trust board meeting to be held on wednesday 30 … · hospital, coventry, cv2 2dx 2 agenda item...

TRUST BOARD MEETING TO BE HELD ON WEDNESDAY 30th

JANUARY 2013IN ROOM 20063/64, CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITAL, COVENTRY, CV2 2DX

PUBLIC AGENDA

THE PUBLIC SESSION OF THE TRUST BOARD WILL COMMENCE PROMPTLY AT 1.00PM

P:\Trust Board\Trust Board - Master File\2013\1 - JANUARY 2013\PUBLIC\Enc 0 - AGENDA JANUARY 2013 (Final).doC

Resolution of Items Heard in PrivateIn accordance with the provisions of Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, and the Public Bodies(Admissions to Meetings) (NHS Trusts) Order 1997, it has been resolved that the representatives of the press and other members of thepublic are excluded from the second part of the Trust Board meeting on the grounds that it would be prejudicial to the public interest due tothe confidential nature of the business transacted. This section of the meeting has been held in private session.

1 General Business Paper Presenter Category1.1. Apologies for Absence Verbal Chairman N/A

1.2.Minutes of Meeting held on 28

thNovember

2012Enc 1 Chairman

N/A

1.3. Actions Enc 2 Chairman N/A1.4. Matters Arising Verbal Chairman N/A1.5. Declarations of Interest Verbal Chairman N/A1.6. Chairman’s Report Verbal Chairman N/A

1.7Private Trust Board Meeting Session Report– 28

thNovember 2012

Enc 3 ChairmanN/A

1.8 Chief Executive’s Report Verbal Chief Executive Officer N/A

2Delivering safe, high quality andevidenced patient care

Paper Presenter Category

2.1 SIG Report Enc 4 Mrs M Pandit, Chief Medical Officer Governance2.2 Mortality Report Enc 5 Mrs M Pandit, Chief Medical Officer Governance

2.3Quality Governance Committee MeetingReport 13

thNovember 2012*

Enc 6Mr T Sawdon, Non-ExecutiveDirector

Governance

3Improving the business and serviceframework


3.1Finance and Performance Meeting Report –29

thOctober 2012*

Enc 7Ms S Tubb, Senior IndependentDirector

Governance

3.2 Integrated Performance Report Tabled Mrs G Nolan, Chief Finance Officer Governance

3.3 Provider Management Regime Enc 8Mr D Eltringham, Chief OperatingOfficer

Governance

3.4 Calendar of Meetings Enc 9 Mr A Hardy, Chief Executive Officer Governance3.5 Workforce Strategy Enc 10 Mr I Crich, Chief Executive Officer Strategy

4Developing excellence in research,innovation and education


4.1 Education Report Enc 11 Mrs M Pandit, Chief Medical Officer Performance

5Building a positive reputation andidentity

PresenterCategory

5.1 Patient and Staff Story Enc 12 Mrs M Pandit, Chief Medical OfficerQuality &

Safety5.2 Foundation Trust Application Update* Enc 13 Mr A Hardy, Chief Executive Officer Strategy

6 Administrative Matters6.1 Work Programme Enc 14 Chairman Governance6.2 Any Other Business Verbal Chairman

7 Questions from the Public up to 15 minutes

8 Date of Next Meeting:Wednesday 27

thFebruary 2013 starting at 13.00

Please note: asterisked items (*) are for noting and, in general, do not require discussion.

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

MINUTES OF THE PUBLIC MEETING OF THE UNIVERSITY HOSPITALS COVENTRYAND WARWICKSHIRE NHS TRUST BOARD HELD ON WEDNESDAY 28

thNOVEMBER

2012 AT 1.00PM IN ROOM 20063/64, CLINICAL SCIENCES BUILDING, UNIVERSITYHOSPITAL, COVENTRY, CV2 2DX

1

AGENDA ITEMDISCUSSION ACTION

HTB 12/501PRESENT

Mr D Eltringham, Chief Operating OfficerMr A Hardy, Chief Executive OfficerMrs G Nolan, Chief Finance Officer/Deputy Chief Executive OfficerProfessor Radford, Chief Nursing OfficerMr T Robinson, Non-Executive DirectorDr P Sabapathy, Non-Executive DirectorMr T Sawdon, Non-Executive DirectorMr N Stokes, Non-Executive DirectorMr P Townshend, ChairmanMs S Tubb, Senior Independent DirectorProfessor P Winstanley, Non-Executive Director

HTB 12/502IN ATTENDANCE

Ms M Brown, Deloitte LLPMr I Crich, Chief HR OfficerMrs J Gardiner, Trust Board SecretaryMr M Owen, Deloitte LLPDr A Phillips, Deputy Medical DirectorMs J Guy, Grant Thornton LLPMrs Paula Young, Executive Assistant (note taker)

HTB 12/503APOLOGIES

Mrs M Pandit, Chief Medical Officer

HTB 12/504MINUTES OFMEETING HELD26th SEPTEMBER2012

The Trust Board APPROVED the minutes of the meeting held onWednesday 31st October 2012 as a true record of the meeting.

HTB 12/505ACTIONS

In response to a query from Dr Sabapathy, Mrs Gardiner noted inrelation to item HTB 12/410 that the Clinical Commissioning Groupshave indicated that there are not in a position to hold a Board to Boardmeeting with the Trust and therefore, this item will be revisited in July2013.

The actions completed and actions in progress were NOTED.

HTB 12/506MATTERSARISING

There were no matters arising.

HTB 12/507DECLARATIONSOF INTEREST

There were no declarations of interest.

HTB 12/508CHAIRMAN’S

The Chairman reported that the local health economy partnershipworking dinner held on 21st November 2012 proved to be interesting

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



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REPORT and eventful. It gave a clear indication of the great willingness toexplore collaborative working. The University of Warwick displayed anoutstanding commitment to help with overall delivery and engagement.

The Chairman noted that he had been approached by the Chair ofSouth Warwickshire Foundation Trust for a meeting. He also noted thathe had recently had a meeting with the Chair of NHS Midlands andEast; further details of which will be provided to Board members in theprivate session of the Trust Board.

Trust Board Terms of Reference

It is annual best practice for the Trust Board to review and approve itsown terms of reference and those of its sub-committees. These arescheduled into the Trust Board work programme for annual review.

The Trust Board terms of reference (TOR) are presented to TrustBoard for ratification and approval. These were last reviewed andapproved by Trust Board in September 2011.

Trust Board TOR have not been considered by any other committeesince they were last approved by Trust Board. There are no materialchanges to the terms of reference from those previously agreed, otherthan minor amends which are identifiable through track changes.

The Trust Board sub-committee terms of reference are key evidence tounderpin the IBP and HDD assessments and require re-approval.

Mr Robinson noted that item 6.1 will need amending given theproposed change to the Trust Board meeting schedule as outlined initem 4.6 Calendar of Meetings. The wording ‘as required’ will be addedto item 6.1 of the TOR.

Mrs Nolan noted that the word committee should be replaced withBoard throughout the document.

The Trust Board APPROVED the Trust Board Terms of Reference

subject the above amendments. Mrs Gardiner

HTB 12/509PRIVATE TRUSTBOARD MEETINGSESSIONREPORTS – 31st

OCTOBER 2012

The Chairman advised that the purpose of the report is to advise of theprivate Trust Board session meeting agenda held on 31st October 2012and any key decisions or outcomes made by the Trust Board.

The Board NOTED the contents of the report.

HTB 12/510CHIEF EXECUTIVEOFFICERSREPORT

The Chief Executive Officer reported that the Secretary of State forHealth has recently published the first mandate to the NHSCommissioning Board. The NHS Mandate sets out the Government’sambitions for the NHS, which it is asking the NHS CommissioningBoard to achieve from April 2013 to the end of 2015.



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The Chief Executive Officer was pleased to report that Worcester AcuteNHS Trust has now secured the funding to progress with the jointdevelopment for the provision of non-surgical oncological radiotherapyservices in Worcester.

The Chief Executive Officer recently attended the HSJ Annual Awardsand was proud to report that a clinician from UHCW was shortlisted forclinician of the year. He added that the Trust has recently won severalawards including Baby Lifeline, Tissue Viability and Communications.

The Trust Board NOTED the Chief Executive Officers Report.

HTB 12/511QUALITYGOVERNANCETERMS OFREFERENCE

The purpose of the report is to advise Trust Board of the change of theQuality Governance Committee Terms of Reference v5

Terms of Reference have been changed to show the revised number ofNon Executive Directors required at Quality Governance Committee.This requirement is now three instead of the original requirement offour, to align with the Finance and Performance Committee which isalso made up of both Executive and Non-Executive Directors..

The 80% attendance requirement, as required by Deloitte, has alsobeen updated.

Dr Sabapathy highlighted that 2.3 of the Trust Board TOR details thatmembers should maintain a minimum 80% attendance level; however,this is not consistent with item 2.6 as detailed in the TOR for QualityGovernance Committee. Mrs Gardiner acknowledged this commentand advised that she would highlight this with the Director ofGovernance to make the necessary amendments.

The Trust Board APPROVED the Quality Governance Committee TORsubject to the above amendment.

Mrs Gardiner

HTB 12/512QUALITYGOVERNANCECOMMITTEEMEETING REPORT– 9th OCTOBER2012

In response to a comment from Mr Robinson, Mrs Gardiner noted thatrisk reporting has improved but acknowledged that more work isrequired to ensure regular review and updates are embedded as a liveprocess rather than a reactive process across the Trust.

Dr Sabapathy noted that the Nutrition Steering Group is beingmonitored to address any training needs and suggested that thereneeds to be a balance of nutritional needs versus cost effectiveness.Professor Radford assured the Board that following a Care QualityCommission nutrition and dignity inspection last year no concerns wereraised. He added that the work is ongoing to improve the patient menuand a new menu is due to be introduced in January 2013. Mr Stokessupported Professor Radford’s comments and added that during award visit today he had opportunity to sample the new menus, whichare excellent.

The Chairman noted that there is some merit visiting wards duringprotected meal times to gauge the patient’s view of the nutritionprovided. Mr Sawdon urged careful judgement of left over food,



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highlighting that often patients are too poorly to eat, rather than haveno appetite for the food which is served.

The Trust Board ACCEPTED the contents of the Quality GovernanceCommittee Report.

HTB 12/513DEVELOPINGEXCELLENCE INRESEARCH,INNOVATION ANDEDUCATION

Professor Winstanley observed that there were no reports presentedunder this item today; however, he suggested developing this itemfurther.

Mrs Pandit

HTB 12/514INTEGRATEDPERFORMANCEREPORT

Mrs Nolan tabled the Integrated Performance Report (IPR) the purposeof which is to provide the Board with a summary of the integratedquality, performance and finance report for October 2012.

Mrs Nolan advised that the full IPR had been presented and scrutinisedat the Finance and Performance Committee on 26th November 2012.The paper presented to the Trust Board today is a summary of the fullreport and is therefore, significantly less substantial.

The report sets out the Trusts performance against an agreedscorecard of 55 indicators. Improvements to the reporting have beenmade including more detailed escalation reporting to the Finance andPerformance Committee, setting out actions being taken to rectifyunderperformance. Further improvements will take place over the nextthree months.

Dr Sabapathy noted that changes to the presentation highlighted at theFinance and Performance Committee have not translated through tothe document tabled today i.e. 31 day diagnosis to treatment shoulddemonstrate that this target relates to cancer patients.

Ms Tubb noted a detailed discussion was held at the Finance andPerformance Committee on 26th November 2012 and invited MrEltringham to share the detail of those discussions with Boardmembers. Mr Eltringham advised the Trust had not achieved the 95%A&E 4-hour wait target in October with a performance of 94.3% and thechallenge has continued into November. Mondays and Tuesday arenaturally the busiest days of the week and if the week is not started ona positive bed balance this has a negative impact for the week. Actionshave been taken to address the situation and a recent two-week pilotproved successful whereby weekends were treated as normal workingdays with additional resources available to progress patients throughthe system. This was re-introduced two weeks ago but will take sometime before the maximum effect is realised.

Mr Eltringham advised that the Trust is testing another initiative of ‘hotclinics’ whereby patients can be referred directly from A&E, which willhopefully make an impact and is due to come on line within the nextfew weeks. The Department of Health (DH) Emergency Care IntensiveSupport Team (ECIST) have been invited to visit the Trust and test the



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progress made in this area.

Dr Sabapathy suggested that emphasis must be placed upon clinicaldischarge. Mr Eltringham advised that extreme efforts have been madeto engage with clinicians to enable timely discharge.

Mr Stokes noted that recent data suggests that performance is good ona Monday but by Wednesday has deteriorated significantly and queriedwhat the drivers were for this. Mr Eltringham advised that in an idealsituation the Trust would have 30 empty beds to accommodate theincreased activity that naturally flows on a Monday and Tuesday,however, this initiative is something that will take time to embed.

In response to a query from Mr Sawdon, the Chief Executive Officerconfirmed that the never event as detailed in item 3.8 on page 7 of thereport is not a new event but one which has already been reported tothe Board.

In response to a query from Mr Sawdon, Mrs Nolan acknowledged thatitems 3.10 (No of Dr Foster Red mortality alerts) and 3.11 (No of DrFoster High relative risks) on page 7 of the report should not featurewithin the table of indicators with no areas of concern and advised thatthis would be addressed going forward.

The latest reported position against the Net Promoter Score ispresented in compliance with CQUIN requirements; this shows anoverall improvement from 54.10 in September to 54.30 in October.Discussion ensued in relation to the Net Promoter Score (NPS). MrSawdon suggested that it would be helpful to know the level ofresponse for each ward and speciality.

The Trust Board;

NOTED performance delivery for October 2012 and the Net PromoterScore.

ENDORSED and SUPPORTED the escalation action being taken byManagement subject to further recommendations being made in theprivate session of the Trust Board today.

HTB 12/515FINANCE REPORT

The purpose of the report is to update the Board as to the financialposition of the Trust as at Month 7 of the 2012/13 financial year and theforecast year end position.

The month 7 position is a deficit position of £3.8m which is an adversevariance of £3.1m against a planned deficit of £0.7m. The forecastsurplus remains at £2.5m which is dependant on the robustmanagement of risk.

The deterioration of the Trust’s year to date position has now prompteda programme of ‘financial recovery’ across all Groups and Corefunctions. All Clinical and Corporate Function Directors have beenbriefed on the seriousness of the situation and their responsibility for



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addressing the net expenditure pressure that needs to be addressedfor the Trust to meet its surplus target of £2.5m for the year. Escalationissues have been pursued through the Finance & PerformanceCommittee.

It was noted that additional activity associated with emergencyadmissions continues to rise, for which the Trust received only marginaltariff. Overspends against expenditure budgets totalling £5.9m islargely driven by the increased activity levels.

£4.9m of additional savings over and above the original CIPrequirement are necessary to achieve the £2.5m surplus forecast

£3.7m of QIPP reductions are currently built into the income forecast.Plans for these reductions are not yet finalised (by commissioners). Ifthese are realised in future months the associated expenditure isassumed removed from group positions. Plans to remove theexpenditure have not yet been finalised.

The Chairman acknowledged that the Trust is working in a verychallenging financial market and that the Board need to support theactions taken by Chief Officers to address the financial issue.

The Trust Board APPROVED the report and in particular the Trust’sposition in month 7 of 2012/13 and agreed to continue this discussionin the private session of the Trust Board.

HTB 12/516FINANCE ANDPERFORMANCEMEETING REPORT– 24th SEPTEMBER2012

In response to a query from Mr Sawdon regarding the CIP target for2013/14 the Chief Executive Officer advised that this was £41m;however, he emphasised that this is a moving target. Ms Tubbsupported this and added that this will continue to be fluid but is thebest estimate based on the information that exists currently.

The Trust Board ACCEPTED the contents of the report.

HTB 12/517AUDITCOMMITTEEMEETING REPORT– 17th SEPTEMBER2012

The Trust Board ACCEPTED the contents of the report.

HTB 12/518PROVIDERMANAGEMENTREGIME

The SHA wide Provider Management Regime (PMR) has been rolledout which each Trust is required to complete on a monthly basis.

The PMR process has been fully operational from April 2012 onwards.This regime was introduced to support Trusts, by working with the SHAin a “Monitor like” way, to help prepare Trusts for their DH and MonitorFoundation Trust assessment and subsequent monitoring postauthorisation under the Monitor Compliance Framework.

The regime provides an opportunity for providers to earn autonomyfrom the SHA. Providers who can demonstrate consistent performance



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of governance, finance, quality and contract management will makeless frequent PMR returns and meet with the SHA less often than thoseTrusts that face issues. There is also a clear escalation process forTrusts with persistently poor ratings or other issues.

Mr Eltringham noted that there are two exceptions highlighted withinthe report; A&E 4-hour wait target and financial position.

As there is no Trust Board in December, Mr Eltringham asked theBoard to grant delegated responsibility to enable the November returnto be submitted to the SHA in December.

The Trust Board;

APPROVED the Provider Manager Regime return based on October2012 data for onward submission to the SHA.

CONFIRMED support for Governance Declaration 2 (for insufficientassurance that all targets are being met) in relation to the FinancialRisk Rating and total time in A&E.

