

4 4 16 Develop plan for trauma patients to be treated outside of required elective care capacity


Strategic Objective B Be financially viable Lead Director DoF


Failure to achieve the planned deficit of £7.8m for 2013/14 Date added to BAF 1st

April 2013


October 2013





current I L

• Finance Improvement Plan (FIP)

• Divisional Financial Management Framework (DFMF)

• Patch Financial Management Framework (PFMF)

• Budgetary control system (Budgets, actuals and forecasts)

• Programme controls on 2013/14 income and cost improvements

• Reports to Executive Team and Audit Committee on FIP progress

• Monthly finance reporting to the organisation (Budget, actual and forecast)

• Divisional self certification outputs

• Reports on DFMF and PFMF to Finance committee

• Reports on income and costs improvements

• Internal Audit Reports on the budgetary control system

• External assurance on the financial plan

• Revised arrangements are being put in

place to improve grip and reduce the transactional burden of the programme management.

• The first year of the FIP is about embedding basic financial controls. Until this happens there remains a risk of gaps in assurance on finance.

• As noted above a revised process is being put in place improve assurance. This will be fully operational in October.

5 3 15 • Implement 2014/15 income and cost improvements before 31st Match 2014


Strategic Objective B To be financially viable Lead Director Director of Finance


Failure to achieve to achieve run rate balance by the 1st

April 2014 resulting in liquidity issue in quarter one of the 2014/15 financial year.


April 2013


October 2013





current I L

• Long Term Financial Plan (LTFP)

• Service Line Management Process

• Process to identify and implement 2014/15 income and cost improvements

• Process to agree budget control totals for 2014/15

• 2014/15 Contracting Strategy

• 2014/15 Cash management plan

• Reports to Finance Committee and Board on the development on the LTFP

• Shadow Service Line Management reporting

• Specific reports to finance committee on run rate balance from 1st April

• Reports on 2014/15 Budget setting process to Finance Committee

• Reports on 2014/15 Contracting process to Finance Committee

• Reports on 2014/15 Cash management to Finance Committee

• SLM being developed, the Board will be briefed on this in October 2013

• Assurance reports to be in place from November 2013

5 4 20 • The detailed financial planning process for 2014/15 is scheduled to be concluded by the end of February 2014. At that point will need to make the decision as to whether the Trust will be able to operate in Quarter one of 2014/15 without cash support from the DoH.

• The 2014/15 budget setting process will be presented for approval at the November finance committee

• The 2014/15 contracting strategy will be presented for approval at the November finance committee

• The 2014/15 cash management plan will be presented for approval at the November finance committee

• The gaps in control and assurance noted are expected at this stage of the planning cycle given the Trusts financial position. All the actions noted have been programmed in the Finance Improvement Plan since April 13.


Strategic Objective C Be well governed Lead Director CEO


Failure to address the compliance requirements and enforcement undertakings caused by inadequate governance could lead to escalation by Monitor and further intervention


April 2013


October 2013





current I L

• An action plan has been agreed with Monitor to address the 200+ recommendations in the external reports, this is supported by more detailed action plans responding to each recommendation.

• The Governance action plan is routinely monitored by the CEO and at the Board of Directors.

• Regular feedback following PRM meetings with Monitor

• Although progress has been made in some areas there is still a significant amount of work to do with regard to risk management processes

• Assurance and Escalation Framework not yet developed

5 2 10 Actions have been agreed to address the following areas identified in the KPMG and Deloitte reports • Board Assurance Framework and risk management –

escalation and reporting of risks • Performance Reports and Information • Data Quality • Review of Board and Committee effectiveness • Requirement for an assurance and escalation framework • Requirement for a single overarching Quality Strategy • Communication and Engagement

• PwC will review the implementation of these

recommendations to assure Monitor and the Board – the review on the KPMG report will be completed by 31/12/13; the review of Deloitte recommendations will be conducted by 31/01/14


Strategic Objective C

Well governed Lead Director Director of Nursing


Failure to ensure the safe management, statutory reporting, internal reporting and learning from incidents will lead to inadequate safety management systems leading to compromised patient safety


April 2013


October 2013





current I L

• reporting all incidents on-line via safeguard system within 24 hours.

• monitoring and validating of all incidents before reporting to NRLS.

• daily incident reporting to managers and directors.

• learning from incidents communicated to divisions.

• dashboard reporting of volumes; themes; numbers to the board monthly.

• RIDDOR reporting on-line to HSE.

• CAS alerts circulated; recorded and monitored on safeguard system.

• Harm free care data reported via safety thermometer and on board dashboard.

• Significant harm/never events, dealt with as SUI’s and reported to QAC monthly.

• Internal audit reports.

• Dashboards.

• No RIDDORs/HSE prosecutions or

• enforcement notices.

• NRLS mid-table performer on

• incident reporting against 45 acute

• trusts in cluster.

• reduction in certain incident

• categories & claims.

• significant assurance on reporting.

• Red rated incidents subject to

• exception reporting to the Board.

• Exceptional performance

• benchmarked against other trusts.

• 8,000 incidents will be reported on

• safeguard in 2013/2014.

• improved falls and reduced OL/EL

• claims.

• Poor governance controls within divisions.

• delays in divisions signing off incidents within 72 hours.

• External financial risks from clinical incident claims will impact on future NHSLA

• premiums when this changes to a claims performance model, current value of

• clinical claims in system is circa £38m, premium is circa £10m presenting a

• significant financial risk to the trust, hence the score of 25 (RAG=red)

• Feedback from divisions on implementation of learning from SUI’s and Divisional

• reviews to QAC.

• Compliance reporting from divisions on managers signing off completed

• incidents on safeguard within 72 hours.

• Compliance with all other non CAS alerts to be reported to QAC.

4 4 16 • Review the current incident reporting policy and framework. Timescale – November 2013, launch December 2013.

• Development of risk assurance framework. Timescale – December

2013.


Strategic Objective C Well Governed Lead Director COO


A failure to comply with standards for Information Governance as a result of paper based systems and failure to adhere to policies and protocols could result in a breach of information security leading to breach of confidentiality, potential fines and reputational damage


April 2013


October 2013





current I L

• Access Controls for systems

• Information Governance (IG)Training

• Policies and Procedures

• Privacy Impact Assessments (PIA)

• Encryption standards for email and laptops

• Audits – external/internal

• IT Contingency Plans

• Training for staff

• Regular audits of tracking

• Reduction in incidents/complaints

• Compliance with IG Toolkit – internal/external audit

• Third party contracts – suppliers and temporary staff

• Information Governance group review and reporting

• Achievement against target levels of IG training

• Internal/external audit of records management

• Reduction of reported incidents e.g. missing notes, misfiled notes, wrong patient record etc.

• NHSLA standards

• Access controls not applied universally across Acute/Community

• PIAs not applied to all new projects/service changes

• Paper-based information – continued incidents

• Trust not yet achieving its target levels of mandatory training in IG

• Staff awareness of procedures and standards

• Health records filing – non- compliance with standards

• Inadequate tracking

3 3 9 • Apply access controls to all systems managed by Bolton FT

• Review and audit staff training re: IG, information security/confidentiality – achieve at least 95% of all staff

• Audit third party contracts and obligations

• Planning for Electronic Patient record/Electronic document management system.

• Promote use of PIAs

• Implement recommendations from SUI – (Handover Notes incident)

• Plan to achieve target level of IG training.

• Formal training in defensible documentation for staff

• Integrate community/acute records off site

• Move towards electronic document management systems


Strategic Objective D Be a great place to work Lead Director Director of Nursing


A failure to reduce sickness absence and improve staff health and wellbeing would have implications for the quality of care and staff morale alongside the financial implications of providing cover for absent staff


April 2013


October 2013





current I L

• Consistent application of attendance management policy

• Focused review and discussion at workforce committee including focus on Divisional Performance against Divisional Attendance Management Action Plans overseen

• Regular audit of Return to work interviews and application of the consistent application of the appropriate policy.

• Workforce committee reports

• Workforce dashboard reported to Executive Board and Workforce Committee

• Audit of performance reports

• Regular benchmarking with other NHS Trusts

• Managers failing to apply policies consistently.

• Different policies for managing attendance following integration/TUPE transfer under MiB

4 4 16 • Integration of all attendance management policies by end of December 2013

• Divisional Action Plans reviewed monthly by Deputy Director of Workforce with escalation to Workforce Committee as appropriate.

• Meeting with OH Physician to discuss long term sickness cases and management of going forward – October 2013


Strategic Objective D To be a great place to work Lead Director Dir Workforce and OD

Risk to achieving objective

2

A failure to strengthen communication and engagement with staff throughout the integrated organisation during organisational change could lead to increased turnover, increased sickness and a failure to address other issues within the Trust and a loss of discretionary effort and potential employee relations issues.


April 2013


October 2013





current I L

• Organisational Change Policy in place for all staff relating to framework for organisational change

• Staff engagement action plan in place to continue proactive engagement with staff.

• Leadership development programmes focus on importance of communication and engagement during organisational change

• Workforce reports to Board /Exec Board

• Workforce Committee reports

• Staff survey

• Staff quarterly temperature check

• Leadership Management Styles Questionnaire (LMSQ)

• Impact of turnaround/CIP and loss of discretionary effort

4 4 16 • Reflection and learning session with staff side colleagues on implementation of organisational change and lessons learnt

• As a result of the above review of organisational change policy and guidance including training for managers

• Continue to run the Engaging Manager Programme supporting managers in engaging skills including the LMSQ (Leadership Management Styles Questionnaire) which provides 180 feedback on how the manager is engaging with the team.

