a meeting of the board of directors will take …2. to review the register of interests and receive...

BoD Jan 2017: Agenda (PUM)

A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE ON 12 JANUARY 2017, 9AM

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL AGENDA

No Item Sponsor Ref

1. Apologies and Welcome

S Wragg, Chairman

2. To review the Register of Interests and receive any further declarations of interests 17/01/P-02

3. To approve the Minutes of the meeting of the Board of Directors held in public on 1st December 2016 17/01/P-03

4. To approve the Action Log in relation to progress to date and review any outstanding actions 17/01/P-04

Strategic Aim: Patients will experience safe care

5. To receive and review latest Patient’s Story H McNair Dir of Nursing & Quality Presentation

6. To receive and support the Chair’s Log and assurance from the Quality & Governance Committee

R Moore, Quality & Governance

Committee Chair 17/01/P-06

7. To review latest report on Mortality Ratios Dr R Jenkins Medical Director 17/01/P-07

8. To review the Chair’s Log on any escalation issues from the Executive Team

D Wake Chief Executive Verbal

Strategic Aim: People will be proud to work for us Strategic Aim: Performance matters

9. To receive and endorse the Chair’s Log and assurance from the Finance & Performance Committee

F Patton Committee Chair 17/01/P-09

10. To review the integrated performance report (month 8) Executive Team 17/01/P-10

Strategic Aim: Partnership will be our strength

11. To endorse the Breathe 2025 Campaign Dr R Jenkins Medical Director 17/01/P-11

12. To note the monthly report from the Chairman S Wragg Chairman 17/01/P-12

13. To note the monthly report from the Chief Executive D Wake, Chief Executive 17/01/P-13

14. To note latest Agenda and Minutes from the Council of Governors.

S Wragg, Chairman 17/01/P-14

15. In accordance with the Trust’s Standing Orders and Constitution, to resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted. Date of next meeting: 02 February 2017, 9am

Signed: ………..…………………… CHAIRMAN Please see reference section at back of papers for key to business plan and glossary of terms/acronyms

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REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT REF: BoD 17/01/P-02

BoD January 2017: 02(i)_Register of Interests

SUBJECT: REGISTER OF INTERESTS

DATE: JANUARY 2017

PURPOSE:

Tick as applicable Tick as

applicable For decision/approval Assurance

For review Governance For information Strategy

PREPARED BY: Carol Dudley, Secretary to the Board & Governors SPONSORED BY: Diane Wake, Chief Executive PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT

To support the Trust’s ethos of transparency in all matters, including the financial interests of the Board of Directors and senior management.

EXECUTIVE SUMMARY

The report presents the Registers of Interests of the Board of Directors, collated in accordance with the National Health Service Act 2006 (as amended by the Health & Social Care Act 2012) and the Trust’s Constitution. It also presents the Register of Directors for the Executive Team and Clinical Directors, compiled in accordance with the Board’s agreed good practice and as recommended by the Audit Committee. It should be noted that whilst every effort is made to assist Directors’ declarations, it is the responsibility of each individual to ensure that his or her interests are declared in a timely and appropriate manner. A Register of Interests is also held separately for the Council of Governors. The Registers will be presented to the Audit Committee and are available for public inspection RECOMMENDATION(S)

The Board is asked to receive and note the Register of Interests for the Board of Directors and the Register for the Executive Team and Clinical Directors.

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Register of Interests_BoD January 2017 Signed: Secretary to Board Page 1 of 4 Dated: 06 January 2017

BARNSLEY HOSPITAL NHS FOUNDATION TRUST REGISTER OF BOARD OF DIRECTORS’ INTERESTS (JANUARY 2017)

EXECUTIVE DIRECTORS Entry No 1 DIRECTOR Date of

appointment INTERESTS Date interest registered2

Date entry reviewed

34 Dr Richard Jenkins – Medical Director January 2015

• Member, Labour Party • Member, BMA • Secondary Care Clinician, North Kirklees

Clinical Commissioning Group

15 June 2016 07 July 2016

32 Karen Kelly – Director of Operations

01 July 2014 (exec) • None 01 July 2014 07 July 2016

38 Robert (Bob) Kirton – Director of Strategy &

Business Development

01 September 2016

a) Director, BHSS b) Partner Governor (for Trust),

Yorkshire Ambulance Service

15 Aug 20133 December 2015 07 July 2016

24 Heather Mcnair – Director of Nursing & Quality

05 December 2011 • None 08 December

2011 07 July 2016

30 Ms Diane Wake – Chief Executive

28 October 2013 • None 08 November

2013 07 July 2016

35 Mr Michael Wright – Director of Finance (Acting Dir to 1 Dec 2015)

20 July 2015 • Director, Barnsley Hospital Support Services Limited 20 July 2015 07 July 2016

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BARNSLEY HOSPITAL NHS FOUNDATION TRUST

REGISTER OF BOARD OF DIRECTORS’ INTERESTS (JANUARY 2017) NON EXECUTIVE DIRECTORS Entry No 1 DIRECTOR Date of

Appointment INTERESTS Date interest registered2

Date entry reviewed

37 Ms Janet Dean – Non Executive Director

01.01.2016 – 31.12.2018

• Board Member Metropolitan Housing & Chair of Clapham Park Homes (subsidiary)

January 2016 07 July 2016 • Trustee and Clerk to Finance Sub-

Committee, The Mount School, York

• Director, Dean Knight Partnership Ltd

• Director, The Mount School (Estates) Ltd June 2016

39 Mrs Keely Firth – Non Executive Director

01.01.2017 – 31.12.2019

• Volunteer Trustee, Healthcare Financial Management Association (HFMA)