GRANTED delegated responsibility to the Chief Executive Officer andthe Chairman to enable the November return to be submitted to theSHA in December by virtue of there being no Trust Board in December.

HTB 12/519CALENDAR OFMEETINGS

The purpose of the report is to provide the Board with an overview ofthe Trust Board, Board Seminar, and Sub-Committee meetings for2013/14.

It is noted that compared to previous years, additional Board Seminarshave been scheduled (two per month) in preparation for FoundationTrust assessment, and four strategic Board Away Days have beenscheduled.

At the November private Trust Board meeting, the first iteration of theintegrated performance dashboard was presented. The reporthighlights the following issue which impacts on the scheduling of TrustBoard dates;

Currently performance and CIP data is released on the 10th workingday. Based on the Trust’s current governance arrangements, thisinformation must be released by the 6th working day to enable thePPMO to process and validate in advance of all of the OPPMs. Inaddition, based on the availability of performance data, the Financeand Performance Committee will not be able to review the draft TrustBalanced Scorecard and CIP position prior to Trust Board submission.Therefore, to ensure that operational Committees and Board SubCommittees (Finance and Performance Committee) have sufficientscrutiny of the previous month data, will require the Trust Board toreschedule its Committee dates

In light of this it was agreed to review the re-phasing of Trust Board andFinance and Performance Committees dates to ensure that Finance



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and Performance Committee has an opportunity to scrutinise the data,prior to submission to Trust Board.

On the advice of the Chief Finance Officer and Chair of Finance &Performance Committee it is suggested that;

Finance and Perfomance committee meetings remain the lastMonday of the month

Trust Board meetings move from the last Wednesday of everymonth to the first Wednesday of every month

The Trust Board Seminar moves from the first Wednesday ofthe month to the last Wednesday of the month.

Trust Board continues to meet ten times per annum, but thatthere are no scheduled meetings in January and August(currently there are no meetings in December and August).

That the proposed changes take effect from April 2013.However, this would effectively mean that there are Boardmeetings in March and April within 1 week of each other. It istherefore proposed that the 27th March 2013 Trust Boardmeeting is cancelled and the agenda items rolled forward to themeeting on 3rd April 2013.

In light of these changes there would no longer be arequirement for an extraordinary Trust Board meeting in Juneto agree the annual report to accounts.

The Trust Board;

RECEIVED the report.

APPROVED the suggested changes to Trust Board and BoardSeminar dates as recommended by the CFO from 1st April 2013.

AGREED to cancel 27th March 2013 Trust Board and roll agenda itemsforward to 3rd April 2013 meeting.

Board members to ENSURE dates are diarised

HTB 12/520PATIENT ANDSTAFF STORY

The purpose of the report is to give assurance to the Trust Boardregarding the quality of the nursing care on wards 10 and 2.

A patient experience report to Trust Board in October highlightedissues which related to patient experience. Following this a review wasrequested of both wards 10 and 2.

Ward 10

It is evident that the nursing team within Cardiology strive to ensurethat patients understand their care and treatment plan and are fullyinvolved in decisions that affect their ongoing care. Patients confirmedthat they were treated with dignity and respect and those asked wouldhave no concerns about their friends and family being cared for on theward.



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The Ward Manager is continuing to work closely with the support of theHR Manager and Modern Matron to proactively manage attendanceand reduce absence levels.

The Ward Manager will contact the Lead Nurse for SafeguardingVulnerable adults and arrange ward based sessions to further raiseawareness related to safeguarding.

Ward 2

Ward staff indicated a strong team approach to patient care, a greatdeal of respect was shown towards both Ward Manager and ModernMatron. Staff reported that they were very well supported and wereable to confidently raise concerns to minimise risk to both patients andwork colleagues.

The ward has received 2 formal complaints in the last 3 months, acomplaint registered in July has not been resolved as yet. Poordocumentation has contributed to the wards inability to provide anaccurate account of the incident.

The ward team communicates a strong focus on involving patients andtheir carers in decision making regarding their treatment, options andcare. However, nursing documentation does not always support this,with inconsistent evidence of patients being involved in care planningor explanations given regarding treatment.

Practice Facilitators are to undertake a formal record keeping audit andprovide additional training and education to all ward staff in order toimprove standards.

The Modern Matron will arrange for additional support/training of staffto further understand the process of and management of complaintsand review the outstanding complaint and provide feedback to wardstaff.

Mr Stokes noted that this report has been presented to and scrutinisedby the Quality Governance Committee.

In response to a query from Ms Tubb in relation to sickness absence,Professor Radford confirmed that the sickness absence record for ward10 had consistently been high for two months prior to the analysis,which included two long-term sickness absentees. An assurance pieceof work is currently being done around recruitment in this environmentand management of sickness absence. Mr Crich added that work isongoing at a macro level with sub specialties. The HR Committee haveagreed to single out sub specialties and invite the Modern Matron,Clinical Director and Group Manager for these areas to attend toexplain the position and review actions being taken to address issues.This will be reported through the Quality Governance Committee.

The Trust Board;



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SUPPORTED the outcome of the review undertaken.

APPROVED the actions taken.

HTB 12/520FOUNDATIONTRUSTAPPLICATION*

The Chief Executive Officer advised that the purpose of the report is toprovide an update on the progress and timeline for Foundation Truststatus application.

UHCW NHS Trust is working to a Department of Health submissiondate of 1st June 2013.

The Trust Board;

RECEIVED and ACCEPTED this report.

GRANTED delegated authority to the Chairman and Chief ExecutiveOfficer for approval of the integrated business plan for 18th January2013 submission to the SHA.

GRANTED delegate authority to the Chief Executive Officer forapproval of the historical due diligence report.

HTB 12/521WORKPROGRAMME

The Trust Board NOTED the Work Programme.

HTB 12/522ANY OTHERBUSINESS

Dr Phillips reported that the DH wrote to all NHS Trusts in England on8th October 2012 to share recent issues highlighted at Kings millHospital in relation to pathology services. This is in relation to themisclassification of oestrogen receptor status affecting the treatment ofwomen with breast cancer.

Dr Phillips advised the Board that the Pathology Network haveprovided assurance that the Trust is meeting all of the necessaryrequirements.

The Chairman thanked Dr Phillips for the update but requested thatfrom a governance view, this should be reported to the QualityGovernance Committee in detail and any concerns referred to the TrustBoard.

Mrs Pandit

HTB 12/523QUESTIONS FROMTHE PUBLIC

In response to a suggestion from the public in relation to complaintsmanagement, the Chief Executive Officer advised that the Trustprovides a very clear complaints management service but it isinevitable that some complaints will be referred to the HealthOmbudsman. He added that he encourages all attempts to managecomplaints locally and that the Trust employs a PALS service to helpfacilitate this. Complainants are offered the opportunity to meet withclinicians who oversee their care or independent clinicians, if this isdeemed appropriate.

The Chairman noted that he has met with complainants, either at hisinstigation or at the request of the complainant. Events occur and



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sometimes mistakes happen; however, the Trust always investigatescomplaints fairly, objectively and as timely as possible.

HTB 12/524DATE OF NEXTMEETING

The date of the next meeting is Wednesday 30th January 2013 at1.00pm in the Clinical Sciences Building, University Hospital, CoventryCV2 2DX.

HTB 12/525APPROVAL OFMINUTES

These minutes are approved subject to any amendments agreed at thenext Trust Board meeting.

SIGNED……………………………………………..

CHAIRMAN

DATE……………………………………………..

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTACTIONS UPDATE: PUBLIC TRUST BOARD MEETINGS

30th

January 2013

Red = outstandingBlack = in progress not yet dueGreen = complete

Unless a date is specified it will be assumed that the date for completion is the 1st Monday following the next Trust Board.

- 1 -

AGENDA ITEM ACTION LEAD DATE TO BECOMPLETED

COMMENT

ACTIONS IN PROGRESSHTB 12/467 (31.10.12)ANY OTHERBUSINESS

Mr Stokes queried why Non-Executive Directorshad not been alerted to the television mediacoverage of a mother campaigning to lobbyGovernment for medics to take parents commentsmore seriously following the care her daughterhad received at UHCW NHS Trust. The ChiefExecutive Officer responded that the particularmedia story in question was not expected to beshared so soon and that he would ask Mr Crich toraise this matter with the CommunicationsDepartment.

IC 3.12.12

HTB 12/468 (31.10.12)QUESTIONS FROMTHE PUBLIC

In response to a suggestion from the public, theChairman requested that the Chief Nursing Officerwork with the Communications Team to betterpromote the effectiveness of the smokingcessation clinics

MR 3.12.12

ACTIONS COMPLETEHTB 12/508 (28.11.12)CHAIRMAN’SREPORT

The Trust Board APPROVED the Trust BoardTerms of Reference subject the aboveamendments.

JG 4.2.13 Terms ofReferenceupdated

HTB 12/511 (28.11.12)QUALITYGOVERNANCETERMS OFREFERENCE

Dr Sabapathy highlighted that 2.3 of the TrustBoard TOR details that members should maintaina minimum 80% attendance level; however, this isnot consistent with item 2.6 as detailed in the TORfor Quality Governance Committee. Mrs Gardineracknowledged this comment and advised that shewould highlight this with the Director ofGovernance to make the necessary amendments.

JG 4.2.13 E-mail sent toPaul Martin3.12.12

HTB 12/513 (28.11.12)DEVELOPINGEXCELLENCE INRESEARCH,INNOVATION ANDEDUCATION

Professor Winstanley observed that there were noreports presented under this item today; however,he suggested developing this item further.

MP 4.2.13 EducationReport to bepresentedJanuary 2013.Research KPIfeatures aspart of theintegratedperformancescore card.

HTB 12/522 (28.11.12)ANY OTHERBUSINESS

Dr Phillips reported that the DH wrote to all NHSTrusts in England on 8

thOctober 2012 to share

recent issues highlighted at Kings mill Hospital inrelation to pathology services. This is in relation tothe misclassification of oestrogen receptor statusaffecting the treatment of women with breastcancer.

Dr Phillips advised the Board that the PathologyNetwork have provided assurance that the Trust ismeeting all of the necessary requirements.

The Chairman thanked Dr Phillips for the update

MP 4.2.13 Referred toQualityGovernanceCommittee viae-mail 3.12.12

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTACTIONS UPDATE: PUBLIC TRUST BOARD MEETINGS

30th

January 2013

Red = outstandingBlack = in progress not yet dueGreen = complete

Unless a date is specified it will be assumed that the date for completion is the 1st Monday following the next Trust Board.

- 2 -

AGENDA ITEM ACTION LEAD DATE TO BECOMPLETED

COMMENT

but requested that from a governance view, thisshould be reported to the Quality GovernanceCommittee in detail and any concerns referred tothe Trust Board.

HTB 12/230 (30.5.12)EDUCATION REPORT

The Trust Board RECEIVED the report andSUPPORTED the work undertaken by Mr Fraser.The Chairman requested that the issue ofeducation be referred to the Training, Educationand Research Committee with a view to exploringmatters of research, development and educationto be brought back to the Trust Board as part ofthe strategic objectives of the Trust, and willfeature as part of the scheduled Education reportin November.

MP Scheduled forNovember2012

Deferred toJanuary 2013in line withrevised TrustBoard workprogramme

REPORTS SCHEDULED FOR NEXT MEETING

REPORTS SCHEDULED FOR FUTURE MEETINGSHTB 12/061 (29.2.12)CHIEF EXECUTIVESREPORT

Mr I Crich would present a paper on the future ofmedical education

IC Scheduled forFebruary 2013

HTB 12/410 (26.9.12)PERFORMANCEREPORT

HTB 12/460 (31.10.12)SUSTAINABLESPECIALTIES &FRAIL OLDERPEOPLESPROGRAMME

The Board will look to have more formal periodicalmeetings with the CCG’s to engage with them andbuild up good solid working relationships. TheChairman requested that Mrs Gardiner facilitate ameeting in the next 2-3 months. Mrs Gardineradvised that she will need to take guidance fromthe CCG’s in terms of whether they yet have fullBoard appointments.

Dr Sabapathy suggested that this be the first itemfor discussion on the Board to Board agenda withthe CCG’s as a topic for partnership working.

JG

JG

July 2013

As above

Exec to Execmeetings withCCG’s on24.10.12 and21.11.12 bothcancelled byCCG. CEOconfirmed withCCGAccountableOfficer that theCCG does notrequire Boardto Boardmeetings atthis time. To bereviewed in sixmonths i.e.July 2013

ACTIONS REFERRED TO TRUST BOARD SUB-COMMITTEES


REPORT TO THE TRUST BOARD: PUBLIC

30th

January 3013

Enc 3 - Chairman's report November 2012 I/\trust board\templates\revised header public\Version 2\January 2010

Subject: Trust Board Meeting Session Reports of 28th

November 2012Report By: Philip Townshend, ChairmanAuthor: Jenny Gardiner, Trust Board SecretaryAccountable Executive Director: Philip Townshend, Chairman

GLOSSARYAbbreviation In FullNPS Net Promoter ScoreCQUIN Commissioning for Quality Innovation

WRITTEN REPORT (provided in addition to cover sheet)? Yes No

POWERPOINT PRESENTATION? Yes NoNB Presentations need to be submitted for inclusion in Board papers

TitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:To advise the Board of the private Trust Board Session meeting agendas for 28

thNovember 2012 and of any

key decisions/outcomes made by the Trust Board.

Chairman’s Report: Mr P Townshend, ChairmanThe Trust Board;

RECONISED the current situation of the Trust in relation to the impending FT application and the significantchallenges faced by A&E performance and financial performance both in the current year and subsequentyears.

RESOLVED to continue to commit to its current FT application.

RESOLVED to proceed with the Board Readiness Assessment on 13th

December 2012, giving frank disclosurewith regard to the challenges faced and the strategy for addressing these challenges.Estates Strategy: Mr I Crich, Chief HR OfficerThe Trust Board;

APPROVED in principle, the Estates Strategy (2012 – 2017)

RESOLVED to give delegated authority to the Chairman and Chief Executive to agree final versions of all foursupporting strategies (ICT, Workforce, Quality, Estates) prior to submission to the SHA alongside the revisedIBP.Chief Executive’s Report: Mr A Hardy, Chief Executive OfficerThe Trust Board RECEIVED and ACCEPTED the Chief Executive Officer’s report.CQC Registration: Mrs M Pandit, Chief Medical OfficerThe Trust Board ENDORSED the Trust’s registration with the CQC for 2011/12.Quality Governance Committee Chairs Meeting Report – 13

thNovember 2013: Mr T Sawdon, Non-

Executive DirectorThe Trust Board NOTED the Quality Governance Committee Chairs Report.Quality Governance Committee Draft Minutes of the Meeting – 13

thNovember 2012: Mr T Sawdon, Non-

Executive DirectorThe Trust Board ACCEPTED the Quality Governance Committee meeting report of 13

thNovember 2012.

Finance and Performance Strategy: Mrs G Nolan, Chief Finance OfficerThe Trust Board ENDORSED the Chief Executive Officer to report publicly partnership working in relation topathology.

Constitution (Review SO’s, SFI’s and Scheme of Delegation: Mrs G Nolan, Chief Finance OfficerThe Trust Board APPROVED the proposed revisions to Standing Orders, Standing Financial Instructions and



30th

January 3013

Enc 3 - Chairman's report November 2012 I/\trust board\templates\revised header public\Version 2\January 2010

Scheme of Reservation and Delegation as set out in this report.RIS/PACS: Mr D Eltringham, Chief Operating OfficerThe Trust Board APPROVED the full business caseHBP Business Case: Mr D Eltringham, Chief Operating OfficerThe Trust Board APPROVED recruitment to the additional consultant post.Consultant Neonatologist and Paediatricians Reconfiguration: Mrs M Pandit, Chief Medical OfficerThe Trust Board;

APPROVED progression to advertising the three consultant posts.

REQUESTED that the full business case be presented to the Trust Board in January 2013.Draft Finance and Performance Committee Meeting Report – 29

thOctober 2012: Ms S Tubb, Senior

Independent DirectorThe Trust Board ACCEPTED the Finance & Performance Committee meeting report of 29

thOctober 2012.

Finance and Performance Committee Chairs Meeting Report – 26th

November 2012: Ms S Tubb, SeniorIndependent DirectorThe Trust Board AGREED that the integrated performance report will continue to be reported monthly to thepublic session of the Trust Board.Audit Committee Chairs Meeting Report – 19

thNovember 2012: Mr T Robinson, Non-Executive Director

The Trust Board REQUESTED that the Chief Medical Officer provide a progress report to Board membersregarding the review of Consultant PA’s in January 2013.Criminal Records Bureau: Mr I Crich, Chief HR OfficerThe Trust Board AGREED that Mr Crich would seek guidance from the DH and re-present this report to theTrust Board in January 2013.Transforming Community Pathology Services: Mr A Hardy, Chief Executive OfficerThe Trust Board;

NOTED progress with regard to the SHA proposal and DELEGATED authority to the bid team to respond to thePQQ.

SUMMARY OF KEY RISKS:No risks were identified.

RECOMMENDATION / DECISION REQUIRED:For Noting.