• Continued regular dialogue with staff side representatives.


Strategic Objective E Fit for the Future Lead Director CEO


If the Healthier Together exercise downgrades the RBH scope of service this will threaten the financial and clinical viability of the organisation


April 2013


October 2013





current I L

• Clinicians and other staff will be supported to make the case clearly for the service strategy

• Clinicians and other staff will attend planning forums and contribute to the anticipated consultation process

• The Trust will continue to work with other providers in the NW sector of G Manchester

• Arrangements are in place to work closely with the commissioners to secure the changes needed in the local model of care

• Healthier Together publications and meetings

• The Trust has limited influence on the outcomes of the Healthier Together exercise

5 3 15 Continued engagement in Healthier Together


Strategic Objective E Fit for the Future Lead Director CEO


Failure to achieve integrated care in Bolton will lead to escalating demand on hospital services and increasing pressure on the achievement of financial stability for the Health Economy


April 2013


October 2013





current I L

• Full engagement with partners in primary and social care in the planning and delivery of the vision for integrated care in Bolton

• Regular meetings with Health

Economy partners

• Trial of integrated care between CCG, FT and social care

Development of workforce capacity and capability to ensure the Trust realises the full benefits of integrated services within the organisation


Strategic Objective E Fit for purpose supportable community IM&T Infrastructure Lead Director COO


Failure to secure funding for the upgrade and on going support of legacy community IT infrastructure will lead to loss of IT access in the community setting.

Date added to BAF May 2013

Date of last update 22nd October 2013





current I L

Required capital investment of £1.6M incorporated into the IM&T investment plans for 2014/15. Investment strategy for IT and community shared with Monitor. Finance exploring the flow down of 480k former PCT funds which was used to support the community infrastructure which has not been transferred to the Trust budget.

Effective financial planning for 2014/15 including the integration of legacy Community systems.

Risk review at the Informatics committee.

4 5 Implementation of the IM&T Investment Strategy in 2014/15.


Strategic Objective E Fit for the Future Lead Director COO


Failure to provide an efficient fit for purpose estate may restrict the implementation of service plans and lead to an adverse impact on financial and quality indicators


April 2013


October 2013





current I L

Estates Committee

4 4 16 Implementation of the agreed Estates strategy


.

Agenda Item No


Date 31st October

Title Quarter 2 submission to Monitor

Executive Summary

As a Foundation Trust regular declarations are required with regard to compliance with targets and financial performance.

These declarations are made on a template provided by Monitor which includes worksheets for financial performance, governance declarations and performance against targets.

The governance and target templates will be uploaded with the monthly financial templates by the close of play on October 31st 2013.

The Trust will remain red rated until Monitor are satisfied that actions taken have led to a sustained improvement and compliance with the Provider Licence

In April 2013 the “Terms of Authorisation” for Foundation Trusts were replaced by a Provider Licence; from October 1st the Compliance Framework has been replaced by the Risk Assessment Framework.

This paper includes a briefing note outlining the new Risk Assessment Framework process

Next steps/future actions

Directors are asked to approve signing of the proposed Q2 declaration to Monitor.

Following analysis of the Trust’s Q2 data, Monitor will publish a shadow Risk Assessment Framework rating.

Discuss Receive

Approve Note 9


Strategy Financial Implications Performance Legal Implications 9 Quality Regulatory 9 Workforce Stakeholder implications NHS constitution rights and pledges Equality Impact Assessed For Information Confidential

Prepared by Esther Steel Trust Secretary Presented by Esther Steel

Trust Secretary

16

Compliance Declaration Q2 2013/14

1. PURPOSE

The purpose of this paper is to inform the Board’s consideration of the quarter two submission to Monitor.

2. BACKGROUND

As a Foundation Trust regular declarations are required with regard to compliance with targets and financial performance.

These declarations are made on a template provided by Monitor which includes worksheets for financial performance, governance declarations and performance against targets.

3. CURRENT POSITION

An update on the current position with regard to operational performance, quality and finance is included on the Board agenda.

4. RECOMMENDATIONS

Board members are asked to agree that the following statements are signed for submission to Monitor for the Q2 return.

The Continuity of Service risk rating replaces the FRR – this remains at 1 – response must therefore be “not confirmed”

Compliance with targets is included in the performance report – the Trust has breached the Q2 target for C. difficile and must therefore respond “not confirmed”

During quarter 2 exception reports on SUIs and the outcome of the CQC review were provided to Monitor in line with the requirements of the Risk Assessment Framework.

Diagram 6 from the RAF is included for information.

Election Results

During Quarter 2 elections for Foundation Trust Governors were conducted. The outcome of these elections is also reported through the quarterly submission

Risk Assessment Framework

Monitor has issued a Provider License to the Trust which replaces its Terms of Authorisation.

Compliance will be overseen by Monitor using its new Risk Assessment Framework (August 2013) and enforced using its Enforcement Guidance (March 2013). The Monitor Risk Assessment Framework came into full effect from 1st October 2013, replacing the outgoing Compliance Framework.

1. The process. Monitor will broadly follow a four-step process to oversee the Trust’s compliance with its provider license:

2. Submission of information and reports. Monitor requires the Trust to make

annual and in year information submissions, together with exception reports and additional reports to assess its risk to compliance. The frequency of in-year submissions will depend on the risk ratings assigned to the trust.

3. Assessing risk to continuity of services and financial risk. Monitor will assess this risk and apply a new Continuity of Services Risk Rating to the Trust. This risk rating will be derived from two metrics, Liquidity and Capital Servicing Capacity, resulting in a rating of 1-4 (with a rating of 1 showing significant risk to the Trust).

4. Assessing risk to governance. Monitor will assess this risk and apply a new Governance Rating to the Trust. This will be derived from a number of metrics including CQC judgements, access and outcomes targets, third party reports, quality governance indicators and financial risk. Of particular note in relation to this rating is the following:

a) The majority of the access and outcome metrics are the same as those in the outgoing compliance framework (e.g. 18 week referral to treatment times, cancer waits and C.Diff. Incidence). However, the MRSA target, seen in the outgoing Compliance Framework, is no longer included.

b) Quality governance Indicators will also be used by Monitor in calculating the governance risk rating. Such indicators include patient satisfaction, staff metrics (e.g. staff satisfaction, sickness/absence rates, staff turnover and proportion of temporary staff), and use of aggressive cost reduction plans

c) Monitor requires the Trust to commission an external review of its governance at least once every three years. Such a review must include at least one of the following: board governance, quality governance, organisational oversight and board capability. Monitor will use this review to inform the Trust’s governance risk rating.

d) Monitor will no longer assign a colour risk rating to any grading between green and red (e.g. no amber/green, amber or amber/red ratings will be given). Instead, where a Trust is categorised as falling between a green and red rating for governance, a description of the status will be given together with any issued identified.

5. Investigating actual or potential breaches. If, following assessment, Monitor identifies an actual or potential breach in the Trust’s provider license conditions, it will initiate an investigation. The steps taken to fulfil this are discussed further in the accompanying paper.

6. Enforcement powers. If, following investigation, Monitor finds a Trust in breach of its Provider License, Monitor has powers under the Health and Social Care Act (2012) and competition law to initiate enforcement action against the trust using its Enforcement Guidance.

Next steps

The Trust’s new Governance and Continuity of Services risk ratings will be updated and applied by Monitor as follows:

Monitor have assigned the Trust a Governance Risk Rating, based on its new Risk Assessment Framework (appendix 1)

Following its analysis of the Trust’s Q2 13/14 data, Monitor will publish both the outgoing Compliance Framework Financial Risk Rating alongside the new Risk Assessment Framework Continuity of Services Risk Rating which will be identified as a ‘shadow’ rating.

The Continuity of Services Risk Rating will be the only financial rating published following Monitor’s analysis of Q3 13/14 data.

17 September 2013 Ms Jackie Bene Interim CEO and Medical Director Bolton NHS Foundation Trust Royal Bolton Hospital Minerva Road Farnworth Bolton BL4 0JR Dear Ms Bene Introduction of Risk Assessment Framework risk ratings As you are aware, from 1 October 2013 the Risk Assessment Framework (‘RAF’) will replace the Compliance Framework as Monitor’s approach to overseeing foundation trusts. A key part of this new framework is the new risk rating methodology, as set out in the RAF. The role of ratings is to indicate when there is a cause for concern at a provider. It is important to note that they will not automatically indicate a breach of its licence or trigger regulatory action. Rather, they will prompt us to consider where a more detailed investigation may be necessary to establish the scale and scope of any risk. Monitor will assign foundation trusts a governance risk rating based on the RAF on or shortly after 1 October. This will appear on our website shortly afterwards, replacing the Compliance Framework governance rating. This reflects that the governance risk rating represents Monitor’s current view of governance at foundation trusts. In advance of introducing the new governance rating, Monitor’s relationship teams will assess which ratings are appropriate for each foundation trust in accordance with the criteria set out in the RAF. Trusts will be informed of their governance rating before publication. Following the conclusion of our analysis of Q2 13/14, Monitor will publish both the Compliance Framework financial risk rating and the RAF continuity of services risk rating, which will be identified as a ‘shadow’ rating. This dual publication reflects that the Q2 performance data on which these ratings are based relates to a period when the Compliance Framework was in force, while the RAF will be in force at the time of publication. The continuity of services risk rating will be the only financial rating published following our analysis of Q3 13/14. If you have any queries relating to the above, please contact me by telephone on 020-7340-2519 or by email ([email protected]).

