meeting of the board of directors thursday 28 june 2018 at ......2018/06/28 · meeting of the...
TRANSCRIPT
Meeting of the Board of Dire 2010 in the boardroom
Meeting of the Board of Directors
Thursday 28th June 2018 at 12.45 pm
Trust Administration meeting room 6
Public Meeting of the Board of Directors Thursday 28th June 2018 at 12.45 pm in Trust Administration
Presentation: Improving outcomes through the Paterson redesign – Professor Nick Slevin
Key:
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Page 24/18 Standard business
a Apologies Chair b Declarations of interest Chair c Minutes of previous meeting – 24th May 2018 * Chair 3 d Action plan rolling programme, action log & matters arising * CEO 11&14
25/18 Key reports a Chief executive’s report * CEO 15 b Executive medical directors report * EMD 23 c Integrated performance report */p Exec dirs 27
26/18 Other reports a Medical appraisal & revalidation annual report 2017-18 * EMD 59 b 62 day cancer target progress * COO 75 c Workforce plan progress report * DoW 81
27/18 Board assurance a Board assurance framework 2017/18 * CEO 89
28/18 Any other business Chair Date and time of the next meeting Thursday 27th September 2018
CEO EMD COO DoW
Chief Executive Officer Executive Medical Director Chief Operating Officer Director of Workforce
* paper attached v verbal p presentation
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DRAFT Public minutes of the meeting of the Board of Directors of The Christie NHS Foundation Trust held on Thursday 24th May 2018 at 12.45pm in the trust administration meeting room
centre, The Christie NHS Foundation Trust Present: Christine Outram (CO)
Kathryn Riddle (KR) Neil Large (NL) Prof Kieran Walshe (KW) Jane Maher (JM) Robert Ainsworth (RA) Tarun Kapur (TK) Roger Spencer (RS) Fiona Noden (FN) Jackie Bird (JB) Joanne Fitzpatrick (JF) Chris Harrison (CH) Wendy Makin (WM) Eve Lightfoot (EL)
Chairman Non-Executive Director Non-Executive Director Non-executive director Non-Executive Director Non-Executive Director Non-Executive Director Chief Executive Chief Operating Officer Chief Nurse and Executive Director of Quality Executive Director of Finance & Business Development Executive Medical Director Executive Medical Director Director of Workforce
In Attendance: Louise Westcott (minutes) Company secretary Cathy Heaven Director of Education Dr Louise Sell Insight Programme David Makin (DM) Partner Governor Roger Bowman (RB) Public Governor
Presentation: Psycho-Oncology: A Service Overview and Mental Health Promotion – Dr Anita
Ghosh & Dr Tania Hawthorne & Ann Cook
CO welcomed the speakers. AG outlined the service provided by the psycho-oncology team. A cancer diagnosis can have a significant effect on mental health as can the drugs we give. The team see exacerbation of pre-existing disorders and new symptoms. They deal with depression, major depression and anxiety. Cancer has a significant emotional impact and patients with mental health problems have a worse quality of life, treatment adherence is worse and healthcare costs are higher. Patients with a mental health disorder and cancer are dying sooner and more are dying. AG showed survival data that demonstrates that patients with psychiatric diagnoses are dying sooner and more are dying compared to those without a mental health diagnosis for patients with curative intent and same disease staging. It is reported that the most difficult aspects of cancer are the emotional aspects. AG outlined that the service supports psychological wellbeing and the mental health of Christie patients, diagnosing and treating patients with mental disorders and supporting and upskilling staff. AG advised that the team only support the tip of the iceberg and there are currently about 1000 new referrals per year and a 15-30% Do Not Attend rate. The counselling & psychology service was described as was the liaison psychology service. The plan for education was outlined with the aim of developing the organisations capacity to care by up-skilling & supervising staff. AG outlined some of the initiatives that the team have supported across the Trust including Mental Health awareness week and health & wellbeing events. The team also provide supervision and staff support is given across the trust with group supervision for level 2 specialist nurses, complimentary therapists and Teenage & Young Adult staff. The teaching programme aims to upskill staff in mental health skills. A recent survey has shown low confidence in staff in managing patients mental health. The team work alongside staff in practice development – to develop pathways and upskill staff in clinic settings. The aim is to continue to upskill staff to improve the quality of life of our patients.
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Questions were invited DM asked if staff are also supported with mental health issues. TH responded that staff are directed to occupational health and we have a service externally they are referred to. TK – if we were to identify more patients with mental health problems would we have the capacity to support them. TH responded that this support would need to be developed. JM asked about the management of lower level distress – does this get supported. AC responded that the team support staff to offer this support, we deliver level 2 training to staff to get them to feel more confident in assessing low level distress. They can offer simple interventions and be supported by the team. It’s a cascade. Patients may also be signposted to the Maggie’s Centre. RB asked what support is given to parents of young people. TH responded that they are currently working up a business case to support patients and their parents. Looking to address the unmet need. AC added that the safeguarding team do support and signpost. RA asked how the service integrates with community mental health. AG responded that the team work very closely and can refer directly. They usually find the services are very supportive and have links with mental health teams before patients arrive. NL asked why there is such a difference in survival and what can we do about it. TH responded that this is about patients struggling to complete treatment when feeling low. Stress response and cancer interface may also be a factor. If we treat the depression then we can reverse this. NL asked if this could be a research project. TH responded that they are using comorbidities scale so the data is rough. Would be ideal to have an assessment earlier on to actively look for mental health problems. KW asked how a service is provided to satellite patients. TH responded that any patient with a Christie number can be referred. The patient would have to come to the Withington site and patients can be linked in with services locally. There are some very good services in the voluntary sector and there are also some very poor ones. This is being looked at through Manchester Cancer psych-oncology board. There are psych-oncology services at Wythenshawe and Oldham. WM asked about the fact that 50% of women who have brachytherapy experience post traumatic stress, how are we identifying this and looking to develop strategies. TH responded that Dr Barraclough is looking at how the pathway can be made less distressing. There needs to be more training and support in this aspect of cancer care and treatment. CO agreed that this is a stark number. DM asked how representative the membership of the pathway board is. AC responded that it is increasingly representative and that this is growing. CH commented that the survival data is shocking and we need to follow this up. Is there any sense of changes in mental health conditions over time / trend data as treatments are changing. TH responded that mental health conditions tend to be static, suicide changes due to economic factors. There is a feeling that with increased survivorship, more people are living with mental health issues. CO added that there is an opportunity to make even more improvements for patients. CO thanked the team for their presentation.
No Item Action 18/18 Standard business
a Apologies No apologies were received.
b Declarations of interest No declarations of interest were made.
c Minutes of the previous meeting held on 26th April 2018 The minutes of the meeting held on 26th April 2018 were accepted as a correct record.
d Action plan rolling programme, action log & matters arising All items are on the agenda or complete. No actions from the last meeting. 19/18 Key reports
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No Item Action a Chief executive’s report
RS highlighted the following items from his report; • CQC inspection update – formal notification has been received, preparations are
going ahead, responses have been given to the CQC as necessary. Mock inspections are being undertaken for the well-led review. Feedback from the Management Board has been very good.
• An excellent meeting with the chairs of NHSE and NHSI took place in May. No questions received.
b Executive Medical Directors report – education report Cathy Heaven was welcomed to the meeting.
WM introduced the report, this report is framed against the strategy of the School of Oncology, and there is also an overview of the finances of the school. Prof Richard Cowan sent his apologies. CHv presented the report and highlighted that the School of Oncology staff are involved in the trainee nurse associates programme. Students are now half way through the programme and the experience of them moving around for placements has been very helpful. Apprenticeships target was met last year, so far we have spent 7% of the levy, this will significantly change this year as there will be more clinical programmes that cost more. The school work on staff support and linking with HR to support staff to provide best care. CHv highlighted the innovation bursaries with opportunities to bring back good practice to change services here. Gateway C has been funded by Health Education England to be rolled out, CRUK continue to support this. Cancer programme – aims to meet strategic approach to being a national comprehensive cancer centre, provides route for research dissemination, platform for researchers to develop as experts. The income comes back to divisions through this. Where people teach they also provide better quality care, our staff benefit from teaching. CHv noted that the school runs study days to support disease group teams to provide support to pathways and these are expensive to put on. The school also need to look for bigger events to cover the salaries of the events team. Conferences are run as they are profitable. Cystic fibrosis conference - 2 events run, which were profitable. There are 6 conferences being run this year that are all about cancer which is a sustainable events programme. Finance The income to the trust is about £6m from education, most of this goes into the divisions, the school manage £284k of this. The income generation target was outlined. The school is not for profit so much of this is spent to fund Schwartz rounds, work in clinical divisions, fellowships managers, innovation bursaries etc The trading budget has been very successful. Questions were invited. KW asked how trusts manage surpluses on trading accounts. JF responded that this is managed through reserves if necessary. It is managed in the overall financial position. RA asked about the vision to be the leading provider of cancer education – how realistic is this. CHv responded that we are challenging for this and our portfolio is growing. We are looking at both skills based and academic teaching, and it depends
CHv
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No Item Action how you measure it. CHv to look at metrics. NL commented that this is great for the trust and asked how far we go and if there is a target. JF noted that the school give back through CIP year on year. This is just direct costs. CHv added that we are starting to include a trust overhead in costings, a hosting charge. JF added that we have done this gradually. CHv concluded that we have maintained our status against an austere climate, and that the next 12 months will be tricky. We will look at potential investments. The school has also paid for updating of the education centre rather than this coming through our estates. Vanguard and System C income is accounted for separately. University income is sustainable and will grow. CO asked how CIP has been achieved. CHv responded that a lot has been delivered through efficiencies. The school is also delivering more with the same staffing. KW asked what we are doing around apprenticeships. CHv responded that big national schemes are being progressed as apprenticeships. We are looking at being a trail blazer for clinical roles. In initial 2 years wasn’t flexibility but this looks like it is now progressing. We are not offering apprenticeships that others can buy into at the moment. May be an opportunity for GM to challenge. These apprenticeships will come on line. Time and resource will also need to be factored in. JM asked about gateway C and whether HEE have got plans to roll this out further. CHv responded that they haven’t currently, they have a year of funding for the North, will then look at impact / usability etc. Lung health check programme has not started yet – MCIP team have built a module for this and there is a mechanism to get this out there. Report noted
c Integrated performance report – month 1 FN reported on a good performance in month. Patient satisfaction is excellent at
98.4% and chemotherapy treatments are performing well at 92.3%. Pharmacy performance improved to 82%; an action plan to support continued improvement is being followed. There have been no cancelled operations in month. Staff PDRs are still below target at 87.9% and the executive team have brought divisions in to speak about expected improvement and this is being addressed through performance reviews. In regard to infection control there have been no cases of MRSA bacteraemia, 1 case of CDiff (going through review) and 3 cases of Ecoli. We have achieved a 62% reduction in Cdiff results for 2017/18 year and this is a reflection of the hard work that has gone on across the trust in the quality improvement collaborative. There is one operational risk at 20 which is against the delivery of the 62 day performance target. All safe staffing levels have been achieved. There have been no SI panels or incidents but there were 4 executive reviews, 8 complaints and 1 inquest. All access standards (18 weeks, 31 and 62 days) have been achieved in month. Length of stay is below plan at 6.94 days. Patients treated year to date is below plan in month 1 at -4.23%. Sickness absence is at 3.07% and the NHSI expenditure ceiling is above plan at 112.1%. FN reported the Trusts financial position. We have a financial surplus of £3,248m which is £560k higher than plan. The I&E deficit is £255k, £557k below plan and we have a cash balance of £33,701k. Our debtor days are 25. CIP is looking very positive at the beginning of the year at 42.4% achieved in year, 33.9% recurrently. We have scored a single oversight framework rating of 1 for both governance and
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No Item Action financial sustainability. Questions were invited. CO noted the positive start. KW asked why LOS is declining. FN responded that zero length of stay patients were removed and it’s now restabilising following the change. JB added that we have also done a lot of work around discharge of patients that has helped considerably. FN noted that we have been on green for beds since the start of April. The ward stock apart from haematology ward are all now under 1 division. RA added that pharmacy turnaround has improved but this is not divided into outpatients and inpatients. The outpatient performance is improving but it still has a long way to go. Mix of the business changed in month to improve the overall figure. Improvements have been seen and the Pharmacy board will look at this in detail at their meeting tomorrow. NL asked about the YTD activity being 4% down in chemotherapy / radiotherapy. FN responded that we believe that this is a timing issue as this is based on the first cut of data and the second cut looks better. NL asked about the exec walkround for rehabilitation and the reference to data capture and asked if this is an issue. EL responded that we are working with the teams to get a better electronic system in place. FN highlighted that there is a new indicator on the dashboard around the internal 24 day turnaround. This should start to improve as there is further focus on it. RS stressed that this is for all patients and not just the small subset of 62 day patients. There are about 120 patients on a 62 day pathway each month – these are the ones we provide the first treatment for. Many are treated elsewhere. FN noted that this improvement is clinically led. KR picked up the comment from rehabilitation who say they don’t have enough space. RS commented that there is a process we use to test what we do in terms of space. We have invested huge amounts to ensure we provide enough space – this dialogue will be ongoing. KW asked about the quality & standards walk around & the comments about their accommodation. JF responded that as we no longer plan to build MCRC2 we will now look at what we do. There is some work happening to improve this accommodation. WM commented that walk rounds are very valuable and it gives a great understanding of issues, allows us to improve some things we wouldn’t otherwise here about. We also have a trust with great contrasts as there are some amazing new areas and some very old. CO noted how valuable the qualitative data from the exec walk rounds is for the board. It is very open and very useful. We do need to consider the quality of accommodation for staff as well as patients.
20/18 Approvals a Annual report & accounts 2017/18
RGS reminded board that this was distributed separately. Audit opinion has been received this morning in the joint audit & quality meeting. It was agreed to be submitted to board for approval from that meeting. The report will be sent off to be laid before parliament. Board approved the report and accounts. CO congratulated the team for the work.
b NHS Improvement self-certification declarations RS noted that this is about licencing condition requirements. We need to make these
declarations in line with the requirements. The evidence we rely upon is the segmentation under the Single Oversight Framework – we are in segment 1 which is the best possible. No reports to board of any changes that affect that. Governors statement is also here and the annual report & accounts annual
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No Item Action governance statement provides the evidence. Board approved.
c General Data Protection Regulations (GDPR) action plan LW reported on the GDPR action plan.
The General Data Protection Regulation comes into effect on 25th May (tomorrow) and one of the requirements of the regulation is to appoint a data protection officer who must report on compliance directly to board. LW has been appointed to this role for The Christie. This report gives an update on the action plan that has been developed to achieve full compliance and asks for approval of the action plan outlined. GDPR applies to the EU & also looks at the export of personal data outside the EU; its primary aim is to give control to individuals over their personal data. As a trust we have been preparing for the enforcement of GDPR for a number of months, following the guidance from the Information Commissioners Office. A task & finish group has been set up with representatives from across the trust to deliver this. In order to assess our preparedness MIAA were asked to undertake a gap analysis audit, from which a detailed action plan has been developed. We were assessed against 100 items, 56 of which were assessed as 'in place' with 44 identified as 'work in progress'. None were assessed as 'not in place'. Some of the key actions in our plan relate to relooking at the information we hold & we have undertaken a data flow mapping exercise across the trust to update these flows of data and establish our legal basis for processing this data. We have also updated our privacy notices and replaced the previous information on our website and in public areas of the trust. There is still work to do on preparing tailored privacy notices for specific groups. We have updated policies and contracts we hold and we have done considerable work across key areas such as The Charity, membership and research to ensure our processing complies with the new requirements. We are also looking at our data security & working towards the certified Cyber Essentials programme – we anticipate that this work will take in the region of 12 months and a plan is in place. As a trust we are working towards compliance against the GDPR, we have had an external assessment & produced a detailed action plan. LW noted that the trust are focusing on the key actions identified in this paper as well as the full plan and this will be monitored through the Audit Committee. NHSI have confirmed that their requirement for NHS organisations is to have a board approved action plan in place that looks to achieve full compliance. Board were asked to approve the action plan produced through MIAA's independent review & receive 6 monthly updates. RA asked if this is just the Christie not the charity. LW confirmed this includes the charity. RA asked if TCC and CPP are required to comply , LW confirmed , JF reported that TCPC had reported on progress of compliance at the Board meeting on Monday
21/18 Board assurance a Board assurance framework 2018/19
RS presented the BAF for 2018/19 – minor changes have been made since the last meeting. Suggesting that the risk relating to the PBT build is taken off – agreed. Noted
b Audit committee annual report 2017/18
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No Item Action
Report was presented to this morning’s joint meeting – report discussed in that meeting. Noted
c Quality Assurance committee annual report 2017/18
Report was presented to this morning’s joint meeting – report discussed in that meeting. Noted
22/18 Any other business NHSI chair and NED development unit are coming to observe the next meeting.
RS introduced work commissioned by NHSE and filmed by ITN to commemorate 70 years of the NHS. We are 1 of 8 trusts that have been part of this. We are the only cancer segment in the film.
Date of the next meeting: Thursday 28th June 2018
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Agenda item 24/18d
Month From Agenda No Issue Responsible Director
Action To Agenda no
June 2018 Annual reporting cycle Integrated performance report COO Monthly report 25/18cResponsible Officer report IEMD Medical Appraisal &
Revalidation Annual report26/18a
02/18c 62 day cancer target COO 6 month update on progress 26/18bWorkforce plan update DoW Progress report 26/18c
Integrated performance report COO Monthly report By email
Integrated performance report COO Monthly report By email
Sepember 2018 Annual reporting cycle Integrated performance report COO Monthly reportCompliance with NICE Safe Staffing Guidelines
CN&EDoQ Six month review
14/16f, 19/17c & 30/17b Organisational development plan (incl WRES & Personal Development Reviews (PDR))
DoW Six month review
Annual reporting cycle Risk Management strategy CN&EDoQ Annual reviewWRES update DoW Annual update
October 2018 Annual reporting cycle Corporate objectives & board assurance framework
CEO Interim review
Annual reporting cycle Medical directors report - Research review (key issues, progress against objectives and future plans)
DoR Six month review
November 2018 Annual reporting cycle Integrated performance report COO Monthly report
August 2018 - no meeting
Public Meeting of the Board of Directors - 2018
Action plan rolling programme after May 2018 meeting
July 2018 - no meeting
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Month From Agenda No Issue Responsible Director
Action To Agenda no
Annual reporting cycle Medical directors report - Education review (key issues, progress against objectives and future plans)
DoSoO Six month review
Freedom to speak up FtSUG Annual report
January 2019 Annual reporting cycle Integrated performance report COO Monthly report
March 2019 Annual reporting cycle Corporate planning (corporate objectives / BAF 2019/20)
Executive directors
Approve next year's annual plan
Annual reporting cycle Letter of representation & independence Chair Directors to signAnnual reporting cycle Register of directors interests Chair Report for approvalAnnual reporting cycle Integrated performance report COO Monthly reportAnnual reporting cycle Declaration of independence (non-executive
directors only)Chair For completion by NEDs
Annual reporting cycle Chair ApproveSix monthly compliance with NICE safe staffing guidelines
CN&EDoQ Review
Workforce plan DoW UpdateEPR update
April 2019 Annual reporting cycle Integrated performance report COO Monthly reportAnnual reporting cycle Annual compliance with the CQC
requirementsCN&EDoQ Declaration / approval
Register of matters approved by the board CEO April 2018 to March 2019Annual reporting cycle Medical directors report - Research update
(key issues, progress against objectives and future plans)
DoR Review
Annual reporting cycle Annual Corporate Objectives CEO Review 2018/19 progressModern Slavery Act update CEO Chief Executive's report
May 2019 Annual reporting cycle Integrated performance report COO Monthly reportAnnual reporting cycle Annual reports from audit & quality assurance
committeesCommittee
chairsAssurance
February 2019 - no meeting
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Month From Agenda No Issue Responsible Director
Action To Agenda no
Annual reporting cycle Annual report, financial statements and quality accounts (incl Annual governance statement / Statement on code of governance)
EDoF&BD Approve
Monitor provider licence Self certification declarations EDoF&BD To approve the declarationsAnnual reporting cycle Medical directors report - Education update (to
include policy for managing potential conflicts of iinterest when securing bids to host conferences funded by pharmaceutical companies)
DoSoO Review
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Action log following the board of directors meeting held on
Thursday 24th May 2018
Public
No. Agenda Action By who Progress Board review
19/18b Education report - vision to be the leading provider of cancer education – metrics for achieving this to be evaluated CHv Report to 29th November
2018 meeting
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Agenda item 25/18a
Meeting of the Board of Directors Thursday 28th June, 2018
Report of Chief executive
Paper Prepared By Roger Spencer
Subject/Title Chief executive’s report
Background Papers n/a
Purpose of Paper To keep the board of directors updated on key external developments & relationships
Action/Decision Required The board is asked to note the contents of the paper
Link to:
NHS Strategies and Policy
Link to:
Trust’s Strategic Direction
Corporate Objectives
Achievement of corporate plan and objectives
Impact on resources and risk and assurance profile
You are reminded that resources are broader than finance and also include people, property and information.