IMPLICATIONS:Financial: N/A

HR / Equality & Diversity: N/A

Governance: N/A

Legal: N/A

REVIEW:Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee Executive MeetingAudit Committee

DATA QUALITY:Data/information Source: Report provided to the private sessions of the Trust Board held on 26

th

September 2012Data Quality Controls:Data Limitations:



30 JANUARY 2013

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

Subject: Significant Incident ReportReport By: Meghana Pandit, Chief Medical OfficerAuthor: Yvonne Gatley, Associate Director of Governance (Patient Safety)Accountable Executive Director: Meghana Pandit, Chief Medical Officer

GLOSSARY

Abbreviation In FullSI Significant incident



TitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:

To provide the Trust Board with a quantitative summary of the significant incidents that were opened orclosed during the quarter October - December 2012.

All SIs are reviewed at the weekly SI Group, who ensure that investigations are undertaken and appropriateactions are put in place to reduce identified risks.

Details of SI investigations are also presented monthly to the Patient Safety Committee and QualityGovernance Committee.

Incidents that fall into the SIRI category (Significant Incident Requiring Investigation, NPSA definition) arealso reported to the SHA and PCT. These incidents include healthcare-associated infections such asMRSA, C Difficile & Norovirus. Each has to be investigated by root cause analysis and the commissionersrequire a copy of the investigation report and action plan within a timescale of 45 working days from thedate of notification, unless a clock-stop has been negotiated with them.

SUMMARY OF KEY ISSUES:

See report 36 SIs were opened during quarter 3: see report for details of types of incident 32 SI investigations were completed during the quarter

SUMMARY OF KEY RISKS:

Never events – the Trust has conducted a corporate gap-analysis and continues to put in measures tominimise the risk of further never events. CMO has requested all specialties to review their practicesagainst the guidance and thereby minimise the risk of a never event occurring. Compliance with thesurgical safety checklist is monitored monthly. Paul Martin & Meghana Pandit are meeting withAttainability, MPS & TEREMA (external consultants) for additional support to review the teams’ “humanfactors”.

Serious Falls – the Falls Group is putting additional measures into practice to mitigate the risks based onthe findings of the investigations.

Infection Control incidents – Norovirus outbreaks are reportable as SIs. Each is managed by theInfection Prevention & Control Team to minimise risks to patients and to ensure timely re-opening of wards.



30 JANUARY 2013


RECOMMENDATION / DECISION REQUIRED:

The Trust Board are asked to RECEIVE and ACCEPT the report.

IMPLICATIONS:

Financial:

HR / Equality & Diversity:

Governance: Patient Safety

Legal:

REVIEW:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee Executive MeetingAudit Committee

DATA QUALITY:

Data/information Source: DATIX Risk Management System

Data Quality Controls: Internal quality checksData Limitations:

SIGNIFICANT INCIDENT REPORT TO TRUST BOARD JANUARY 2013

- 1 -

1.0 SUMMARY OF SIs (including Never Events) FOR OCTOBER-DECEMBER 2012

1.1 New SIs:

Oct 8

Nov 11

Dec 17

Total 36

1.2 Completed SIs:

Oct 14

Nov 5

Dec 13

Total 32

1.3 Never events:

No. of Never Events reported this quarter: 2

Types of Never event:

1. Wrong-site surgery 22/11/2012

Lumbar decompression at incorrect level

2. Retained foreign object post-operation 22/12/2012

Swab found in abdomen from previous surgery


- 2 -

1.4 New SIs by Specialty and Type of Adverse Event

An

aest

he

sia

and

pai

n

serv

ice

s

Car

dia

c/

Tho

raci

cSu

rge

ry

Co

lore

ctal

Surg

ery

Eme

rge

ncy

De

par

tme

nt

End

ocr

ino

logy

Gas

tro

en

tero

logy

Ge

ne

ralS

urg

ery

ICT

Infe

ctio

nC

on

tro

l

Car

dio

logy

Ge

ron

tolo

gy

Re

nal

serv

ice

s

Ne

uro

logy

Ne

uro

surg

ery

Ort

ho

pae

dic

s

Pae

dia

tric

s

Pla

stic

surg

ery

Rad

iolo

gy

Re

spir

ato

rym

ed

icin

e

Re

tin

alSc

ree

nin

g

The

atre

s

Tota

l

Delay / difficulty in obtaining clinical assistance 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1

Bradycardia 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Breach of patient confidentiality 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 2

Unintended injury 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Delay 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1

Inadequate handover of care 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Fall from a height, bed or chair 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1

Failure of a device or equipment 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1

Missing needle/swab/instrument 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1

Accident of some other type or cause 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1

Other - Infection control incident 0 0 0 0 0 0 0 0 4 1 0 0 0 0 1 0 0 0 1 0 0 7

Treatment, procedure - other adverse event 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1

Failure of IT systems 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1

Retained needle/swab/instrument 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 2

Operation or procedure wrongly sited 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1

Fall on level ground 0 0 0 0 0 1 0 0 0 0 1 0 1 0 3 0 0 0 0 0 0 6

Unplanned admission/transfer to specialist care unit 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 2

Unexpected deterioration 0 0 0 0 0 0 0 0 0 0 0 2 0 1 0 0 0 0 0 0 0 3

Diagnostic images / specimens missing 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Delay or failure to monitor 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Totals: 1 2 1 1 1 1 1 1 4 1 1 3 1 2 7 1 1 1 3 1 1 36


- 3 -

1.5 Completed SIs by Specialty and Type of Adverse Event

An

aest

he

sia

and

pai

n

serv

ice

sC

ard

iac

/Th

ora

cic

Surg

ery

Eme

rge

ncy

De

par

tme

nt

End

ocr

ino

logy

Ge

ne

ralS

urg

ery

Gyn

aeco

logy

ICT

Infe

ctio

nC

on

tro

l

Ge

ron

tolo

gy

Mo

rtu

ary

Re

nal

serv

ice

s

Ne

uro

logy

Ne

uro

surg

ery

Ob

ste

tric

s

Ort

ho

pae

dic

s

Oth

er

Age

ncy

/Tr

ust

Pla

stic

surg

ery

Re

spir

ato

rym

ed

icin

e

The

atre

s

Tota

l

Delay / difficulty in obtaining clinical assistance 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1

Bradycardia 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Breach of patient confidentiality 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Unintended injury in the course of an operation or clin task 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

External - Confidentiality breach 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1

Failure to follow guidelines/procedures/policy 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1

Failure or overload of IT or telecommunications system 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1

Missing equipment / device 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Missing needle/swab/instrument 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1

Accident of some other type or cause 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1

Other - please specify in description 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Other - Infection control incident 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 1 0 3

Labour or delivery - other 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1

Referral declined by external agencies 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1

Fall on level ground 0 0 0 1 0 2 0 0 2 0 0 0 0 0 1 0 0 1 0 7

Stillbirth 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1

Suspected fall 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1

Unplanned admission / transfer to specialist care unit 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1

Unexpected deterioration following treatment/procedure 0 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 3

Diagnostic images / specimens missing 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1

Delay or failure to monitor 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 2

Totals: 1 2 1 1 3 2 2 2 4 1 1 1 1 3 2 1 1 2 1 32



30 JANUARY 2013


Subject: MortalityReport By: Meghana Pandit, Chief Medical OfficerAuthor: Alexander Brough, Mortality Review FacilitatorAccountable Executive Director: Meghana Pandit, Chief Medical Officer

GLOSSARY

Abbreviation In FullHSMR Hospital Standardised Mortality RatioSHMI Summary Hospital-Level Mortality IndicatorMRG Mortality Review Group



TitleApprox. Length


To provide the Trust Board with a quantitative summary of Trustwide mortality data for September 2012 (thereis a 2-month time lag for this data).

All mortality alerts are discussed at MRG on a monthly basis. If they are a negative alert (red or high relativerisk alert) they are investigated by an appropriate senior clinician and any findings are reported back to MRG.

Actions are agreed at this meeting and any further progress is again fed back to MRG.


The Trusts HSMR in October 2012 was 91.4, which is below the national benchmark of 100 and also below ourpeer group.

HSMR is a measure of in-hospital mortality. These deaths are attributed to the hospital where the patient entersthe health care system and is risk adjusted for several factors including palliative care.

The Trust’s SHMI in October 2012 was 107.39 which is above the national bench mark of 100.

SHMI is a different measure of mortality, which includes both in-hospital and 30 day mortality. These deaths areattributed to the hospital where the patient leaves the health care system and is risk adjusted for fewer factorsthan are used in HSMR and it excludes palliative care.

There are currently six HSMR alert investigations in progress at various stages of completion:

Four alerts with investigation in progress: Urinary Tract Infection Clip and Coil Aneurysms Complex Reconstruction of Hand and Foot Other Femoral Bypass



30 JANUARY 2013


Two alerts with investigation complete and actions are in progress: Therapeutic Transluminal Operations on Iliac Artery

Action: To pilot the risk scoring checklist and feedback to MRG in 3 months time - Oct2012.

Action: Further feedback will be given at January MRG

Repair of Abdominal Aortic Aneurysm (AAA) Action: Prospective audit of referrals from George Elliot hospital Action: Investigate follow up for elective patients.

Updates on the progress of these investigations will be presented at MRG in due course.


Rising mortality will indicate failure of implementation with internal safety measures.


The Trust Board are asked to RECEIVE and ACCEPT the report.

IMPLICATIONS:

Financial:


Governance:

Legal:

REVIEW:


DATA QUALITY:

Data/information Source:Data Quality Controls:Data Limitations:



30 JANUARY 2013


Time period SHMI (All Deaths)

July 2010 to June 2011 107.34

October 10 to September 11 105.25

January 2011 – December 2011 106.06

Apr 2011-Mar 2012 107.39

SUMMARY FOR DR FOSTER DATA – 31st October 2012(2 Month Time Lag)

Month All HSMR Non-ElectiveHSMR

ElectiveProcedures

AllProcedures

Peer Group (12)

October 2012 91.4 91.1 142.5 112.3 102.2

Nov 2011 – Oct 2012 96.0 96.1 101.6 102.9 105.1Month Red Alerts Green Alerts High Relative Risk

October 2012 0 2 0



30 JANUARY 2013


All HSMR Trend: November 2011 – October 2012

0

20

40

60

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100

120

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Peer Group (12) HSMR Trend: November 2011 – October 2012

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UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTREPORT TO THE TRUST BOARD: PUBLIC

30th

January 2013


Subject: Quality Governance CommitteeReport By: Tim Sawdon, Non-Executive DirectorAuthor: Paul Martin, Director of Clinical GovernanceAccountable Executive Director: Meghana Pandit, Chief Medical Officer

GLOSSARYAbbreviation In FullHRED Human Resources Equality & DiversityTER Training, Education and ResearchA&E Accident and EmergencyPALS Patient Advice Liaison ServiceHRMC Health Records Management CommitteeCQC Care Quality CommissionNHSLA National Health Service Litigation Authority


POWERPOINT PRESENTATION? Yes NoNB Presentations need to be submitted for inclusion in Board papersTitleApprox. Length


To advise Trust Board of the details of the Quality Governance Committee meeting on 13 November 2012

SUMMARY OF KEY ISSUES: Minutes, actions, and matters arising from October 2012 meeting all agreed HRED – Mandatory Training report to be submitted to this meeting in December. Equality & Diversity Report approved

by the Committee TER – Learning & Development Strategy is receiving extra focus. Chairman requested key areas for attention to be

highlighted in the next report. Patient Experience Committee – A work programme is being planned and a workshop formulated to discuss possible

projects the group could work on. Chairman to receive a copy of the draft strategy in advance Patient Safety Committee – Junior Doctors’ Survey has received a good response from the Deanery. The report was

approved. Information and IT Committee – report agreed and approved, no issues highlighted. Risk Committee – introduction of Datix was explained to the Committee and it was reported the system had been found

to be a very useful tool. Loss of data during retinal screening programme was reported and the meeting was advisedthat back ups are now taken to ensure any further problems are easily resolved.

Ad Hoc Reports -o 8.1 Care Quality Commission Registration report was presented and the meeting advised that 139 lines were worse

than expected and could trigger a CQC inspection in the future.o 8.2 Quality Account Priorities need to be agreed for next year’s account.o 8.3 Commendation expressed for the work carried out to eliminate grade 3 and 4 pressure sores. Report approved.o Friend & Family Test Results, actual scores will be presented to the Trust Board. Data collection methods could be

changing in 2013 and could change the way some external figures are represented.o Revised Schedule of Business, updated version to be presented to the meeting in December.o Quality Governance Committee Terms of Reference was presented to the Committee, detailing the reduction of Non

Executive Directors for QGC to 3. Assurance Report Wards 10 & 2. This report was compiled following concerns expressed by Trust Board in regard to

comments from a patient expressed on Impressions. Assessments and report on care have been carried out andrevealed that there were difficulties with staffing levels on Ward 10 which are now being addressed. On Ward 2 poornursing documentation existed and actions have been put in place to remedy this. The issue regarding handling ofcomplaints has also been resolved. Report was approved and the Chairman confirmed he would feed back to TrustBoard,

Report on Delayed Discharge to be submitted to the December meeting. Following a recent report from Deloittes, dashboards are to be reported regularly after approval from COG at next

meeting.

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUSTREPORT TO THE TRUST BOARD: PUBLIC

30th

January 2013



Identified within individual reports


For consideration by the Board

IMPLICATIONS:Financial: None Highlighted

HR / Equality & Diversity: None highlighted

Governance: Potential risk to compliance with CQC Registration outcomes re QRP

Legal: None

REVIEW:Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee 13.11.12 Remuneration CommitteeFinance and Performance Committee Executive MeetingAudit Committee

DATA QUALITY:Data/information Source:Data Quality Controls:Data Limitations:



30 January 2013


Subject: Finance and Performance Committee Minutes from 29 October2012 Meeting

Report By: Ms S Tubb, Non-Executive DirectorAuthor: Mrs G Nolan, Chief Finance OfficerAccountable Executive Director: Mrs G Nolan, Chief Finance Officer

GLOSSARY

Abbreviation In FullA&E Accident and emergencyC.diff Clostridium difficileCIP Cost improvement programmeIBP Integrated business planLTFM Long term financial modelOPPM Operational and Performance Planning MeetingPPMO Performance and Programmes Management OfficeSLR/PLC Service line reporting/patient level costing



TitleApprox. Length


To advise the Board of the Finance and Performance Committee meeting agenda for 24 September 2012 andof any key decisions/outcomes made by the Finance and Performance Committee.


DEVELOPMENT REPORTS – PPMO UpdateMrs Nolan updated the Committee on the recent appointment to the post of Director of Performance and ProgrammesManagement. The Committee noted the updated.DEVELOPMENT REPORTS – Integrated Performance ReportThe new performance and programme reporting framework was received by the Committee and agreed the draft TrustBalanced Scorecard. The Trust Balanced Scorecard is to be scrutinised by the Committee prior to submission to the TrustBoard. The Committee noted the contents of the report, agreed the draft Trust Balanced Score Card and that the ScoreCard should be scrutinised by the Committee before being submitted to the Trust Board.

DEVELOPMENT REPORTS – Financial Planning Update, to include efficiency strategyThe financial plan for 2013/14 has been drafted. The Committee considered the initial plan for 2013/14, notedthe plan assumptions and considered the risks associated with the plan. The Committee agreed to thedifferential approach to allocate the CIP and to confirm to the Trust Board the basis on which the LTFM isaligned to the draft IBP. The Committee also agreed to receive updates of the financial plan at future meetings.DEVELOPMENT REPORTS – LTFM for IBP SubmissionThe LTFM was presented which will form the financial section of the IBP. The Committee received the presentation andaccepted the need for fundamental service changes, whilst acknowledging that growth was open to the Trust in some areasthat were not available to other smaller Trusts.DEVELOPMENT REPORTS – Board Governance Assurance Framework (Finance) UpdateThe Report was received by the Committee.PERFORMANCE REPORTS – Key Performance IndicatorsThe Key Performance Indicators were presented and the Committee noted that performance for September had improvedagainst the C.diff target but performance against the delayed transfers of care target continued to fail. The 4 hour A&Etarget remained a significant challenge with performance being just below target for the month and year to date. In order toimprove performance, a pilot scheme had been put in place to increase the numbers of discharges daily.



30 January 2013


PERFORMANCE REPORTS – OPPM Feedback ReportThe Committee noted that Round 7 of the OPPM meetings had been cancelled and discussions with the Clinical Directorswill take place regarding the role and function of the meetings.PERFORMANCE REPORTS – Update on Newton Efficiency ReportsThe Committee received the report and were advised that the Director of Service Improvement will validate the savingsmade against the costs.FINANCE REPORTS – Integrated Finance ReportThe Integrated Finance Report was received by the Committee and attention was drawn to salient points within the report.FINANCE REPORTS – CIP UpdateAn update on progress with regard to the Cost Improvement Programme was received and focus given to the programmefor the next 3 years.FINANCE REPORTS – Finance Risk RegisterThe Risk Register was presented to the Committee.FINANCE REPORTS – Costing (including SLR/PLC)The Committee noted the numbers and the ongoing work. There was acknowledgement that the information is a means ofallocating the efficiency target.ADMINISTRATIVE MATTERS – Workplan and Draft Agenda for November meetingThe Workplan was approved but it was acknowledged that the plan would change with the new Integrated PerformanceReport. There was no need to specify on the agenda the performance escalation reports. It was agreed that for futureagendas, the Finance Risk Register should be annotated for information only.