4 Matthew Parker Street London SW1H 9NP T: 020 7340 2400 F: 020 7340 2401 W: www.monitor-nhsft.gov.uk

Yours sincerely

Kate Sutherland Senior Regional Manager cc: Mr David Wakefield Chairman Mr Simon Worthington Director of Finance

Agenda Item No : 18



Title Academic Health Science Network (AHSN) – Update

Executive Summary

The Board has received previous reports on the establishment of a Greater Manchester Academic Health Science Network and, in April, formally approved the Trust’s participation.

The GM AHSN is now coming into place, with a confirmed funding settlement and key appointments, including Raj Jain who has now joined the AHSN as Managing Director.

In April the Board asked for a six-month update on the benefits of AHSN Membership. Raj has kindly agreed to attend the meeting to provide an update and a look forward, including opportunities for Trusts like BFT to be involved.

Next steps/future actions

Identify key workstreams for Trust involvement.

Ensure related CQUIN requirements are met.

Discuss Receive

Approve Note

Assurance to be provided

by:




Quality Regulatory




Prepared by A Schenk, Director of Strategy &

Improvement Presented by

A Schenk, Director of Strategy

& Improvement

BoD Meeting – 31st October 2013

Academic Health Science Network (AHSN) – Update

Background The Board will recall earlier items on Board agendas relating to the national policy paper “Innovation, Health and Wealth” and the related commitment to establish a series of Academic Health Science Networks (AHSNs) across the country. In order to encourage the uptake and development of specific innovations and improvements highlighted in “Innovation, Health and Wealth”, there is a schedule of developments now linked to CQUINS payments for all providers. In February, the Board received an outline of the proposed governance arrangements for the Greater Manchester AHSN, and, in April, the Board formalised its commitment to participation in the GM ASHN and asked for a six-month update, focussing the benefits of membership. The AHSN is now approved and established. The attached “Senior Leaders’ Update” was circulated in June, reaffirming the proposals and priorities of the AHSN and confirming senior appointments. The newly appointed Lead for the AHSN, Raj Jain has kindly agreed to attend the Board meeting to outline progress and next steps and answer any questions from the Board. Ann Schenk Director of Strategy & Improvement

Edition 2 – 3 June 2013

Senior Leaders Update

2 Edition 2 – 3 June 2013

1. Licence agreement update

On 20 May, 2013 a small subgroup of the Steering Board attended a meeting with Rachel Cashman at NHS

England. Rachel outlined the next steps for AHSN authorisation, apologised for the delays and gave feedback

from the Interview with Sir John Bell, Sir Alan Langland’s and Sir Ian Carruthers on GM AHSN’s plan. Full

details are available in the appendix to this document but in summary the application and interview were

considered strong. The focus on informatics was seen as unique and of potential benefit to clinical outcomes

improvement, research and interactions with industry. These strengths placed GM AHSN in the first cohort of

funded networks and enables us to negotiate our position as the lead AHSN for informatics and information.

2. Funding

NHS England has allocated the GM AHSN £4.63m in FY 2013-14 which will be available for release in July

2013 based on satisfactory licence negotiations. The planning cycle for FY 2014-15 will begin in September

2013 and deliverables in year 1 will be negotiated alongside the licence. See the Business planning section

about our plans to reflect the smaller resource envelope.

3. Draft licence

On 23 May, 2013, the draft Five Year Licence Agreement between the Academic Health Science Networks and

NHS England was issued. The licence is available in the appendix to this document. NHS England have asked

all AHSN’s to comment on the licence and to look at how it might need to be modified to account for local

innovation. The response from Greater Manchester will be available in June 2013.

3. Business planning

At the May steering board of the AHSN the programme leads for Innovation and Research (Keith Chantler),

Health and Implementation (Maxine Power), Wealth and Investment (Martin Gibson) and Education and

Capability (Maxine Power – acting) were asked to review their business plans and make suggestions about how

the work plan could be delivered with a smaller resource envelope. Since then, work has been underway on

reformatting. This work now needs to accelerate and partners have been invited to participate in the revision of

plans under the work stream leads. Leads have been asked to address the elements of their work streams that

map directly onto the licence requirements. From this reconciliation process gaps will be identified and

addressed in the next stage of the planning.

4. Establishment milestones

The Steering Board have approved a number of appointments:

Peter Ellington as interim Chair for a 6 month period. Peter is the Chief Executive of the Association of

British Healthcare Industries and he will start with us on 28 June 2013. A short bio is available in

Appendix 2.

Raj Jain has accepted the role of Managing Director. He is on 3 months’ notice and during this period

will be working 2 days a week on GM AHSN establishment and connecting with the membership. Raj is

currently Chief Executive at Liverpool Heart and Chest Hospital NHS Foundation Trust.

The Board are meeting monthly and have been reconstituted to include broader representation from the Higher

Education Establishments and the LETB. An industry advisory committee will provide a single point of entry to


the sector for the Academic health Science Centre and network. We have been working with Finnamore as our

management consultants to finalise the business plan and will be advertising for an operations lead within the

next 2-3 weeks.

5. Next steps

In the coming weeks, we will be focusing on:

The establishment of new governance arrangements

Getting boards that have not already done so signed up to the new AHSN

Sent by

Ian Wilkinson Clinical Lead Oldham CCG GM AHSN Steering Group Chair

David Dalton Chief Executive Salford Royal NHS Foundation Trust GM AHSN acting Accountable Officer

Appendix

1. NHS England GM AHSN Feedback

2. Peter Ellingworth biography 3. Appendix 3, Raj Jain biography


Appendix 1 - NHS England GM AHSN Designation Interview Feedback

NHS England recognises the huge amount of interest and commitment that has gone into making the

fifteen AHSN applications across the country. The application teams have marshalled an impressive

range of leaders from the NHS and universities and some application teams had senior and

experienced colleagues from industry integrated into the application. There had been only 6 or 7

months between the publication of the national guidance and the panel interview during which all the

teams had produced a prospectus, a draft business plan and a 100 day delivery plan.

Building on the guidance published in summer 2012, the designation interview and designation

feedback each AHSN should describe their ambition setting out the 2 or 3 service areas where they

will have a significant national impact in its first five years. All AHSNs will have an agenda to drive

adoption and spread of innovation across all areas of healthcare provision and population health but

they also need to have a small number of areas where each AHSN will bring together the resources

and assets in their geography to create a synergy between researchers in universities, industry and

entrepreneurs, and the local NHS to identify, exploit and commercialise innovations that will have

national and international significance. AHSNs need to be focused as trying to achieve this in too

many areas will not deliver the necessary impact.

All applications need to undertake further work to translate their work plan into agreed, measurable

deliverables and milestones that the AHSN commits to and crucially work on how these commitments

will be delivered through the network’s systems and processes.

The AHSN is based on a membership model with a wide range of partners holding each other to

account. All application teams need to continue to build their leadership teams with people who have

the personal qualities to be effective in leading networks, the vision for the future, and the knowledge

of the NHS-industry-academic interface. Most of the applications need to develop a governance

structure that industry can understand and engage with.

The dual purpose of AHSNs to improve health and create wealth was recognised in all applications

but the maturity of the thinking and the specificity of the proposed actions on the wealth creation

agenda varied greatly across the fifteen applications. All teams need to accelerate their work in this

area and put in place the infrastructure to effectively bring together industry, the NHS and universities

to focus on delivering specific projects and partnerships. All AHSNs need a quantified plan for wealth

creation and to create a single technology transfer mechanism across the whole network, ideally

integrated with the research infrastructure.

AHSNs should be thinking of and demonstrating industry collaboration that focuses on adoption and

spread of innovative treatment, technology and models of care delivery and AHSNs should be

demonstrating how they are developing their commercial acumen in order to demonstrate ROI and

match funding requirements.

Most applications recognised the key role that their AHSN will play in promoting and supporting

research in the NHS across their geography, working alongside NIHR research

infrastructure. However, they varied significantly in the extent to which they had clear, robust plans to

make this a reality. NHS England hope that AHSNs will work in alignment with Strategic Clinical

Research Networks and not seek to replicate or duplicate. It is for the local AHSN and the Strategic

Clinical Research Networks to identify how best to work together. Similarly AHSNS should work with

and build upon existing research structures and not seek to duplicate or replicate. AHSNs may


choose to fund CLARHCS if they feel by doing so it will enable the AHSN to deliver the outcomes set

out in its business plan and agreed in the Licence. It is not an expectation or requirement from NHS

England that AHSNs should use their funding allocation in this way.

Improved integrated information shared between primary & hospital care and linking research,

evaluation and clinical practice will be at the heart of the successful AHSN. Those licenced with

immediate effect provided evidence that this was a central part of their application and proposed work

plan and all teams need to develop the detailed mechanisms so that members can effectively

collaborate in network-wide sharing and analysis of data.