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
SOF - Single Oversight Framework JAG - Joint Advisory Group GRS - Global Rating Scale RCR - Royal College of Radiologists PET - Positron Emission Tomography GM HSC SPB - GM Health and Social Care Strategic Partnership Board PFB - Provider Federation Board HInM - Health Innovation Manchester LHCRE - Local Health and Care Record Exemplars
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Agenda item 25/18a
Meeting of the Board of Directors Thursday 28th June, 2018
Chief executive’s report
1. Annual Members’ Meeting
Our 2018 Annual Members’ Meeting will be held on Thursday 19th July at 2pm in The Christie Auditorium. In addition to the general business of an annual members’ meeting, the event will include a review of 2017/18. There will also be a presentation from Professor Karen Kirkby on Proton Beam Therapy. There will also be an opportunity to see displays on our work and plans for the future. Further information can be found at http://www.christie.nhs.uk/about-us/the-foundation-trust/membership/annual-members-meeting/
2. Open Day The Christie open day will take place on Saturday 28th July from 10am until 3pm. It is open to all, and visitors will be able to take tours of our new proton beam therapy centre, theatres, clinical trials unit and the integrated procedures unit. There will also be displays to view and drop in areas to visit. Further information can be found at http://www.christie.nhs.uk/about-us/nhs70-celebrating-70-years-of-the-nhs/trust-open-day-28-july-2018/
3. Joint Advisory Group (JAG) Accreditation Following the submission of a satisfactory Global Rating Scale (GRS) census and the review of the Annual Report Card submitted by our endoscopy unit, we were informed that the endoscopy unit had met all of the requirements to be awarded JAG Accreditation for 2018. Further information on JAG can be found at https://www.thejag.org.uk/
4. National Cancer Programme Event - 4th June This event brought together the National cancer team, cancer alliances and the vanguard. Greater Manchester presented its clinical leadership model together with other alliances. Further plans for the operation of alliances were reviewed. Further information can be found at https://www.england.nhs.uk/cancer/strategy/alliance-guidance/
5. Royal College of Radiologists (RCR) Awards Congratulations to three of our clinicians who were recently recognised at The RCR Fellows Admissions Ceremony. Professor Tim Illidge won the Gold Medal, Professor Neil Burnet won the Exceptional Contribution Award, and Professor Catherine West was awarded an honorary fellowship. A wonderful achievement by all. For further information about these awards, please visit https://www.rcr.ac.uk/posts/welcome-new-fellows-spring-2018
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6. Staff Awards The staff recognition event took place on the 7th June. Out of nearly 300 nominations, the following winners were announced. Category Winner Exceptional Standards of Quality and Care Metastatic spinal cord compression team Innovation and Improvement Sugar Matters Team Behind the Scenes – Non Clinical Staff Car Park and Security Teams Rising Star Alex Daly Partnership Working The Christie at Salford SRS Team The Christie Values Debra Bradley Research Team of the Year Experimental Cancer Medicine Team Researcher of the Year Dr. Fiona Thistlethwaite Research Nurse of the Year Elaine Blowers Research Administrator of the Year Jane Rogan Outstanding Contribution to Research & Education
Professor Andrew Hughes
The Christie Award for Contribution to Education - Nationally or Internationally
Dr.Rille Pihlak
The Christie Educationalist of the Year Kerry Millington Learner of the Year Nicola Chesman Long service awards were also presented to volunteers who are celebrating 10 years’ service and staff with 20, 30 or 40 years’ service. The event was a celebration of all the hard work and fantastic achievement of all our staff over the last 12 months.
7. Britain’s Best Home Cook Huge congratulations to Christie tissue bank technician Pippa Middlehurst, who was named winner of the BBC’s Britain’s Best Home Cook by judges Mary Berry, Chris Bavin and Dan Doherty on June 14. Pippa competed over an eight week period against nine other contestants. Further information can be found at https://www.bbc.co.uk/programmes/b0b6trzt
8. Christie Staff Summer Ball The Christie staff summer ball took place on Saturday, 23rd June at the The Imperial War Museum North. Over 300 staff members attended the event where entertainment for the evening was provided by Dr Richard Berman and his band Inhale.
9. NHS Confederation The NHS Confederation’s annual conference and exhibition took place on the 13th and 14th June in Manchester. This years conference concentrated on workforce, reform and the 70th birthday of the NHS. A film celebrating the NHS at 70 was launched, featuring several services including The Christie. The film can be viewed via this link https://drive.google.com/open?id=16myVevFET046PTvI6K5CjkWJRuzii5gI Further information can be found at http://www.nhsconfed.org/confed18
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10. Leading European Hospitals Forum
On the 14th and 15th June the leading European hospitals forum took place. The event brought together 20 CEOs from leading European institutions to share perspectives on the changing health care landscape, discuss the role of major providers, share learnings, and build international networks. The UK was represented by Royal Brompton and Harefield Hospitals, Barts Heart Centre, University College London Hospitals NHS Foundation Trust, University Hospitals Bristol and The Christie.
11. Greater Manchester Health and Social Care Partnership The Christie and Manchester Foundation Trust submitted a bid for the provision of Greater Manchester PET services. The award announcement is expected imminently and should our partnership be successful plans are already in place to update existing infrastructure and increase the PET capacity and access for Greater Manchester Patients. The Christie is a key partner in the final submission for the national genomics lab re-designation. Genomic service providers across Manchester, Liverpool and Lancashire have collaboratively developed a bid to provide high quality efficient genomic services to the population of the North West. The submission recognises the importance of genomic medicine for the continuing improvement of cancer care for which The Christie is key in ensuring fast and universal adoption of the optimum tests for cancer patients in the north west. The North West team attended a bid clarification meeting in May with the national team which resulted in positive dialogue on the themes of the submission. The Christie is working closely with partners on the reorganisation of urology and gynaecology surgery. Capacity has been developed at The Christie to accommodate the first phase of additional prostate surgery on the path to The Christie being the dedicated prostate surgical centre for Greater Manchester. The Christie prostate surgical team are in the process of setting up a joint clinic in Oldham to support access to the services from the North East sector. In addition the surgical colorectal team, working with the Manchester Cancer pathway board, have identified the need for additional capacity for complex multi-speciality pelvic clearance work. The Christie is working closely with commissioners to ensure those patients that can benefit from this surgery have the option to receive this care. The GM Health and Social Care Strategic Partnership Board (GM HSC SPB) has approved the establishment of a GM Health and Social Care Digital Board. The Board – which is chaired by Jon Rouse and Rowena Burns - is made up of representatives from the GM HSC Partnership Executive, Health Innovation Manchester (HInM) Board and the GMCA Digital Board.
The delivery of GM’s digital vision will be overseen by this Board through the creation of two related programmes - an Interoperability Hub that will use patient-level data for direct care purposes, and an Innovation Hub that will drive forward transformational change. The Interoperability Hub will be chaired by a representative of the Provider Federation Board (PFB) and the Innovation Hub will be chaired by the CEO of HInM, Ben Bridgewater. The Innovation Hub will host curated data for secondary use by clinicians, planners, academics and the life sciences, biotech and technology industries. It will operate via a federated model and include and enhance existing digital platforms, products and services currently provided through North West eHealth (for the life science industry), Connected Health Cities (for clinical pathway innovation) and learning health systems/technology/industry engagement delivered through the Salford Global Digital Exemplar, at Salford Royal.
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Earlier this month, GM became one of five new Local Health and Care Record Exemplars (LHCRE), receiving £7.5m from NHS England. Each regional LHCRE will build on existing local work on shared records to further develop joined up regional health and care information reference sites, focused on improving direct patient care. Further information can be found at http://www.gmhsc.org.uk/
12. NHS Improvement Review Meeting On the 25th May NHS Improvement visited us for a quarterly review meeting. We were advised that we continue to be categorised in the single oversight framework (SOF) segment 1, the best performance possible, and that they anticipate the SOF rating to remain stable over the next quarter. Further information can be found at https://improvement.nhs.uk/
13. Site Developments Proton Beam Therapy Centre The building works to the Proton Beam Therapy Centre were completed on programme and the building was handed over on 9th April. A programme of Trust works to commission the building is now complete and the building has been handed over to the operational teams. Varian are continuing their commissioning programme and have now successfully delivered the proton beam into the first treatment gantry. Activities for delivering patient care are due to commence in the centre in August. Outpatients Redevelopment The phase 1 works to the ground floor of the Proton building started on Monday 15th January and is due to be handed over in August 2018. Works to the Central Phlebotomy suite are due to commence in early July and will be complete by March 2019. Car Parking The staff Park and Ride service has now been relocated to the Withington Community Hospital site on Nell Lane. This new site provides CCTV coverage, 24 hour security and a shorter bus transfer time. The park and ride service remains free to staff. Manchester City Council are currently undertaking local surveys to enable a review and extension of the controlled parking zone. Manchester City Council have previously approved the planning application for the development of a new tiered car park on Cotton Lane. This new car park will provide an additional 407 car parking spaces. A business case for the tiered car park is planned for consideration at the September Board of Directors. Christie @ Cheshire East Feasibility options have been developed for a new Christie cancer centre at East Cheshire Hospital in Macclesfield. The proposed cancer centre will include radiotherapy, chemotherapy and outpatient facilities. An outline case is to be considered at the June Board of Directors.
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Improving Outcomes Through Paterson Redesign The Christie and its partners (University of Manchester and CRUK) continue to consider options for redesigning and redeveloping the site of the Paterson building. It is intended to create a facility that ensures the on-going integration of clinical and scientific activities at The Christie. A report considering development plans will be considered at our June Board of Directors meeting. More information about our new developments can be found at: http://christie.nhs.uk/about-us/our-future/our-developments/
21
22
Agenda item 25/18b
Meeting of the Board of Directors
Thursday 28th June 2018
Report of Executive Medical Director
Paper Prepared By Yvonne Clooney
Subject/Title Executive Medical Director’s report
Background Papers n/a
Purpose of Paper To bring to the attention of the Board of Directors current issues relating to the Trust or external network
Action/Decision Required To note
Link to:
NHS Strategies and Policy Cancer Outcomes Framework
Link to:
Trust’s Strategic Direction
Corporate Objectives
All objectives of the Trust
Impact on resources and risk and assurance profile
You are reminded that resources are broader than finance and also include people, property and information.
Nil
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
RCNi – Royal College of Nursing institute HNA – Holistic Needs Assessment CRF – Clinical Research Facility NIHR – National Institute for Health Research
23
24
Agenda item 25/18b Meeting of the Board of Directors
Thursday 28th June 2018
Executive Medical Director’s Report
Research Update 1. Nurse shortlisted for prestigious prize Advanced Nurse Practitioner Lorraine Tuner has been shortlisted for the prestigious
RCNi Nurse Awards in recognition of her work in identifying the holistic needs of patients referred to experimental cancer medicine trials. Lorraine has been shortlisted in the Excellence in Cancer Research category for her project to audit the holistic needs of patients. Nearly 200 patients took part in the audit and completed a holistic needs assessment (HNA), which focused on physical, psychological, effects of treatment, religious and spiritual concerns. Award winners will be announced at a ceremony in July.
2. Study paves the way for better treatment of prostate cancer A new study, led by Professor Catharine West of The Christie and The University of
Manchester, has found a way to identify men with locally advanced prostate cancer who are less likely to respond well to radiotherapy. Professor West, Professor of Radiation Biology, and her team created a method of selecting patients who would benefit from treatments which target oxygen-deficient tumours. Such tumours are associated with a poor prognosis and the lower the oxygen, the greater the resistance to treatment and the greater the likelihood the tumour will spread.
3. International nurses visit Two overseas nurses paid a visit to the Clinical Research Facility as part of a National
Institute for Health Research initiative. Kristen Legor, Associate Chief Nurse of research nursing at the Dana-Farber Cancer Institute in Boston, Massachusetts, and Noriko Fujiwara, a research nurse and project manager at the Institute of Medical Science at the University of Tokyo, visited the Cancer Research Facility over two days. The visit was designed to give insights into UK clinical research processes. Meanwhile, a team from the NIHR’s Central Commissioning Facility and its office for clinical research infrastructure visited The Christie, where Prof Nick Webb, Manchester CRF Director, outlined Manchester’s five-year strategy.
4. Grant for excellence Melissa Frizziero was awarded a European Neuroendocrine Tumour Society Centre of
Excellence (ENETS CoE) Young Investigator Grant 2018 (for salary) for ‘Development of an alternative ‘precision medicine’ platform for identifying and testing novel therapeutic strategies for advanced extra-pulmonary (EP), poorly differentiated (PD), neuroendocrine carcinoma (NEC)’. The grant is worth 50,000 euros.
5. Research staff back International Clinical Trials Day The Christie joined International Clinical Trials Day in May by taking part in the NIHR
Thunderclap, which involved a message being shared simultaneously across social media accounts. The message was shared by more than two million accounts. Christie research staff also posted selfies on social media under the hashtag #IAmResearch.
25
6. Trial successes Our breast team were top global recruiters on to two trials in recent weeks, both phase
II multi-centre trials. The first, known as Hi BarrSTEM, is a study for patients with a form of metastatic breast cancer. The second, known as BerGenBio, is a study for patients with a previously treated, locally advanced and unresectable form of breast cancer. We were also the top global recruiter for a colorectal trial known as PRAER-1.
Appraisal & Revalidation Annual Report 2017-18 The annual Responsible Officer report for the Board is included in the papers.