No significant risks were identified.


The Board is asked to review and note the minutes of the Finance and Performance Committee meeting heldon 29 October 2012.

IMPLICATIONS:

Financial:


Governance:

Legal:

REVIEW:


DATA QUALITY:



REPORT TO TRUST BOARD: PUBLIC

30th

JANUARY 2013

Subject: Provider Management RegimeReport By: David Eltringham, Chief Operating OfficerAuthor: Simon Reed, Senior Performance ManagerAccountable Executive Director: David Eltringham, Chief Operating Officer

GLOSSARYAbbreviation In FullDH Department of HealthUHCW University Hospitals Coventry and WarwickshireSHAs Strategic Health AuthoritiesPCTs Primary Care TrustsPMR Provider Management Regime



TitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:The SHA wide Provider Management Regime (PMR) has been rolled out which each Trust is required tocomplete on a monthly basis.

The PMR was introduced in shadow form for East Midlands and West Midlands Trusts during the periodJanuary to February 2012. The return from Trusts for March 2012 was reported at the SHA’s public boardmeeting in May 2012. The PMR process has been fully operational from April 2012 onwards. This regime wasintroduced to support Trusts, by working with the SHA in a “Monitor like” way, to help prepare Trusts for theirDH and Monitor Foundation Trust assessment and subsequent monitoring post authorisation under the MonitorCompliance Framework.

The regime provides an opportunity for providers to earn autonomy from the SHA. Providers who candemonstrate consistent performance of governance, finance, quality and contract management will make lessfrequent PMR returns and meet with the SHA less often than those Trusts that face issues. There is also aclear escalation process for Trusts with persistently poor ratings or other issues. The detailed processes andrules by which a Trust can gain autonomy or might face escalation are outlined within separate SHA guidance.

The first return of the Provider Management Regime templates to the SHA was on the last working day ofJanuary (31 January 2012); and is required on the last working date of every month thereafter. Latesubmissions are automatically given a red governance risk rating. The expectation is that the monthly templatereturns are signed off by the Trust Board.

The East and Midlands SHA published the new PMR process for 2012/13. A new section of the return hasbeen included for Trusts to demonstrate progress against their Tripartite Formal Agreement (TFA) to become aFoundation Trust. A new performance metric has been included in the Governance Risk Ratings (GRR)section (patients on an incomplete, 18-week pathway) and new overriding rules have been applied that willeffect performance where these rules are not being satisfied. In additional a new quality metric has beenincluded in the Quality section (completion of consultant personal development plans) and new detail is to besubmitted regarding financial and contractual performance. Further amendments have been included in arevision to the PMR template for December including changes to the GRR, Financial Trigger and Contractualsections. Errors in the template have been identified in the spreadsheet which are being progressed with theSHA. The following metrics have been removed from the PMR:

GRR Section - Line 8b: Quality – A&E Financial Risk Triggers Section - Line 3: FRR 2 for any one quarter



30th

JANUARY 2013

The East and Midlands SHA have confirmed that the overriding rules in the Governance Risk Rating Section ofthe PMR will be applied at their discretion. The Overriding Rules are the same as the governance red-ratedoverrides in the 2012/13 Monitor Compliance Framework. Using this framework, Monitor may apply theoverriding rules where Foundation Trusts are not compliant and escalate the Trust for consideration as towhether it is in significant breach. If Monitor is satisfied a Trust is in significant breach they have the discretionto intervene. The SHA have confirmed that they will be taking a similar approach to Monitor and Trust’s whoseoverriding rules have been applied will be deemed “unauthorisable”.

SUMMARY OF KEY ISSUES:Based on the data provided by the relevant leads the Trust risk ratings are as detailed below:

PERIODGovernanceRisk Rating

FinancialRisk Rating

ContractualPosition

PMRVersion

APR-12Amber/Green

(1.0)Green (3.0) Amber 1

stversion

MAY-12Amber/Green


stversion

JUN-12Amber/Red


stversion

JUL-12 Green (1.0) Red (2.0) Blank 2nd

versionAUG-12 Green (1.0) Red (2.0) Blank 2

ndversion

SEP-12 Green (0.0) Red (2.0) Blank 2nd

versionOCT-12 Red (4.0) Red (2.0) Blank 2

ndversion

NOV-12 Red (4.0) Red (2.0) Blank New versionDEC-12 Red (4.0) Red (2.0) Blank New version

The deteriorated Governance Risk Rating for December 2012 is because the overriding rule has been appliedby the SHA which automatically gives an overall weighting of 4. This has retrospectively been applied back toOctober 2012 (see below)

Note: the scoring in the revised PMR return has changed so that a GRR weighing of greater than or equal to 1but less than 2 will give a rating of Amber/Green (in the previous version used for reporting performance forJuly to October 2012 a score of 1 or under gave a rating of Green). The SHA clarified this change in January2013. Furthermore, the SHA are in the process of resolving an error in the GRR section of the PMR templatewhich is incorrectly applying an additional weighting against the c-diff metric. The Contractual Position is nolonger rated in the PMR return and guidance from the SHA is that this should be reported as “Blank”.

Appendix A is UHCW’s proposed submission to the SHA at the end of January 2013.

Specified areas of insufficient assurance and associated actions are:

A&E - maximum waiting time of four hours from arrival to admission/transfer/discharge: The LeadershipTeam have consolidated all actions being taken to address this issue into a single consolidated action planwhich deals with: Prehospital, Arrival at ED, Capacity and flow, Internal discharges, External discharges.The plan is subject to performance management at Tuesday and Thursday meetings with ClinicalDirectors.

Financial Risk Rating (FRR) - The Trust is reporting an FRR of 2 based on the year-to-date position. Thegovernance declaration is now based on the year-to-date FRR (forecast outturn in previous months) as pera change in the SHA guidance. The year-to-date position means an FRR of 2, although this remains theTrust plan for this point in the year. The Trust continues to forecast an FRR 3 for the financial year, withthe improvement being delivered by delivery of the forecast surplus position.

The Overriding Rule which has been applied by the SHA is:

A&E Clinical Quality Indicator: UHCW did not achieve the 95%, 4-hour A&E target in Q4 2011/12. The targetwas not achieved in Q1 2012/13. UHCW has therefore failed to meet the A&E target twice in any two quarters



30th

JANUARY 2013

over the last 12 months. UHCW did not achieve the target in October, November or December 2012 and at thetime of writing this report achievement of the target for January 2013 was at risk. The SHA have confirmed theoverriding rule has been applied retrospectively from October 2012 because this target has been failed in thesubsequent nine-month period from Q1 2012/13. This means that UHCW is in escalation. However, the SHAhave advised that they will recommend mitigation of UHCW’s red status due to the overriding rule for A&E ifthere is evidence of a sustained improvement and delivery against the A&E target for a 6-month period.


The Governance Risk Rating and Financial Risk Rating are showing as Red The overriding rule against the 95%, 4-hour A&E target has been applied by the SHA for

October, November and December 2012


Trust Board to approve the Provider Manager Regime return based on December 2012 data for onwardsubmission to the SHA.

Trust Board to confirm its support for Governance Declaration 2 (for insufficient assurance that all targetsare being met) in relation to the Financial Risk Rating and A&E.

IMPLICATIONS:Financial: N/A

HR / Equality & Diversity: N/A

Governance: Performance against the PMR submission will impact on the trusts ability tomove forward with its Foundation Trust application

Legal: N/A


DATA QUALITY:


SELF-CERTIFICATION RETURNS

Organisation Name:

University Hospitals Coventry & Warwickshire NHS Trust

Monitoring Period:

December 2012

NHS Trust Over-sight self certification template

Returns [email protected] by the

last working day of each month

2012/13 In-Year Reporting

Name of Organisation: Period: December 2012

Organisational risk rating

* Please type in R, AR, AG or G and assign a number for the FRR

Governance Declarations

Supporting detail is required where compliance cannot be confirmed.

Governance declaration 1

Signed by: Print Name:

on behalf of the Trust Board Acting in capacity as:

Signed by: Print Name:

on behalf of the Trust Board Acting in capacity as:

Governance declaration 2

Signed by : Print Name :AndrewHardy

on behalf of the Trust Board Acting in capacity as: Chief Executive Officer

Signed by : Print Name :Philip

Townshend

on behalf of the Trust Board Acting in capacity as: Chairman

If Declaration 2 has been signed:

Target/Standard:

The Issue :

Action :

Target/Standard:The Issue :

Action :

Target/Standard:The Issue :Action :



The governance declaration is now based on the year-to-date FRR (forecast outturn in previous months)as per a change in the SHA guidance.

The year-to-date position means an FRR of 2, although this remains the Trust plan for this point in theyear.

The Trust continues to forecast an FRR 3 for the financial year, with the improvement being delivered bydelivery of the forecast surplus position.

For each target/standard, where the board is declaring insufficient assurance please state the reason for being unable to sign the declaration, and explainbriefly what steps are being taken to resolve the issue. Please provide an appropriate level of detail.

A&E: total time in A&E

Increased A&E attendances, increased medical admissions, high acuity and norovirus. Extensive

analysis has been undertaken to investigate these further.

The Leadership Team have consolidated all actions being taken to address this issue into a singleconsolidated action plan which deals with: Prehospital, Arrival at ED, Capacity and flow, Internaldischarges, External discharges. The plan is subject to performance management at Tuesday and

Thursday meetings with Clinical Directors.

Financial Risk RatingThe Trust is reporting an FRR of 2 based on the year-to-date position

At the current time, the board is yet to gain sufficient assurance to declare conformity with all of the Clinical Quality, Finance and Governance elements of theBoard Statements.

Normalised YTD Financial Risk Rating (Assign number as per SOM guidance) 2

Declaration 1 or declaration 2 reflects whether the Board believes the Trust is currently performing at a level compatible with FT authorisation.

Please complete sign one of the two declarations below. If you sign declaration 2, provide supporting detail using the form below. Signature may be eitherhand written or electronic, you are required to print your name.

The Board is sufficiently assured in its ability to declare conformity with all of the Clinical Quality, Finance and Governance elements of the BoardStatements.

Governance Risk Rating (RAG as per SOM guidance) R

NHS Trust Governance Declarations :

University Hospitals Coventry & Warwickshire

NHS Trust

Each organisation is required to calculate their risk score and RAG rate their current performance, in addition to providing comment with regard to anycontractual issues and compliance with CQC essential standards:

Key Area for rating / comment by Provider Score / RAG rating*

For each statement, the Board is asked to confirm the following:

For CLINICAL QUALITY, that: Response

1

2 3

For FINANCE, that: Response

4 5

For GOVERNANCE, that: Response

6

7

8

9

10

11

12

13

14

15 Signed on behalf of the Trust: Print name Date

CEO Andrew Hardy

Chair Philip Townshend

December 2012

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

The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after theapplication of thresholds) as set out in the Governance Risk Rating; and a commitment to comply with all commissionedtargets going forward.

The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to theSOM's Oversight Regime (supported by Care Quality Commission information, its own information on serious incidents,patterns of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place,effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to itspatients.

The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care QualityCommission’s registration requirements.

The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care onbehalf of the trust have met the relevant registration and revalidation requirements.

The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months.

All current key risks have been identified (raised either internally or by external audit and assessment bodies) andaddressed – or there are appropriate action plans in place to address the issues – in a timely manner

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

The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience andskills to discharge their functions effectively, including setting strategy, monitoring and managing performance andrisks, and ensuring management capacity and capability.

The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accountingstandards in force from time to time.


The necessary planning, performance management and corporate and clinical risk management processes andmitigation plans are in place to deliver the annual plan, including that all audit committee recommendations accepted bythe board are implemented satisfactorily.

The trust has achieved a minimum of Level 2 performance against the requirements of the Information GovernanceToolkit.

The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests,ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, orplans are in place to fill any vacancies, and that any elections to the shadow board of governors are held in accordancewith the election rules.

Board Statements

The board will ensure that the trust at all times has regard to the NHS Constitution.

The board has considered all likely future risks and has reviewed appropriate evidence regarding the level of severity,likelihood of occurrence and the plans for mitigation of these risks.

Information to inform the discussion meeting

Unit Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Board Action

1 SHMI - latest data Score 106.0 107.3 107.3 105.3 105.3 105.3 106.1 106.1 106.1 107.4 107.4 107.4

The SHMI is produced and published quarterly by the NHS

IC. 107.4 relates to published data in November. SHMI's first

publication was end of October 2011

2Venous Thromboembolism (VTE)

Screening% 94.2 94.7 93.8 93.4 93.3 92.3 93.1 93.3 92.6 93 93.68 93.64

3a Elective MRSA Screening % 129.26 131.67 126.81 137.96 125.52 136.36 135.22 136.62 137.37 137.6 140.8 129.961453 tests were undertaken on patients needing screening

out of the 1118 total number of admissions.

3b Non Elective MRSA Screening % 70.8 69.3 65.4 65.3 70.0 69.9 70.3 71.1 76.2 70.3 72 69.42

4Single Sex Accommodation

BreachesNumber 0 0 0 0 0 0 0 0 0 0 0 0

5Open Serious Incidents Requiring

Investigation (SIRI)Number

21

4

7

3

24

2

16

7

16

1

22

2

24

6

19

7

21

7

21

5

22

7

28

1

Open SIRIs

Number that were over the 45 day target on the last day of

the month.

NB Sep-Nov 2011 data was not collected. Since the figures

are a snap-shot on the day, this data cannot be gathered

retrospectively.NB -

6 "Never Events" occurring in month Number 1 0 0 0 0 1 0 0 0 0 1 1

Never events - 1. confirmed retained swab post-operatively

2. Wrong-site surgery (lumbar decompression)

3. Retained foreign object post-op

7 CQC Conditions or Warning Notices Number 0 0 0 0 0 0 0 0 0 0 0 0

8Open Central Alert System (CAS)

AlertsNumber 19 15 13 12 13 13 11

9

2

8

2

8

1

7

2

5

2

5 open CAS alerts. 2

outstanding with "Action Required - Ongoing"2

9RED rated areas on your maternity

dashboard?Number 4 0 4 2 2 1 2 3 2 4 3 4

1. 7 Meconium Aspirates 2. C/ S

Rate in month 27.22% 3. Smoking At

Delivery 13.27%

10Falls resulting in severe injury or

deathNumber 0 1 0 0 2 3 4 1 2 3 2 4

interpreted as those falls incidents graded as 'major' or

'catastrophic'

11 Grade 3 or 4 pressure ulcers Number 6 8 2 2 1 4 0 3 0 0 2 0 Hospital Acquired - avoidable

12100% compliance with WHO surgical

checklistY/N N N N N N N N N N N N N

Dec-11 94.6%, Jan-12 94.8%, Feb-12 94.4%, Mar-12

96.4%, Apr-12 97.7%, May-12 98.4%, Jun-12 98.9%, Jul-12

99.2%, Aug-12 99.1%, Sep-12 99.6%, Oct 99.2%, Nov

99.5%, Dec 99.7%

13 Formal complaints received Number 35 37 44 41 44 29 48 45 47 40 37 36

14Agency as a % of Employee Benefit

Expenditure% 1.54 2.19 3.43 2.88 3.17 2.94 3.39 4.1 2.84 4.23 3.7 3.17

Historic and current information changed to reflect the

different definition. Agency costs ONLY as a % of Employee

Benefit Costs - previously Agency & Bank as a % of Turnover

15 Sickness absence rate % 4.26% 5.22% 4.24% 4.59 4.69 4.73 4.62 4.32 4.56 4.79 5.23 5

16Consultants which, at their last

appraisal, had fully completed their

previous years PDP

% 59.48 58.67 52.34 50.6 55.74 53.39 46.23 52.98 55.62 57.49 59.94 63.93

The figure provided here is based on the number of

Consultants whom have completed an appraisal within the

previous rolling 12 months as extracted from ESR. Part of

the appraisal process incorporates a discussion on the

previous year’s objectives and PDP and therefore the figure

provided presumes that all appraisals have included such

discussions


Insert Performance in Month

QUALITY

Criteria

Refresh Data for new Month

Criteria Indicator Weight 5 4 3 2 1Year to

Date

Forecast

Outturn

Year to

Date

Forecast

OutturnBoard Action

Underlyingperformance

EBITDA margin % 25% 11 9 5 1 <1 3 4 3 4YTD deficit position means that this metric isbelow the forecast outturn value (based ondelivery of the surplus plan)

Achievementof plan

EBITDA achieved % 10% 100 85 70 50 <50 4 4 4 4The Trust has delivered EBITDA within 85% ofplan YTD

Net return after financing % 20% >3 2 -0.5 -5 <-5 2 3 2 3YTD deficit position means that this metric isbelow the forecast outturn value (based ondelivery of the surplus plan)

I&E surplus margin % 20% 3 2 1 -2 <-2 2 2 2 2YTD deficit position means that this metric isbelow the forecast outturn value (based ondelivery of the surplus plan)

Liquidity Liquid ratio days 25% 60 25 15 10 <10 1 2 1 2YTD deficit position means that this metric isbelow the forecast outturn value (based ondelivery of the surplus plan)

100% 2.2 2.9 2.2 2.9

2 3 2 3

2 3 2 3

£4.5m of transitional support contained withinthe main commissioner contract to supportrecurrent delivery of the QIPP agenda has beennormalised out of the posititon

Overriding Rules :

Max Rating

3 No3 No2 No2 Unplanned breach of the PBC No2 2 23 3 3 3 312

* Trust should detail the normalising adjustments made to calculate this rating within the comments box.