Although most AHSNs had some discussions with their Local Education and Training Boards and

had input from a range of universities, the depth of these relationships varied greatly. Only in a few

applications was there evidence of a sophisticated shared vision and proposals for common

approaches about how education would support the collaboration between industry, academia and

the NHS on innovation and adoption.

Applications teams all included strong representation from NHS providers and universities. The

contribution of clinical commissioning groups, industry, local government and public health was

variable with some application teams including experts in each of these areas but others not even

evidencing an active input from these stakeholders beyond the statements in the written application.

All AHSNs would benefit from support in continuing their development, especially in how they

developed their governance and in working with industry partners. As part of the Organisational

Development of AHSNs in the new system we will ask all to attend a Kick-starter event in July 2013

and to participate in an Organisational Development process that will be co-designed between NHS

England, NHS Improving Quality and each individual AHSN.

Greater Manchester

Potential specialist area(s): e-health and patient safety.

AHSN Total funding 2013/14 First

allocation

Second allocation

Greater

Manchester

£4.63m £3.2m £1.43m

The application reflected the large volume of work that has been undertaken by the partners in

developing a distinctive model for innovation and knowledge transfer in the Greater Manchester area.

The application builds on the strengths of the Manchester AHSC, but the separate approach to the

Network demonstrates a good grasp of the specific expectations for a successful AHSN, focusing on

the wider engagement with industry and on the adoption and spread of innovations. The work on the

digital economy and the creation of shared data sets that can be used to measure clinical benefit and

outcomes and inform commercial opportunities came through clearly in the presentation and

documents. Although the document highlights the need for collective working across the AHSN,

there needs to be more detailed work about this will actually happen in practice

Recognise the request for designation with specific “Leadership” for E-Health on behalf of the whole

system NHS England is giving active consideration to this and will feedback in due course. NHs


England will also welcome a proposal from Greater Manchester AHSN on a single model of VC and

Angel investor funding for AHSNs led by a single AHSN.

Appendix 2, Peter Ellingworth

Peter is Chief Executive of the Association of British Healthcare Industries

(ABHI), the industry association for the UK medical device sector. ABHI

work with government and NHS England to improve patient outcomes and

deliver more cost efficient healthcare through the uptake of innovative

medical technologies. Under Peter’s leadership the association has become

a key government partner, supporting NHS England in its work to improve

patient access to innovation.

Peter has built strong links with NHS leaders and currently represents

industry on the Implementation Board of the ‘Innovation Health and Wealth

Report’, the NHS Chief Executive’s report focussed on improving the uptake

of innovative technology.

Peter leads the industry secretariat for the Ministerial Medical Technology Strategy Group, is the

Chair of MATCH and a Trustee and Vice Chair of the Thackray Museum, which houses the world’s

largest collection of medical trade literature. Peter sits on the board of the Health Tech and Medicines

Knowledge Transfer Network. He is also a member of the EPSRC Strategic Advisory Network and

the Eucomed National Association Network.

Peter has 30 years of experience in sales, marketing and general management in the UK & Ireland

and across Europe.

Appendix 3, Raj Jain

Since 2008, Raj has been Chief Executive at Liverpool Heart and Chest

Hospital NHS Foundation Trust (LHCH), one of the largest cardiothoracic

specialist hospitals in Europe. LHCH was named HSJ Provider of the Year in

2012, which recognised its continuing work to establish the Trust as a world

class organisation. Raj is Board Director at the Institute of Cardiovascular

Medicine and Science and Liverpool Health Partners. He is a board member

of NIHR Cheshire and Merseyside CLRN and the North West Coast AHSN.

Raj started in the NHS 18 years ago after spending 10 years in the oil and

gas industry. He was an Executive Director at Salford Royal NHS

Foundation Trust for 5 years prior to his appointment at LHCH.

During his time as CEO and Executive Director Raj has led a number of

regional programmes including QIPP Lead for Workforce for the Northwest Region and Workforce

lead for Merseyside.

Agenda Item No : 19



Title Finance & Activity Report Month 6

Executive Summary

• Why is this paper going to the Board

• To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

Please find attached the monthly Financial Board Reporting pack The key points to note are:-

• The financial position for month 6 was a deficit of £(0.7)m which is £(0.1)m worse than planned.

• The year to date position was a deficit of £(5.4)m deficit compared to the planned £(6.3)m.

• Income is £(0.1m) below plan this month but remains favourable by £0.8m YTD.

• Pay costs have now been static at £16.6m per month for the last four months.

• Income and cost improvement are below plan year to date. It is forecast that there will be a shortfall in CIP’s of £3.2m for this financial year.

• The forecast shows that the Trust’s plan deficit of £7.8m is still achievable by not utilising the £2.2m risk reserve that was set aside in the plan and by using non recurrent schemes to offset recurrent shortfalls. The Trust has a range of actions in place to secure run rate balance by the year end but there is delivery risk associated with these actions.


Discuss Receive

Approve Note





Quality Regulatory




Prepared by Andrea Bennett Deputy Director of Finance Presented by Simon Worthington

Director of Finance

Finance Report for the year to the end of September 2013 (Mth 6)

1. Introduction

1.1 This report is intended to update the committee and provide more information on the financial position of the Trust as at month 6 and to provide further detail on the forecast for the remainder of the financial year.

1.2 The Trust is ahead of plan year to date and is forecasting to deliver the planned deficit of £(7.8)m by the end of the year.

1.3 There is a plan in place to achieve run rate balance by the end of the financial year but there is delivery risk associated with this.

2. Month 6 Financial position

2.1 The financial position for month 6 was a deficit of £(0.7)m which is worse than the £(0.6m) deficit planned. The year to date position is a deficit of £(5.4)m which is £0.9m better than the planned deficit of £(6.3)m.

2.2 Income is £(0.1M) below plan mainly this month but remains £0.8m better than plan YTD.

2.3 Pay costs are static for the fourth month running and continue to show good cost control within the divisions. However, an under-delivery of CIP schemes produces an overspend of £0.4m on pay (2.5%). Some of the overspend on pay has produced an over-delivery in income

2.4 Non Pay expenditure is significantly lower this month. This is due to a number of reasons. In particular pass through drugs and estates costs are lower than last month.

2.5 The financial plan included PDC funding of £11.7m to the end of quarter 2. The improved financial position in the first six months and the revised phasing of planned restructuring costs indicates that the Trust will only need to request £5.75m to the end of November.

3. Cost improvements

3.1 Income and cost improvements year to date are now behind plan due to the Board decision to reinvest nursing savings on the wards and lower delivery rates some other workstreams than planned at the start of the financial year. This is being mitigated by additional CIP plans which are in place in the divisions and are part of the divisions’ financial recovery plans.

3.2 The Trust currently forecasts an under-delivery of £3.2 on income and cost improvements as shown below

Plan Forecast Diff £,000 £,000 £,000 CIP ‐ Recurrent 14,600 8,731 ‐5,869 CIP ‐ Non Recurrent 0 2,669 2,669 Income 1,575 1,575 0 Turnaround – Total 16,175 12,975 ‐3,200 Financed by £,000 Risk Reserve 2,200 Non Recurrent 1,000 Total 3,200

3.3 It is planned to use the risk reserve of £2.2m and non- recurrent items of £1m to offset the under achievement on income and cost improvements.

3.4 The actual / forecast performance by work stream compared to plan is contained within the body of the report.

4. Forecast for the Financial Year 2013/14

4.1 The forecast deficit for the financial year 2013/14 remains unchanged from last month. This is based on bottom up forecasts signed off by the Divisions which have then been adjusted for forecasting risk. The forecasting method used is primarily a ‘run rate plus’ type approach which looks at the run rate in each area and then adjusts for known changes

4.2 The forecast shows that the Trust’s plan deficit of £7.8m is achievable by utilising the £2.2m risk reserve that was set aside in the plan and by using non recurrent schemes to offset recurrent shortfalls.

4.3 Action is being taken to secure run rate balance by the year end. The actions are as follows:

• Bringing forward of the corporate directorate CIP requirement for 2014/15 into 2013/14.

• Work with Bolton CCG the community service model. £1.2m non recurrent support to community services has been allocated by the CCG in this financial year.

• Work with Bolton CCG on the “Making it Better” service specification

• Other improvements in the clinical divisions cost improvement programmes.

• Divisions with forecast underspends are being required to maintain these.

4.4 Progress is being made on the actions set out in in paragraph 4.3 however their remains significant deliver risk in respect of run rate balance at the year end.

4.5 The risk range on the income and expenditure forecast is £(9.0m) to £(5.2)m.

5. Recommendation

5.1 It is recommended that the committee notes the content of the report.

1. Executive Dashboard

1

(10.0)(9.0)(8.0)(7.0)(6.0)(5.0)(4.0)(3.0)(2.0)(1.0)

-

Apr il May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Surplus / (deficit) £m

Cumulative P lan Cumulative Actual / Forecast

0.0

5.0

10.0

15.0

20.0

13-O

ct

20-O

ct

27-O

ct

03-N

ov

10-N

ov

17-N

ov

24-N

ov

01-D

ec

08-D

ec

15-D

ec

22-D

ec

29-D

ec

05-J

an

13 Week Cash Forecast(£m)

Cash forecast

0.0

1.0

2.0

3.0

4.0

5.0

6.0

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

Forecast month end cash balance (£m)

Forecast Actual

(25.0)

(20.0)

(15.0)

(10.0)

(5.0)

0.0


Net Current assets / (liabilities) (£m)

Actual Plan

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0


Cumulative capital expenditure (£m)

Actual spend Annual Budget

(0.5)

0.0

0.5

1.0

1.5

2.0


In-month turnaround delivery(£m)

Plan Actual

1. Executive Summary

2

1.1 Executive SummaryKey Issue Executive Summary Year to

date vs budget

Forecast Outturn

Actions to be taken (where appropriate)

EBITDA(1) In month EBITDA (£0.2m). Cumulative EBITDA of £0.1m. G R Trust in deficit cumulatively.