26
Integrated Performance & Quality Report May 2018
Responsive Effective
Safe Caring
Well Led
27
Month 2 (May) Performance Report
Introduction The Integrated Performance and Quality report presents a summary dashboard that provides an overview of performance. Exception reports set out information about breach of standards highlighted red as well as any other areas of concern within the report, together with action taken and projected performance. Overall Performance 62 day performance for May has been achieved. Our length of stay has reduced but remains slightly above plan. There is one risk rated at 20 which is related to our 62 day performance, 2 risks rated at 16 and 1 risk rated at 15 in month. Full descriptions of the risks can be found in section 2. Quality In month the patient satisfaction survey results remain high with a 98.6% positive response score. Patient safety There have been no cases of MRSA bacteraemia and one case of C-difficile. The one case is still under the review process. Finance The Trust is exceeding the NHSI Control Total by £92k and our position assumes meeting all criteria for Sustainability and Transformation Fund (STF) core funding. Our overall income and expenditure position is a deficit of £708k, which is £915k above plan. Our recurrent CIP position is at 54.7% and is above the Q1 trajectory. Under the Single Oversight Framework, our Use of Resources score is 1. Additional Reports There are two additional reports this month:
• Christie Onsite Deaths: June 2018 • National Inpatient Survey 2017/18
28
2018/19 Dashboard
29
1. Responsive 1.1 National Standards
1.1.1 Cancer Standards – 62 Days – (Trust Level) *All Cancer standards figures are subject to validation
National Standard Standard / Threshold Apr-18 May-18Cancer Standards - 62 Days 85% 87.9% 85.0%
Cancer Standards - 31 Days 96% 97.0% 97.3%
18 Weeks - Incomplete Pathw ays 92% 98.2% 98.6%
Diagnostic Waiting Times - CT 100% 100%
Diagnostic Waiting Times - MRI 100% 100%
Radiotherapy Average Waiting Times - Palliative 14 Days 11.3 11.1
Radiotherapy Average Waiting Times - Radical 28 Days 25.4 23
Delivering Same Sex Accommodation - Breaches 0 0 0
6 Weeks
50.0%
55.0%
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18
May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-1862 day CWT 68.6% 57.5% 70.8% 70.2% 67.3% 70.5% 60.5% 63.5% 52.8% 62.7% 75.2% 63.9% 58.0%62 day (Adjusted) 90.8% 85.2% 90.5% 82.5% 85.5% 88.4% 87.2% 90.1% 69.1% 87.5% 92.9% 87.9% 85.0%62 Day Standard 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%
62 day CWT 62 day (Adjusted) 62 Day Standard
Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/1862 day CWT 67.0% 69.3% 65.3% 62.6%62 day (Adjusted) 88.1% 86.0% 88.4% 82.6%62 Day Standard 85% 85% 85% 85%
50.0%
55.0%
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
62 day CWT 62 day (Adjusted) 62 Day Standard
30
1.1.2 Cancer Standards – 62 Days – (Networked Services)
1.1.3 Cancer Standards – 62 Days – (Clinical Support & Specialist Surgery)
1.1.4 Cancer Standards – 31 Days
1.1.5 18 Weeks Incomplete Pathways
50.0%
55.0%
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
May-17
Jun-17
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17
Jan-18
Feb-18
Mar-18
Apr-18
May-18
62 day (Adjusted) - NSDivision 96.0%84.8%90.0%88.5%91.3%88.3%88.2%93.8%87.3%90.1%95.1%91.3%90.8%
62 Day Standard 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%
62 day (Adjusted) - NS Division 62 Day Standard
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
May-17
Jun-17
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17
Jan-18
Feb-18
Mar-18
Apr-18
May-18
62 day (Adjusted) -CSSS Division 74.2% 86.7% 92.3% 63.6% 63.0% 88.6% 84.0% 76.5% 36.8% 73.3% 81.8% 78.9% 71.9%
62 Day Standard 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%
62 day (Adjusted) - CSSS Division 62 Day Standard
80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%
100.0%
31 Day Performance 31 Day Standard
80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%
100.0%
31 Subsequent (surgery) 31 Subsequent Standard (surgery)
80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%
100.0%
31 Subsequent (XRT) 31 Subsequent Standard (XRT)
80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%
100.0%
31 Subsequent (drug) 31 Subsequent Standard (drug)
80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%
100.0%
18 Weeks Incomplete Compliance Incomplete Standard
31
1.1.6 Diagnostic Waiting Times – CT 1.1.7 Diagnostic Waiting Times - MRI
1.1.8 Radiotherapy Waiting Times (Ready to Be Treated to Treated)
1.1.9 Delivering Same Sex Accommodation 1.1.10 70 Day Target
1.2 Trust Internal Standards
60.0%65.0%70.0%75.0%80.0%85.0%90.0%95.0%
100.0%
CT - 4 Wk Compliance CT - 6 Wk Compliance
6 Week Standard
60.0%65.0%70.0%75.0%80.0%85.0%90.0%95.0%
100.0%
MRI - 4 Wk Compliance MRI - 6 Wk Compliance
6 Week Standard
0
2
4
6
8
10
12
14
Palliative Avg Waiting Time (days) Palliative Threshold
0
5
10
15
20
25
30
Radical Avg Waiting Time (days) Radical Threshold
0
1
DSSA Breaches DSSA Standard
0102030405060708090
100
16-17 Q3 16-17 Q4 17-18 Q1 17-18 Q2 17-18 Q3 17-18 Q4
Actual Predicted
Trust Internal Standard Standard / Threshold May-1824 Day Internal Standard 85% 78.0%
Pharmacy Waiting Times 80% 81.5%
Chemotherapy Waiting Times - All patients 80% 91.5%
Chemotherapy Waiting Times - 2 Day patients 90% 95.6%
Cancelled Operations On The Day For Non-Clinical Reasons 0 2
Number of Surgical Operations — 324
Number of PET Scans — 707
Inpatient Length Of Stay 7 Days 6.84
32
1.2.1 Internal 24 Day Standard 1.2.2 Pharmacy Waiting Times
1.2.3 Chemotherapy Waiting Times
1.2.4 Cancelled Operations On The Day For Non-
Clinical Reasons 1.2.5 Number of Surgical Operations
1.2.6 Number of PET Scans 1.2.7 Inpatient Length of Stay - ALL (Rolling 12
Months)
77.0%
79.0%
81.0%
83.0%
85.0%
87.0%
89.0%
24 Internal Day 24 day Internal St andard
Improvem ent Traje ctory
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Waiting Time Compliance Threshold
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Waiting Under 1 hour Compliance - (ALL Patients) Threshold
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Waiting Under 1 Hour Compliance - (2 Day Patients) Threshold
0
1
2
3
4
Cancelled Operations On The Day - Non Clinical Reasons
Threshold
0
50
100
150
200
250
300
350
Number of Surgical Operations Undertaken
0
100
200
300
400
500
600
700
800
Number of PET Scans Completed
6.706.756.806.856.906.957.007.057.107.15
Inpatient Length Of Stay - (Days) - ALL Patients Threshold
33
1.2.8 Elective (Rolling 12 Months LOS) 1.2.9 Non Elective (Rolling 12 Months LOS)
1.2.10 Longest Inpatient Length of Stay (LOS) (at month end)
Patient admitted as an emergency on 25th March 2018 and as of 31st May 2018 had been an inpatient for 67 days. 1.2.11 Transfers (Rolling 12 Months LOS) 1.2.12 LOS Over 30 Days
1.2.13 LOS Over 30 Days (Discharged –
Breakdown by Admission Type) 1.2.14 Patients Recruited to Trials
1.2.15 New Studies Opening to Recruitment 1.2.16 Studies Open to Recruitment
5.605.655.705.755.805.855.905.956.006.05
Inpatient Length Of Stay - (Days) - Elective
7.407.457.507.557.607.657.707.757.807.857.90
Inpatient Length Of Stay - (Days) - Emergency
17.00
18.00
19.00
20.00
21.00
22.00
23.00
Inpatient Length Of Stay - (Days) - Transfers
0
5
10
15
20
25
30
35
Patients Discharged In Month Still IP As At End Of Month
0
5
10
15
20
25
30
35
Electives Emergencies Transfers
0
500
1000
1500
2000
2500
Actual Predicted
020406080
100120140160180
Actual Predicted
0
100
200
300
400
500
600
700
800
Total Studies
34
1.3 Activity
1.3.1 Summary Activity – In Month & YTD
1.3.2 1st Cut Data & Refresh Variance
Point of Delivery Plan Actual VarianceDay Cases 891 1092 22.51%
Elective 381 364 -4.39%
Non Elective Emergency 531 562 5.80%
Non Elective Non Emergency 14 8 -43.87%
OP First Attendances 1377 1464 6.34%
OP Follow up Attendances 7398 7936 7.27%
Telephone Consultation 2562 2414 -5.76%
Homecare Treatments 185 153 -17.15%
OP Follow up Attendances Chemotherapy Review 5138 4628 -9.93%
OP Follow up Attendances Radiotherapy Review 1588 1486 -6.43%
Supportive Care Hormonal Drug Review 408 390 -4.46%
OP Procedures 1129 1268 12.36%
AHP Attendances 664 621 -6.45%
Chemotherapy Delivery 6117 5785 -5.43%
Radiotherapy Treatment 8823 8494 -3.72%
Month 2 Activity 37205 36665 -1.45%Month 2 Cumulative Activity 71888 70132 -2.44%
Core / Unbundled
Point of Delivery High Level Total Plan Total Activity Variance % Variance Total Plan £ Total Actual £ Variance £
Day Cases 891 1092 201 22.51% £607,952 £792,150 £184,199Elective 381 364 -17 -4.39% £2,378,974 £1,826,208 -£552,766Non Elective Emergency 531 562 31 5.80% £1,299,866 £1,333,975 £34,109Non Elective Non Emergency 14 8 -6 -43.87% £85,157 £41,849 -£43,308OP First Attendances 1377 1464 87 6.34% £289,840 £308,141 £18,301OP Followup Attendances 7398 7936 538 7.27% £760,864 £822,479 £61,615Telephone Consultations 2562 2414 -148 -5.76% £91,368 £82,351 -£9,016Homecare Treatments 185 153 -32 -17.15% £169,378 £84,117 -£85,261OP Followup Attendances Chemotherapy Review 5138 4628 -510 -9.93% £575,639 £518,469 -£57,170OP Followup Attendances Radiotherapy Review 1588 1486 -102 -6.43% £177,890 £166,459 -£11,432Supportive Care Hormonal Drug Review 408 390 -18 -4.46% £45,988 £43,973 -£2,015OP Procedures 1129 1268 139 12.36% £237,918 £246,194 £8,276AHP Attendances 664 621 -43 -6.45% £53,332 £44,591 -£8,741Chemotherapy Delivery 6117 5785 -332 -5.43% £1,805,836 £1,639,267 -£166,570Radiotherapy Treatment 8823 8494 -329 -3.72% £1,272,526 £1,216,075 -£56,451
37,205 36,665 -540 -1.45% £9,852,528 £9,166,297 -£686,231Figures are an extract from the Trust’s total activity position.
May
Core
Unbundled
Grand Total
Core / Unbundled
Point of Delivery High Level Total Plan Total Activity Variance % Variance Total Plan £ Total Actual £ Variance £
Day Cases 1740 1995 255 14.64% £1,186,953 £1,453,863 £266,910Elective 743 722 -21 -2.86% £4,644,663 £4,036,544 -£608,119Non Elective Emergency 1045 1047 2 0.16% £2,557,801 £2,521,567 -£36,233Non Elective Non Emergency 28 15 -13 -46.52% £167,566 £76,516 -£91,050OP First Attendances 2688 2794 106 3.95% £565,878 £588,659 £22,781OP Followup Attendances 14444 15091 647 4.48% £1,485,496 £1,560,285 £74,790Telephone Consultations 5030 4868 -162 -3.22% £179,205 £165,630 -£13,575Homecare Treatments 361 306 -55 -15.13% £330,690 £174,198 -£156,492OP Followup Attendances Chemotherapy Review 9849 9231 -618 -6.27% £1,103,309 £1,034,067 -£69,241OP Followup Attendances Radiotherapy Review 3044 2764 -280 -9.19% £340,957 £309,617 -£31,339Supportive Care Hormonal Drug Review 782 740 -42 -5.42% £88,143 £83,410 -£4,734OP Procedures 2203 2481 278 12.61% £464,507 £479,832 £15,325AHP Attendances 1296 1299 3 0.23% £104,125 £90,479 -£13,646Chemotherapy Delivery 11724 11251 -473 -4.04% £3,461,186 £3,207,703 -£253,483Radiotherapy Treatment 16910 15528 -1382 -8.17% £2,439,008 £2,235,474 -£203,534
71,888 70,132 -1,756 -2.44% £19,119,487 £18,017,847 -£1,101,641Figures are an extract from the Trust’s total activity position.
Core
Unbundled
Grand Total
YTD
1st Cut of Data Total Activity Refreshed Total Activity 1st Cut Variance Refreshed VarianceApr-18 33030 33467 -4.23% -3.50%
May-18 36665 -1.45%
35
1.3.3 External Referrals
1.3.4 Activity against Plan
0200400600800
100012001400160018002000
External Referrals (17-18) External Referrals (18-19)
0100200300400500600700800900
1000
Inpatients Plan
0100200300400500600700800900
Daycases Plan
0
200
400
600
800
1000
1200
1400
1600
OP First Attendances Plan
0100020003000400050006000700080009000
OP Follow Up Attendances Plan
0
200
400
600
800
1000
1200
1400
OP Procedures Plan
0
1000
2000
3000
4000
5000
6000
7000
Chemotherapy Delivery (Treatments) Plan
0100020003000400050006000700080009000
10000
XRT Delivery (Fractions) Plan
36
1.4 Infection Control
1.4.1 MRSA Bacteraemia 1.4.2 C-Difficile
1.4.3 MSSA Bacteraemia 1.4.4 GRE Bacteraemia
Period National Standard Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19
MRSA Bacteraemia 0 0
National Threshold 0 0 0 0 0 0 0 0 0 0 0 0
C-Diff icile Avoidable 0 0
C-Diff icile Unavoidable 1 1
C-Diff icile Avoidable + Unavoidable 1 1
C-Diff icile Avoidable + Unavoidable 1 2
C-Diff icile Avoidable + Unavoidable Threshold 1 3 5 6 8 9 11 12 14 15 17 18
In Month MSSA bacteraemia 3 4
In Month GRE bacteraemia 1 1
In Month Klebsiella Species 1 4
In Month Pseudomonas Aeuriginosa 2 0
E-Coli - Pre 48 Hrs 3 11
E-Coli - Post 48 Hrs 2 0
E-Coli - Post 48 Hrs 2 2
E-Coli - Post 48 Hrs Threshold 2 5 8 10 13 15 18 20 23 25 28 30
In Month
In Month
Cumulative
In Month
Cumulative
0
1
2
3
4
5
MRSA bacteraemia Threshold
02468
101214161820
Avoidable + Unavoidable Avoidable Threshold (National)
0
1
2
3
4
5
MSSA bacteraemia
0
1
2
3
4
5
GRE bacteraemia
37
1.4.5 E-Coli 1.4.6 Klebsiella Species
1.4.7 Pseudomonas Aeuriginosa
1.5 Financial Summary In Month
1.5.1 Income & Expenditure
0
5
10
15
20
25
30
E-Coli - Post 48 Hrs E-Coli - Pre 48 Hrs
Reduction Trajectory (post 48 hours)
0
1
2
3
4
5
Klebsiella Species
0
1
2
3
4
5
Pseudomonas Aeuriginosa
Gre
en =
Ambe
r =
Red
=
UOR - Financial Sustainability Balance sheet sustainability - Capital service cover (times) 20% 2.5 1.75 1.25 5.0 1
UOR - Financial Sustainability Liquidity - Liquidity (days) 20% 0 -7 -14 120.2 1
UOR - Financial Eff iciency Underlying performance - I&E margin (%) 20% 1% 0% -1% 3.2% 1
UOR - Financial Controls Variance from plan - I&E margin variance (%) 20% 0% -1% -2% 0.9% 1
UOR - Financial Controls Agency Spend (%) 20% 0% 25% 50% -5.8% 1
Overall NHSI Risk Rating Use of Resources (UoR) Metrics 1 2 3 1
Income & Expenditure: YTD Overall f inancial position variance (%) - (underspend)/overspend against plan - bottom line
<0% <0 to 3% >3% -56.4%
Income & Expenditure: YTD Overall f inancial position variance (%) - (underspend)/overspend against plan - control total
<0% <0 to 3% >3% -6.3%
CIP Performance Underperformance against target - In year to current month (%) excluding reserves mitigation
<80% 90% to 100% >100% 39.4%
CIP Performance Underperformance against target - Full year impact - in year (%) <80% 90% to 100% >100% 39.4%
CIP Performance Underperformance against target - Full year impact - recurrent (%) <80% 90% to 100% >100% 45.3%
Capital Expenditure Exchequer Capital Spend to date (£'000) £4,896Cash Balance Current balance to date (£'000) £50,804Cash Balance Percentage of planned value >90% 80-90% <80% 148.4%
Principal purpose cap Income derived from principal purpose exceeds income derived from other purposes
<50% <50% to 99% >100% 35.0%
Debtor Days Average length of time debt is outstanding <16 >20 24
Public Sector Payment Policy Trade creditors paid cumulatively w ithin 30 days (%) >95% 90-94% <90% 96.8%
Public Sector Payment Policy Trade creditors paid cumulatively w ithin 10 days (%) >80% 65-80% <65% 93.6%
Trust Objective Themes & Performance Indicators
Wei
ght
Tolerances
Cur
rent
Mon
th D
ata
NH
SI ri
sk ra
ting
Apr-
18
M2 Target
May
-18
38
• EBITDA position is a surplus of £6,277 (901k above plan).
• The month 2 I&E deficit is £708k (£915k above plan).
• We have achieved (£92k above plan) the NHSI Control Total and our position assumes meeting all criteria for STF core funding.
• CIP delivery stands at 60.6% in year and 54.7% recurrently.
• Agency spends in month, and therefore cumulatively is above the monthly NHSI ceiling.
• Under the Single Oversight Framework, the Trust’s finance score is 1.
1.5.2 Trust Performance against NHSI Control Total
1.6 Balance Sheet & Liquidity
• Cash balances stand at £50,804k (148.4% of
plan). • Debtor days have reduced to 24 in line with year-
end and quarterly trend in relation to the NHS Agreement of Balances exercise and the raising of quarterly invoices.
• Capital expenditure stands at 109.9% of the internal plan.
1.6.1 Exchequer Cash Balances 1.6.2 % Staff Clinical-Non-Clinical
1.6.3 Aged Debt
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
Control Total - Actual (£000's) Trust Plan
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
Liquidity Days - Actual Plan
£0
£10,000
£20,000
£30,000
£40,000
£50,000
£60,000
£70,000
£80,000
£000
's
Cash Balances Cash Flow Plan
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Medical staf f Nurse staff Clinical staff Non clinical staff Total agency/other
0
5000
10000
15000
20000
25000
30000
0-30 Days 31-60 Days 61-90 Days 90-180 Days >180 Days
39
1.7 CIP The annual target for CIP in 2018-19 is £7.8m in year and £6.8m recurrently. As the end of month 2 49.6% of recurrent and 60.6% of in year efficiency savings against the targets have been removed from budget. With the risk assessment value of the schemes in work up and removed from budget, 54.7% of CIP recurrently and 60.6% in year has been identified. • Within month 2, 10 PIDs were submitted and 10 PIDs were completed in month to release £1.4M in-year
savings and £1.4M recurrently. • There are no active schemes anticipated. • CIP as at month 2 is currently above trajectory.
1.8 Agency
Quarter Target Actual Actual + Risk Assessed Value of SchemesQ1 30% 46.9% 54.7%
Q2 50%
Q3 88%
Q4 100%
Division / Area of Spend Apr-18 May-18
Clin Support & Spec Surgery £62,374 £28,430
Netw ork Services £19,576 £17,682
Finance & Business Development £1,683 £4,939
Programme Management Office
Estates & Facilities
Medical Physics £6,084 £8,669
Manchester Cancer £3,313 £2,549
The Christie Charity
R&D
SoO
The Christie Pharmacy
TOTAL Actual - in month £93,030 £62,268
NHS Improvement Expenditure Ceiling - in month £83,000 £83,000
% of Ceiling Used - in month 112.08% 75.02%
TOTAL Actual - cumulative £93,030 £155,299
NHS Improvement Expenditure Ceiling - cumulative £83,000 £166,000
% of Ceiling Used - cumulative 112.1% 93.6%
% of Total Pay Bill (Target) 1% 1%
% of Total Pay Bill (Actual) 0.90% 0.60%
40
1.9 Exception Reports
Indicator Threshold Apr-18 May-18 YTDHospital Cancelled Operations On The Day of Surgery 0 0 2 2
Expected Date of Performance Delivery01/06/2018
Impact
Executive LeadChief Operating Officer
Issue
1. Anaesthetist o/c over night prior to surgical session and due to acuity on OCCU w as on site until 5am therefore unable to attend planned session safely and no cover available from anaesthetic team. 2. Letter to patient not sent due to admin error.
Proposed Action
1. Review of anaesthetic scheduling SOP, additional anaesthetists due to commence in post x3 in next 2 months, BC in development for expansion of anaesthetic team. 2. Reiteration of process for listing of patients in surgical chamber.
Assessing ImprovementNo further non clinical cancellations
Indicator Threshold Apr-18 May-18 YTD24 Day Internal Compliance 85.0% 80.9% 78.0% 77.6%
Expected Date of Performance Delivery31.10.18
ImpactReputational for not achieiving the 62 day standard.
Executive LeadChief Operating Officer
IssueA new indicator of 24 days from CaRP reciept to treatment commenced in April 2018 for patients on a 62 day pathw ay.
Proposed ActionThe Trus tis now monitoring this standard against all patients on a 62 day pathw ay. We are predicting to potentially fail Q1 and Q2 until our action plan has been embedded.
Assessing Improvement
Monthly reporting in the board reports as w ell as performance review s and divisional boards.
Indicator Threshold Apr-18 May-18 YTDOverall Trust Activity Vs Plan > -1% -3.50% -1.45% -2.44%
Expected Date of Performance DeliveryAll completed before 2nd Cut (14th June 2018)
ImpactActivity improved from -350 to -129
Executive LeadChief Operating Officer
IssueChemotherapy delivery activity below plan at 1st cut
Proposed ActionReview of activity identif ied an issue w ith one of the schedulers IT settings, resulting in procurements only being coded rather than deliveries. IT have rectif ied the problem and a report to identify the missed treatmens has been actioned.
Assessing ImprovementAll missed activity has been added betw een cuts 1 and 2.