FINANCIAL RISK RATING

Financialefficiency

Rule

Weighted Average

Overriding rules

University Hospitals Coventry &Warwickshire NHS Trust

Risk Ratings

Overall rating

Insert the Score (1-5) Achieved for each

Criteria Per Month

Normalised

Position*

Plan not submitted complete and correct

Reported

Position

Two Financial Criteria at "2"

One Financial Criterion at "1"One Financial Criterion at "2"

PDC dividend not paid in full

Two Financial Criteria at "1"

Plan not submitted on time

FINANCIAL RISK TRIGGERS

CriteriaQtr to

Mar-12

Qtr to

Jun-12

Qtr to

Sep-12Oct-12 Nov-12 Dec-12

Qtr to

Dec-12Board Action

1Unplanned decrease in EBITDA margin in two consecutivequarters

Yes Yes Yes Yes Yes Yes YesEBITDA performance below trajectory in Q1 of 2012/1, Q2 andQ3 of 2012/13

2Quarterly self-certification by trust that the normalisedfinancial risk rating (FRR) may be less than 3 in the next12 months

No No Yes Yes Yes Yes Yes

Due to change in guidance from the SHA as to which FRRshould be used to measure. The Trust was previously usingthe forecast outturn FRR for 2012/13 and 2013/14 to informthis assessment and is now using the YTD position forecast bymonth for the curren

3Working capital facility (WCF) agreement includes defaultclause

N/a N/a N/a N/a N/a N/a N/a

4Debtors > 90 days past due account for more than 5% oftotal debtor balances

Yes Yes Yes Yes Yes Yes YesAction - Increased focus on debt recovery

5Creditors > 90 days past due account for more than 5% oftotal creditor balances

Yes Yes Yes Yes Yes Yes YesIssues around large intra-NHS balances

6Two or more changes in Finance Director in a twelvemonth period

No No No No No No No

7Interim Finance Director in place over more than onequarter end

Yes No No No No No NoSubstantive FD appointed in Jan 2012

8 Quarter end cash balance <10 days of operating expenses Yes Yes Yes Yes Yes Yes YesImprovement requires ongoing increases in liquidity - M82012/13 position also <10 days of operating expenditure

9 Capital expenditure < 75% of plan for the year to date No No No No No No No

10 Yet to identify two years of detailed CIP schemes Yes Yes YesDevelopment of 2 years of CIP schemes is progressing but notyet complete


Insert "Yes" / "No" Assessment for the Month

Historic Data Current Data

Refresh Triggers for New Quarter

See 'Notes' for further detail of each of the below indicators

Area Ref Indicator Sub SectionsThresh-

old

Weight-

ing

Qtr to Mar-

12

Qtr to

Jun-12

Qtr to


Qtr to

Dec-12Board Action

Referral to treatment information 50%

Referral information 50%

Treatment activity information 50%

Patient identifier information 50% N/a N/a N/a N/a N/a N/a Yes

Patients dying at home / care home 50% N/a N/a N/a N/a N/a N/a Yes

1c Data completeness: identifiers MHMDS 97% 0.5 N/a N/a N/a N/a N/a N/a Yes

1cData completeness: outcomes for patientson CPA

50% 0.5 N/a N/a N/a N/a N/a N/a Yes

2aFrom point of referral to treatment inaggregate (RTT) – admitted

Maximum time of 18 weeks 90% 1.0 Yes Yes Yes Yes yes yes Yes

2bFrom point of referral to treatment inaggregate (RTT) – non-admitted

Maximum time of 18 weeks 95% 1.0 Yes Yes Yes yes yes yes Yes

2cFrom point of referral to treatment inaggregate (RTT) – patients on anincomplete pathway

Maximum time of 18 weeks 92% 1.0 Yes Yes Yes yes yes yes Yes

2d

Certification against compliance withrequirements regarding access tohealthcare for people with a learning

disability

N/A 0.5 Yes Yes Yes Yes Yes Yes Yes

Surgery 94%

Anti cancer drug treatments 98%

Radiotherapy 94%

From urgent GP referral forsuspected cancer

85%

From NHS Cancer ScreeningService referral

90%

3cAll Cancers: 31-day wait from diagnosis tofirst treatment

96% 0.5 Yes Yes Yes Yes yes yes Yes

all urgent referrals 93%

for symptomatic breast patients(cancer not initially suspected)

93%

3eA&E: From arrival to

admission/transfer/dischargeMaximum waiting time of four hours 95% 1.0 No No Yes No No No No

During December 2012, 2,169 patients out of

16,637 attendances at A&E were seenoutside of 4 hours. This means that

UHCW’s performance was at 86.96% or

8.04% below the minimum performance

threshold of 95%. However, this

performance threshold is based on thecumulative position and cumulatively for the

period April to December 2012, 8,940

patients out of 138,670 attendances at A&E

were seen outside of 4 hours. This means

that UHCW’s cumulative performance wasat 93.55% or 1.45% below the minimum

performance threshold of 95%.

ACTIONS:

The Leadership Team have consolidated all

actions being taken to address this issue intoa single consolidated action plan which deals

with:

o Prehospital

o Arrival at ED

o Capacity and flowo Internal discharges

o External discharges

This plan is subject to performancemanagement at Tuesday and Thursday

meetings with Clinical Directors

Receiving follow-up contact within 7days of discharge

95%

Having formal reviewwithin 12 months

95%

3gMinimising mental health delayed transfersof care

≤7.5% 1.0 N/a N/a N/a N/a N/a N/a Yes

3hAdmissions to inpatients services hadaccess to Crisis Resolution/Home

Treatment teams


3iMeeting commitment to serve newpsychosis cases by early intervention

teams


Red 1 80% 0.5 N/a N/a N/a N/a N/a N/a Yes

Red 2 75% 0.5 N/a N/a N/a N/a N/a N/a Yes

3kCategory A call – ambulance vehicle

arrives within 19 minutes95% 1.0 N/a N/a N/a N/a N/a N/a Yes

Is the Trust below the de minimus 12 No No No No No No No

Is the Trust below the YTD ceiling 70 No No Yes Yes Yes Yes Yes

Is the Trust below the de minimus 6 Yes Yes Yes Yes Yes Yes Yes

Is the Trust below the YTD ceiling 2 Yes Yes Yes Yes Yes Yes Yes

CQC Registration

ANon-Compliance with CQC EssentialStandards resulting in a Major Impact on

Patients

0 2.0 No No No No No No No

BNon-Compliance with CQC EssentialStandards resulting in Enforcement Action


C

NHS Litigation Authority – Failure tomaintain, or certify a minimum publishedCNST level of 1.0 or have in place

appropriate alternative arrangements


TOTAL 2.0 2.0 1.0 2.0 2.0 2.0 2.0

Yes

In July we had 1 MRSA. YTD there hasbeen 1 MRSA case which is 1 (50%) below

the trajectory of 2.

In December 2012 there were 7 c-diffinfections in UHCW. YTD there have been

53 cases which is 1 (1.85%) below the

trajectory of 54 cases. The SHA haveconfirmed the spreadsheet is applying a

weighting of 1 for this metric where Trustsare exceeding the de minimus level but they

are within the YTD ceiling. Therefore the

overall weighting for Dec-12 should be 1(Amber/Green) and not 2

Sa

fety

1.0

1.0

3a

3b All cancers: 62-day wait for first treatment:

1.0

Care Programme Approach (CPA)patients, comprising:

All cancers: 31-day wait for second or

subsequent treatment, comprising:

Pa

tie

nt

Exp

erie

nce

Qu

alit

y

0.5

1.01a

1bData completeness, community services:

(may be introduced later)

Category A call –emergency response

within 8 minutes3j

1.0

GOVERNANCE RISK RATINGS

Insert YES, NO or N/A (as appropriate)

Eff

ective

ne

ss

N/aData completeness: Community servicescomprising:


NHS Trust

Yes

Yes

Yes

Yes

3f

YesCancer: 2 week wait from referral to date

first seen, comprising:3d

N/a

Yes Yes Yes yes yes

1.0

yesyesYes

MRSA4b

4a Clostridium Difficile

yes

N/a

YesYes

Yes

N/a N/a

N/a

Yes

N/a

yes

N/aN/a

N/a N/a

Yes

Yes

Yes

N/a

Current DataHistoric Data

Refresh GRR for New Quarter

See 'Notes' for further detail of each of the below indicators

GOVERNANCE RISK RATINGS

Insert YES, NO or N/A (as appropriate)


NHS Trust

Current DataHistoric Data

Refresh GRR for New Quarter

RAG RATING : AR AR AG AR AR AR AR

Overriding Rules - Nature and Duration of Override at SHA's Discretion

i) Meeting the MRSA Objective

iv) A&E Clinical Quality Indicator Yes Yes Yes Yes

UHCW did not achieve the 95%, 4-hour A&E

target in Q4 2011/12. The target was notachieved in Q1 2012/13. UHCW has

therefore failed to meet the A&E target twice

viii) Any other Indicator weighted 1.0

Adjusted Governance Risk Rating 2.0 2.0 1.0 4.0 4.0 4.0 4.0

AR AR AG R R R R

GREEN = Score less than 1

iii) RTT Waiting Times

AMBER / RED = Score greater than or equal to 2, but less than 4

Meeting the C-Diff Objective

RED = Score greater than or equal to 4

v)

Fails to meet the A&E target twice in any two quarters over a12-month period and fails the indicator in a quarter during thesubsequent nine-month period or the full year.

ii)

Greater than six cases in the year to date, and breaches thecumulative year-to-date trajectory for three successivequarters

Cancer Wait Times

Greater than 12 cases in the year to date, and either:

Reports important or signficant outbreaks of C.difficile, asdefined by the Health Protection Agency.

Breaches the cumulative year-to-date trajectory for threesuccessive quarters

AMBER/GREEN = Score greater than or equal to 1, but less than 2

The incomplete pathway 18 weeks waiting time measure fora third successive quarter

Breaches either:

the 31-day cancer waiting time target for a third successivequarter

the 62-day cancer waiting time target for a third successivequarter

Breaches:

The admitted patients 18 weeks waiting time measure for athird successive quarter

The non-admitted patients 18 weeks waiting time measurefor a third successive quarter

the category A 8-minute response time target for a thirdsuccessive quarter

either Red 1 or Red 2 targets for a third successive quarter

the category A 19-minute response time target for a thirdsuccessive quarter

vii) Community Services data completeness

Fails to maintain the threshold for data completeness for:

vi) Ambulance Response Times

Breaches either:

Breaches the indicator for three successive quarters.

referral to treatment information for a third successivequarter;

service referral information for a third successive quarter, or;

treatment activity information for a third successive quarter

Qtr to

Mar-12

Qtr to

Jun-12

Qtr to


Qtr to

Dec-12Board Action

1 Are the prior year contracts* closed? Yes Yes Yes Yes Yes Yes Yes

2Are all current year contracts* agreed andsigned?

Yes Yes Yes Yes Yes Yes Yes

3Has the Trust received income support outsideof the NHS standard contract e.g.transformational support?

Yes Yes Yes Yes Yes Yes YesThe Trust has received non-recurrenttransitional support for the achievement ofQIPP and general efficiency metrics

4Are both the NHS Trust and commissionerfulfilling the terms of the contract?

Yes Yes Yes Yes Yes Yes Yes

5Are there any disputes over the terms of thecontract?


6Might the dispute require third party interventionor arbitration?


7 Are the parties already in arbitration? No No No No No No No

8 Have any performance notices been issued? Yes Yes Yes No No Yes Yes A contract query has been issued withregard to the Trusts A&E performance in

9 Have any penalties been applied? Yes Yes Yes No No No No

*All contracts which represent more than 25% of the Trust's operating revenue.

Current Data

Insert "Yes" / "No" Assessment for the Month


Criteria

CONTRACTUAL DATA

Information to inform the discussion meeting

Historic Data

Refresh Data for new Quarter

TFA Progress

Jan-13

Milestone

DateDue or Delivered

MilestonesFuture Milestones Board Action

1SHA Interviews with the board, SHA initial meeting with thecommissioners

Mar-12 Fully achieved in timeCompleted

2 SHA/UHCW discussion of IBP/LTFM & PMR escalation meeting Mar-12 Fully achieved in timeCompleted

3 Self-assessment completion of BGAF Mar-12 Fully achieved in timeCompleted but will be refreshed during late 2012/early 2013 for external

assessment in March 2013

4 Submit 1st draft of IBP/LTFM and authorization for HDD1 refresh Nov-12 Fully achieved in time Completed

5Trust complete self-assessment against quality dashboard and submit tothe SHA

Mar-13 On track to deliver

6 HDD1 Jan-13 On track to deliver Draft report received. Final report awaited.

7 Submit high quality draft of IBP/LTFM to SHA Jan-13 On track to deliver Board seminars held and scheduled including IBP development

8 Final Draft of the IBP/LTFM to the SHA Feb-13 On track to deliver Board seminars held and scheduled including IBP development

9 CQC Opinion received by SHA (SHA action) Mar-13 On track to deliver This is an SHA action

10 HDD 2 Mar-13 On track to deliver Date to be confirmed with HDD auditors and agreed with SHA.

11 NTDA interview with lead HDD reviewer May-13 On track to deliver NTDA action

12 Complete IBP/LTFM and appendices submitted to SHA Apr-13 On track to deliver Dates TBC by SHA/NTDA

13NTDA/UHCW Board to Board (Full Voting Board), includes review ofPMR

May-13 On track to deliver Dates TBC by SHA/NTDA

14 Submit FT application to the DH Jun-13 On track to deliver

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

TFA Milestone (All including those delivered)


Select the Performance from the drop-down list

Notes

Ref Indicator Details

Thresholds

1a

DataCompleteness:CommunityServices

Data completeness levels for trusts commissioned to provide community services, using Community Information Data Set (CIDS) definitions, toconsist of:- Referral to treatment times – consultant-led treatment in hospitals and Allied Healthcare Professional-led treatments in the community;- Community treatment activity – referrals; and- Community treatment activity – care contact activity.

While failure against any threshold will score 1.0, the overall impact will be capped at 1.0. Failure of the same measure for three quarters willresult in a red-rating.

Numerator:

all data in the denominator actually captured by the trust electronically (not solely CIDS-specified systems).

Denominator:

all activity data required by CIDS.

1b DataCompletenessCommunityServices (furtherdata):

The inclusion of this data collection in addition to Monitor's indicators (until the Compliance Framework is changed) is in order for the SHA totrack the Trust's action plan to produce such data.

This data excludes a weighting, and therefore does not currently impact on the Trust's governance risk rating.

1c Mental HealthMDS

Patient identity data completeness metrics (from MHMDS) to consist of:- NHS number;- Date of birth;- Postcode (normal residence);- Current gender;- Registered General Medical Practice organisation code; and- Commissioner organisation code.

Numerator:

count of valid entries for each data item above.(For details of how data items are classified as VALID please refer to the data quality constructions available on the Information Centre’swebsite: www.ic.nhs.uk/services/mhmds/dq)

Denominator:

total number of entries.1d Mental Health:

CPAOutcomes for patients on Care Programme Approach:

• Employment status:

Numerator:

the number of adults in the denominator whose employment status is known at the time of their most recent assessment, formal review or othermulti-disciplinary care planning meeting, in a financial year. Include only those whose assessments or reviews were carried out during thereference period. The reference period is the last 12 months working back from the end of the reported month.

Denominator:

the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during thereported month.

• Accommodation status:

Numerator:

the number of adults in the denominator whose accommodation status (i.e. settled or non-settled accommodation) is known at the time of theirmost recent assessment, formal review or other multi-disciplinary care planning meeting. Include only those whose assessments or reviews werecarried out during the reference period. The reference period is the last 12 months working back from the end of the reported month.

Denominator:

the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during the reported month.

• Having a Health of the Nation Outcome Scales (HoNOS) assessment in the past 12 months:

Numerator:

The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months.

Denominator:

The total number of adults who have received secondary mental health services and who were on the CPA during the reference period.

2a-c RTT

Performance is measured on an aggregate (rather than specialty) basis and trusts are required to meet the threshold on a monthly basis.Consequently, any failure in one month is considered to be a quarterly failure. Failure in any month of a quarter following two quarters’ failure ofthe same measure represents a third successive quarter failure and should be reported via the exception reporting process.

Will apply to consultant-led admitted, non-admitted and incomplete pathways provided. While failure against any threshold will score 1.0, theoverall impact will be capped at 2.0. The measures apply to acute patients whether in an acute or community setting. Where a trust with existingacute facilities acquires a community hospital, performance will be assessed on a combined basis.