Surplus/(Deficit) In month deficit of (£0.7m) and cumulative of (£5.4m). R R £0.9m better than plan cumulatively. KPI will remain red rated whilst Trust is in deficit.

Cash and Liquidity At the end of month 6 the Trust had £0.5m in cash which is £0.1m better than planned G R No cash support was required in Sept 2013. Further cash support of £2.5m

forecast for November 2013.

Capital Expenditure £2m behind plan R G Programme expected to balance at year end

CIP Savings in yearAlthough savings are being delivered to plan as evidenced by the overall Trust financial performance being ahead of plan, overall recurrent forecast savings are below plan.

A R Insufficient savings are being delivered recurrently.

CIP Savings recurrent

All savings achieved not yet validated as being recurrent R R Ensure all savings are delivered recurrently

Monitor Financial Risk Rating

FRR of 1 R R KPI will remain red rated whilst FRR = 1

EBITDA and surplus/(deficit) Capital ExpenditureG On or better than target G On or within 10% or £0.1m of plan whichever is higher

A Between 0% and 5% below target A Outside green and red metrics

R Greater than 5% below target R Greater than 25% below plan

CIP Savings Cash and Liquidity

G On or better than target G Higher cash balance than plan or within 10% lower than plan

A Between 0% and 10% below target A Cash balance lower than plan by 10% up to 20%

R Greater than 10% below target R Cash balance lower than plan by greater than 20%

1.1 Executive Commentary

3

Income and Expenditure• This month shows a deficit of £0.7m (£0.1m adverse variance from plan) and is primarily driven by a marked reduction in

non-pay.• Income is £0.1m below budget this month. Detailed commentary is provided in section 2.2• Pay costs are static this month and continue to show good cost control within the divisions. However, an under-delivery of

CIP schemes produces an overspend of £0.4m on pay (2.5%). Some of this has produced an over-delivery in income.• It has been noted at previous F&I committee that whilst the deficit for the first 3 months was much better than expected,

this needs to be set against a rapidly accelerating CIP/efficiency programme for the last 9 months of the year where there was a known delivery gap of £3.2m (due to early start of corporate restructures but late start of clinical restructures).

• The monthly trend figures suggest that the divisions are strongly focussed on achieving the year end position and savings are being made over and above those identified by the turnaround programme. At present the three clinical divisions show a net adverse variance of £0.5m on a budget of £109.0m. The divisions have plans to bring most of the adverse variance back in line.

• Work is being undertaken to understand the reasons for these additional savings and the split due to timing, non-recurrent or recurrent savings (some is known to be related to vacancies being held by clinical divisions prior to department restructures in the income and cost improvements programme in order to assist with redeployment).

• The year end outturn position remains forecast to be £7.8m deficit as last month. The organisation is taking action to achieve run rate balance, this includes: bringing forward CIPs, funding discussions with CCGs and maintaining underspends in divisions (further details see 8.1).

• All divisional gaps within budgets have been removed and all CIP targets have been allocated to specialities.

M1 M2 M3 M4 M5 M6 YTDActual £m £m £m £m £m £m £mIncome 23.1 22.8 23 23.5 22.8 22.5 137.7Pay ‐16.9 ‐16.7 ‐16.6 ‐16.6 ‐16.6 ‐16.6 ‐99.9

Non‐pay ‐7.4 ‐7.3 ‐7.1 ‐7.2 ‐7.6 ‐6.6 ‐43.2Deficit ‐1.2 ‐1.2 ‐0.7 ‐0.3 ‐1.4 ‐0.7 ‐5.4Budget ‐1.8 ‐1.4 ‐1.9 0 ‐0.4 ‐0.6 ‐6.3

Variance 0.6 0.2 1.2 ‐0.3 ‐0.9 ‐0.1 0.9

Cash and Capital

• Cash has been managed effectively with a £0.1m cash outflow and a £0.5m cash balance at the end of the month.

• PDC funding is currently forecast with a £2.5m requirement in November and another £1.0m in December well within the profile agreed with Department of Health.

• The year end position assumes support of £17.25m from DoH. The assumptions behind this assume delivery of £7.8m deficit.

• The Trust cash position at the end of September is £0.1m better than plan. However the Trust hasn’t drawdown £8.4m of PDC as planned. The main reason for this is commissioners haven’t yet deducted penalties from their cash payments.

• The capital budget for the year is £5.9m profiled equally by month. To date this is underspent by £2.0m. Historically capital expenditure accelerates through the year.

4

2.1 Income & Expenditure

5

2.1.1 Summary I&E

• This month the trust shows a deficit of £0.1m worse than budget . YTD the Trust has a deficit of £5.4m, £0.9m better than plan and has a budgeted and forecast deficit for the whole year of £7.8m.

• Income shows an adverse variance of £0.1m in month but is favourable £0.8m YTD. £0.3m of the variance relates to over-performance on pass-through drugs.

• The adverse variance on pay in month is driven by non delivery of pay CIPs

• Although there is a £0.3m underspend on non-pay YTD, there is an overspend of £0.3m on pass-through drugs in this category. This demonstrates a good underlying control on non-pay expenditure.

2.1.1 I&E

Income and Expenditure M6Annual Budget Budget Actual Var.

Prior Year Budget Actual Var.

£m £m £m £m £m £m £m £mPatient income 245.6 20.5 20.6 0.1 123.9 123.7 123.9 0.3Other Income 27.8 2.2 1.9 (0.3) 13.2 13.2 13.8 0.5Total Income 273.5 22.7 22.5 (0.1) 137.1 136.9 137.7 0.8Pay (194.6) (16.2) (16.6) (0.4) (103.4) (99.8) (99.9) (0.1)Non-Pay (75.7) (6.2) (5.7) 0.5 (37.9) (37.9) (37.6) 0.3Total Expenses (270.4) (22.4) (22.3) 0.1 (141.2) (137.7) (137.5) 0.2EBITDA 3.1 0.3 0.2 (0.1) (4.1) (0.8) 0.1 1.0Depreciation, interest & dividends (9.6) (0.8) (0.8) 0.0 (4.8) (4.8) (4.6) 0.2Normalised Surplus/ (Deficit) (6.5) (0.5) (0.6) (0.0) (8.9) (5.6) (4.4) 1.2Non-recurrent & exceptional (1.3) (0.1) (0.2) (0.1) - (0.7) (1.0) (0.3)Deficit (7.8) (0.6) (0.7) (0.1) (8.9) (6.3) (5.4) 0.9

Year To DateIn-Month

2.1 Income & Expenditure

6

(6.3)(5.4)

0.3

0.5 0.3 0.2(0.1)

(0.3)

(7.0)

(6.0)

(5.0)

(4.0)

(3.0)

(2.0)

(1.0)

-

Budget deficit YTD Patient Income Other Income Pay Non-Pay Depreciation, interest& dividends

Non-recurrent andExceptional

Actual deficit YTD

2.1.2 YTD deficit bridge (£m)

(9.0)

(8.0)

(7.0)

(6.0)

(5.0)

(4.0)

(3.0)

(2.0)

(1.0)

-

April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2.1.3 Surplus / (deficit) £m

Cumulative Plan

Cumulative Actual / Forecast

2.2 Income

2.2.1 Income summary

• Gross PbR income is (£0.4m) below plan in M06. Year to date gross PbR income is (£1.0m) below plan.

• M06 PbR income is below plan in all areas other than Outpatients which is only marginally above plan.

• Year to date income reductions are £(0.3)m higher than expected mainly due to the estimate for the potential impact of being above the C-Diff trajectory.

• There was minimal favourable adjustment for the NEL threshold in month as the actual value for relevant NEL admissions was very close to the 2008-09 baseline

7

2.2.1 Income Summary

Plan Actual Var Plan Actual Var£'000 £'000 £'000 £'000 £'000 £'000

Gross PbR income (2.2.4) 13,481 13,095 (385) 80,901 79,949 (952)Income reductions (2.2.6) (309) (264) 45 (1,854) (2,105) (252)Other patient income (2.2.7) 7,325 7,700 375 44,626 46,105 1,479Ledger timing differences(1) - 104 104 - - -Total patient income 20,497 20,636 139 123,673 123,948 276Other income (2.2.8) 2,172 1,893 (279) 13,222 13,751 529Total income 22,669 22,529 (140) 136,895 137,699 805

Month 6 Year to date

(1) reflects impact of coding of prior month activity and in respect of the plan represents agreed contract variation

136.9 137.7

(0.6) (0.3)(0.1) (0.1)

+1.5+0.5

130.0131.0132.0133.0134.0135.0136.0137.0138.0139.0140.0

Budget Income YTD PbR - Volume PbR - Price Reductions - Contract Reductions - Other Other patient income Other income Actual Income YTD

2.2.3 YTD Income variance (£m)

2.2.2 Monthly IncomeApr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 YTD

£'000 £'000 £'000 £'000 £'000 £'000 £'000Gross PbR income 13,746 13,513 12,816 13,976 12,802 13,095 79,949Income reductions (605) (343) 29 (627) (295) (264) (2,105)Other patient income 7,636 7,546 7,682 7,600 7,940 7,700 46,105Ledger timing dif ferences(1) (171) (342) 46 504 (141) 104 (0)Total patient income 20,607 20,374 20,572 21,454 20,306 20,636 123,948Other Income 2,503 2,411 2,427 2,070 2,446 1,893 13,751Total income 23,109 22,786 23,000 23,523 22,753 22,529 137,699

2.2 Income

8

2.2.4 Gross PbR Income

• Gross PbR income is £(0.4)m (2.9%) below plan in M06. This is driven by a volume variance & price variance of £(0.2)m each

• Total income from activities (after penalties etc.) is £0.1m , 0.7% above plan in M06 and £0.3m, 0.2% above plan year to date.