41
2. Safe 2.1 Safe Staffing
2.1.1 Breakdown by ward
2.2 Bed Occupancy
DAY NIGHTHours Hours
Registered NursesTotal monthly PLANNED 15919 11314.5
Total monthly ACTUAL 15586 11153.5Average Fill Rate % 97.9% 98.6%
Care StaffTotal monthly PLANNED 7502.5 3077
Total monthly ACTUAL 7281 3027.75Average Fill Rate % 97.0% 98.4%
ALL StaffTotal monthly PLANNED 23421.5 14391.5
Total monthly ACTUAL 22867 14181.25Average Fill Rate % 97.6% 98.5%
Hours Planned Hours Actual Hours Planned Hours ActualCritical Care Unit 1782.5 1757.5 1712.5 1700Palatine Trt Centre 3243.5 3016 2262.5 2137.510 Ward-Surg Onc Unit 1660.5 1660.5 1275 127511 Ward 1937 1902 1410 1386.512 Ward 2061 2045 1339.5 1339.504 Ward 2365.5 2349.5 1292.5 1292.5Oncology Assessment Unit 2068 2054.5 1362.5 1362.501 Ward 801 801 660 660TOTAL 15919 15586 11314.5 11153.5
Hours Planned Hours Actual Hours Planned Hours ActualCritical Care Unit 357.5 345 100 100Palatine Trt Centre 1170 1079 737.5 737.510 Ward-Surg Onc Unit 1066.5 1054 387.5 387.511 Ward 1261.5 1234.5 411.25 399.512 Ward 1148 1099.5 399.5 399.504 Ward 1306 1306 528.75 528.75Oncology Assessment Unit 850.5 823.5 512.5 47501 Ward 342.5 339.5 0 0TOTAL 7502.5 7281 3077 3027.75
Registered Nurses DAY NIGHT
100.0% 100.0%93.0% 94.5%
% Fill Rate % Fill Rate98.6% 99.3%
99.3% 100.0%99.2% 100.0%98.2% 98.3%
97.9% 98.6%100.0% 100.0%99.3% 100.0%
Care Staff DAY NIGHT% Fill Rate % Fill Rate
98.8% 100.0%92.2% 100.0%96.5% 100.0%
100.0% 100.0%95.8% 100.0%97.9% 97.1%
97.0% 98.4%99.1% 100.0%96.8% 92.7%
Ward
BM
RU
WA
RD
4
WA
RD
11
WA
RD
12
Pal
atin
e W
ard
Acu
te
Onc
olog
y U
nit
War
d 1
War
d 10
Crit
ical
C
are
May-17 63% 97% 96% 97% 97% 79% 89% 89% 50%Jun-17 64% 98% 98% 97% 98% 84% 87% 90% 67%Jul-17 76% 94% 95% 95% 94% 80% 82% 86% 57%
Aug-17 55% 91% 92% 94% 91% 76% 89% 86% 54%Sep-17 42% 95% 96% 96% 92% 81% 88% 81% 61%Oct-17 55% 94% 95% 93% 90% 81% 82% 86% 62%Nov-17 44% 97% 94% 97% 92% 76% 85% 83% 60%Dec-17 66% 88% 90% 88% 93% 72% 91% 80% 52%Jan-18 56% 96% 95% 98% 97% 82% 89% 80% 61%Feb-18 63% 93% 96% 95% 88% 80% 88% 90% 65%Mar-18 60% 94% 92% 92% 93% 75% 81% 86% 50%Apr-18 61% 95% 93% 93% 91% 77% 75% 71% 47%May-18 46% 91% 93% 92% 84% 72% 72% 74% 46%
Efficiency Benchmark = 85%
42
2.3 Clinical Incidents
2.3.1 Pressure Ulcers – (Cumulative Totals) 2.3.2 Inpatient Falls – (Cumulative Totals)
2.4 Clinical Governance
2.4.1 Inquests
2.4.2 Claims & payments
2.4.3 Serious Incident Panels
None 2.4.4 Serious Incidents Reported
None
Grade Incident Type Additional Details Location
Medical equipment Blister from epidural dressing. WARD10
Inpatient fall Patient fell on w ard and suffered a cut under left eye and under nose. WARD 4
Communication Patient w as incorrectly instructed to take Moviprep before attending for gastroscopy. IPU
Outpatient fall Patient fell from w heelchair follow ing scan and suffered bruising. MR
Medical equipment Skin tears follow ing dressing removal. DAY
Inpatient fall Patient fell on w ard and suffered grazing to knees. WARD 4
TOTAL = Grade 2 Pressure Ulcers (3)
TOTAL = extravasations (15)
Grade 2 (Minor)
0
5
10
15
20
25
30
2017/18 Total 2018/19 Total 18/19 Reduct ion Trajectory
0
5
10
15
20
25
30
2017/18 Total 2018/19 Total 18/19 Reduct ion Trajectory
Coroner Staff called VerdictBolton NO Died as a consequence of a rare but recognised complication of her anticoagulation treatment
May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18Clinical Negligence 15 16 15 14 15 14 17 16 16 16 17 16 16
Employer Liability 4 4 4 4 5 5 5 6 7 7 8 8 8
Public Liability 2 2 2 2 2 2 3 4 4 4 4 4 4
Payments £0 £0 £0 £0 £0 £0 £0 £1,000 £0 £13,538 £0 £24,395 £0
43
2.4.5 Executive Reviews
2.4.6 Top Operational Risks
Ris
k N
umbe
r
Risk
Cur
rent
Sco
re
Targ
et d
ate
for r
educ
tion
of s
core
Control Measures
1
Failure to meet 62 day target, resulting in delays to patient care, reduced patient care and reputational risk of non-compliance with national cancer target at Trust and Manchester Cancer level.
20 31st July 2018
• Daily PTL meetings • Additional capacity for theatres and outpatients, including weekend lists
and third sessions • Review of all breach pathways • Review of referral pathways • Recruitment of additional consultant staff across specialties • Weekly escalation meeting with exec team
2
Trust-wide staffing gaps due to national shortages in some occupations with a specific potential impact on junior doctors engagement levels and work experience
16 31st Jul
2018
• Commencement of a Trust wide workforce planning and transformation project
• Involvement of junior Dr leads in the project to ensure feedback and experience is included
• Nurse recruitment and retention project group and plan • Implementation of regular focused retention meetings and discussions
with a range of nursing staff including newly recruited nurses and nursing associates
3
Risk of significant disruption of trust hosted systems and data due to network infrastructure failure/poor performance.
16 30th Jun
2018
• Monitoring of the issue has increased – more teams have visibility and we have the data on big display screens so we can react quicker.
• Network router bug causing disruption w/c 14/04/18. Mitigations put in place with additional fibre link. Router module replaced. Cisco and ANS (supplier) expert support has improved network configuration and backup additionally as part of work undertaken.
Date of executive
review
Incident Report
Number
Incident Date Description Root Cause
•Agree w ith histopathology a process for reissuing amended reports and ensure an alert is sent to the responsible consultant
• Ensure that updated histopathology reports are raised at MDTs
• Review MDT processes and agree a forw ard plan
03/05/18 C3264-18 07/01/18 Complaint regarding care and communication
• Meeting w ith complainant planned for mid-June Meeting w ith complainant planned for mid-June
•Consider alternative cassette system to eliminate the need for handling at the embedding stage.
• Document WHO sign out procedure in Endoscopy Suite to ensure a w ritten record is available
•Develop clear protocols for w hen adjuvant treatments are required to indicate w hich treatments should be given f irst.
•Establish clear process for recording w hether a patient is palliative or curative at MDT
•Identify w hose responsibility it is to update the plan of care w hen changes occur
Adjuvant treatment w as required; how ever there w as lack of clarity as to w hich cancer pathology should be treated f irst.
17/05/18Claim 2018-01
W37485 12/10/17 Employer liability claim • Claim to be defended.The Claimant failed to follow manual handling training
24/05/18 C3268-18 29/03/18 Complaint regarding alleged misdiagnosis
• There had not been a misdiagnosis and the complaint letter is being formulated
N/A
Failure to follow up f indings of the reissued histopathology report, w hich had not been assigned to a named consultant
The investigation could not categorically identify w here the error occurred, but it possibly occurred during processing w ithin the laboratory, at the embedding stage as this is w here the tissue is handled.
There w as no clear plan for the patient’s pathw ay betw een the tw o MDT’s w hich led to uncertainty as to w hether treatment w as palliative or curative.
17/05/18 W3264-18 07/03/18
17/05/18 W39627 14/03/18
Delayed referral for adjuvant treatment for a patient w ho had tw o different cancers
Examination of biopsies by histopathologist, revealed that 2 pieces did not match and further testing by cytogenetics confirmed that they w ere from different patients.
Discrepancy betw een histology report, addendum and MDT record
Outcome
03/05/18 W39630 15/03/18
44
Ris
k N
umbe
r
Risk
Cur
rent
Sco
re
Targ
et d
ate
for r
educ
tion
of s
core
Control Measures
4
2018/19 Recurrent Trust Wide Cost Improvement Programme not achieved.
15 30th Sep 2018
• CIP allocation into divisions. Divisions working up delivery plans • Growth allocation plans in work up • Transformation office coordinating organisational response • Three organisational themes in place with clinical leadership • Controls through weekly deputies meeting and Finance and Resource
Group
2.4.7 Exception Reports
None
45
3. Effective 3.1 Clinical Effectiveness
3.1.1 Treatment Survival
3.1.2 Wrong Route Chemotherapy 3.1.3 Critical Care Unit Mortality Rates
3.1.4 Inpatient Deaths – Onsite Deaths
The Christie process for learning from deaths follows the NHSI guidance, 2017. All in-patient deaths are screened and where flagged by one or more triggers an independent structured case note review (SCR) is undertaken. Reviews are discussed by the Mortality Surveillance Group and the findings and actions from these are reported to the Executive Review meetings. Quarterly reports are made to Patient Safety and the Trust Quality Assurance Committees. The monthly performance report includes details of deaths in the previous month. Quarterly reports after completion of the mortality review process will be included when due.
90.00%91.00%92.00%93.00%94.00%95.00%96.00%97.00%98.00%99.00%
100.00%
Radical XRT 90 day survival rate
80.00%
82.00%
84.00%
86.00%
88.00%
90.00%
92.00%
94.00%
Palliative XRT 30 day survival rate
90.00%91.00%92.00%93.00%94.00%95.00%96.00%97.00%98.00%99.00%
100.00%
Final chemotherapy 30 day survival rate
90.00%91.00%92.00%93.00%94.00%95.00%96.00%97.00%98.00%99.00%
100.00%
30 day post surgery survival rate
0102030405060708090
100
Intrathecal administrat ions Wrong route chemotherapy
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
Unit mortality Total mortality
May-18Elective/planned admission 0Non Elective/emergency admission 24TOTAL 24Mortuary screened triggers (including reported to the coroner) - 4Bereaved families raised concern – 0Medical Triggers - 2Nursing Triggers - 0(note there may be more than one trigger)
Number of NHS Christie onsite deaths
Number of deaths that have triggered Structured Casenote Review (SCR)
Note: screening is ongoing so further triggers may be identif ied
3
46
4. Caring 4.1 Patient Satisfaction Surveys & Outpatient Satisfaction Surveys
4.1.1 Patient Satisfaction – recommended. 4.1.2 Patient Satisfaction – not recommended
4.2 Complaints
Questions Strongly Agree Agree Disagree % Rec % Not Rec
Acceptable IP admission w aiting time 49 19 2 97.1% 2.9%
Acceptable OP treatment w aiting time 33 32 0 100.0% 0.0%
Acceptable OP test w aiting time 2 3 3 62.5% 37.5%
Informed of pharmacy w aiting time 1 14 1 93.8% 6.3%
Informed of medical physics scan w aiting time 9 1 0 100.0% 0.0%
Acceptable w aiting time to be seen by doctor 36 111 21 87.5% 12.5%
Treated w ith respect by staff 238 114 1 99.7% 0.3%
Involved in decisions 186 126 3 99.0% 1.0%
Given enough privacy 179 125 4 98.7% 1.3%
Access to call bell 62 7 0 100.0% 0.0%
Member of staff to talk to 173 126 2 99.3% 0.7%
Treated w ith compassion 189 98 0 100.0% 0.0%
Received required care 190 121 2 99.4% 0.6%
Received necessary information 191 148 3 99.1% 0.9%
Received suff icient pain control 162 122 5 98.3% 1.7%
High standard of cleanliness 208 135 1 99.7% 0.3%
Recommend Christie services 233 111 1 99.7% 0.3%
TRUST Score 2141 1413 49 98.6% 1.4%
91.00%92.00%93.00%94.00%95.00%96.00%97.00%98.00%99.00%
100.00%
Recommended % Threshold
0.00%0.50%1.00%1.50%2.00%2.50%3.00%3.50%4.00%4.50%
Not Recommended % Threshold
Complaint Grade Primary Concern by Complainant1 3 Care, communication
2 3 Communication
3 2 Delays
4 2 Care, communication
5 3 Diagnosis, treatment, staff attitude
6 2 Communication
7 3 Treatment
8 3 Delays, w aiting times
47
4.2.1 Complaints Comparison 4.2.2 PALS Contacts
4.3 Friends & Family Test 4.3.1 Inpatients & Daycases 4.3.2 Outpatients
4.3.3 Inpatients by Ward
4.4 Staff Friends & Family Test
0
2
4
6
8
10
12
2018/19 Total 2017/18 Total
0
20
40
60
80
100
120
140
2018/19 Total 2017/18 Total
91.00%
92.00%
93.00%
94.00%
95.00%
96.00%
97.00%
98.00%
99.00%
Threshold % Recommended
92.50%93.00%93.50%94.00%94.50%95.00%95.50%96.00%96.50%97.00%97.50%
Threshold % Recommended1 - Extrem
ely Likely
2 - Likely
3 - Neither likely nor unlikely
4 - Unlikely
5 - Extremely
unlikely
6 - Don't Know
01 Ward (Dept 33) 39 2 0 0 0 1 42 42 100.0%
03 Ward (Dept 48) 4 0 0 0 0 0 9 4 44.4%
04 Ward (Dept 52) 25 2 0 0 0 0 77 27 35.1%
10 Ward-Surg Onc Unit (Dept 4) 77 4 3 0 0 2 145 86 59.3%
11 Ward (Dept 4) 16 1 1 0 0 0 76 18 23.7%
12 Ward (Dept 4) 15 1 0 0 0 0 84 16 19.0%
CTU Inpatient Ward (Dept 1) 1 0 0 0 0 0 17 1 5.9%
Endocrine Ward (Dept 63) 11 0 0 0 0 0 15 11 73.3%
Haematology Day Unit (Dept 26) 27 1 0 0 0 1 105 29 27.6%
Integrated Procedure Unit (Dept 2) 92 2 0 0 0 2 201 96 47.8%
Oncology Assessment Unit (Dept 14) 33 3 1 0 2 0 156 39 25.0%
Palatine Ward (Dept 27) 36 0 0 0 1 0 85 37 43.5%
Planned Admission & Transfer Suite (Dept 25) 13 1 0 0 0 0 37 14 37.8%
The BMR Unit (Dept 16) 32 3 0 0 0 0 78 35 44.9%
Total 421 20 5 0 3 6 1127 455 40.4%
Ward name
Total responses in each category for each wardTotal
Number of people
eligible to respond
Total responses for each
ward
Response rate for each
ward
50%55%60%65%70%75%80%85%90%95%
100%
% recommend as a place to work % recommend as a place for treatment
0.0%5.0%
10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%50.0%
% response
48
4.5 Executive Walk rounds 4th May 2018 – Interventional Radiology – Executive Director of Finance and Business Development Things to be proud of:
• Following initial teething problems the team is integrating well (this took about 12 months). They have now settled in well.
• Much improved facility (male & female beds, better environment, flows better). All agreed the new environment is beneficial to patients.
• Consultants encourage/reward staff by taking them to international meetings. • Low level of staff turnover • Good place to work; gaining lots of experience (travelling to work can be an issue) • Unique service which improves patient care • There is no official on call service but this is covered on an ad hoc basis; staff are not paid for this but it
works well Challenges:
• Issue with nurse staffing levels (maternity leave and sickness absence) as there are only 3 members of the nursing team.
• Currently training staff who have never worked in radiology. • CT on a different floor which makes it more difficult – staff stretched • No staff room on IPU (tend to go back to radiology for down-time) • Issue with capacity (the second room, when open, should relieve the pressure) • Awaiting approval of 4 business cases
Things to take forward: • The 4 business cases: • Development of lung ablation service • Development of liver ablation service • Development of thyroid ablation service • Trans Arterial Catheter Embolization (TACE) service • Potential over-establishment for nursing posts
This was a very positive visit
10th May 2018 – Deep Clean Team – Executive Medical Director and Responsible Officer Things to be proud of:
• Great team spirit; they work well with, and for, each other to get jobs done to the best of their abilities. • Very patient centred and mindful that they are part of the wider team to provide good care in good facilities. • The managers (Gary and Steve) are very supportive. • There are examples of helpful communications; the IPU staff were highlighted for giving advance notice of a
clean and for having an appreciative attitude towards the deep clean team. • All valued their interactions with patients and their families; an example of this is that the team had a
collection to purchase some trainers as a Christmas present for a young lad whose mother was sad because his friends were not visiting him.
Challenges: • There are ongoing issues with managing workflow with not enough notice to plan shifts efficiently – this often
has a knock on effect to those on the evening shift sometimes, with demands to work late. • Not being informed early enough when a discharge was anticipated and a deep clean needed. • Being contacted to clean a room but there were delays with the current inpatient discharge so the room was
still occupied – felt there could be better communication with the ward team. • The team were aware that duty managers and others are under pressure in accommodating new admissions,
but often the managers failed to appreciate or recognise the part played by the deep clean team. • The team felt they did not fully understand how the patient pathway works from accepting admission to
discharge and it would help them to understand this better. • Attitude of managers; on occasions they have been told that a patient could not be ‘brought in’ because of
them. • One of the team was working in part of the trust where the bleeps did not work and was reprimanded for
being ‘off site’ – this has since been remedied by the provision of a radio. Things to take forward:
• Better communication between wards and team; bed and duty managers and team • Opportunities to share understanding of how the deep clean team fits into patient flow processes in the
hospital, for example involving them in projects to improve this. • Raising awareness amongst all ward managers around what the deep clean team need from them to carry
out their duties as promptly as possible; for example wherever possible encourage discharge-ready patients to wait in the day room and discharge lounge.
• It might be helpful to audit the reasons for delays in carrying out a deep clean due to poor communication or delayed access.
• They felt they were not always kept fully informed with changes within their own department / division
49
The team commented that there were more positives than negatives
16th May 2018 – Chaplaincy - Chief Operating Officer Things to be proud of:
• Volunteers within the chaplaincy are wonderful and provide confidence that all wards are visited and patients gently assessed for their spiritual needs. The team are very grateful for them.
• Volunteers commented that there is a great structure around them and clear lines of accountability, their training is extraordinary and they feel able to respond to any issues. There is also great respect to differences within the team.
• Volunteers commented that they feel very valued in the role • Volunteers don’t just pass on referrals, there is discussion about issues raised and learning is shared. • Increased engagement with other teams is working very well, there’s been involvement in recent events such
as International Nurses Day and Mental Health Week. Also working well with the bereavement centre and supportive care team to learn about patients at the end of life.