The SHA will take account of breaches of the referral to treatment target in 2011/12 when considering consecutive failures of the referral totreatment target in 2012/13. For example, if a trust fails the 2011/12 admitted patients target at quarter 4 and the 2012/13 admitted patients targetin quarters 1 and 2, it will be considered to have breached for three quarters in a row.

2d LearningDisabilities:Access tohealthcare

Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH,2008):a) Does the trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways of careare reasonably adjusted to meet the health needs of these patients?b) Does the trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria:- treatment options;- complaints procedures; and- appointments?c) Does the trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities?d) Does the trust have protocols in place to routinely include training on providing healthcare to patients with learning disabilities for all staff?e) Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers?f) Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings inroutine public reports?

Note: trust boards are required to certify that their trusts meet requirements a) to f) above at the annual plan stage and in each month. Failure to do so will result in the application of the service performance score for this indicator.

3a

Cancer:31 day wait

31-day wait: measured from cancer treatment period start date to treatment start date. Failure against any threshold represents a failure againstthe overall target. The target will not apply to trusts having five cases or less in a quarter. The SHA will not score trusts failing individual cancerthresholds but only reporting a single patient breach over the quarter.. Will apply to any community providers providing the specific cancertreatment pathways

3bCancer:62 day wait

62-day wait: measured from day of receipt of referral to treatment start date. This includes referrals from screening service and other consultants.Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases or less in aquarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply toany community providers providing the specific cancer treatment pathways.

National guidance states that for patients referred from one provider to another, breaches of this target are automatically shared and treated on a50:50 basis. These breaches may be reallocated in full back to the referring organisation(s) provided the SHA receive evidence of writtenagreement to do so between the relevant providers (signed by both Chief Executives) in place at the time the trust makes its monthly declarationto the SHA.

In the absence of any locally-agreed contractual arrangements, the SHA encourages trusts to work with other providers to reach a local system-wide agreement on the allocation of cancer target breaches to ensure that patients are treated in a timely manner. Once an agreement of this nature has been reached, the SHA will consider applying the terms of the agreement to trusts party to the arrangement.

3c CancerMeasured from decision to treat to first definitive treatment. The target will not apply to trusts having five cases or fewer in a quarter. The SHAwill not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply to any communityproviders providing the specific cancer treatment pathways.

3d Cancer

Measured from day of receipt of referral – existing standard (includes referrals from general dental practitioners and any primary careprofessional).Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases orfewer in a quarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter.Will apply to any community providers providing the specific cancer treatment pathways.

Specific guidance and documentation concerning cancer waiting targets can be found at:http://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/documentation

The SHA will not utilise a general rounding principle when considering compliance with these targets and standards, e.g. a performance of 94.5% will be considered as failing toachieve a 95% target. However, exceptional cases may be considered on an individual basis, taking into account issues such as low activity or thresholds that have little or notolerance against the target, e.g. those set between 99-100%.

Notes

Ref Indicator Details

3e A&EWaiting time is assessed on a site basis: no activity from off-site partner organisations should be included. The 4-hour waiting time indicator willapply to minor injury units/walk in centres.

3f Mental 7-day follow up:

Numerator:

the number of people under adult mental illness specialties on CPA who were followed up (either by face-to-face contact or by phone discussion)within seven days of discharge from psychiatric inpatient care.

Denominator:

the total number of people under adult mental illness specialties on CPA who were discharged from psychiatric inpatient care.

All patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed up withinseven days of discharge. Where a patient has been transferred to prison, contact should be made via the prison in-reach team.

Exemptions from both the numerator and the denominator of the indicator include:- patients who die within seven days of discharge;- where legal precedence has forced the removal of a patient from the country; or- patients discharged to another NHS psychiatric inpatient ward.

For 12 month review (from Mental Health Minimum Data Set):

Numerator:

the number of adults in the denominator who have had at least one formal review in the last 12 months.

Denominator:

the total number of adults who have received secondary mental health services during the reporting period (month) who had spent at least 12 months on CPA (by the end of the reporting period OR when their time on CPA ended).

For full details of the changes to the CPA process, please see the implementation guidance Refocusing the Care Programme Approach on the Department of Health’s website.

3g Mental Health:DTOC

Numerator:

the number of non-acute patients (aged 18 and over on admission) per day under consultant and non-consultant-led care whose transfer of carewas delayed during the month. For example, one patient delayed for five days counts as five.

Denominator:

the total number of occupied bed days (consultant-led and non-consultant-led) during the month.

Delayed transfers of care attributable to social care services are included.

3h Mental Health: I/Pand CRHT

This indicator applies only to admissions to the foundation trust’s mental health psychiatric inpatient care. The following cases can be excluded:- planned admissions for psychiatric care from specialist units;- internal transfers of service users between wards in a trust and transfers from other trusts;- patients recalled on Community Treatment Orders; or- patients on leave under Section 17 of the Mental Health Act 1983.

The indicator applies to users of working age (16-65) only, unless otherwise contracted. An admission has been gate-kept by a crisis resolutionteam if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted inadmission.

For full details of the features of gate-keeping, please see Guidance Statement on Fidelity and Best Practice for Crisis Services on theDepartment of Health’s website. As set out in this guidance, the crisis resolution home treatment team should:a) provide a mobile 24 hour, seven days a week response to requests for assessments;b) be actively involved in all requests for admission: for the avoidance of doubt, ‘actively involved’ requires face-to-face contact unless it can be demonstrated that face-to-face contact was not appropriate or possible. For each case where face-to-face contact is deemed inappropriate, a declaration that the face-to-face contact was not the most appropriate action from a clinical perspective will be required;c) be notified of all pending Mental Health Act assessments;d) be assessing all these cases before admission happens; ande) be central to the decision making process in conjunction with the rest of the multidisciplinary team.

3i Mental HealthMonthly performance against commissioner contract. Threshold represents a minimum level of performance against contract performance,rounded down.

3j-k

AmbulanceCat A For patients with immediately life-threatening conditions.

The Operating Framework for 2012-13 requires all Ambulance Trusts to reach 75 per cent of urgent cases, Category A patients, within 8 minutes.From 1 June 2012, Category A cases will be split into Red 1 and Red 2 calls:• Red 1 calls are patients who are suffering cardiac arrest, are unconscious or who have stopped breathing.• Red 2 calls are serious cases, but are not ones where up to 60 additional seconds will affect a patient’s outcome, for example diabeticepisodes and fits.Ambulance Trusts will be required to improve their performance to show they can reach 80 per cent of Red 1 calls within 8 minutes by April 2013.

4a C.Diff

Will apply to any inpatient facility with a centrally set C. difficile objective. Where a trust with existing acute facilities acquires a communityhospital, the combined objective will be an aggregate of the two organisations’ separate objectives. Both avoidable and unavoidable cases of C.difficile will be taken into account for regulatory purposes.

Where there is no objective (i.e. if a mental health trust without a C. difficile objective acquires a community provider without an allocated C.difficile objective) we will not apply a C. difficile score to the trust’s governance risk rating.

Monitor’s annual de minimis limit for cases of C. difficile is set at 12. However, Monitor may consider scoring cases of <12 if the HealthProtection Agency indicates multiple outbreaks. Where the number of cases is less than or equal to the de minimis limit, no formal regulatoryaction (including scoring in the governance risk rating) will be taken.

If a trust exceeds the de minimis limit, but remains within the in-year trajectory for the national objective, no score will be applied.If a trust exceeds both the de minimis limit and the in-year trajectory for the national objective, a score will apply.If a trust exceeds its national objective above the de minimis limit, the SHA will apply a red rating and consider the trust for escalation.

If the Health Protection Agency indicates that the C. difficile target is exceeded due to multiple outbreaks, while still below the de minimis, the SHA may apply a score.

4b MRSA

Will apply to any inpatient facility with a centrally set MRSA objective. Where a trust with existing acute facilities acquires a community hospital,the combined objective will be an aggregate of the two organisations’ separate objectives.

Those trusts that are not in the best performing quartile for MRSA should deliver performance that is at least in line with the MRSA objectivetarget figures calculated for them by the Department of Health. We expect those trusts without a centrally calculated MRSA objective as a resultof being in the best performing quartile to agree an MRSA target for 2012/13 that at least maintains existing performance.

Where there is no objective (i.e. if a mental health trust without an MRSA objective acquires a community provider without an allocated MRSAobjective) we will not apply an MRSA score to the trust’s governance risk rating.

Monitor’s annual de minimis limit for cases of MRSA is set at 6. Where the number of cases is less than or equal to the de minimis limit, noformal regulatory action (including scoring in the governance risk rating) will be taken.

If a trust exceeds the de minimis limit, but remains within the in-year trajectory for the national objective, no score will be applied.If a trust exceeds both the de minimis limit and the in-year trajectory for the national objective, a score will apply.If a trust exceeds its national objective above the de minimis limit, the SHA will apply a red rating and consider the trust for escalation



30/01/13


Subject: Trust Board and Sub-Committee Calendar of meetings 2012/13Report By: Jenny Gardiner, Trust Board SecretaryAuthor: Jenny Gardiner, Trust Board SecretaryAccountable Executive Director: Andy Hardy, Chief Executive Officer

GLOSSARY

Abbreviation In Full



TitleApprox. Length


At the request of the CFO a proposal was made and subsequently approved by Trust Board in November 2012to delay the timing of its meetings to the first week of each month in order that there is sufficient time for thePPMO information to be produced, consolidated, validated and analysed for reporting purposes.

However, on further reflection and as highlighted by Grant Thornton in their HDD review, the change in timingwill affect

the Board's ability to provide information in line with FT reporting timescales i.e. this arrangement doesnot comply with Monitor's quarterly reporting timetable once authorised as an FT, or the monthlyapproval of the SHA’s Provider Management Regime (PMR) return

the timely review of performance information by the Board i.e. performance information is reviewed nomore than a month after the period under review

It is therefore proposed that that the resolution approved by November Trust Board is reversed and the timingsremain as they were previously i.e. Trust Board on the last Wednesday of each month.


A revised timetable is attached which outlines the proposed Trust Board and sub-committee dates for 2013.For information, a summary of each sub-committees membership and attendees is provided for reference.


Risks of non-compliance with Monitor and SHA returns if Board dates are moved to first week of the month.

Replicating the current schedule of meetings will impact on the scrutiny of the integrated performance data bythe relevant committees prior to submission to Trust Board unless the production process for collating andvalidating information is reduced. This may require further revisions to the sub-committee schedule ofmeetings to align them to PPMO data availability.



30/01/13



Trust Board to:

Rescind the previous resolution made at November 2012 Trust Board to;o APPROVE the suggested changes to Trust Board and Board Seminar dates as recommended by

the CFO from 1st April 2013o AGREE to cancel 27th March 2013 Trust Board and roll agenda items forward to 3rd April 2013

meeting.

APPROVE the suggested changes to Trust Board and Board Seminar dates for 2013/14 to maintainthe original timetable whereby Trust Board meetings occur on the last Wednesday of every month.

IMPLICATIONS:

Financial: NA

HR / Equality & Diversity: Attendance at all Trust Board and sub-committee meetings is monitored andshould be at least 80% for each attendee.

Governance: Minimum attendance levels are required to ensure meetings are quorate.

Legal: NA

REVIEW:


DATA QUALITY:

Data/information Source: NaData Quality Controls: NaData Limitations: Na

Meeting times may vary depending upon size of agendaP:\Trust Board\Trust Board - Master File\2013\1 - JANUARY 2013\PUBLIC\Enc 9.1 - TRUST BOARD AND SUB-COMMITTEE MEETING SCHEDULE 2013 - 2014 v9.docP:\Trust Board\Trust Board - Master File\2013\1 - JANUARY 2013\PUBLIC\Enc 9.1 - TRUST BOARD AND SUB-COMMITTEE MEETING SCHEDULE 2013 -

2014 v9.doc

Trust Board and Sub-Committee Meeting Schedule 2013/14 - Paperwork Deadlines

2013 2014 Mtgs/yrDeadline for TB Papers to EA 12 Apr 17 May 14 Jun 19 Jul 13 Sep 18 Oct 15 Nov 17 Jan 14 Feb 14 MarPapers copied fordistribution

17 Apr 22 May 19 Jun 24 Jul 18 Sep 23 Oct 20 Nov 22 Jan 19 Feb 19 Mar

TRUST BOARD 24 Apr 29 May 26 Jun 31 Jul No Mtg 25 Sep 30 Oct 27 Nov No Mtg 29 Jan 26 Feb 26 Mar 10 TB + 1 EO

MEETING TIMES 1pm-6pm 1pm-6pm 1pm-6pm 1pm-5pm 1pm-6pm 1pm-6pm 1pm-6pm 1pm-6pm 1pm-6pm 1pm-6pm

Papers copied fordistribution

2 Apr 7 May 4 Jun 2 Jul 3 Sep 1 Oct 5 Nov 3 Dec 4 Feb 4 Mar

QUALITY GOVERNANCE 9 Apr 14 May 11 Jun 9 Jul No Mtg 10 Sep 8 Oct 12 Nov 10 Dec No Mtg 11 Feb 11 Mar 10 QGC

MEETING TIMES 9.30am-11.30am 9.30am-11.30am 9.30am-11.30am 9.30am-11.30am 9.30am-11.30am 9.30am-11.30am 9.30am-11.30am 9.30am-11.30am 9.30am-11.30am 9.30am-11.30am

Deadline for Audit Papers toEA

2 May 27 Jun 28 Aug 31 Oct 30 Jan


7 May 1 Jul 2 Sep 4 Nov 3 Feb

AUDIT No Mtg 13 May No Mtg 8 Jul No Mtg 9 Sep No Mtg 11 Nov No Mtg No Mtg 10 Feb No Mtg 5 AC + 1 EO*

MEETING TIMES 1pm-3pm 1pm-3pm 1pm-3pm 1pm-3pm 1pm-3pm

Deadline for F&P Papers toEA




FINANCE & PERFORMANCE 22 Apr 28 May 24 Jun 29 Jul No Mtg 23 Sep 28 Oct 25 Nov No Mtg 27 Jan 24 Feb 24 Mar 8 F&PC

MEETING TIMES 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm


1 May 4 Dec

REMUNERATION No Mtg 8 May No Mtg No Mtg No Mtg No Mtg No Mtg No Mtg 11 Dec No Mtg No Mtg No Mtg 2 RC

MEETING TIMES 5pm-6pm 5pm-6pm


26 Mar 23 Apr 28 May 25 Jun 30 Jul 27 Aug 24 Sep 29 Oct 26 Nov 28 Jan 25 Feb

BOARD SEMINAR 3 Apr 1 May 5 Jun 3 Jul 7 Aug 4 Sep 2 Oct 6 Nov 4 Dec No meeting 5 Feb 5 Mar 11 BS

MEETING TIMES 1pm-5pm 1pm-5.00pm 2pm-5pm 3pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 3pm-5pm 1pm-4.30pm 1pm-5pm 3pm-5pm


10 Apr 1 May 5 Jun 10 Jul 7 Aug 4 Sep 9 Oct 6 Nov 4 Dec 8 Jan 5 Feb 5 Mar

BOARD SEMINAR 17 Apr 8 May 12 Jun 17 Jul 14 Aug 11 Sep 16 Oct 13 Nov 11 Dec 15 Jan 12 Feb 12 Mar 12 BS

MEETING TIMES 1pm-5pm 1pm-4.30pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-5pm 1pm-4.30pm 1pm-5pm 1pm-5pm 1pm-5pm


26 Jun 30 Oct 26 Feb

CHARITABLE FUNDS No Mtg No Mtg 3 Jul No Mtg No Mtg No Mtg No Mtg 6 Nov No Mtg No Mtg No Mtg 5 Mar 3CF

MEETING TIMES 1pm – 3pm 1pm – 3pm 1pm – 3pm

Extraordinary, Away Day and Board to Board Meetings:

Papers copied for distribution 29 May 2013 Time

EO AUDIT 5 June 2013 10am – 12noon

Papers copied for distribution 29 May 2013 Time

EO TRUST BOARD 5 June 2013 12.30pm – 2.00pm

Papers copied for distribution 11 Sept 2013 12 Feb 2014

BOARD TO BOARD (Project Co) 18 Sept 2013 19 Feb 2014

Facilitated By Project Co UHCW

MEETING TIMES 2pm – 4pm 2pm – 4pm

Papers copied for distribution 27 Mar 2013 1 Jul 2013 30 Sep 2013 14 Jan 2014

TRUST BOARD AWAY DAY 10 Apr 2013 10 Jul 2013 9 Oct 2013 22 Jan 2014

MEETING TIMES 9am – 5pm 9am – 5pm 9am – 5pm 9am – 5pm

Papers copied for distribution 24 July 2013

AGM 31 Jul 2013

MEETING TIMES 5pm – 6.30pm

Committee Membership(M-Member, A-Attendee)

QualityGovernance

Audit Finance &Performance

RemunerationCommittee

Trust Board /Board Seminar

CorporateTrusteeBoard

Philip Townshend Chair Chair Chair

Nick Stokes M M M M M

Trevor Robinson Chair M M M M

Samantha Tubb Chair M M M

Peter Winstanley M M M M

Tim Sawdon Chair M M M M

Paul Sabapathy M M M M M

Chief Executive Officer M A M A M M

Chief Nursing Officer M M M M

Chief Operating Officer M A M M M

Chief Medical Officer M M M

Chief HR Officer M M A A A

Chief Finance Officer A M M M



30 January 2013


Subject: Workforce Strategy (2013 – 2018)Report By: Human Resources Management TeamAuthor: Human Resources Management TeamAccountable Executive Director: Ian Crich Chief Human Resources Officer

GLOSSARY

Abbreviation In FullIBP Integrated Business PlanSHA Strategic Health Authority



TitleApprox. Length


The attached document is the proposed Workforce Strategy 2013 – 2018 and is submitted to the Boardfollowing its earlier, detailed consideration at the Board Seminar held on 2 January 2013.