• Elective Care & Family Care divisions were below plan for both gross PbR income and activity in M06.

• To date Adult Acute division is ahead of plan for both income & activity for gross PbR income. Elective Care is now slightly below circa 1%) the YTD gross PbR income & activity plan due to the underperformance in M05 & M06.

• Family Care Division is below plan by £(1.1)m of which Delivery episodes and Ante / Postnatal pathways registrations & other Obstetric / Midwifery activity account for £(1.0)m, Paediatrics/Neonatology are £(0.4)m below plan offset by Gynae being over plan by £0.3m.

2.2.4 Gross PbR Income

Plan Actual Var Var Plan Actual Var Var Plan Actual Var Var Plan Actual Var Var# # # % £'000 £'000 £'000 % # # # % £'000 £'000 £'000 %

A&E 9,469 8,977 (492) (5.2%) 963 922 (41) (4.2%) 57,479 57,269 (210) (0.4%) 5,844 5,885 41 0.7%Day Cases 2,079 2,306 227 10.9% 1,624 1,515 (109) (6.7%) 12,620 13,087 467 3.7% 8,927 8,922 (4) (0.0%)Elective IP 533 504 (29) (5.5%) 1,281 1,228 (53) (4.2%) 3,238 3,166 (72) (2.2%) 7,776 7,813 38 0.5%Non-Elective IP 3,043 3,136 93 3.1% 4,969 4,883 (85) (1.7%) 18,470 18,638 168 0.9% 30,160 29,767 (393) (1.3%)Delivery Episodes 521 521 0 0.1% 927 903 (24) (2.6%) 3,160 2,962 (198) (6.3%) 5,626 5,157 (469) (8.3%)Outpatients 22,580 22,308 (272) (1.2%) 2,466 2,481 15 0.6% 137,064 135,676 (1,388) (1.0%) 14,971 15,117 147 1.0%Ante/Postnatal Pathw ays 978 945 (33) (3.4%) 904 835 (69) (7.7%) 5,939 5,783 (156) (2.6%) 5,488 5,350 (138) (2.5%)Excess Bed Days 1,462 1,440 (22) (1.5%) 347 329 (19) (5.4%) 8,874 8,312 (562) (6.3%) 2,109 1,936 (173) (8.2%)Gross PbR Income 40,665 40,137 (528) (1.3%) 13,481 13,095 (385) (2.9%) 246,845 244,893 (1,952) (0.8%) 80,901 79,949 (952) (1.2%)Income Reductions (2.2.6) (309) (264) 45 (14.7%) (1,854) (2,105) (252) 13.6%Other patient income (2.2.7) 7,325 7,700 375 5.1% 44,626 46,105 1,479 3.3%Ledger timing dif ferences - 104 104 n/a - - - n/aTotal income from activities 20,497 20,636 139 0.7% 123,673 123,948 276 0.2%Memo: Divisional PbR IncomeAcute Adult 19,174 18,948 (226) (1.2%) 5,092 5,143 52 1.0% 116,391 116,543 152 0.1% 30,907 31,657 750 2.4%Elective 16,645 16,253 (392) (2.4%) 5,078 4,859 (219) (4.3%) 101,039 99,990 (1,049) (1.0%) 30,824 30,446 (378) (1.2%)Family 4,846 4,677 (169) (3.5%) 3,093 2,966 (127) (4.1%) 29,415 27,974 (1,441) (4.9%) 18,777 17,658 (1,119) (6.0%)Gross PbR 40,665 39,878 (787) (1.9%) 13,263 12,969 (294) (2.2%) 246,845 244,507 (2,338) (0.9%) 80,508 79,761 (747) (0.9%)

Month 6 Year To DateIncome IncomeActivityActivity

2.3 Pay

2.3.1 Pay spend

• The classification as “other pay budgets” arises because although the division and speciality has agreed the savings these are only allocated at specialty level not subjective code level.

• The ‘other pay budget’ contains the divisional and CIP gap where costs have not yet been allocated to individuals budget lines.

• Although the pay budget is now overspent by £0.1m YTD an additional £0.8m of income has been generated.

9

2.3.1 Pay - Actual vs Budget

Annual Budget Budget Actual Var.

Prior Year Budget Actual Var.

£m £m £m £m £m £m £m £mSenior Managers (5.0) (0.4) (0.4) 0.0 (3.0) (2.5) (2.1) 0.4Medical and Dental (47.3) (4.0) (3.9) 0.1 (22.9) (24.1) (23.3) 0.8Nursing, Midw ifery And Health Visiting (75.3) (6.3) (6.0) 0.3 (37.3) (37.9) (36.5) 1.3Scientif ic, Therapeutic and Technical (23.4) (1.9) (1.8) 0.1 (12.2) (11.7) (11.1) 0.6Professional and Technical (5.1) (0.4) (0.4) 0.0 (2.6) (2.6) (2.3) 0.3Administrative and Clerical (23.2) (1.9) (1.8) 0.1 (11.9) (11.7) (11.1) 0.7Healthcare Assistants and Other Suppo (20.6) (1.7) (1.5) 0.2 (9.7) (10.2) (9.2) 1.0Other Pay Budgets 8.0 0.8 0.0 (0.8) (0.0) 2.3 (0.1) (2.3)Agency Staff (2.6) (0.3) (0.7) (0.4) (3.7) (1.4) (4.1) (2.8)Pay (194.6) (16.2) (16.6) (0.4) (103.4) (99.8) (99.9) (0.1)Bank (included in above) (3.0) (0.3) (0.5) (0.2) (2.9) (1.7) (2.9) (1.2)

Agency SplitNursing (0.2) (0.0) (0.2) (0.1) (0.1) (1.0) (0.9)A&C (0.7) (0.1) (0.2) (0.1) (0.3) (0.8) (0.5)Locum Doctors (1.7) (0.2) (0.3) (0.1) (0.9) (2.0) (1.1)Other (0.0) (0.0) (0.0) (0.0) (0.0) (0.3) (0.3)

Year To DateIn-Month

(48)

(765)

(55)

765

(102)

8

(447)

(15)

45

(410)

(1,000)

(500)

-

500

1,000

Acute Elective Family Corporate Trust

2.3.2 Pay variance to budget (£'000)

YTD In month

5. Cashflow

5. Cashflow summary

• The 13 week cash forecast includes PDC funding of £2.5m in November and £1.0m in December.

• The DH has approved £11.7m of funding to the end of quarter 2. Current forecast indicate that the Trust will only need to request £6.75m to the end of December.

10

Key assumptions

The cashflow forecast is underpinned by the followingassumptions:

• PDC funding of £17.25m included in the forecast;• Level of overdue debt to remain at current levels;• Forecast is based on a outturn of a £7.8m I&E deficit

before exceptional items.

0.0

4.0

8.0

12.0

16.0

20.0

13-O

ct

20-O

ct

27-O

ct

03-N

ov

10-N

ov

17-N

ov

24-N

ov

01-D

ec

08-D

ec

15-D

ec

22-D

ec

29-D

ec

05-J

an

5.1 13 Week Cash forecast (£m)

Cash forecast

0.0

1.0

2.0

3.0

4.0

5.0

6.05.2 Actual month end cash balance (£m)

Forecast Actual

6. Capital expenditure

6.1 Capital expenditure

• The Trust capital plan as submitted to Monitor at the end of May is £5.9m

• At the end of September capital expenditure was £2.0m underspent

• The Trust has spent 37% of the capital plan, this is below the 85% Monitor threshold

11

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0


Cumulative capital expenditure (£m)