Challenges: • Chaplaincy volunteers unhappy with wearing the green volunteer polo shirt as feel it can be
counterproductive in this role. There are often other volunteers on wards in the same uniform who provide very different support, the roles are not interchangeable. Confusing for patients.
• Chaplaincy volunteers are not representing the trust but rather the role – this is about the chaplaincy not the volunteer service. The red lanyards are distinctive enough.
• Need to keep an eye on the space requirements for the Muslim prayer room – can get very crowded for Friday prayers with staff and patients
• Communications around who is at end of life is difficult as don’t have access to CWP – a flag and access would be helpful
• Currently no way of logging activity within the team or of the volunteers – others can’t see if a patient has had contact with the chaplaincy. Can’t record that a spiritual assessment has been done.
Things to take forward: • Signage on main stairs off the corridor to improve as well as an additional Chapel sign at the door facing
down the corridor • Consideration of changing the requirement for chaplaincy volunteers to wear the green volunteer polo shirts • Look at the use of the flat roof outside the Palatine Ward for a roof garden • Look at inclusion of a ‘quiet room’ in the new outpatient footprint or somewhere on the ground floor • Need replacement pagers – lost 3 when changed network and never replaced. • Window blind in the multi faith room keeps falling down – needs putting up • No heating in the department at all – needs addressing • Would like some portable stools available on the wards for conversations with patients • Would like a kneeler for the chapel
22nd May – Maintenance – Director of Workforce
Things to be proud of: • Good teamwork – helping each other out
Challenges: • The team don’t feel valued. • They are understaffed because vacancies can’t be filled and this is compounded by extra work generated
from developments such as Proton. • Pay lower than industry average outside of the NHS e.g. Sunday rates only 1½ at The Christie and 2 outside
the NHS. • A team member raised the fact that he was not given a day off in lieu when working a bank holiday. • The team felt that there was an absence of feedback when they raised issues with line managers and that
they were not kept updated by their managers – generally poor communication. • Staff parking availability was raised as an issues, as was the lack of availability of relevant training in building
management services despite requests over a 3 year period. • They felt that their facilities were poor – lack of a workshop and lack of capacity in the general staff area.
They have access to just 2 computers between them and these are housed in the staff room/kitchen area. Things to take forward:
• Improve recruitment and retention • Better facilities • Improved access to training • Benchmarking of pay against other NHS trusts • Address the issue of bank holiday lieu days
50
31st May 2018 – Dispensary – Chief Nurse and Executive Director of Quality
Things to be proud of:
• Enjoy their jobs and find the work very worthwhile
• They always try to do their best every day, coping with increasing workloads, uneven workflows from other areas and perceptions from staff and patients that delays are mainly due to pharmacy
• Increasing communication and developing relationships across the trust which is allowing improvements to be made, eg working to encourage prescriptions to be written and sent earlier after ward rounds
Challenges:
• Pharmacy have outgrown the premises and there is insufficient space to expand the team • Recruitment is now improving with 8 staff in post in the last 2 months and training is ongoing • The waiting area is not conducive to a good patient flow - screen that provides updates to patients has
broken and a sign apologising for the area being upgraded has been up since August • Posting medicines (considered as an option to reduce waiting times) is expensive and labour intensive so is
not being encouraged (£2-3k per month plus additional processing time for staff) • Changes required within IQemo have made it necessary to chase prescribers and causes patient frustration
when drugs are ready but can’t be released
Things to take forward:
• Work with IT and Estates to develop a business case to cover new software, different ways of working, particularly for outpatients and aspirations for service development in medium and long term
• Developing a rest room as staff are currently using a changing room and it is not fit for purpose, there is an IT server and all the wiring for this in the room. When the new rest room is complete the offer of a purchase of a fridge for staff has been made.
• Consider if there is a way of over recruiting to ensure that key skilled roles are not affected by turnover and thereby impacting on the patient experience and the efficiency of the service.
• To consider developing a job description for voluntary staff role in the pharmacy waiting room.
4.5.1 Exception Reports
None
51
5. Well Led 5.1 Trust Headcount & FTE
5.2 Trust Sickness
May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-182734 2740 2730 2747 2756 2728 2797 2798 2825 2838 2841 2845 28472503 2504 2501 2518 2533 2501 2563 2567 2596 2607 2610 2610 26082632 2611 2626 2632 2627 2656 2665 2694 2694 2692 2704 2787 2813
*March establishment figure will be updated in May following financial year shutdown
TrustTotal HeadcountTotal FTEEstablishment
2300
2400
2500
2600
2700
2800
2900
Total Headcount Total FTE Establishment
Division Apr-18 May-18 YTDCancer Centre Services 3.43% 3.14% 3.33%Christie Medical Physics and Engineering 1.28% 2.21% 1.73%Clinical Netw orked Services 2.54% 2.72% 2.66%Corporate Development 0.84% 3.04% 2.60%Education (School of Oncology) 0.78% 1.04% 1.50%Estates & Facilities 6.63% 6.65% 6.68%Finance & Business Development 0.21% 0.51% 0.36%Medical Director's Off ice 0.00% 0.00% 0.00%Performance 10.14% 5.32% 7.48%Quality and Standards 0.45% 0.00% 0.22%Research and Development 3.88% 1.96% 2.84%Service Transformation 0.56% 0.00% 0.27%Trust Administration 0.00% 0.00% 0.00%Workforce 3.58% 4.10% 3.89%Grand Total 3.07% 2.91% 3.02%RAG Rating (>=Apr-16): <=3.4 GREEN; >3.4 RED** This includes Corporate Development, Education, Performance, Quality and Standards, Trust Admin and Workforce
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
5.00%
Threshold Trust total
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5.3 PDRs
5.4 Essential Training
5.5 Staff Turnover
Division Apr-18 May-18Cancer Centre Services 88.86% 87.67%Christie Medical Physics and Engineering 94.12% 92.76%Clinical Netw orked Services 80.10% 82.11%Corporate Development 97.06% 90.00%Education (School of Oncology) 95.92% 98.00%Estates & Facilities 97.00% 92.44%Finance & Business Development 80.00% 91.06%Medical Director's Off ice 50.00% 100.00%Performance 89.47% 95.24%Quality and Standards 100.00% 100.00%Research and Development 88.49% 90.63%Service Transformation 75.00% 75.00%Trust Administration 100.00% 100.00%Workforce 95.83% 88.00%Grand Total 87.92% 88.15%RAG Rating (>=June-15): >=94.5% GREEN; 85<>94.5 AMBER; <=84.5 RED
Division Apr-18 May-18Cancer Centre Services 87.31% 88.14%Christie Medical Physics and Engineering 94.34% 94.02%Clinical Netw orked Services 85.93% 86.22%Corporate Development 94.08% 92.79%Education (School of Oncology) 96.47% 97.12%Estates & Facilities 90.92% 90.68%Finance & Business Development 93.98% 96.02%Medical Director's Off ice 94.44% 97.22%Performance 90.56% 90.55%Quality and Standards 98.79% 89.58%Research and Development 93.72% 93.66%Service Transformation 96.51% 96.47%Trust Administration 98.77% 99.18%Workforce 96.08% 97.11%Grand Total 89.15% 89.53%RAG Rating (>=June-15): >=94.5% GREEN; 85<>94.5 AMBER; <=84.5 RED
Leavers Headcount May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18Dismissal 0 0 4 5 0 1 3 2 1 1 2 3 1
End of Fixed Term Contract 4 2 3 8 8 4 0 1 1 3 0 2 2
Mutually Agreed Resignation 0 0 0 0 0 0 0 0 0 1 21 0 0
Redundancy 0 0 0 0 0 0 1 0 0 1 0 0 0
Retirement 1 2 0 1 1 3 1 3 0 1 4 2 4
TUPE 0 0 0 0 0 0 0 0 0 0 0 0 0
Voluntary Resignation 17 14 22 28 12 29 22 35 14 18 13 24 19Others 0 0 0 1 0 1 0 0 0 0 0 2 0
Grand Total 22 18 29 43 21 38 27 41 16 25 40 33 2612 Month Turnover % Headcount 13.28% 12.96% 12.86% 13.03% 12.19% 13.51% 13.48% 14.38% 13.63% 13.10% 14.07% 13.96% 14.05%Adjusted 12 month Turnover %* 11.70% 11.46% 10.00% 10.96% 10.09% 10.22% 11.14% 11.77% 11.30% 10.75% 11.46% 11.32% 11.45%
* Turnover based on substantive leaving reasons only (Dismissal, M.A.R.S, Redundancy, Retirement, Voluntary Resignation, Other)
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6. Additional Documents 6.1 Christie Onsite Deaths: Jun 2018 The Christie process for learning from deaths follows the NHSI guidance, 2017. All in-patient deaths are screened and where flagged by one or more triggers an independent structured case note review (SCR) is undertaken. Reviews are discussed by the Mortality Surveillance Group and the findings and actions from these are reported to the Executive Review meetings. Quarterly reports are made to Patient Safety and the Trust Quality Assurance Committees. The monthly performance report includes details of deaths in the previous month. Quarterly reports after completion of the mortality review process will be included when due.
1. Deaths which occurred in May 2018
May 18
Number of NHS Christie onsite deaths
Elective/planned admission 0 Non Elective/emergency admission 24
TOTAL 24
Number of deaths to date that have triggered Structured Case-note Review (SCR)
Note: screening is ongoing so
further triggers may be identified
• Mortuary screened triggers (including reported to coroner) – 4
• Bereaved families raised concern – 0 • Medical triggers – 2 • Nursing triggers - 0
(note there may be more than one trigger)
3
2. Learning from deaths: national mortality review quarterly report (Q4)
The table shows the validated outcomes for SCRs in relation to the final avoidability ratings (additional reviews may still be in process). Q4 data is highlighted. Key: RCP 1 = definitely avoidable; RCP 2 = strongly avoidable; RCP 3 = > 50% avoidable; RCP 4 = <50% avoidable RCP 5 = strongly unavoidable; RCP 6 = unavoidable LD = learning disability
Mon
th
(201
7-18
) Total Deaths
(not LD)
SCR final (not LD)
Deaths Avoidable > 50% (not LD) RCP1 RCP2 RCP3 RCP4 RCP5 RCP6
LD Deaths
LD Deaths
Reviewed
LD Deaths Avoidable
> 50%
Apr 23 8 0 0 0 0 0 1 7 1 1 0 May 22 9 0 0 0 0 0 0 9 0 0 0 Jun 26 14 0 0 0 0 1 1 12 0 0 0 Jul 22 9 1 0 0 1 0 2 6 0 0 0 Aug 28 10 0 0 0 0 2 1 7 0 0 0 Sep 22 10 0 0 0 0 0 0 10 0 0 0 Oct 27 13 1 0 1 0 2 2 13 0 0 0 Nov 16 9 0 0 0 0 0 0 9 0 0 0 Dec 22 5 0 0 0 0 0 0 5 0 0 0 Jan 31 13 0 0 0 0 0 0 13 0 0 0 Feb 13 6 0 0 0 0 0 0 6 0 0 0 Mar 18 7 0 0 0 0 0 0 7 0 0 0
4
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6.2 National Inpatient Survey 2017/2018
National inpatient survey 2017/2018 1. Introduction
The Care Quality Commission (CQC) commissions the national inpatient survey and uses the results for their regulation, monitoring and inspection of NHS acute trusts in England. Each trust report is published. 2. Scoring
The results are standardised by age, gender and route of admission and are converted into a score from 0 to 10. An analysis technique called the ‘expected range’ is used to determine if The Christie is performing ‘about the same’, ‘better’ or ‘worse’ compared with other trusts. The higher the score, the better the performance. 3. Methodology 1249 patients of The Christie who had a stay of at least one night and were discharged between April and July 2017 were sent a questionnaire, followed by two reminders. 577 patients responded. The response rate was 52% when those who are ineligible are discounted. (In 2016 sample size 1250, 621 responses and 55% response rate). 4. Respondent characteristics
• 64% of patients were on a waiting list/planned in advance and 32% came as an emergency or urgent case
• 70% had an operation or procedure during their stay • 45% were male; 55% were female • 4% were aged 16-35; 9% were aged 36-50; 39% were aged 51-65 and 47% were aged 66+ • 93% identified their ethnicity as white, 1% as multiple ethnic groups, 2% as Asian or Asian British,
1% as Black or Black British, 3% not known. 5. Outcomes A review of the results shows the following outcomes: The results remain excellent with all eligible section scores being better than most other trusts and this continues the theme we have seen over the last few years. Of the 60 questions, 18 results were better than last year, 29 had shown a small fall and 6 remained the same. 6 new questions were added. Five questions received a highest score from our patients; getting enough to drink, nurses not talking in front of patients as if they weren’t there, involvement in decisions, information about condition or treatment and privacy when examined or treated. Whilst the Trust had an excellent set of results, four questions showed a change downwards from last year’s survey that was significant; patients finding someone on hospital staff to talk to about worries and fears, enough nurses on duty to care for patients, having enough emotional support from staff during stay and overall treated with respect and dignity while in hospital. There was one result that showed a change upwards that was significant which was being given enough notice of discharge.
5
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6. Identification of outliers
Analysis is undertaken by the survey centre on behalf of the CQC, to identify those trusts whose patients’ experience care is better, or worse than expected when the survey results are compared across all trusts. Each trust has been assigned one of five bands: ‘much worse than expected’, ‘worse than expected’, ‘about the same, ‘better than expected’ or ‘much better than expected.
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7. Comparison with Greater Manchester Hospitals
Name of Organisation Section Scores out of 11 Overall Score Central Manchester University Hospitals NHS Foundation Trust About the Same 8.2
University Hospital of South Manchester NHS Foundation Trust
About the Same 8.2
Salford Royal NHS Foundation Trust
Better in 1 About the Same in 10 8.3
Tameside & Glossop Integrated Care NHS Foundation Trust About the Same 8.0
The Christie NHS Foundation Trust
Better in all 10 section scores 8.9
Wrightington, Wigan & Leigh NHS Foundation Trust About the Same 8.4
Stockport NHS Foundation Trust About the Same 8.0
Bolton NHS Foundation Trust About the Same 8.4
Pennine Acute Hospitals NHS Trust
About the Same in 8 Worse in 3 7.9
8. Comparison with specialist cancer centres Name of Organisation 10 Section Scores Overall Score
(out of 10) Response Rate
The Royal Marsden NHS Foundation Trust
Better in all section Scores 9.1 48%
The Christie NHS Foundation Trust
Better in all section scores 8.9 52%
The Clatterbridge Cancer Centre NHS Foundation Trust
Better in all section scores 9.0 48%
9. Next Steps The Trust has worked with PICKER our vendor for the national inpatient survey and they have helped us to understand how we can develop a more focussed plan to move some of the scores that have stayed similar for a number of years and this developing plan is being led by the patient experience committee. This year’s results will be analysed locally by each of the clinical divisions and the agreed Trust action plan will be presented to and monitored by the Patient Experience Committee.
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Owners Fiona Noden, Chief Operating Officer
Wendy Makin, Medical Director Joanne Fitzpatrick, Director of Finance & Business Development
Jackie Bird, Chief Nurse & Executive Director of Quality Eve Lightfoot, Director of Workforce
Marie Hosey, Assistant Chief Operating Officer – Performance & Operational Standards
Report Produced by Andrew Gibson – Senior Performance Lead
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Agenda item 26/18a
Meeting of the Board of Directors Thursday 28th June 2018
Report of Executive Medical Director
Paper Prepared By Yvonne Clooney
Subject/Title Medical Appraisal & Revalidation Annual Report 2017-18
Background Papers n/a
Purpose of Paper The Board is asked to note the content of this report and the on-going improvement plan.
Action/Decision Required To note
Link to:
NHS Strategies and Policy Medical Appraisal Policy
Link to:
Trust’s Strategic Direction
Corporate Objectives
All objectives of the Trust
Impact on resources and risk and assurance profile
You are reminded that resources are broader than finance and also include people, property and information.
Nil
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
HEENW – Health Education England North West MAG – Medical Appraisal Guide RO – Responsible Office ARC – Appraisal & Revalidation Co-ordinator GMC – General Medical Council SAS – Staff and Associate Specialist EMD – Executive Medical Director ELA – Employee Liaison Advisor NHS – National Health Service SACT – Systemic Anti-Cancer Therapy ESR – Electronic Staff Record PDP – Personal Development Plans CQC – Care Quality Commission HR – Human Resources DPME – Director of Postgraduate Medical Education PDR – Performance Development Review
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Agenda item 26/18a
Meeting of the Board of Directors Thursday 28th June 2018
Responsible Officer Annual Report for the Board of Directors
Medical Appraisal and Revalidation 2017-18
1. Executive summary 2017-18
There is a well-established process for annual appraisal of consultants and non-training medical staff at The Christie. This provides robust evidence for medical revalidation and is also closely integrated with the clinical governance of the organisation.
• The number of doctors connected to The Christie continues to rise. As at 31st March
2018 there are 234 doctors (160 consultants, 74 non training); HEENW oversees the process for our trainees.
• We are compliant with quarterly appraisal monitoring and the Annual Organisational
Audit report was submitted within the required timeframe to NHS England. • All doctors connected to The Christie for the purpose of revalidation in Years 0, 1, 2, 3, 4
& 5 have now been through the revalidation process successfully. All recommendations were made within the required timeframe.
• 17 positive recommendations have been made by the Responsible Officer in year.
Another 1 recommendation was for deferral of revalidation; this was for specific reasons and for a maximum period of up to 12 months. The individual deferred has a revalidation date later in 2018 and a positive recommendation will be made once under notice from the GMC. There were no deferrals for non-engagement.
• Completed appraisal rates remain high, however there has been a minor increase in the
number of appraisals signed off outside the 28 day timeline. 2 doctors failed to complete appraisal in year without the reason for this being agreed in advance by the RO, these appraisals have since been completed. Feedback from doctors about their appraisal remains positive.
• The contract for the electronic platform Equiniti ceased on 31st March 2018. Following a
successful trial of a new electronic platform from Clarity Informatics, amongst our fixed term post-holders, we have contracted with Clarity for the provision of the electronic platform for all Medical Staff, for a period of 3 years. The system provides an electronic portfolio for use by doctors, a framework for appraisals, 360 feedback, and system administration.
• During 2017/18, the Executive Medical Director/Responsible Officer met each quarter
with the GMC Employment Liaison Advisor. The Executive Medical Director/Responsible Officer attends the RO Network meetings and is also a Responsible Officer appraiser for NHS England North.
• In 2017-18 there was only one serious concern involving a doctor that required formal
process.
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2. Purpose of the Paper The Responsible Officer (RO) is required by NHS England to provide a full annual report to
the Board of the organisation or ‘designated body’ on the compliance with national requirements for appraisal and revalidation of doctors.
This is a summary of the achievements and activities undertaken in the past year to support
this process and to bring to the Board’s attention any concerns and actions to be taken. This report follows the NHS England Framework template for quality assurance (April 2014). 3. Background Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated,
with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical profession.
The process for GMC revalidation of doctors licensed to practise in the UK commenced on 3
December 2012; as a designated body, The Christie has a responsibility for all non-training grade doctors employed by the Trust. This includes consultants, SAS and specialty doctors, non-agency locums and clinical academics. Doctors undergoing foundation year, core medical training or higher specialist training are connected to HEE North West.