The document is, of course, one of the key underpinning strategies to the IBP and therefore, following Boardapproval, will be submitted to the SHA for consideration and feedback.

Notwithstanding its requirement for the IBP and Foundation Trust application, this new 5 year WorkforceStrategy has been necessarily refreshed to ensure its continued synergy with the revised overall, and clinical,strategies for the Trust.


None


The lack of a clear workforce strategy would leave the Trust at risk of not aligning the efforts of itsworkforce with its strategic goals.

This strategy is one of the underpinning strategies required to support the Trust application forFoundation status.


The Trust Board are recommended to APPROVE the Workforce Strategy 2013-18.



30 January 2013


IMPLICATIONS:

Financial: The workforce strategy has to be aligned to the clinical and Trust overallstrategies, and any subordinate business plans, to ensure that the workforce isaffordable within the financial resources of the Trust.

HR / Equality & Diversity: All people management activity within the Trust and all policies, procedures andpractices will have at their core the principles of equality and diversity.

Governance: None

Legal: All people management activity within the Trust and all policies, procedures andpractices will be in accord with employment and other related legislation.

REVIEW:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance and Performance Committee Executive MeetingAudit Committee Trust Board Seminar 2 /01/13

DATA QUALITY:

Data/information Source: N/AData Quality Controls: N/AData Limitations: N/A


Workforce Strategy 2013 - 2018


Workforce Strategy 2013-2018

Confidential – Workforce Strategy Page 1 28/01/2013

Introduction

This document outlines the Trust Workforce Strategy that defines our workforce intentions over the next5 years and is aligned to the Trust Strategy outlined in the Integrated Business Plan. The WorkforceStrategy is also closely aligned, through Annual Workforce Plans, with the Trust Clinical Strategy in orderto emphasise the clear and intrinsic link between our workforce and the patient centred services weprovide.

The Workforce Strategy is broken down into 8 key areas of people management activity, that togetherform a comprehensive overall strategic direction for the workforce of UHCW NHS Trust. Each of the 8areas is described in terms of the key business drivers (i.e. why these areas are of importance to thesuccess of the Trust), key HR Principle(s) (i.e. the people management principles that guide both themeeting of the business needs and the setting of deliverable objectives) and finally a number of keydeliverables which will ensure the strategy is realised.

The Workforce Strategy is relevant to every member of staff at UCHW, led by the Trust Board andfacilitated by the HR function. The Strategy will be reviewed annually to ensure that it continues to berelevant and consistent with the overall strategy of the Trust.

Aim

The overall aim, or vision, of the workforce strategy is:

“By 2018, all UHCW employees will be strong advocates for UHCW, living the Trust’s values andaiming to support the Trust’s overall vision of being amongst the leading healthcare providers inthe UK and beyond. Our agile, adaptable and affordable workforce will be the key drivers ofquality and high performance. UHCW workforce performance and development will be viewed asan exemplar in the NHS and beyond”

Monitoring & Evaluation

This strategy will be implemented and realised on an incremental basis over the next 5 years. TheHuman Resource, Equality and Diversity Committee (HREDC) alongside the Training, Education &Research Committee (TERC) will provide formal monitoring and evaluation throughout the 5 years and,through their upward reporting to the Quality Governance Committee, will provide assurance to theBoard.

The detailed objectives that support the delivery of the Workforce Strategy will be provided in the HRBusiness Plan which is set, performance managed and revised annually by the HREDC.

While our HR team is responsible for providing expert support, guidance and staff development to assistthe delivery of our Workforce Strategy, the Trust Board, Chief Officers Group (COG) and senior leadershave a key role in:

Forging a leadership style and supportive environment for the Trust to succeed;

Guiding the ongoing development of our Workforce Strategy;

Assuring itself that at all times the Workforce Strategy is aligned to the overall strategy of theTrust.




1. Values & Behaviours

Business Drivers

To ensure that the only people we employ are those who can demonstrate those behaviours andvalues that are aligned to the Trust’s visions and aims.

To ensure that patient care and experience is optimised.

To ensure that UHCW is positively recognised as an employer and healthcare provider of choice.

HR Principle

We have a shared set of values that are embedded, understood and adhered to in the Trust.

Our staff will be strong advocates for UHCW.

How will this be achieved?

1. We will embed the Trust’s values in all people management processes across the wholeemployee life cycle.

2. We will develop and implement a comprehensive communication and engagement strategy tosupport the embedding of the values across the Trust.

3. We will develop expected standards of communication when interacting with staff, patients andvisitors in support of the Trust’s clinical strategy.

4. We will consistently reflect on feedback from staff / patient surveys to inform the development ofour Trust priorities and action plans associated with this feedback.




2. Equality & Diversity

Business Drivers

To ensure that the workforce is able to provide the most appropriate care and responses to thediverse communities that use our services by taking into account differing needs.

To ensure that, decisions are informed, with involvement of our diverse workforce and are basedon the principles of equality.

To provide employees with opportunities to achieve their full potential, recognising andcelebrating diversity

HR Principle

We have working practices that promote, encourage and sustain a diverse workforce.


1. We will ensure that the workforce are appropriately trained, managed and given appropriateguidance in all matters relating to equality and diversity.

2. We will further develop and implement our Equality & Diversity Strategy ensuring that it is alignedto the Workforce and Clinical Strategies.

3. We will support the development of all staff, and ensure that specific opportunities are created foragreed target minority groups.

4. We will closely monitor workforce information to inform any necessary actions to ensure that ourworkforce is representative of the communities we serve.

.




3. Managing for High Performance

Business Drivers

The Trust needs staff that are led and managed to excel in their role, ensuring all Trust objectivesare met.

By proactively managing those with unsatisfactory performance, the Trust can ensure that thereis no compromise with regard to patient care, that resources are not wasted, that our reputation isnot damaged and that focus can be rightly given to the development and nurturing of high calibretalent.

HR Principle

We have integrated practices to ensure we proactively manage performance.

We have a high performance environment where staff are clear about what is expected of them,receive regular feedback on how they are doing, where high performance is celebrated and poorperformance is addressed.


1. We will ensure that our people management policies and procedures are fit for purpose, understoodand effectively used.

2. We will introduce and maintain a systematic process for succession planning and talentmanagement.

3. We will ensure that all employment policies and procedures support the development of talent andthe management of poor performance.

4. We will ensure that Trust managers at all levels are accountable for people and performancemanagement.

5. We will ensure that all job plans are reviewed on an annual basis to ensure that they are consistentwith current and future service provision and that all consultants are achieving their designatedobjectives.




4. Workforce Planning

Business Drivers

The Trust needs an affordable, adaptable and agile workforce who have the capability andcapacity to meet the service needs of the future.

HR Principle

We have integrated workforce plans across the Trust that are aligned to our service and financialplans.


1. We will develop annually refreshed workforce plans that provide assumptions for the next five yearsbased on our service and financial intentions.

2. We will ensure that workforce plans remain aligned with both internally and externally drivenchanges in health care provision.

3. We will ensure that the workforce plans provide for staffing capacity necessary to meet the needs ofour services.

4. We will ensure that workforce planning is integrated with the operational planning by individualspeciality management groups.

5. We will ensure that workforce plans are developed to be in line with commissioning and educationprovision intentions and developments.




5. Learning and Development

Business Drivers

To ensure a competent, safe and innovative workforce to enhance the services we provide to ourpatients and customers.

As a University Teaching Hospital, we need to lead the development of future healthcareprofessionals and others, across the health economy.

We need to nurture and develop talent to support the aspirations of a high performing teachinghospital.

HR Principle

We train and develop our staff to perform to the best of their ability and exceed expectations.

We develop and reinforce a culture where learning and development of staff is embedded acrossthe Trust.


1. We will ensure that all staff will be trained to be competent in those areas deemed to be mandatoryfor their role.

2. We will implement initiatives which support the recognition and development of current andprospective (at all levels) managers, leaders and innovators.

3. We will ensure that all staff have, as a minimum, an annual appraisal that focuses on personaldevelopment as well as performance.

4. Alongside the Workforce Planning model we will ensure that learning and development is targeted tosupport those areas where service model changes require people changes.

5. We will implement and embed the Trust wide Learning and Development Strategy in conjunction withother relevant Trust strategies.

6. We will enable more effective learning by improving our commissioning and provision internally, andworking with key partners.




6. Recruit, Induct & Retain

Business Drivers

The Trust needs to attract and appoint the highest calibre of staff to realise the organisation’svision.

To ensure continuity of service delivery.

HR Principle

We get the right people at the right time and performing well quickly.


1. Our recruitment plans and objectives will be proactively driven by our workforce plans.

2. We will continue to build upon our reputation and our employer brand based on ‘Care, Achieve andInnovate’ to become an “employer of choice”.

3. We will ensure that our recruitment processes are competency and values based.

4. We will use innovative practices to support areas where recruitment and retention is challenging.

5. We will continue to deliver and enhance effective induction processes which enable staff to performwell quickly.

6. We will actively monitor, evaluate and improve the way in which we recruit, induct and embed peopleinto the Trust to make sure we are delivering an excellent return on this investment.

7. We will use feedback from such mechanisms as the staff and patient surveys to inform our prioritiesfor ensuring the retention the best workforce to realise the Trust’s ambitions.




7. Wellbeing and Engagement

Business Driver

The Trust needs staff who are committed, engaged and flexible.

Healthy and cared for staff provide better patient care.

Maximised attendance leads to greater productivity and continuous high quality patient care.

HR Principle

We create and sustain high levels of employee engagement, well being and commitment.


1. We will provide a clear understanding of expectations for each member of staff that is aligned to theagreed values and behaviours for the Trust.

2. We will develop and introduce a comprehensive employee communication and engagement strategyto enhance an open environment, where staff actively seek to share their views and ideas.

3. We will ensure that all managers understand their key role in employee engagement andcommunication.

4. We will deliver a comprehensive strategy for health & well being so that our employees aresupported to perform at their optimum level.

5. We will ensure that the goal of achieving continuous high quality patient care is supported by theactive management of absence within the Trust whilst meeting national standards for attendancemanagement.

6. We will incorporate the four staff pledges within the NHS Constitution into our HR planning andpractice, so as to support staff to maintain their health, well being and safety.




8. Leadership

Business Drivers

The Trust must have in place a competent and capable senior leadership team to realise theTrust’s vision and deliver results as a high performing Trust.

There must be effective leadership at all levels of the Trust in order that we deliver betterorganisational outcomes.

We recognise that outstanding clinical leadership leads to high quality patient outcomes andexperience.

HR Principle

We identify, develop and support leaders at all levels of the Trust.


1. We will ensure that programmes and interventions are in place which results in the Trust Boardhaving the individual and collective capability and capacity to lead the Trust to deliver its strategicobjectives.

2. We will ensure that clinical leaders have the capacity, skills and talent to lead their services andimplement the clinical strategy

3. We will develop and implement strategies which enable the Trust to nurture talent, fast track risingstars and plan for succession at all levels.

4. We will collaborate with partners, be that locally, regionally and / or nationally, to link Trust leadershipdevelopment with other aligned initiatives.



30th

January 2013


Subject: Education ReportReport By: Maggie Allen, Associate Medical Director - EducationAuthor: Maggie Allen, Associate Medical Director - EducationAccountable Executive Director: Meghana Pandit, Chief Medical Officer

GLOSSARY

Abbreviation In FullAHP Allied health professionalCDs Clinical directorsDoH Department of HealthGMC General Medical CouncilHR Human ResourcesO&G Obstetrics & GynaecologySLA Service level agreementSPA Supporting professional activityST Specialist Trainee (n=year of specialist training)UG/ PG Undergraduate/ postgraduateWMS Warwick Medical School



TitleApprox. Length


To update the Board about Trust medical educational activities


UHCW must maintain its place as a major teaching hospital to attract high quality staff, specialty status& associated funding. It is imperative that the Board supports this as core to the Trust’s function &success.

The Trust faces considerable challenges with central reductions in funding for Medical Education, localfinancial stringencies & service pressures

Consultant job plans & appraisals must value & support their educational roles. New GMC requirements for all UG teachers & PG trainers to undergo Trainer Accreditation have

focussed our efforts in faculty development. We are reasonably well prepared for this. Deanery reviews of Postgraduate training have centred on operational issues compromising both

patient safety & training. The Trust is seen as broadly supportive of training. Our Surgical Training Suite continues to develop & enhance its reputation, but our new Clinical Skills &

Simulation Centre will struggle to achieve the same success with current resources. The improved ‘Grand Round’ is a notable success in providing a quality weekly education slot for

clinical staff & students.


The MPET review will result in a substantial fall in Trust income for Education & Training Failure to meet the Deanery’s recommendations will lead to revisit & sanctions including the potential



30th

January 2013


withdrawal of trainees. Failure to identify resources to support the Clinical Simulation Suite will severely limit its potential to

deliver high quality training across all grades & specialities.


Report to be received & agreed

IMPLICATIONS:

Financial:


Governance:

Legal:

REVIEW:

Trust Standing Committee Date Trust Standing Committee DateQuality Governance Committee Remuneration CommitteeFinance & Performance Committee Executive MeetingAudit Committee

DATA QUALITY:


ANNUAL REPORT TO UHCW TRUST BOARD – January 2013

UHCW seeks to be the leading partner to one of the top medical schools in thecountry and a recognised site of excellence in postgraduate education, but to achievethis requires a huge emphasis on teaching quality over the coming years and we facea number of challenges.

Consultant/ workforce issues.

The job planning process provides opportunities to examine, individually andcollectively, the focus of our efforts and to define appropriate job plans. However,financial and clinical pressures inevitably ‘squeeze‘ educational time. We requireclarity on the educational components of consultants’ SPA time. Whilst there isidentifiable funding available for undergraduate teaching (from the SIFT - ServiceIncrement for Teaching) budget, there is no such funding available to Departments orindividuals for postgraduate teaching and supervision. Nevertheless, the Trust mustdeliver this against our SLA, which funds basic salaries of our trainees, so the SPAsneeded must be Trust based. We focus on the need for adequate educational timeand good quality supervision, with sound standards and accountability against thesessional time allowed, particularly for those with lead roles, but against thismanagers focus on cost savings. Increased emphasis on educational activities atappraisal and revalidation should help with this focus.

MPET.

The MPET (Multi-Professional Education & Training) review will bring additionalfinancial pressures upon Education within the Trust. A major Department of Healthpolicy review of the multi-profession education & training (MPET) levy includes theundergraduate medical and dental component ‘service increment for teaching’(SIFT). A new formula results in the Trust losing the “Facilities funding” that originallyformed a large part of our £9million SIFT allocation. Instead, a per student fee ofc.£35k per annum will be received, resulting in a reduction to SIFT of £1.685mill. Wemust work closely with University colleagues to attempt to mitigate this. The onlyalternative is to reduce the training that we offer, but money will follow students awayfrom UHCW. SIFT has supported a number of ‘non- teaching’ activities since WMSstarted e.g. research/ academic (non-teaching) posts and secretarial support; difficultdecisions might include withdrawal of such funding to concentrate on teachingactivities.

Overall there is some counter to the SIFT reduction in that a placement fee will bereceived for Non-Medical Training (NMET), increasing NMET allocation by £845k,giving a net reduction of £840k. Of course, nurse/AHP colleagues will want to ensurethat this money is used to support Non-Medical training.

Post graduate monies are as yet unaffected. The Department of Health cannot workout how to calculate the salary replacement for trainees (ie the “contribution toservice” of any particular trainee will vary by specialty and grade).

Trainer accreditation.

There are new GMC requirements for Trainer accreditation. Specific requirementsvary by role, but broadly most active UG teachers/ PG trainers will need 2 days ofbasic or update training every 2 to 3 years, plus a few ‘add ons’ e.g. Equality &

Diversity training. Those with lead roles will need additional training. The Trust isrequired to monitor and provide/ allow training. We are reasonably well prepared forthis; successful Faculty Development initiatives over the past 2 years have seenmany consultants and trainees attending for basic ‘Teaching the Teachers’ courses,and we are working directly with WMS leaders on further short courses to meet UGand PG needs.

Postgraduate training.