Actual spendAnnual Budget

6.1 Capital expenditure YTD

Budget Actual Var Budget Fcast Var£000 £000 £000 £000 £000 £000

ReplacementsSigmoid Flexiscope 56.5 0.0 56.5 113.0 113.0 0.0Blood Gas Analyser 26.5 0.0 26.5 53.0 53.0 0.0Laporoscopic Stacking System 29.5 0.0 29.5 59.0 59.0 0.0Upgrade of Haemoglobin Testing Systems 171.0 0.0 171.0 342.0 342.0 0.0Tissue Processor 20.0 0.0 20.0 40.0 40.0 0.0Replacement of Franking Machine 8.5 16.2 (7.7) 17.0 17.0 0.0Replacements Subtotal 312.0 16.2 295.8 624.0 624.0 0.0MaintenanceUrology Fire Precautions and Structural Floor 71.0 0.0 71.0 0.0 0.0 0.0Urology Scheme Design and Consultancy Fees 0.0 0.0 0.0 40.0 40.0 0.0Repairs to Highw ays Churchill Drive 0.0 0.0 0.0 50.0 50.0 0.0C Diff icile - Purchase of 4 HPV fogging units 43.5 125.8 (82.3) 300.0 300.0 0.0Upgrade of Ward A4 401.0 392.5 8.5 802.0 802.0 0.0Churchill Service Duct Fire Precautions 648.5 0.0 648.5 1,297.0 1,297.0 0.0Ugrade of Parental Accomodation for MIB 5.0 6.1 (1.1) 10.0 10.0 0.0Maintenance Subtotal 1,169.0 524.4 644.6 2,499.0 2,499.0 0.0EnhancementsEndoscopy 425.0 357.5 67.5 850.0 850.0 0.0PACS 150.0 93.7 56.3 300.0 300.0 0.0CT Enabling Works 25.0 1.0 24.0 50.0 50.0 0.0Information Technology 403.5 0.0 403.5 807.0 807.0 0.0Enhancements Subtotal 1,003.5 452.2 551.3 2,007.0 2,007.0 0.0OtherCapitalised Salary Costs 65.0 65.0 0.0 130.0 130.0 0.0Fees Maternity Unit 16.7 1.5 15.2 40.0 40.0 0.0Other Subtotal 81.7 66.5 15.2 170.0 170.0 0.0

2012/13 SlippageEndoscopy - phase 1 365.0 0.0 365.0 365.0 365.0 0.0Other 235.0 111.2 123.8 235.0 235.0 0.02012/13 Slippage Subtotal 600.0 111.2 488.8 600.0 600.0 0.0

GROSS CAPITAL EXPENDITURE 3,166.2 1,170.4 1,995.8 5,900.0 5,900.0 0.0

Year to date Annual

10. Financial risks & opportunities

12

10.1 Financial risks and opportunities

Risk PlanMitigated

Risk @ Mth6Residual

Risk£m £m £m

Planned deficit (7.8) - (7.8)Bolton CCG income (including QIPP) - no dow nside risk because of the patch f inancial management framew ork. - - -Other income - Results for f irst six months show signif icant mitigation to this risk. (1.4) 0.7 (0.7)Turnaround cost reduction - gap in identif ied savings mitigated by delivery of budget balance at divisional level. (5.9) 3.0 (2.9)Maintain non recurrent savings risk 50% (2.7) 1.3 (1.4)Cost pressure management - the operation of the Divisional Financial Management Framew ork and the results at month six give comfort that this risk has reduced. (2.0) 1.0 (1.0)Downside risk scenario (19.8) 6.0 (13.8)

10.1 Financial risks and opportunities

• The risk on the income and cost improvements has been mitigated by use of the risk reserve and non recurrent savings

11.1 Appendix: Activity trends

13

7,000

7,500

8,000

8,500

9,000

9,500

10,000

10,500

11,000

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

A&E activity

13/14 Actual 13/14 Plan 12/13 Actual

3,000

3,100

3,200

3,300

3,400

3,500

3,600

3,700

3,800

3,900

4,000


Non elective activity (spells only) inc births


15,000

17,000

19,000

21,000

23,000

25,000

27,000


O/P activity (including procedures)


1,500

1,750

2,000

2,250

2,500

2,750

3,000


Elective / day case activity (spells only)


2013/14 I&E Forecastas at 30th September

Context • Based on bottom up forecasts signed off by Divisions• Divisional forecasts have improve since Q2• Adjusted for forecasting risk

Forecast • £7.8m is deliverable – by non recurrent means • Recurrent position major concern

Actions• The Trust is taking measures to ensure run rate balance by the end of

2013/14• The Trust is bringing forward delivery of the pay element of the

corporate directorates 2014/15 cost improvement plan into quarter 4 of 2013/14

BFT ‐ 2013/14 I&E Forecast Summary

RevisedControl Forecast Variance

Total Plan £m £m £mPbR income 161.4 159.8 ‐1.6Other income 90.5 91.8 1.3Income reductions ‐3.8 ‐4.0 ‐0.2Divisional Income 26.2 27.3 1.1Total income 274.4 275.0 0.6

Pay ‐196.2 ‐198.1 ‐1.9Non‐Pay ‐72.9 ‐75.0 ‐2.1Capital items, interest & dividends ‐9.6 ‐9.3 0.3Non recurrent items ‐1.3 ‐1.4 ‐0.1Risk Reserve ‐2.2 1.0 3.2Total Expenditure ‐282.1 ‐282.8 ‐0.6

Surplus/(deficit) ‐7.8 ‐7.8 0.0

BFT ‐ 2013/14 I&E Forecast Divisional Variance

Q2 Q3£m £m

Adult ‐1.5 ‐0.9Elective ‐1.5 0.0Family Care ‐1.0 ‐0.3Estates 0.0 0.4Community Funding 0.0 1.2Activity undertrade 0.0 ‐1.5Corporate 0.3 1.0Financial Charges 0.5 0.3Risk Reserve 2.2 2.2Balance Sheet 1.0 1.0

Sub Total 0.0 3.4

Forecast ‐ optimism bias 0.0 ‐2.8Winter 0.0 ‐0.6

Total 0.0 0.0

Committee Chair Report

Name of Committee: Quality Assurance Committee

Date of Meeting: 9th October 2013

Report to: Board of Directors

Chair: Gina Ashworth

Key Issues Discussed

Chairman’s report the Committee noted the items devolved from the Board for further

consideration:

Audit of compliance with the falls strategy

Audit of readmissions

Integrated performance – the Committee received a presentation outlining the background

to the development of the new integrated performance report scheduled for presentation to

the Board in October. The new report has been designed to provide an Executive summary

to the full board with the option to drill down into ward level detail for areas of interest or

concern. The Quality Committee will focus routinely on the Quality metrics in this report.

The Committee also received the NHS North Quality dashboard and agreed that this should

be received quarterly by the Committee.

Division Reports – The Family Division attended to present their Q1 Quality report.

Committee members discussed the metrics and assurance included in the report and asked

for further assurance to be provided with regard to learning from incidents and data

protection issues.

From November all three divisions will share their reports at the same meeting at the end of

the reporting quarter. This will provide timelier reporting and allow divisions to share

learning.

SUIs – The Committee received an update on implementation of SUI action plans.

CQC report – The Trust is now fully compliant with all standards

C Difficile action plan – The QA committee continue to receive monthly updates on the

implementation of the CDT action plan.

Keogh Review and Berwick report – The Committee received presentations on the

implications of these national reports

For Escalation to the Board

Committee members agreed that their concerns with regard to the closure of incidents on

Safeguard should be escalated to the Board

Apologies received from

See minutes

Date of next meeting – 6th November 2013

Agenda Item No : 23



Title Charitable Funds

Executive Summary

• Why is this paper going to the Board

• To summarise the main points and key issues that the Board should focus on including risk, compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

• To accept the Minutes of the Charitable Funds Committee Meeting held on 28/08/2013.

• To approve the amended Charitable Funds –Terms of Reference.


Discuss Receive

Approve Note





Quality Regulatory




Prepared by Alison Tilley Finance Manager Presented by Mr E Adia

Non-Executive Director

MINUTES OF THE CHARITABLE FUND MEETING held on Wednesday 28th August 2013

in the Estates Conference Room, Royal Bolton Hospital

PRESENT Abbreviation for

Minutes Mr A Duckworth Non-Executive Director (Chair) AD Mr S Worthington Director of Finance SW Ms Sheila Roberts Interim Divisional Director of

Families SR

Ms Pauline Lee Public Elected Governor PL Ms Janet Roberts Staff Elected Governor JR Dr G Halstead Consultant – Medicine &

Emergency Care GH

Mrs A Tilley Deputy Finance Manager AT 1. Apologies

Apologies were received from E Adia, Gina Ashworth and J Ramsden. No conflict of interests were disclosed.

2. Minutes of Previous Meeting

The minutes of the meetings held on 12th March 2013 were accepted as a true record.

3. Matters Arising Ethiopia Fund – AT met with Mr Hobbiss and a visit is to be arranged to Gondar.

4. Terms of Reference

The updated Terms of Reference (ToR) were discussed, AD asked how the ToR compared to other standard ToR’s and SW stated that they were comparable. AT went through the points that had changed. SR asked why the Estates department weren’t represented, SW suggested that Estates would be represented at future meetings if required.

SW asked if the Audit Committee had reviewed the ToR and AT confirmed that they hadn’t and that the ToR are sent to the Board of Directors for approval. CFC/1301- AT to send the Terms of Reference to the Board of Directors for

Approval.

5. Investments

The Committee has approximately £1.3m to Invest, SW stated that for the short term leave the money in the bank.

The Committee discussed the possibility of depositing the monies in a bank account with a better rate of interest and a guarantee.AD asked if the Committee had ever looked into pooling the money with another Trust’s Charitable Fund, AT informed the committee that this had never been done, she was then asked to investigate this.PL asked if we could put the monies into a Bond. AD suggested that the committee review the Investments every 12 months.

It was decided that there will be a further update at the next meeting to consider Investment options that are available.