Revalidation is an on-going process; and we are now in the second cycle of revalidation,
which will be based upon evidence of satisfactory practice over a 5 year cycle. Provider organisations have a statutory duty to support their Responsible Officer in
discharging their duties under the Responsible Officer Regulations 1 and it is expected that provider boards / executive teams will oversee compliance by:
• monitoring the frequency and quality of medical appraisals in their organisations; • checking there are effective systems in place for monitoring the conduct and
performance of their doctors; • confirming that feedback from patients is sought periodically so that their views can
inform the appraisal and revalidation process for their doctors; and • ensuring that appropriate pre-employment background checks (including pre-
engagement for locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.
4. Governance Arrangements The Executive Medical Director (EMD) ensures that there are arrangements with the Trust’s
clinical governance and human resources teams to ensure that information from the past year, specific to a doctor, is included as a statement within their portfolio and discussed at annual appraisal. Such reports are also requested prior to revalidation recommendations. The EMD/Responsible Officer ensures that there are robust processes for responding to, and managing, a concern about a doctor.
The role of Responsible Officer is held by the Executive Medical Director and supported by the appraisal and revalidation co-ordinator (ARC). The RO / Clinical Appraisal Lead and ARC
1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The General Medical Council (License to Practice and Revalidation) Regulations Order of Council 2012’
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meet regularly to review appraisal and revalidation progress, additionally the RO meets with the medical workforce manager monthly, to monitor and discuss any concerns; there is also a quarterly meeting where they are joined by the GMC Employment Liaison Advisor (ELA).
The HR Team are responsible for:
• ensuring robust pre-employment checks are carried out; • providing information to the ARC on doctors who are joining the Trust and the nature of
their contract; and • providing information to the ARC on doctors who are leaving the Trust. The RO will liaise with the RO at another Trust in relation to concerns about an individual doctor who may be leaving, or transferring to, The Christie.
The appraisal and revalidation co-ordinator is responsible for maintaining an accurate database of the doctors who have a prescribed connection to The Christie. The ARC has responsibility for the Electronic Appraisal platform and supports both doctors and appraisers in its use. A regular review of the system is undertaken to ensure that those doctors who are due for appraisal, have commenced their portfolio preparation; they are sent reminders, any lack of activity is escalated to the Clinical Director and Responsible Officer. The RO is compliant with training and attends NHS England regional and national RO meetings as a requirement of the RO post. The RO had a satisfactory external appraisal with a level 2 RO on 19th October 2017. The RO is also an appraiser for NHS England North. Compliance with medical appraisal is reported via email to confirm we are on track, in addition an annual summary is submitted to NHS England in May each year. This detailed annual report is prepared for the executive team and Board of Directors.
5. Medical Appraisal
5.1 Equiniti This is the platform on which substantive medical staff completed their 2017/18 annual appraisal 160 (69%). The remaining 74 (31%) of doctors with shorter term contracts (12 months or less) had the option of using the interactive web-based MAG form, as this is easily transferrable to another organisation, or trialling the Clarity Appraisal Toolkit.
5.2 Appraisal performance data 2017-18 In 2017/18, 225/234 (96%) doctors had completed their annual appraisal in year. 7/234 (3%) were recorded as approved incomplete appraisals for reasons accepted by the Responsible Officer. 2/234 (1%) were unapproved incomplete appraisals.
Table 1 Summary of 2017/18 Medical Appraisals: Designated Body Connections
234
(Completed appraisal between 9-15 months / signed off within 28 days) 1a
(Completed appraisal – <9->15 months, not signed off within 28 days) 1b
(Approved Incomplete appraisal) 2
(Unapproved Incomplete appraisal) 3
Consultant 160 137 17 4 2 Staff Grade 16 13 1 2 0 Other (clinical fellows, specialty doctors)
58 48 9 1 0
Total 234 198 27 7 2
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There were 27/234 (12%) appraisals that whilst complete, did not meet the specified 28 day sign off, despite chasing by the co-ordinator. This represents an increase on last year (16 for 16-17) and actions are in place to improve. The reasons are captured; In some cases there were unforeseen and acceptable circumstances affecting either the appraiser and doctor; in others a lack of organisation, use of the Clarity platform for all doctors will enable the co-ordinator to track these.
The 2/234 (1%) unapproved incomplete appraisals have now been completed.
5.3 Appraisers The number of trained appraisers fluctuates as individuals step down and new appraisers are recruited. Currently we have 37 trained appraisers and the Medical Appraisal Lead which exceeds our original target of 34, however, given the increase in appraisees we have revised our target to 40, further work is ongoing to increase this pool of appraisers with 2 further doctors being trained post April 2018. The Responsible Officer does not undertake appraisal of doctors who are connected to the Christie but has been selected to be an RO appraiser for the North of England and has been trained for this role. The appraiser group meets four times a year. Appraisers are aware of the expectation for them to attend at least 50% of these. Attendance is monitored by the ARC and any issues are highlighted to the RO if not in attendance. A refresher training session with an external facilitator was held for all appraisers in the past year. There has been a change in the lead for medical appraisal, Dr Vidya Kasipandian took on this role from January 2018. In line with national guidance we now allocate doctors to appraisers in the coming year. Between 5-7 appraisals are allocated to each appraiser. Individuals are notified who their appraiser will be and may request a change in their allocated appraiser. Any change must be requested within 3 months of the appraisal and any request to change appraiser outside this timeline, must first be approved by the RO.
6. Quality Assurance
6.1 Appraisal portfolio content: The initial appraisal notification to a doctor contains a link to access guidance on their preparation including supporting information that should be gathered in preparation for appraisal. This relates to the domains of good medical practice and provides some consistency in terms of what is expected. Doctors are provided with trust level activity data with additional information through the Clinical Outcomes Unit where available. We are aware that activity information relating to individual clinicians may not be completely accurate, particularly where consultants work in a team; additionally corporate systems do not record the detail for some surgical procedures and these are maintained in individual log books. Any such discrepancies should be discussed with the appraiser and noted if appropriate, in the summary. As clinical teams continue to enter more accurate and clinician-specific data through the clinical outcomes unit; this enables clinician-specific outcome reports to be generated. We anticipate the richness of these reports will increase year on year. Other outcomes are demonstrated through audit and research activity. Doctors are expected to reflect on their practice and outcomes within their portfolio.
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In the past year the national issues raised through a high profile medical tribunal have been discussed in the appraiser group, as this was a source of concern about reflective practice and how such documents might be used. The Responsible Officer and medical education team have circulated the guidance on this from the Academy of Royal Medical Colleges and the GMC to all medical staff including trainees. We continue to promote reflective practice at appraisal.
An annual statement is also generated from HR and the Quality and Safety team. The latter also documents the audit activity and status of any projects that have been undertaken in the past year. Doctors should also include their mandatory training record which is accessible via ESR Live. Additionally, all consultant medical staff must complete a Fit and & Proper person form annually and include this in their portfolio. Of the 160 consultant medical staff, 59 (37%) completed the F&PP form and uploaded this into their portfolio. This represents a 15% increase on 2016-17. However, it is clear that further work is required to ensure that all consultant medical staff, include their F&PP form in their portfolio as a routine practice. The Equiniti system, MAG tool and Clarity System allow the appraiser to view the portfolio contents and approve when ready for appraisal. All provide a view of evidence brought to the appraisal discussion each year.
6.2 360 feedback reports The ARC co-ordinates both colleague and, for doctors with a clinical role, patient feedback exercises. Both should be undertaken within the first 3 years of the revalidation cycle but the RO may request further feedback in subsequent years if concerns have arisen. The RO reads all patient feedback reports before they are released to individual doctors. The colleague feedback is discussed with the doctor’s appraiser but this may be outside of the appraisal meeting. A reflection of this feedback and the feedback from patients is expected to be within each portfolio; additional reflections expected in response to any complaints. No serious concerns about an individual doctor were identified via patient feedback in the past year.
6.3 Appraisal outputs The outputs of the appraisal are the summary and the personal development plan, both of which are signed off by the doctor and appraiser. These are checked for completion by the ARC, who highlights any gaps or concerns to the RO. The RO and the appraisal lead share in reading through a sample of summaries and PDPs from the appraisal process. A process for on-going QA of outputs, undertaken by the RO and lead appraiser is now in place. The model ‘Excellence tool’ for audit of outputs was modified slightly to fit with the Christie/Equiniti system and agreed with the appraiser group. The RO and appraisal lead will discuss appraisal outputs with an appraiser where there are aspects to improve; general feedback and reminders are provided to the quarterly appraiser group meetings. Where a concern is discussed and included in the appraisal output, the RO is able to follow this up with the appraiser and individual doctor or will liaise with the clinical director.
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6.4 Feedback from doctors following appraisal Feedback was received from 163/234 (70%) appraisals. Of these 153 (94%) were completed using Equiniti with the remaining 10 (6%) being completed by individuals using the MAG form. The feedback was extremely positive and demonstrated that doctors do value their appraisals and the role of their appraisers Appendix A. Appraisers have each received their summary feedback reports as a result of having completed appraisals on the electronic platforms, Information on Christie benchmarking with sector and England performance on appraisal and revalidation is not yet available for year ending March 2018.
7. Access, security and confidentiality The appraisal portfolios and appraisal output documents are held within the password-protected electronic system (Equiniti/Clarity) for the large majority of doctors now. A small number (short term contracts or imminent retirement) use paper based or electronic MAG forms. Copies of these are held in a locked cupboard by the Medical Directors Office. All doctors and appraisers are aware that there should be no patient identifiable information within appraisal portfolios and this is monitored by the appraiser. The Responsible Officer/Medical Director, and ARC are able to view information within the electronic platform. Appraisal outputs (summary and PDP) can be seen by the respective Clinical Director and also the appraisal lead. Information on individual doctors within electronic platforms is otherwise accessed only by the doctor and their appraiser for that year.
Appraisal and revalidation history is provided about a doctor to the following:
- any private organisations where they undertake work if requested - University of Manchester (doctors on academic contracts) - In response to requests by new employers after a doctor has left The Christie - If there is an issue about which another RO should be made aware; in such
circumstance the doctor would also be informed of this.
No breaches of confidentiality or concerns have been identified in the past year. 8. Clinical Governance The Christie has a well-established structure for clinical governance. While outcome
information is brought to appraisal for discussion there are separate processes for peer review and monitoring through Divisional and directorate governance process and disease group/departmental quality meetings. Moderate incidents, complaints and trends are seen weekly by the Executive Review Group which includes the Responsible Officer. Actions are monitored through the Risk and Quality Governance Committee chaired by the Executive Medical Director.
Both HR and the Safety & Risk teams provide a summary letter which highlights any
complaints/incidents involving the doctor, or any additional concerns. HR and clinical governance reports are generated before each annual appraisal, and also before recommendations for revalidation are made.
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In the event of a serious concern involving a trainee, the Christie RO would inform our director of postgraduate medical education and liaise directly with the lead employer; their RO is within HEE North West who would also be informed. If a concern involved a doctor who works at another site or organisation there would also be RO to RO liaison.
9. Revalidation Recommendations made 1st April 2017 - 31st March 2018
In year there were 17 (95%) positive recommendations to revalidate, all were completed on time. There was 1 (5%) deferral request due to further information being required, this was deferred for a second time due to insufficient information being available. The outstanding information is now available for the deferred individual who has a revalidation date set later in 2018. Note: recommendation of deferral is not a negative action. The most common reason is to ensure that recommendations are made only when the RO is satisfied there is sufficient supporting information provided. The deferral may be for between 3-12 months at the discretion of the RO.
Recommendations made:
Within 0-13 days of date due 2 (includes 1 Deferral) Within 14-27 days of date due 2 >28 days <55 days before date due 11 (includes 1 Deferral) > 56 days <83 days before date due 0 More than 84 days before date due 3
There were no missed or late recommendations and no notifications for non-engagement. All revalidation recommendations made in year have been accepted by the GMC.
10. Recruitment and engagement background checks The HR recruitment team ensure that all pre-employment checks are undertaken in
accordance with NHS employment check standards and in line with all legal, statutory and good practice guidance requirements.
These meet six standards for:
- Verification of the doctor’s identity - Their right to live and work in the UK - Professional registration and qualification checks - Employment history and reference checks - Criminal records checks - Occupational health checks.
In relation to revalidation, all newly appointed medical staff must complete the Revalidation Checklist. This is then cross referenced with GMC Connect in order that we can check the doctor is connected to this designated body. This also enables the ARC to identify the doctor’s previous RO and request information pertaining to their last appraisal for our records.
In the past year the Christie has worked with the HR team at the University of Manchester to ensure consistency in the recruitment of academic posts and new guidance produced.
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11. Monitoring Performance The performance of all doctors at The Christie is monitored by the Executive Medical Director
and Responsible Officer through robust governance systems including reviews of deaths and referrals to the coroner; untoward incidents and complaints; and concerns raised through any other route, externally or internally.
Incidents and complaints involving a doctor, and the doctor’s reflection on these, are brought
to annual appraisal. If these involve a training grade doctor, the Christie RO ensures that the Director of Post-
graduate Medical Education is made aware. The DPME provides an annual report to HEE North West on any significant issue involving a trainee.
The Executive Medical Director/Responsible Officer meets regularly with the GMC
Employment Liaison Advisor and a member of the HR team is present. 12. Responding to Concerns and Remediation
The Trust policy for remediation of medical staff is available on the intranet. In 2017-18 there was one serious conduct concern investigated by formal process. This led to a disciplinary hearing and outcome of dismissal of the doctor (an oncology fellow) in April 2018.
13. Risk and Issues
Update on 2016-17 improvement plan
Area for improvement Action Responsibility Status Audit of evidence ‘Fit and proper person’ documentation for appraisal
ARC to audit portfolios for evidence of F&PP form
ARC Complete 37% (22% 2017)
Quality assurance of supporting information against
Undertake review of portfolio information content using QA proforma
Appraisal lead with RO
Deferred due to change in appraisal lead and platform
Scheduled appraiser reviews with individual appraisers
Clinical Appraisal lead to meet with appraisers as appropriate
Lead appraiser Ongoing
Review options for appraisal and revalidation management system before contract renewal 2017-18
Review options and selected new provider - Clarity
RO and ARC Complete
Further recruitment of appraiser to reach minimum target of 34
Further 6 recruited, undertaking training
Appraisal lead with clinical directors
Complete
Incorporate PDRs of medical leader roles into annual portfolio for clinical directors and others with senior non clinical responsibilities
Medical leadership roles and job descriptions revised.
RO Complete
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Action Plan 2017-18
Area for improvement
Action Responsibility Status
Fit & Proper person form
Inclusion of form within Trust guidance for Minimum portfolio content
ARC
Delays in holding appraisal and sign off: delay in alerting ARC of problem
Notify appraisees that they must inform the ARC in advance or as soon as possible so other arrangements or in order that RO approval can be obtained
ARC
28 day sign off Ensure all medical staff are reminded of their responsibility to ensure that the appraisal must be completed within 28 days of the appraisal taking place; discuss at appraiser group
ARC
Assurance all scope of practice is covered
Portfolio audit via new Clarity system
ARC, Appraisal lead
Quality of appraisal outputs
Revise QA process in coming year
Appraisal lead and RO
Assurance of process through peer review
Participation in joint peer review exercise with two other organisations (June-August 2018) Action plan following this.
RO
Recommendations The Board is asked to note the content of this report and the on-going improvement plan. A statement of compliance is to be made by the Chief Executive to NHS England by end of September 2018
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Appendix A Appraisee feedback summary 2017-18 A total of 163/234 (70%) feedback questionnaires were received. Of these 153 (94%) were completed using Equiniti with the remaining 10 (6%) completed manually. Two important aspect were covered: the management of the system and support in the process, and the quality and value of appraisal to the individual doctor. 1) Responses received from Equiniti users 153/161 (95%), indicate that satisfaction with the
whole appraisal process is viewed positively. There was 1 (1%) respondent who felt that the appraiser was poor at giving constructive and helpful feedback and also poor at helping the appraisee to review their practice. These areas will be visited within the appraiser group forum.
Very
Good Good Satisfactory Borderline Poor Unable to
comment Appraiser establishing rapport
124 25 4 0 0 0
Appraiser preparation
120 27 4 2 0 0
Listening
129 18 5 1 0 0
Providing constructive and helpful feedback
122 24 6 0 1 0
Supporting You
118 29 5 1 0 0
Challenging You
106 35 10 2 0 0
Helping to review your practice
107 38 7 0 1 0
Helping you to identify gaps
104 40 7 1 0 1
Reviewing progress against last year’s PDP
111 34 7 0 0 1
Helping to produce a new PDP that reflect development needs
117 30 5 1 0 0
Feedback comments (provided by 58 doctors in total): My appraiser gave me some very useful tips that I had not been given before. He was also very good at presenting a perspective to planning and drafting a PDP that I had not been presented with before. I was impressed with the fact that all of the relevant forms were already on his computed and that he had really read all of them and had a number of comments. This made for a very enjoyable and productive appraisal. Thank you.
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Was actually the most useful and productive appraisal I’ve ever had – really good advice and discussion. My appraiser had clearly prepared well for our meeting, identifying the key requirements and proof required. Over and above this, he facilitated an excellent meeting, made some excellent suggestions and was thoughtful and considerate. I am very grateful to him for all of this. Very perceptive appraiser. Extremely well prepared and provide thoughtful and constructive comments and advise throughout. An excellent appraiser. I always find my appraiser very thorough in going through my appraisal documents and he has always been very enthusiastic and supportive and caring in his role as an appraiser. Highly recommended to my colleagues – I am sure they will find this a positive experience just like I did. Appraisal was useful and I felt it helped me to plan the coming 12 months. My appraiser was very helpful to point out my development needs and gave many helpful ideas and advises which I am going to work on immediately. Very helpful, insightful and though provoking! A positive and honest approach which has helped me to plan my development this year. Very experience appraiser looks at the bigger picture and challenges appropriately. Thank you. My appraiser, like all my colleagues has been very supportive during this “first year” and as such they all contribute for the success of my enrolment at Christie. Insightful and perceptive. Even though not in my specialty, very useful and gave me ideas for the future. No further comments. Well prepared by appraiser; able to identify key challenges in terms of appraisal/revalidation. Clear action points agreed. A very useful meeting. Found the whole process extremely useful due to the time and effort my appraiser put into the process, a fantastic appraiser. Thoughtful, she listens and provides constructive comments – very happy to have her as my appraiser. Good reflection and clear objectives made for the following year. Very efficient and pleasant process. Great appraisal experience. Many thanks to my appraiser, pleasure to meet and know you.