There were 9 Deanery visits to inspect training in the past year. Of these, 6 werelevel 3, i.e ‘triggered’ by significant criticisms or concerns, often over locallyrecognised issues, many of which are operational, rather than directly educational.The visits impose a huge workload upon the PG tutor and admin staff, particularly indata gathering/ analysis. At least 3 of the ‘problem areas’ O&G, general/acutemedicine & neurosurgery can expect further high level visits within 6/12 months.The Trust has responded and is seen as generally supportive of Education andTraining. However, major ‘front door’ pressures and associated patient safety issues,identified by trainees, continue to worry the Deanery. Imminent changes to ourmedical admissions process may help. O&G have made progress in sorting out theirtraining, but the Deanery is keeping a close eye that this is sustained. Whilst makingsome improvements in governance and manpower issues, a safety issue washighlighted in the recent January visit which is being addressed and monitored.

To acknowledge the good news, our Foundation School and Surgical training werevery favourably reviewed. Also the PG Education teams ran 29 external courses lastyear, of which 6 were international in scope.

We are now required to provide regular (6/12) information to the Deanery on anycomplaints, conduct issues and significant incidents for trainee revalidation. Thisrequires the triangulation of information between clinical governance, HR andeducational supervisors and CDs every 6/12. We are considering the feasibility of aTrust database into which all these sources feed.

Undergraduate.

WMS will introduce a new curriculum from September 2013. Phase 2 will affectUHCW most, from 2015. For a year or two we will have to run the old and newcurricula alongside each other, which will create pressure on teaching and space.WMS have taken several opportunities to present the new curriculum to staff here,but I suspect the full impact will only be realised closer to implementation. We willneed substantial enthusiasm and expertise from all teaching staff to successfullyimplement the changes in the face of service and financial pressures.

Over – arching Educational Activities.

Simulation Suites

The Surgical Training Suite continues to grow in scope and reputation, nationally andinternationally. Over 1000 surgeons have now been trained there in varioustechniques, 400 from overseas. Innovative developments including 3D anatomyteaching for medical students and anatomy ‘academy’ events for aspiring schoolsixth formers. There is huge demand to use it from teachers here and externally. It isa substantially self-funding enterprise now.

We now need to achieve the same success with our Clinical Skills and SimulationCentre! This a well equipped facility capable of using Hi-Fidelity (i.e. near reality)simulation of acute medical and surgical emergencies to teach a wide variety of staffand students, all clincal disciplines, often as specialty multi-professional teams. Thebenefits include all aspects of diagnosis and good clinical management butimportantly also ‘human factor’ training e.g. team-working, leadership,communication skills, problem solving, situational awareness; key skills for allworkers and often the root of problems in ‘untoward incidents’.

We were successful in securing funds to set up and equip this facility from both theMedical School and Deanery. However, I am very worried about ongoing resourcing.There are enthusiastic teachers and many staff groups keen to have specialistsessions, but demand far exceeds capacity to deliver sessions, since the same staffare under pressure with resuscitation training/delivery & clinical skills teaching forWMS. More trained facilitators (consultants & ST3+) are urgently needed to facilitatecourses. There has been ‘creeping development’ in the use of the Centre (withoutany identified funding for all but the UG courses), based on successful teaching andthe enthusiasm of teachers. We cannot continue to fund consumables in the longterm, let alone staff time needed and the much needed faculty development to allowexpansion. We have recently applied for Deanery funding to run faculty developmentcourses for them, together with the Hollier Centre (a similar calibre facility), but this isa tiny drop in the ocean. We recently made the difficult decision to greatly limitteaching sessions whilst we sort out these issues. This is not a situation I wouldwish to continue as it is a terrible waste of the resource and the skills we havedeveloped. The Chief Medical Officer and I will develop a business case urgently.

The ‘new’ Grand Round.

Concluding with a notable success, this is our main weekly educational activity for allclinical staff. It had faded into a poorly attended event of variable quality, but overthe past few months it has, with considerable effort from 2 physicians and 1 surgeon,been revived and revamped. The Trust, WMS and the Deanery have supported thisenormously. Quality is much improved and attendance has gone from a pitiful 16attendees at worst, to an average of 160 (max. 196) with medical students, traineesand consultants represented, plus a few nurses and AHPs, which is veryencouraging. We would like this to be a highlight in the working week for all clinicalstaff, coming together for education and discussion.

Maggie AllenAssociate Medical Director for EducationJanuary 2013



30 JANUARY 2013

Patient Experience Board Report – September 20102

Subject: Patient Experience Report : Patient StoriesReport By: Chief Medical OfficerAuthor: Director of GovernanceAccountable Executive Director: Chief Medical Officer

GLOSSARY

Abbreviation In Full



TitleApprox. Length


To appraise the Board of a selection of patient and their families stories taken from the Impressionsfeedback system. The previous patient story report to Board highlighted the variance in patientsexperience within areas of the Trust. This report looks at two categories of experience, cleanliness anddischarge from hospital to highlight patients experience of these two important areas.


98% of the 1,155 patients who provided a response to their impression of the cleanliness of thehospital, found it to be positive. Many of the comments from patients praise the staff for the overallcleanliness

705 patients who responded about their impression of being discharged from our hospital, 85% hada positive impression. This area has shown consistently lower scores on Impressions; howeverthere are still positive responses from patients in particular around the level of information provided.The negative comments again highlight the speed of provision of take home drugs as an area forimprovement and one that continues to cause delay.


o Financial due to CQUIN penaltieso Reputational



30 JANUARY 2013

Patient Experience Board Report – September 20102


To read and consider the enclosed patient and relatives stories.

IMPLICATIONS:

Financial: CQUIN


Governance:

Legal:

REVIEW:


DATA QUALITY:

Data/information Source: ImpressionsData Quality Controls: Comments have been anonymised and spellchecked onlyData Limitations: Nil

Trust Board Patient Stories

Introduction

The chart below shows the positive and negative patient impressions of our servicefor the financial year thus far. It shows that 98% of the 1,155 patients who provided aresponse to their impression of the cleanliness of the hospital, found it to be positive.However, of the 705 patients who responded about their impression of beingdischarged from our hospital, only 85% had a positive impression.

This report will look at those two categories and highlight some of the verbatimcomments that have been left by patients of their impressions of these aspects of ourservice.

Cleanliness

“After the norovirus kickdown was lifted I observed the most amazing clean down of myward!"

"Cleaning was carried out every day whilst I was on CCU and this was always done in avery orderly and quite manner."

"cleaners were conscientious and thorough”

"I saw a cleaner cleaning the stairs and multiple people cleaning floors. Inside the treatmentroom was very clean and tidy. "

"It would be helpful for staff to remind patients and visitors to use the alcohol gel before theyleave."

"The young ISS woman doing the cleaning on Area 3 of Ward 32 was very diligent in hersweeping, high level cleaning and damp dusting. She was very friendly and interactedpositively with the patients."

"Get the Receptionist's to check the waiting areas between clinics and if necessary ask for acleaner to attend"

"The ward was kept in a clean and tidy condition. There was never a time when I did not seesomeone cleaning, tidying wiping things down. Patients had there personal hygiene needsattended to immediately"

"Very impressed with the cleanliness and the brightness of the hospital. This seemedto be the case in all areas"

"Keep it up"

Discharging you from hospital

"Everything was explained as I was discharged. The pain medication was provided"

"On pre-op assessment form I responded "no" to the question "will a responsible person beavailable to accompany you home?" Nobody said at this stage that the ward would notrelease me to go home in a taxi on my own."

"After day surgery this should be an ambulance job."

"You made sure that I would be in safe care after leaving and that I had medications."

"Hospitality suit could be tidied up and the hot drink machine fixed."

"All the discharge papers were ready, the nurses phoned my wife to collect me, themedicine was ready to go and didn't need picking up, and everything was explained in theneeded level of detail!"

"The nurse was sitting at the desk when he could have been putting the medication togetherso I could be discharged earlier and quicker"

"I didn't need any TTO's, but if I did, my discharge would have been delayed by 3 hourswaiting for pharmacy, this is unacceptable. It should not take more than an hour to arrangethe TTO's."

"The registrar gave information while I was recovering & prescribed necessary medication totake home. The nurse gave detailed verbal and written information along with all necessarymedication immediately prior to discharge. My husband & I were given ample opportunity toask questions."

Paul MartinDirector of GovernanceJanuary 2013



30th

January 2013

Subject: Foundation Trust Project

Report By: Andrew Hardy, Chief Executive Officer

Author: Janet White, Foundation Trust Project DirectorAccountable Executive Director: Andrew Hardy, Chief Executive Officer

GLOSSARYAbbreviation In FullBAF Board Assurance FrameworkBGAF Board Governance Assurance FrameworkFT SC Foundation Trust Steering CommitteeHDD Historic Due DiligenceIBP Integrated Business planLTFM Long Term Financial ModelNTDA NHS Trust Development AuthorityNED Non-Executive DirectorPWC Price Waterhouse CooperSHA Strategic Health Authority


POWERPOINT PRESENTATION? Yes NoNB Presentations need to be submitted for inclusion in Board papersTitleApprox. Length

PURPOSE OF THE REPORT / PRESENTATION:To provide an update on the progress and timeline for Foundation Trust status application.

SUMMARY OF KEY ISSUES:Current progress and priorities for the coming month.

SUMMARY OF KEY RISKS:UHCW NHS Trust is in discussions regarding its FT application timeline with the SHA, however necessarypreparatory work continues.


The Trust Board are asked to RECEIVE and ACCEPT this report.

IMPLICATIONS:Financial: Financial performance this year. Importance of achievement of CIPs, work to

increase predicted surplus and achieve financial assumptions for down-sidescenarios.

HR / Equality & Diversity: Recruitment and maintenance of a representative and diverse membership.

Governance: Date for achieving Foundation Trust status.

Legal: Legal constitution and completion of necessary assessment phases.




30th

January 2013

DATA QUALITY:


Foundation Trust Project

9th January for January 2013 Trust BoardProgress since last report

SHA assessment– Following Board observation on 2nd

October and assessment of our IBP/LTFM, SHA confirmed the decision on progression toHDD1 with Grant Thornton’ commencing on site on 3

rdDecember. SHA gave verbal feed back following our Board to Board with them on 13

th

December and confirmed the need to re-consider the FT application timeline. At the time of preparing this report, we await formal written feedbackand confirmation of this decision.

Planning activities & IBP- Work continues on organisational values and to prepare a further iteration of IBP taking into account SHA feedback andthe confirmation/outcome of the decision above.

Finance/LTFM – Work on LTFM continues in line with having further iterations for annual planning and IBP preparation during rest of 2012/13 and topick up on feedback following HDD exercise.

Membership and public communications – Completed membership recruitment data entry from recent recruitment drive. Membership at end ofDecember was 9123 public and 8613 staff. Medicine for Members programme for 2012 completed.

Risks and Issues log – Updated following last FT SC. BGAF – When external assessment will take place is dependent on decisions around NED terms of office and formal feedback from SHA following

decision outlined above. HDD – HDD 1 evidence was submitted to Grant Thornton by 16

thNovember and on-site work commenced on 3

rdDecember and was completed by

21st

December. At time of preparing this report a draft HDD Phase 1 report has been received but confirmation of factual accuracy has not yet beencompleted.

Board development – Reworked Board Seminar schedule to reflect changing requirements and to accommodate feedback from HDD and SHAdecision on FT application timeline. The Board Composition and Contribution work by Deloitte commenced and is expected to be completed by theend of January.

Quality Governance Assessment – All evidence for external assessment was submitted during December. At the time of preparing this report, thereport following this is awaited.

Governance – Proposed Constitution has been updated to reflect the changes in Monitor’s model constitution to reflect 2012 Health Act. Legalopinion will be postponed until new timeline is confirmed and its implications understood.

Priorities for coming month IBP –. Work on strategy, values and service developments will continue as more content is available. Further work on risks for BAF & IBP around

organisational goals and objectives will continue. HDD – Confirm factual accuracy of draft report and sign off report. Feedback and consideration of report at Board seminar in mid January. Action

planning as appropriate to address issues raised. Communications & membership – Medicine for Members events programme for 2013 commences with stroke awareness sessions during January,

followed by sessions on Abdominal Aortic Aneurism Screening in February. Planning for communications following confirmation of new timeline. Nextnewsletter. Review of Membership Development Strategy in line with SHA feedback on IBP.

Board Development – Consider Board Composition and Contribution report findings once available, alongside HDD findings and SHA Board toBoard feedback, and carry out initial planning for continued development activities. Advertise NED vacancies that will arise over next few months.

SHA assessment – Confirm FT application timeline with SHA. Key milestones table and FT project plans - To be re-worked once timeline is agreed. Monitor Guidance – Consider implications of revised Monitor Guidance to Applicant Trusts (published 8

thJanuary)

Current FT application risks rated as red – to be updated after FT Sc on 14th

JanFT R 11 National Targets – If UHCW fails to meet national targets FT application will not go aheadFT R 12 Financial compliance – failure to demonstrate that Trust is on sound enough financial footing to be authorised as an FTFT R 31 Current rate of FT authorisation by Monitor is very low – potential backlog for Monitor to deal with at time of our assessmentFT R 47 Quality Governance Framework – self assessment and PWC assessment gave score well above that required to pass Monitor Quality Governancethreshold (3.5 or less)

Trust Board Work Programme (Public Session)

Report Public Exec

Lead

Lead Manager Frequency No. Set date for in-year report? Report for

Noting /

ApprovalJan Feb Mar Apr May Jun Jul Sept Oct Nov

AHSN Public AH Amanda Royston Annual 1 Oct Approval √Calendar of Meetings Public AH Jenny Gardiner Annual 1 Nov Approval √Foundation Trust Application Update Public AH Janet White Monthly 10 Monthly Noting √ √ √ √ √ √ √ √ √ √Register of Gifts Public AH Jenny Gardiner Annual 1 Apr Noting √Register of Interests Public AH Jenny Gardiner Annual 1 Apr Noting √Work Programme Public AH Jenny Gardiner Monthly 10 Monthly Noting √ √ √ √ √ √ √ √ √ √Signings and Sealing's Public AH Jenny Gardiner Annual 1 April Noting √Provider Management Regime Public DE Simon Reed Monthly 10 Jan, Feb, Mar, Apr, May, Jun, Jul, Sep, Oct, Nov Approval √ √ √ √ √ √ √ √ √ √Integrated Performance Report and Dashboard Public DE/GN Jonathon Lloyd Monthly 10 Jan, Feb, Mar, Apr, May, Jun, Jul, Sep, Oct, Nov Approval

√ √ √ √ √ √ √ √ √ √Annual Plan Public DE John Amphlett/ Sarah Phipps Annual 1 May Noting √Infection Prevention and Control Annual Report and Annual Plan Public MR Mike Weinbren Annual 1 Apr Noting √Infection Prevention and Control Report including Joint Cleaning Update with ISS Mediclean Public MR Mike Weinbren Annual 1 Apr Noting √ICT Report Public DE Robin Arnold Annual 1 May Approval √PR Report Public IC Kerry Beadling Annual 1 January Approval √Annual Financial Plan (Revenue and Capital) including Health Care Contracts with Commissioners Public GN Antony Hobbs / A Jones Annual 1 Mar Approval √Annual Report and Accounts (including Statement of Internal Control and Quality Account) Public GN Alan Jones Annual 1 July (AGM by 30th Sept) Noting √Equality and diversity report Public IC Barbara Hay Annual 1 May Approval √Risk Management (inc H&S & Radiation Protection) Annual Report Public IC Dipak Chauhan Annual 1 Sept Noting √Nolan Principles/NHS Code of Conduct/UHCW Code of Conduct Policy Statement Public IC Jenny Gardiner Annual 1 February Approval √ √PEAT Report Public IC David Powell Annual 1 May Approval √Audit Committee Meeting Report Public NED Alan Jones 6 times per

year

6 As required Approval √ √ √ √ √ √ √ √ √ √Audit Committee TOR Public NED Alan Jones Annual 1 Mar Approval √Finance & Performance Meeting Report Public NED Alan Jones 8 times per

year

8 As required Approval √ √ √ √ √ √ √ √ √ √Finance and Performance Committee TOR Public NED Alan Jones Annual 1 July Approval √Quality Governance Committee TOR Public NED Paul Martin Annual 1 Nov Approval √Quality Governance Meeting Report Public NED Paul Martin 10 times per

year

10 Monthly Approval √ √ √ √ √ √ √ √ √ √Remuneration Committee TOR Public NED Jenny Gardiner Annual 1 Sept Approval √Trust Board Terms of Reference Public NED Jenny Gardiner Annual 1 November Approval √Trust Board meeting report Public NED Jenny Gardiner Monthly 10 monthly Noting √ √ √ √ √ √ √ √ √ √Patient Experience and Engagement Report Public MP Paul Martin Annual 1 Sept Noting √Patient and Staff Story Public MP Paul Martin Bi-monthly 6 Jan, Mar, May, July, Sept, Nov Approval

√ √ √ √ √ √Board Assurance Framework Public MP Jenny Gardiner Bi-annual 2 Mar, Sep Noting √ √Education Report Public MP Maggie Allen Annual 1 January Noting √SIG Report Public MP Paul Martin Bi-annual 2 January and June Approval √ √Mortality Report Public MP Paul Martin Bi-annual 2 January and June Approval √ √Research and Development Annual Report Public MP Ceri Jones Annual 1 May Noting √Number of Reports 109

13 9 12 13 13 12 11 12 10 12

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