CFC/1302 – AT to investigate putting the monies into a Bond. CFC/1303 – AT to investigate pooling the funds with another NHS Charity. CFC/1304 – AT to update the committee on Investments available at the next meeting.

6. Fund Balances

The Fund balances were discussed, AT stated that the divisions were being asked to spend their ‘Old Funds’ by the end of this financial year. Monies are not transferrable from one fund to another. The committee discussed fundraising, SW asked that the divisions discuss fundraising at their divisional board meetings and put forward their fundraising ideas. SW asked that the divisional fundraising ideas are discussed at the next Committee meeting that is due to be held in November. This led to the Committee discussing fundraising and AD suggested that the Committee focus on one large item. Divisions are to be asked to submit their views by the end of October to AT.

CFC/1305 – AT to ask the divisions for fundraising suggestions. CFC/1306 – AT to inform the committee of the divisions suggestions at the next meeting.

7. Annual Report

AT explained how the Annual Report was produced and answered questions raised. It was confirmed that the Auditors were happy with the content and the report was accepted by the committee and the statements be signed off by the Chairman and SW.

8. Funding Requests There were no funding requests for discussion. PL asked how the departments ask for funding. AT explained the process.

9. Any Other Business AT produced a copy of a letter regarding an estate that includes a property that is currently on the market for £69,950 – an offer has been made for £61,500. AT stated that the property was in need of repair. The Committee recommended to accept the offer.

CFC/1307 – AT to confirm acceptance of the offer to the Solicitor.

10. Date and time of next meeting

Wednesday 27th November 2013 at 8.15am in the Estates Conference Room- This is to be confirmed due to the new membership.

Charitable Funds Committee

BOLTON NHS FOUNDATION TRUST

TERMS OF REFERENCE


1. Constitution

The Trust Board has resolved to establish a committee of the Board to be known as the

Charitable Funds Committee (CFC). The board has delegated the responsibility for the overall

management of the Charity to the CFC. The Committee has the responsibility to:

i. Accept, control, apply and administer all Charitable Funds in accordance with the

NHS Charities Act 1977, the National Health Service and Community Care Act

1990.

ii. Ensure that ‘best practice’ is followed in the conduct of all its affairs fulfilling all of

its legal responsibilities.

iii. Ensure that the Trust’s management and reporting arrangements are followed,

and that Charitable funds procedure notes are produced and followed.

iv. Provide support, guidance and encouragement for all its income raising activities

and monitor the receipt of all income.

v. Ensure that the investment policy is followed and that funds are invested to

provide a balanced return from income and capital growth with a low level of risk.

vi. Monitor the activity, performance, and risks of the Charity and keep the Trust

Board fully informed.

vii. Oversee and monitor the functions performed by the Director of Finance as

defined in Section 16 of the Trust’s Standing Financial Instructions.

2. Membership of the Committee

2.i Membership of the Committee shall comprise of:

3 Non-Executive Directors

Director of Finance

Divisional –Nursing Representative

Divisional –H.O.D.

Divisional –D.D.O. or General Manager


Finance Manager (Charitable Funds)

Two Public Elected Governors

A Staff Elected Governor

2. ii The Chair of the committee shall be one of the Non-Executive Directors.

3. Quorum

A quorum shall require the attendance of four or more of the Committee members, which must

include at least one Non-Executive Director, the Director of Finance or Finance Manager and

two other Committee members.

4. Attendance at Meetings

The Committee may request the attendance of relevant senior staff of the Trust as and when

required.

5. Frequency of Meetings

Meetings shall take place at least twice a year.

6. Support and Advice to the Committee

The Committee shall receive reports, advice, support and information at each meeting and on

an ad-hoc basis upon request from:-

The Director of Finance

The Trust’s Investment Advisers

The Trust’s Legal Advisers

The Trust’s Auditors

The Trust’s VAT Advisors

7. Charitable Funds Objectives, Structure & Policy

Bolton NHS Charitable Fund was created using the model declaration of trust and there are a

number of ‘special purpose trusts’ which are registered under the ‘Umbrella’ of the Bolton NHS

Charitable Fund. The Charitable Funds registration number is 1050488. The Trust is responsible

for holding it’s Charitable Funds upon trust, and the object’s of the charity are to apply income

and at their discretion so far as permissible the capital, for any charitable purpose or purposes

relating to the National Health Service.

The Trust has powers to accept gifts, bequests or donations only for the purposes relating to

health services including, patients, staff welfare and amenities and research. All such gifts,


bequests or donations should be accepted in the name of ‘Bolton NHS Charitable Fund’, and

should be administered in accordance with Trust policies and the donor’s wishes.

All correspondence and communications in connection with legacies are conducted through the

Director of Finance in accordance with the Standing Financial Instructions; ‘The Director of

Finance is kept informed of all enquiries regarding legacies and a legacy register is maintained

by the Finance Department. After the death of a testator, all correspondence concerning a

legacy is dealt with on behalf of the Trust by the Director of Finance who alone is empowered to

give an executor a good discharge.

Each fund has a designated signatory and the Charity has a Scheme of Delegation which is:-

Up to £1,000.00 Designated Fund Holder

£1,000.00 to £5,000.00 Divisional Director of Operations

£5,000.00 to £10,000.00 Deputy Director of Finance

Over £10,000.00 Director of Finance

The policy of the charity is to ensure that all fund holders spend donations as they are received

and not to build up fund balances unless funds are being accumulated for a specific purpose,

e.g. the purchase of more expensive piece of equipment. A review is undertaken of fund

balances on a regular basis and a report is made to the CFC detailing the expenditure plans of

funds with balances in excess of £5,000.

8. Investments

The charity’s investment policy is based upon the powers within the trust deed, this forms the

basis of the formal investment agreement with our investment managers. The CFC must comply

with the Trustee Investment Act 1961, The Charities Act 1993 and the terms of the funds

governing documents. The Investment Managers are required to provide;

A balanced return from income and capital growth, with a low level of risk.

The Investment Managers may only purchase investments for the portfolio which it has

reasonable grounds for believing it to be suitable for the Trust.

Ethical considerations should be made when making Investments.

To provide regular updates and visit the Trust when required.


An update on Investments is made to the CFC at every meeting, members of the committee

may be contacted of any material changes or an emergency meeting called if found necessary.

Other funds are held in a bank account that is separate to the Trust’s NHS funds.

9. Application of Funds

9.i. The Committee will ensure and keep under review a scheme of reserved powers and

delegation of powers to commit funds.

9.ii. Monitor expenditure/the application of funds:-

The Charitable Funds Accountant will commit all Charitable Fund expenditure, and

ensure that it is in line with the objectives of the Charity/and the wishes of the donor.

Fund holders will be issued with a list of fund balances on a monthly basis, and

statements will be available upon request, with full explanations given as and when

required.

The Charitable Funds Accountant will produce ad hoc reports for fund holders as

requested.

9.iii. Monitor fund balances to ensure that there are plans to spend large fund balances:-

The Charitable Funds Accountant will investigate fund balances over £5,000 to ensure

that funds are being accumulated for the purchase of a larger piece of equipment.

A report of fund balances will be made to the CFC on a regular basis.

10. Delegated Powers and Duties of the Director of Finance

The Director of Finance or Deputy has the prime responsibility for the Trust’s Charitable Funds

as defined in Section 16 of the Trust’s Standing Financial Instructions (See Appendix A). The

specific powers, duties and responsibilities delegated to the Director of Finance are outlined

below:

10. i. Administration of all existing Charitable Funds.

10. ii. Review the number of funds in existence and were appropriate either rationalise or

increase the number of funds and provide governing documents were appropriate.


10. iii. Provide guidelines in respect of income from donations, legacies and bequests,

fundraising, investment and trading income.

10. iv. Responsible for the management of investment of Charitable funds.

10. v. Ensure appropriate banking services are made for charitable funds.

10. vi. Ensure that regular reports are made available to the CFC and Trust Board.

10. vii. Preparation of the charities Annual Accounts and Annual Report for submission to the

Charities Commission.

Accepted by CFC 28/08/2013

Accepted by Board of Directors xx/xx/2013

Appendix A. Bolton NHS Foundation Trust –Standing Financial Instructions Paragraph 16 – CHARITABLE FUNDS (FUNDS HELD ON TRUST) 16.1 Corporate Trustee

(1) The Trust Board is the corporate trustee of the Charitable Fund(s). (2) The discharge of the Trust’s corporate trustee responsibilities are distinct from its responsibilities for exchequer funds and may not necessarily be discharged in the same manner, but there must still be adherence to the overriding general principles of financial regularity, prudence and propriety. The Board may delegate such trustee functions as it determines to the Charitable Funds Committee subject to written terms of reference approved by the Board. The Board must receive and adopt the annual accounts of the Charitable Fund(s). 16.2 Accountability to Charity Commission The trustee responsibilities must be discharged separately and full recognition given to the Trust’s accountability to the Charity Commission for charitable funds held on trust. 16.3 Applicability of Standing Financial Instructions to funds held on trust (1) In so far as it is possible to do so, these Standing Financial Instructions will apply to the management of funds held on trust. (See overlap with SFI 7.12). (2) The over-riding principle is that the integrity of each Trust must be maintained and statutory and Trust obligations met. Materiality must be assessed separately from Exchequer activities and funds.

bolton nhs foundation trust – board meeting october 31st 2013 · 2013-10-25 · 1 bolton nhs...

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