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My appraisal with my appraiser was very constructive and supportive and has helped me to organise my thoughts and priorities with respect to my work and home commitments. Thank you. This was my 2nd appraisal with this appraiser. On both occasions I have found my appraisal extremely useful. My appraiser has offered practical suggestions, helped to identify areas for development and agree realistic goals within my PDP for the year ahead. Thanks. A very helpful, challenging and supportive appraisal. Thank you. As noted above. A useful opportunity to review where I am and where I am going and what I need to work on. My appraiser acted as a critical friend and sounding board and helped me to refine my priorities for my clinical practice. He helped reflect positively to enable me to begin to action and effect changing in my working conditions to make my job more productive, satisfying and enjoyable. My appraiser has been very helpful and approachable during the process and has provided meaningful insight. My appraiser has completed my appraisal for the past 3 years with good insight on my past achievements and future goals. He has provided good support and great opportunities to discussion professional and personal life stresses. Superb appraiser, challenging but with high levels of empathy and support Thanks. The appraisal process is taken very seriously by my appraiser/s and I am glad my documentation is better prepared than last time. The process was excellent. I felt we managed to explore my role in the Department and felt appreciated being in the role. There is gaps in maintaining my CPD and I feel the Department will support my efforts to fulfil the requirements leading up to the next appraisal and revalidation. My appraiser was extremely encouraging and engaged throughout the appraisal process. She provided extremely helpful feedback and highlighted areas requiring further development. She helped me to develop and appropriate PDP for the next 12 months. Overall the appraisal process has been extremely constructive and helpful to my ongoing career development. My appraiser is a very good listener and her friendly approach makes the appraisal process enjoyable. Her advice has been particularly helpful in my development and to navigate through my position with confidence. I appreciate her contribution towards guiding and mentoring of junior colleagues despite her very busy schedule. Appraiser empathetic and very thorough. I found the experience rewarding. Excellent appraiser. Thank you. Had a very nice appraisal where I was made to feel relaxed, valued and challenged. My appraiser had a detailed knowledge of my appraisal and helped me to focus on how to improve and develop myself in next year.
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My appraiser is a valued colleague and I am grateful for his assistance in evaluating my clinical performance and helping me to reflect on my professional development. My appraiser was well prepared. Had a thorough, well supported appraisal. My appraiser was very understanding and patient. She went through each of the domains and suggested where I can improve and guided me to develop a progressive but realistic PDP. My appraisal was an encouraging experience for me. My appraiser is lovely and very approachable, can talk to him freely. I did not feel challenged but that may be that he had nothing to challenge me about. I really appreciated the thoroughness with which my appraiser had reviewed my portfolio in a very short space of time and the fact that he recognised the pressures on me at the present time due to another doctors absence and acted in an extremely supportive manner, while conducting a comprehensive appraisal. I would wholeheartedly recommend my appraiser. He is open, honest and fair. He is very easy to discuss all relevant issues and makes what can be a very nerve racking experience extremely enjoyable and worthwhile. It was a great pleasure for me to be assessed and appraised by such a great colleague Consultant Anaesthetist. My appraiser who showed a great insight into my surgical practice and overall performance as a doctor. This experience was very valuable for my career progression and my appraiser gave me some really good advice on how to achieve my goals within Christie and in general.. I hope I will have some future appraisals by him again, once that is feasible and I would recommend him to anyone as an excellent colleague and appraiser. I could not ask for better. A good useful appraisal and my appraiser spent time trying to understand my roles in the Trust which allowed a more comprehensive appraisal process. Excellent. My appraiser is a very smart (IQ and EQ) and friendly colleague and “nestor”. He has given me very helpful advice for personal development but also ways to enable to monitor this process. Furthermore, I have been fortunate to hear from him about the background of a lot of ongoing clinical and managerial matters/decisions in the Christie, which I was not aware of, but are very useful to know. Very constructive appraiser. Well-considered, thoughtful appraisal. Thank you. An extremely helpful and uplifting review of my clinical practice, which has enabled me to move forward, greatly encouraged. Appraisal conducted in very timely manner with enough time allocated by the appraiser for my thoughts and reflections. The whole process including PDP orientated on my development than service in general.
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I was regularly asked whether I am happy with current progress of appraisal meeting before proceeding to the next step. That helped my appraisal process to go in line with my own pace rather than feeling rushed through. Very helpful comments and suggestions from the appraiser regarding the importance of maintaining proper balance of work and life. My appraiser is excellent, she puts me at ease, had clearly prepared well, supported and challenged in turn. Moreover the process was all completed within an hour. 2) Responses received from MAG users 10 (6%), indicated that the whole appraisal process
was viewed positively.
Excellent Very Good
Good Fair Poor Not Given
Management of system 1 6 3 0 0 0 Access to necessary supporting information
1 6 3 0 0 0
Appraiser preparation 1 7 2 0 0 0 Conducting the appraisal 4 5 1 0 0 0 Review progress against last PDP 3 4 1 0 0 2 Providing challenge to support practice
2 7 1 0 0 0
Providing support and giving feedback
4 5 1 0 0 0
PDP reflects priorities for development
3 5 1 0 0 1
Appraisal was useful for my professional development
4 5 1 0 0 0
Appraiser help with my PDP to meet my needs
4 5 1 0 0 0
She made the process very easy. Good discussion and suggestions about future plans and career path. Good feedback. First appraisal in the UK so unable to comment on last year PDP. The links on the MAG form for further information often don’t work. I think it would be useful to provide notice in advance of the appraisal about the date to aid in planning. Very useful detailed appraisal. I had not had appraisal of this format in the past and my appraiser explained the process very well. My appraiser has a very calm and relaxed manner of communication which put me at ease for the appraisal. The discussions were beneficial to my continued practice. Very happy with my last appraisal.
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Agenda item 26/18b
Meeting of the Board of Directors Thursday 28th June 2018
Report of Chief Operating Officer
Paper prepared by Fiona Noden, Chief Operating Officer & Bernie Delahoyde, Director of Operations Network Services
Subject/Title 62 Day Cancer Waiting Times
Background papers (if relevant)
Purpose of Paper
To update the Board on performance and actions in relation to the Cancer Waiting Times standard.
Action/Decision required For information
Link to: NHS strategies and
policy
Link to: Trust’s Strategic
Direction Corporate objectives
6. To maintain excellent operational and financial performance
Resource impact NA
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
CWT – Cancer Waiting Times
RTT- Referral to treatment
DTT- Decision to Treat
GM&C – Greater Manchester & Cheshire
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Agenda item 26/18b 62 Day Cancer Waiting Times
Thursday 28th June 2018
1. Purpose
This paper has been produced to update the board in relation to the cancer waiting time standards and the changes in delivering National Cancer Waiting Times standards with the introduction of the new National Breach Allocation Policy. The reporting against this new policy will commence in quarter two 2018/19.
2. Background
The trust has consistently achieved performance against the cancer waiting times standard since the introduction of the Greater Manchester reallocation policy in 2011. However in the past 6 months we have seen a dip in performance especially with the surgical pathways, which impacted on our Q4 performance 2017/18.
Data as of 15/06/18
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Total Timeframe
138 72.5 171 85 120 56.5 161 87.5 161 88.5 166 89.5 183 101.5 157 79.5 115 61 144 78.5 134 70.5 121 71 146 69.5 177 85.5
50% Shared Breach > 38 Days
> 62 Days, Treat > 24 Days 9 4.5 22 11 20 10 15 7.5 15 7.5 26 13 21 10.5 29 14.5 18 9 39 19.5 27 13.5 15 7.5 13 6.5 18 9
50% Shared Compliance <= 38 Days <= 62 Days 76 38 90 45 49 24.5 80 40 84 42 81 40.5 84 42 70 35 46 23 50 25 58 29 59 29.5 66 33 65 32.5
FULL Christie Breach <= 38 Days > 62 Days 5 5 2 2 2 2 6 6 10 10 5 5 4 4 5 5 2 2 8 8 2 2 2 2 3 3 7 7
FULL Christie Compliance > 38 Days <= 62 Days 25 25 27 27 20 20 34 34 29 29 31 31 45 45 25 25 27 27 26 26 26 26 32 32 27 27 37 37
FULL Referring Provider Breach > 38 Days
> 62 Days, Treat <= 24 Days 23 23 30 30 29 29 26 26 23 23 23 23 29 29 28 28 22 22 21 21 21 21 13 13 37 37 50 50
TOTAL Compliances 101 63 117 72 69 44.5 114 74 113 71 112 71.5 129 87 95 60 73 50 76 51 84 55 91 61.5 93 60 102 69.5
TOTAL Breaches 14 9.5 24 13 22 12 21 13.5 25 17.5 31 18 25 14.5 34 19.5 20 11 47 27.5 29 15.5 17 9.5 16 9.5 25 16
86.9% 84.7% 78.8% 84.6% 80.2% 79.9% 85.7% 75.5% 82.0% 65.0% 78.0% 86.6% 86.3% 81.3%
87.1% 90.8% 85.2% 90.5% 82.5% 85.5% 88.4% 87.2% 90.1% 69.1% 87.5% 92.9% 87.9% 84.3%
Mar-18Feb-18Jan-18
% Compliant - NEW Rules
Aug-17 Sep-17
Current reallocated position
Apr-17 May-17 Jun-17 Jul-17 Apr-18 May-18Oct-17 Nov-17 Dec-17
National breach allocation guidance was issued in April 2016. The rationale for this was to bring equity and reduce the overall number of patients waiting beyond 62 days for treatment. Across Greater Manchester and Cheshire (GM&C) we already had an agreed and fully functional patient focussed breach reallocation policy (GM2011). We have been advised by NHSI that we are required to adopt the new national guidance. The existing Open Exeter system (CWT reporting data base) will cease to upload records from 31st March 2018 (end Q4). Therefore all patients treated from 1st April 2018 will have to be uploaded onto the new system. Potentially all trusts will need to provide data for an extra 12 data fields which show inter provider transfer (IPT) dates, this will not be mandated until July 2018, when reporting against this guidance also becomes mandatory. This could mean trusts will not be able to provide cancer performance on an individual trust basis, and across GM&C, unless all trusts voluntarily complete all the data fields. However we are expecting an amendment to the policy which will negate some of these IPT’s.
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3. Summary of Key Changes The following section describes the key changes, and how performance will be managed.
3.1 Two Centre Pathways
At present, the majority of patient pathways span one or two trusts. A two centre pathway is described generally as a first seen Trust who undertakes the diagnostic elements of the pathway and a treating Trust who delivers the patient’s first definitive cancer treatment.
The following items describe the key changes in pathways involving two Trusts: The transfer for treatment timeframe will change (CaRP date). In the GM 2011 breach reallocation this is Day 42 and in the new CWT
guidance it will be Day 38. Currently, compliance (patients treated in time) would be shared between the
first seen and treating Trust. In the new guidance the first seen Trust will no longer receive any of the treatment compliance if transfer is after Day 38 and the patient is treated in time.
GM 2011 - Patients transferred after Day 42 who breach the 62 day standard would be reallocated in full to the first seen Trust.
New CWT - Reallocation for late transfer (now Day 38) will only be applicable if the treating Trust delivers the first definitive treatment within 24 Days – otherwise both Trusts share the breach.
The above changes will result in Trusts gaining breaches, and losing compliances (treatments in time) differently to the way Trusts and GM&C have historically calculated performance.
3.2 Three Centre Pathways (or pathways involving more Trusts)
In GM&C there are a number of established ‘traditional’ three centre pathways. These pathways are defined as three centre when ownership of the patient and their care is transferred to a ‘middle Trust’ who does not deliver the patients treatment. The new guidance describes three centre pathways differently. The new definition includes pathways where patients are transferred for diagnostic tests only, as well as the existing definition used in GM&C. This is significantly different from the way GM&C have operated. In GM&C there are a number of diagnostic hubs that deliver specialist tests for other Trusts, whilst overall responsibility for that patient continues to sit with the referring Trust. (i.e. patient sent for EBUS, EUS, PET-CT or other diagnostics which is not delivered on all hospital sites.) In the new CWT guidance this would mean a much greater proportion of pathways become multi-centre. The allocation of breaches and compliances for multi-centre pathways in the new guidance is very complex, and in some instances not yet defined. The 2011 GM&C breach reallocation policy has defined transfer times in multi-centre pathways (Day 19/Day 38). This ensures breaches and compliances can be determined easily. The new guidance is based on the length of time the patient is with each Trust; regardless of the amount of care or diagnostics being delivered. Trusts would not therefore have any ability to forward look and predict where any breach, or compliance, would be allocated until after the patient has been treated and uploaded onto the new CWT system.
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4. Impact on the Trust An internal assessment on the trust performance based on the new re allocation guidance demonstrated that we would only achieve the standard 2 months out of 12 last year. As a trust our current internal target for RTT is 31 days which we routinely achieve in terms of 85% of patients are treated within this target. In essence to achieve the new CWT standard we need to focus on an internal target of 24 days. The clinical teams recommend that we should be aiming for all patients to be managed equally, as some metastatic patients are more clinically urgent than some patients on a 62 day pathway. As a cancer centre we are aiming to improve waiting times across all our pathways and not just for patients on a 62 day pathway. An assessment in relation to a 24 day target can be seen in the table below. An action plan has been developed by the clinical divisions to improve performance against a new internal target of 24 days.
5. Conclusion
The challenge associated with the implementation of the new reallocation guidance and the impact on the trust performance is significant. A high level action plan has been developed through the divisional teams with further assessment, detail and consultation with disease groups. Our key objective is that we would want all patients to access treatment within 24 days of referral for treatment, where it is clinically safe and in the best interest of the patient. We have until 1st July 2018 to ensure clear plans are in place to be able to meet the CWT standards with the implementation of the new reallocation policy. There are also potential financial implications in terms of changing pathways and there may be a requirement for investment to deliver new pathways or to address capacity issues. We have planned for additional expenditure to ensure we can invest to meet these standards.
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Some of the key actions in progress:- Capacity and demand assessment for surgical theatres Aiming for 85% of new appointments to be within 7 days of receipt of referral Review process for direct booking for outpatient and surgical procedures Review of planning time in radiotherapy Improve timely access to chemotherapy (aiming for 7 days) Expand brachytherapy services Review of disease group capacity to prioritise investment Increase MDT’s for fortnightly to weekly
6. Recommendation
The board is asked to note the content of this report. Further updates will be provided to board through the Integrated Performance Report.
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Agenda item 26/18c
Meeting of the Board of Directors Thursday 28th June 2018
Report of Director of Workforce
Paper Prepared By Rebecca Patel – Head of Engagement (HR)
Subject/Title Workforce Plan Update
Background Papers n/a.
Purpose of Paper To provide an update of the organisation’s engagement strand of the workforce plan
Action/Decision Required To note the update
Link to:
NHS Strategies and Policy
The NHS Constitution
Link to:
Trust’s Strategic Direction
Corporate Objectives
Provide an excellent experience for everyone who comes into contact with us. Adhere to the core set of Christie values
Be compliant with all national standards for performance, quality and financial management
Impact on resources and risk and assurance profile
You are reminded that resources are broader than finance and also include people, property and information.
None
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
FFT – Friends and Family test
KF – Key Finding
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Agenda item 26/18c
Meeting of the Board of Directors
Thursday 28th June 2018
Workforce Plan Update 1. Background In September 2017 the Board of Directors approved the Trust’s Workforce plan which provides the strategic direction and our ambition for our workforce. Within the engaging component of the Trust Workforce Plan, there is a focus on providing and promoting a positive place to work. The purpose of this paper is to provide an update of the work delivered to support staff engagement.
One of the main tools for measuring staff engagement is the staff survey. The national survey was undertaken between September and December 2018. The results of which were presented to the Board in March. In addition to the annual survey staff are invited on a quarterly basis to complete the friends and family test (FFT). 2. FFT results Table one illustrates the annual FFT results in comparison with the previous year’s figures. Our scores are much higher than the national scores which are highlighted in red. Table One
Quarter Care and Treatment Place to Work 2017/18 2016/17 2017/18 2016/17
Q1 97 (81)
98% 98 (80)
97% 75 (64) 77 (64)
Q2 96 (80)
97% 97 (80)
96% 72 (63) 75 (64)
Q4 97 (80)
97% 97 (79)
98% 74 (63) 74 (64)
The results demonstrate that we have increased our scores over the period of 2017/18 and that there is a positive correlation between good staff engagement and excellent quality care our patient scores are highlighted in italics. The national CQC inpatient survey results from 2017, demonstrate that our staff recommendation of our organisation as a place for care and treatment correlates with our patient scores. We scored 8.8 in terms of patient experience of their care and treatment in our organisation, which ranks the organisation into the higher scoring category, the highest score was 9.0 and the lowest was 7.5 across England. In terms of patient’s overall experience of our services, patients scored us 8.9 which again ranks the organisation into the higher scoring category, as the highest score was 9.2 and the lowest was 7.5 across England. As an organisation we have maintained our patient experience scores and this correlates with the friends and family test results where a high proportion of our staff would recommend the organisation as a place to receive care and treatment.
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In addition to the questions, there is also opportunity for members of staff to add any free-text comments. On a quarterly basis, these are analysed from a qualitative perspective and themed. The general feedback is that staff feel a sense of satisfaction, pride and supported by their colleagues. However workload pressure and impact on health and wellbeing has become a recent theme of the feedback which is a priority that we are responding to. These themes correlate with those provided in the annual staff survey. To address the areas for development an organisational action plan has been developed which can be found in appendix one. 3. Progress against actions Some of the initiatives that have been developed as a result of the staff survey feedback to date and link to the wider workforce plan under the themes engagement and performing are as follows:
• Implementation of the “Managing for Success” training1 a programme to assist managers to develop their skills to support teams and individuals across the organisation. The training looks at a range of topics from recruitment, through to holding difficult conversations.
• Delivery of a suite of health and wellbeing events across the organisation, such as the
annual health and wellbeing day, access to promotional materials linked with national campaigns such as mental health awareness week and the development of a quarterly health and wellbeing newsletter available to all staff.
• Resilience training for managers developed in partnership with Zeal Solutions to provide an action learning set environment to develop skills relating to dealing with impacts on staff health and wellbeing, and manager’s resilience to support staff in the workplace.
• As a result of feedback, bespoke health and wellbeing surveys have been implemented in radiotherapy, Informatics, Clinical Support and Specialist Surgery division and the research and development division in order to develop a localised and focused approach to wellbeing in the workplace.
• The organisation took part in the NHS Fab Change Week in November 2017 and
encouraged members of staff and patients to pledge to make a small change which will ultimately improve the outcomes for our organisation.
• Implementation of an organisational recruitment and retention group with clinical and
non-clinical members drawn from across the organisation to identify any issues and raise through the corporate risk channels as appropriate.
• Implementation of a monitoring process for capacity of staffing relating to learning and development opportunities through the Education and Training Committee.
• Promotion campaign delivered to raise awareness of training and development opportunities for staff.
4. Next Steps The organisation have received their divisional feedback and have developed action plans to implement over the next 12 months. The engagement team will be working across the organisation to support delivery of the action plans and to ensure staff are responded to about
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their feedback. Progress of both the local and organisational action plans will be monitored at the Trust performance review and through the workforce committee. 5. Recommendations The Board of Directors is asked to note the results of the staff FFT and the progress against the action plan in line with the organisation’s workforce plan.
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Appendix One: Organisational Action – National Staff Survey Results 2017
Element Areas for improvement Proposed Actions Responsibility Timescales Response rate
Increase response rate
Robust communications plan developed, including myth-busting activity and focus on anonymity of responses
Engagement team
July 2018
Investigate staff incentive for completion such as refreshment vouchers and protected time
Engagement team
August 2018
Paper surveys to be made available for staff unable to access computers on a daily basis
Engagement team
September 2018
Involvement of key stakeholders to identify methods of increasing staff survey responses (Freedom to Speak Up Guardian, Staff Side colleagues, Line Managers, Staff Advisers)
Engagement team and stakeholders
Ongoing from June 2018
Identify Staff Survey Champions within Christie Commitment Champion network
Engagement team
July 2018
Violence, Harassment and Bullying
% of staff / colleagues reporting most recent experience of violence
Promotion and embedding of support mechanisms and networks for staff
Workforce division
September / October 2018
Promotion of Raising Concerns Policy Workforce division
August 2018
Promotion of Freedom To Speak Up Guardian role and mechanism
FTSUG and workforce division
Ongoing from June 2018
Working patterns
% of staff working extra hours
Promotion and re-emphasis of stress management policy including team stress risk assessments and management responsibility
Workforce division
August 2018
Identify trends in divisions in order to provide further support, advice and guidance
Engagement team
July 2018
Investigate matrix to form part of on-going performance review conversations
Engagement team
September 2018
Promotion of Health and Wellbeing module as part of “Managing for Success” programme delivered by the workforce division
Workforce division
Ongoing from June 2018
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Element Areas for improvement Proposed Actions Responsibility Timescales
Violence, Harassment and Bullying
%of staff / colleagues reporting most recent experience of harassment, bullying or abuse
Promotion of Social Partnership Foundation resources to tackle bullying in the NHS
Engagement team
September 2018
Promotion of informal and formal mechanisms such as Freedom To Speak Up Guardian and Staff Advisers
Engagement team
August 2018
Development of mediation options across organisation Head of Talent Ongoing Work with Staff Side colleagues to reiterate messages in relation to harassment, bullying or abuse
Workforce division
Ongoing
Promotion of Tackling Difficult Conversations module as part of “Managing for Success” training to enable managers, supervisors and team leaders to tackle issues earlier
Workforce division
Ongoing
Promotion and embedding of Respect At Work Policy across organisation
Workforce division
September 2018
Health and Wellbeing
%of staff feeling unwell due to work related stress in the last 12 months
Refresh and promote health and wellbeing strategy for organisation
Engagement team
July 2018
Refresh resources and education campaign on informal and formal mechanisms of support for staff across the organisation
Engagement team and SoO
September 2018
Promotion of “Health and Wellbeing” module as part of the “Managing for Success” programme
Workforce division
Ongoing
Promote and embed HSE requirements for stress audits and investigate best practice from other organisations
Workforce division and Health and Safety Committee
Ongoing
Appraisals and support for development
Quality of appraisals (score out of 5)
Draft communications to organisation in relation to PDR expectation and compliance targets
Engagement team
August 2018
Establish task and finish group to identify strategies to improve quality of appraisals
Workforce division
June 2018
Review PDR policy and processes including: • Timing – when PDR should be undertaken • System – i.e. paperwork or IT solution • Content – review links into organisational strategy • Branding • Achievement and objective setting
Workforce division
August 2018
Refresh and develop user guidance to reflect increasing the quality of appraisals
Workforce division
September 2018
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Agenda Item 27/18a
Meeting of the Board of Directors Thursday 28th June 2018
Board Assurance Framework 2018/19
Report of Chief Executive Officer
Paper Prepared By Louise Westcott, Company Secretary
Subject/Title Board Assurance Framework 2018/19
Background Papers Board assurance framework 2017/18. Corporate objectives 2018/19, operational plan and revenue and capital plan 2018/19.
Purpose of Paper To note the refreshed Board Assurance Framework (BAF) 2018/19
Action/Decision Required To consider any updates to the Board Assurance Framework (BAF) 2018/19
Link to:
NHS Strategies and Policy
• NHS Cancer Reform Strategy
• NHS Financial Regime, NHS Planning Guidance, Payment by Results, Monitor annual planning review, Monitor Risk Assessment Framework
Link to:
Trust’s Strategic Direction
Corporate Objectives
• Trust’s strategic direction
• Divisional implementation plans
• 2020 vision strategy
• Key stakeholder relationships
Resource Impact
You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.
BAF Board assurance framework CN&EDoQ Chief nurse & executive director of quality EDoF&BD Executive director of finance & business
development EMD Executive medical director COO Chief operating officer DoW Director of workforce
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Agenda Item 27/18a
Meeting of the Board of Directors Thursday 28th June 2018
Board Assurance Framework 2018/19 1 Introduction
The board assurance framework (BAF) 2018/19 was presented to the Board and Audit Committee in May 2018. Further review of the board assurance framework has taken place by the executive team since the board meeting. There have been minor updates to the BAF since it was presented to Board.
2 Suggested updates
There are no suggested updates to the risks identified in the Board Assurance Framework in June.
3 Recommendation
The Board is asked to note the board assurance framework (BAF) 2018/19 that reflects the risks to achievement of the corporate objectives. The Board is also asked to consider any further updates following discussion.
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BOARD ASSURANCE FRAMEWORK 2018-2019
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Principal Risks Exec Lead Like
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Impa
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Key Control established Key Gaps in Controls Cur
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Assurance Gaps in assurance Ope
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1.1Risk to patients and reputational risk to trust of exceeding the HCAI thresholds (stretched target of 18)
CN&EDoQ 4 3
Patients with known or suspected HCAI are isolated. Medicines management policy contains prescribing guidelines to minimise risk of predisposition to C-Diff & other HCAI's. Need to maintain Gram negative bacteraemia. RCA undertaken for each known case. Induction training & bespoke training if issues identified. Close working with NHS England at NIPR meetings.
None identified 12Levels reported through performance report to Management Board and Board of Directors and quarterly to NHS Improvement.
None identified 12 12
1.2 NEW
Lack of preparedness for a CQC inspection leading to a poor performance CN&EDoQ 2 4 Timetable of mock inspections arranged. Responded to the CQC Routine Provider Information
Request (RPIR). Communication with staff ongoing. None identified 8 Previous Outstanding rating None identified 8 4
1.3Failure to learn from patient feedback (patient satisfaction survey / external patient surveys / complaints / PALS)
CN&EDoQ 2 4
Monthly patient satisfaction survey undertaken and reported through performance report. Negative comments fed back to specific area and plans developed by ward leaders to address issues. Action plans developed and monitored from national surveys. Complaints and PALs procedures in place. Friends & Family Test performance target (40% response rate).
None identified 8
Management Board and Board of Directors monthly Integrated performance and quality report. National survey results presented to Board of Directors. Action plans monitored through the Patient Experience Committee
None identified 8 4
1.4 Non achievement of the quality outcomes for the 2018-19 CQUINS indicators. CN&EDoQ 2 4
Leads nominated for each CQUIN goal. CQUINs steering group (strategic and operational) are in place with strategic and operational representation agreed. Rigour introduced around submission and quality assurance of quarterly reports. Timescales established for provision of data.
None identified 8 Monitoring of performance data and contract KPIs occurs at various monthly meetings and feeds to CQUINS steering group. None identified 8 8
1.5 NEW
Risk of exceeding the thresholds for harm free care indicators (falls, pressure ulcers) CN&EDoQ 3 4
Collaborative projects in place. All falls come through executive nursing panel process. Call don't fall initiative. Falls group. Introduction of the TAB system. Executive review group looks at attribution of avoidable / unavoidable. Trust aim to maintain 16/17 levels. Tissue viability nurse appointed. System for assessment of ulcers / grading used. Training across the trust (focus on theatres/critical care).
None identified 12 Regular reports to Quality Assurance committee and board (through the integrated performance report). None identified 12 9
1.6 NEW
Risk that efficiences and improvements in patient experience relating to the move to the new outpatients department won't be achieved
COO 3 4 Outpatient Board regular updates on progress to Management Board None identified 12 Regular reports to Board None identified 12 4
1.7 NEW
Commissioning decision making impacting on patient care EDoF&BD 4 3 Monthly meetings with CCGs & NHSE. Agreed contract for 18/19 None identified 12 Agreed contract for 18/19 None identified 12 6
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2.1 Risk to Christie Research profile and funding if fail to perform strongly against national metrics EMD 2 3
New performance management system implemented (Jan 17) to track real time delivery; new set-up review group established (Aug 2017) to make recommendations for improvements; regular review at disease team quarterly assurance meetings; SLAs being established with each service department involved in set up and delivery.
None identified 6
Weekly review of 70 day performance. All industry metrics reported through to the Research Divisional Board and Management Board; quarterly review of Disease Group performance
None identified 6 6
2.2 NEW Failure to deliver the Paterson building replacement EDoF&BD /
EMD(S) 2 4 Programme board established with UoM & CRUK. Funding plan agreed in principle. Preliminary review to Board in June 18. None identified 8 Regular reports to Board None identified 8 4
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3.1Non delivery of the School of Oncology strategy due to increased pressure within operational service delivery and misalignment of divisional goals
EMD 2 3
Refresh of the School of Oncology to focus on integration of objectives between clinical divisions, research and education. Review Schools ability to support development PAs and consider funding for development work. Continue with Job Planning activity to increase transparency of educational PAs. Ongoing work with senior managers and divisions to look at longer term models to backfill posts
Continuing difficulty in back filling senior staff despite funding availability
6 School of oncology board reports to Management Board. None identified 6 6
Corporate objective 1 - To demonstrate excellent and equitable clinical outcomes and patient safety, patient experience and clinical effectiveness for those patients living with and beyond cancer
Corporate objective 2 - To be an international leader in research and innovation which leads to direct patient benefits at all stages of the cancer journey
Corporate objective 3 - To be an international leader in professional and public education for cancer care
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Gynaecology - Commissioning agreement for gynae-oncology surgical services to be provided across 2 sites, namely The Christie and CMFT. GM transformation team completed review of service delivery.
2 different service delivery models in GM. Continue to provide commissioned services None identified
Urology - commissioning decision made. Christie to provide prostate services as key provider under agreed specification. None identified Commissioner led review completed. Programme of transfer of
services agreed. None identified
4.3 Loss of trials due to no processes for accessing funding for excess treatment costs for trials EDoF&BD 2 4 Communicating with specialist commissioners on how to access funding. Informed lead clinicians
to ensure no patients are enrolled on inappropriate trials. None identified 8 Reports to research governance committee and commissioner meetings None identified 8 12
4.4Lack of a solution to the patient and relative accommodation issue for the Proton Beam Therapy service
EDoF&BD 2 4
Revenue funding secured through NHSE. Reviewing options for hotel accommodation in the city centre. Ronald McDonald approached to explore options for increasing capacity - initial agreement to prioritise PBT families. Fundraising approach being explored to expand current accommodation. Out to tender - expect award in coming months.
None identified 8 PBT steering group and Strategic Plan Implementation Board. None identified 8 8
4.5 OECI reaccreditation not achieved CN&EDoQ 2 3 Work centrally coordinated based on OECI measures. Accrediattion visit undertaken March 2018. Feedback received - action plan in development. None identified 6 Previous accreditation achieved. None identified 6 6
4.6 Lack of evidence to show progress against the ambition to be leading comprehensive cancer centre EMD(S) 2 3
Regular (bi-annual) board reports. Participation in OECI . Baseline measures identified and presented to Board of Directors. Discussion at time out in March 2017. Looking at how we can be part of International Benchmarking.
Availability of comprehensive data with which to compare ourselves
6Designated as the most technologically advanced cancer centre in the world outside North America. In segment 1 (Single oversight framework). Board discussion
None identified 6 6
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5.1 GM devolution changes have an adverse impact on The Christie objectives EMD(S) 2 4
Input into the business case. MOU produced and shared with board between ''AGMA and all Greater Manchester CCGs and NHS England'. Key directors attending GMH&SC boards and committees.
Uncertainty around impact. 8
Regular Management Board and Board of Director reports from CEO. Presentation to CoG. Greater Manchester Health & Social Care Strategic Plan and Terms of reference for GM Provider Federation Board approved at BoD Jan 16.
None identified 8 8
5.2 Non-delivery of our refreshed chemotherapy strategy
COO / EDoF&BD 3 4 Option appriasal of mobile unit versus static/hospital based provision. Refreshed chemotherapy
strategy approved. None identified 12 Reports to Management Board None identified 12 8
5.3 NEW
Impact of GM pathology on The Christie Pathology Partnership objectives
COO/ EDoF&BD 3 4 The Christie Pathology Partnership board established. Operational management reviewed.
Attendance at meetings. Working with partners in GM around HMDS and Genomics services None identified 12 Reports to BoD from The Christie Pathology Partnership board meetings. None identified 12 8
5.4 Tariff structure resulting in a recurrent loss of income EDoF&BD 2 5 Participating at national level to influence development of specialist tariffs. Contract for 17-18
agreed. Tariff agreed. Activity growth confirmed.
Changes in specialist commissioning as a consequence of GM Devolution
10 To continue to report through Manaagment Board and Board of Directors via the Finance report. None identified 10 10
5.5 Reputational damage caused by an adverse CQC inspection at The Christie Clinic
COO / EDoF&BD /
EMD2 4 Inspection undertaken and report awaited. Very positive feedback received following inspection. No permanent clinical director
in post 8 Governance reports to TCC Board. Partnership report to Board. None identified 8 4
5.6 NEW
The Christie Pharmacy Company objectives not achieved impacting on clinical service, patient experience and Trust reputation
COO 4 4 Weekly reports to Executive Team. Quarterly reports to Board of Directors. None identified 16 Regular reports to Board None identified 16 4
Corporate objective 5 - To provide leadership within the local network of cancer care
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Corporate objective 4 - To integrate our clinical, research and educational activities as an internationally recognised and leading comprehensive cancer centre
4.2Risk of comprehensive cancer centre status due to loss of surgery at The Christie due to uncertainty of commissioning within Greater Manchester
COO 3 5 15 15
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6.1 Key performance targets not achieved COO 2 4
Executive led monthly divisional performance review meetings. Integrated performance & quality report to Management Board and Board of Directors monthly. Digital Maturity board meeting monthly (includes cyber security). Wholly owned subsiduary established to provide pharmacy dispensing services.
None identified 8 Continued achievement of all key performance targets None identified 8 4
Exec led monthly divisional performance review meetings. Finance report to Management Board and Board of Directors monthly. Agency Cap monitored weekly by Executive Team & reported through Risk & Quality Governance and Management Board
None identified Continued achievement of a Single Oversight Framwork segment 1. Use of resources - 1 None identified
Commissioner contract signed for 2018/19. Agreement of control total for 2018/19 with NHSI. Growth monies allocated to divisions to ensure delivery of activity target. CIP target set.
Changes in specialist commissioning as a consequence of GM Devolution
Monthly board report. Portfolio board reviewing progress on CIP delivery None identified
6.3 Non delivery of transformation schemes (CIP) COO 4 4Transformation team to continue to work across clinical and corporate divisions to identify and achieve efficiency and improve environment. Monitor progress through Management Board. Targets for identification and delivery of savings agreed.
None identified 16 Progress monitored through integrated performance report to Management Board and Board of Directors None identified 16 4
6.4 Current EPR unable to support delivery of operational objectives EDoF&BD 2 4
External analysis undertaken to identify options to address issues with CWP (clinical web portal). Option appraisal to Board of Directors in Autumn 2017. Additional staff appointed. New CIO in post. Business case in development for EPR.
Internal capability & expertise to support system going forward. CWP built on an outdated platform
8 Reports to Management Board & Board of Directors. Review of CIO and CCIO roles None identified 8 8
6.5 NEW
Lack of preparedness for the introduction of the General Data Protection Regulation (GDPR) resulting in financial penalties
EDoF&BD 2 4GDPR task & finish group established with trustwide representation. NCC group undertaking data flow mapping. MIAA audit undertaken and detailed action plan developed. Awareness sessions taking place. Risk assessment undertaken
None identified 8 Regular reports to Board None identified 8 8
6.6 NEW
Adverse impact on the Trust reputation from non achievment of the 62 day target following implementation of the new national breach allocation policy
COO 3 4Shadow monitoring of new target in Q1 18/19. Monitoring will commence from Q2. Weekly monitoring of target across all specialties. Weekly reports to Executive Team. Discussion at Risk & Quality Governance. Monthly reports to Management Board & Board of Directors.
None identified 12 Regular reports to Board None identified 12 8
6.7 NEW
Failure to implement Christie Private Care strategy resulting in detrimental impact on profit share EDoF&BD 2 4 JV Board meetings. Approval of CPC strategy. Approval of capital investment to expand theatres. None identified 8 Regular reports to Board None identified 8 8
6.8 NEW
Introduction of a system control total resulting in a deterioration of our SOF score EDoF&BD 2 4 Attendance at GM meetings (PFB / GM DoF's / GM Dir of Ops)
Lack of clarity around implications of a system control total
8 Regular reports to Board None identified 8 8
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7.1 Target reductions in sickness levels not achieved DoW / COO 3 3 Adherence with sickness management policy monitored through performance review meetings. None identified 9 Monthly sickness levels as reported in Integrated performance and quality report None identified 9 9
7.2Reduction in quality of service due to the impact of new shared service models affecting our ability to recruit and retain staff
DoW 2 2Working with GM health & social care devolution and attending relevant meetings. Communication with existing staff in teams impacted by proposed shared service models (HR, Finance, Pathology, Radiology, Pharmacy, IT). Engagement with trade unions.
None identified 4No current impact on recruitment & retention. Involvement in key Greater Manchester Health & Social Care Partnership committees
None identified 4 4
7.3 Underutilisation of the apprenticeship levy DoW 3 3 Workforce committee monitoring progress. Divisional engagement. School of Oncology leading across the trust and externally with the development of higher apprenticeships. None identified 9 Regular report to board None identified 9 9
7.4 Risk of non compliance against PDR action plan to achieve Trust standard DoW 3 2 Performance review meetings. Information shared with managers on compliance. Redesigned
systems and paperwork. Trustwide performance at 86% 6 Regular reporting to Management Board and Board of Directors through the performance report. None identified 6 6
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8.1 Impact on our ability to obtain planning approval for future capital developments. EDoF&BD 3 3
Close working with Manchester City Council (MCC) on implementing the green travel plan . The strategic planning framework approved and includes current and future requirements for travel to site. Options for non-clinical staff accommodation off site are being considered. Communication with residents through the Neighbourhood Forum and newsletters. Green travel plan and sustainability plan in place.
None identified 9
Met the 15/16, 16/17 & 17/18 green travel milestones. Agreement by MCC of strategic development plan. 5 year Capital Plan delivery. Monitored through Management Board & Board of Directors. Continue to meet green travel targets. Monthly meetings with Manchester City Council (MCC). Capital programme shared with MCC and Board of Directors. Plans for tiered car parking approved Jan 18.
None identified 9 6
Corporate objective 7 - To be an excellent place to work and attract the best staff
Corporate objective 8 - To play our part in the local healthcare economy and community
Corporate objective 6 - To maintain excellent operational, quality and financial performance
6.2 Financial performance target not achieved EDoF&BD 4 4 16 16 4
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Chairman: Christine Outram Chief Executive: Roger Spencer
The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX Tel: 0161 446 3000 Fax: 0161 446 3977 www.christie.nhs.uk