• Chief Finance Officer, NHS Rotherham CCG

06 January 2017

40 Mr Philip Hudson – Non Executive Director

01.01.2017 – 31.12.2019 • tbc

35 Mr Nicholas Mapstone – Non Executive Director

01.04.2015 - 31.12.2017

• Director, Nick Mapstone Management Solutions Limited

• Associate, for 360 Assurance • Specialist Advisor,

for Care Quality Commission

April 2015 07 July 2016

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Entry No 1 DIRECTOR Date of


Date entry reviewed

36 Ms Rosalyn Moore – Non Executive Director

01.04.2015 - 31.12.2017

• Trustee, Association for Perioperative Practitioners

• Chief Executive Officer, Parish Nursing Ministries UK April 2015 07 July 2016

• Associate Lecturer with the Open University

17 Mr Francis Patton – Non Executive Director & Deputy Chair

01.01.2008 - 31.12.2009 - 31.12.2010 - 31.12.2013 - 31.12.2016 - 31.12.2017*

• Chairman, The Cask Marque Trust

14 January 2008

07 July 2016

• Treasurer, All Party Parliamentary Beer Group

• Senior Lecturer (part time), Leeds Metropolitan University

• Non Executive Director The BII (British Institute of Innkeeping)

23 June 2009 June 2014

• Managing Director Patton Consultancy 26 August 2010

• Non Executive Director, SIBA, The Society of Independent Brewers

September 2010

• Director, Fleet Street Communications December 2010

• Chairman, Barnsley Hospital Support Services Limited

24 May 2012

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Entry No 1 DIRECTOR Date of


Date entry reviewed

• Director, Cyclops Limited (charitable organisation)

15 September 2014

• Director, Walrus & Carpenter Limited 21 January 2016

19 Mr Stephen Wragg – Chairman

01.01.2009 - 31.12.2011 - 31.12.2014 - 31.12.2017*

• Non Executive Director, Barnsley Premier Leisure Trading 7 January 2009

07 July 2016

• Sole Director, Wragg Consulting Limited 20 May 2010

• Director, 360 Engagement Ltd 18 October 2011

• Governor, Darton College

12 December 2011

• Trustee & Chairman, Barnsley Civic

15 December 2011

Notes: 1 Entry numbers to run consecutive by date order 2 Hard copy of all updates will be required to be initialled by updating officer and retained in the office of the Chief Executive or Nominated Officer 3 Interests registered whilst in previous role as non voting Director (Board member since September 2016)) * Subject to annual review/renewal

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Signed: Secretary to the Board Register of ET_Dirs_CDs January 2017/ Page 1 of 1 Dated: 06 January 2017

BARNSLEY HOSPITAL NHS FOUNDATION TRUST

REGISTER OF EXECUTIVE TEAM & CLINICAL DIRECTORS’ INTERESTS (JANUARY 2017)

Entry No 1 NAME / POST Date of

appointment INTERESTS Date interest

registered Date entry reviewed

41 Dr Robert Atkinson – Clinical Director, CBU1 May 2016 None 07 July 2016

23 Mrs Lorraine Christopher – Director of Estates & Facilities 5 23 Feb 2009

Director, Barnsley Hospital Support Services Limited (BHSS) Familial interest: • Harrison Thompson & Co Ltd

Husband = Sales Director

15 Aug 2013

29th June

2013

07 July 2016

16 Miss Meenakshi Dass – Clinical Director, CBU3 (formerly CBU6)

December 2011 2 None

40 Mr Tom Davidson – Director of ICT

04 January 2016 None 07 July 2016

43 Mr Karl Hickman – Joint Associate Director of HR&OD

04 January 2017 Tbc

43 Mrs Emma Lavery – Joint Associate Director of HR&OD

04 January 2017 None 05 January

2017

32 Ms E Parkes – Director of Marketing & Communications March 20144 None 07 July 2016

42 Mr Stephen Mitchell – Clinical Director, CBU2 May 2016 None 07 July 2016

Notes: 1 Entry numbers to run consecutive by date order

2 Where applicable Clinical Director appointment dates show date of original appointment as Divisional/Clinical Director 3 Previously Interim Director of Transformation from June 2013 4 Previously Associate Director of Communications from April 2013 5 Previously Associate Director of Estates & Facilities, to July 2016

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REF: 17/01/P-03

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

MINUTES OF A MEETING OF THE BOARD OF DIRECTORS

HELD ON 1ST DECEMBER 2016 IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL NHSFT

PRESENT: Ms J Dean Non Executive Director

Dr R Jenkins Medical Director Mr R Kirton Director of Strategy & Business Development Mr N Mapstone Non Executive Director Ms R Moore Non Executive Director Mr F Patton Non Executive Director Ms D Wake Chief Executive Mr S Wragg Chairman Mr M Wright Director of Finance

IN ATTENDANCE: Dr R Atkinson Clinical Director, CBU1 (Medicine services) Mr J J Bannister Deputy Medical Director Ms C Beasley Matron, CBU1 Ms A Bielby Deputy Director of Nursing Mr B Brewis Deputy Director of Operations Mrs L Christopher Director of Estates & Facilities Ms M Dass Clinical Director, CBU3 (Women, Children & Clinical Support) Mr T Davidson Director of ICT Ms C E Dudley Secretary to the Board & Governors Mr K Hickman Joint Associate Director of HR&OD Ms E Parkes Director of Marketing & Communications Mr S Mitchell Clinical Director, CBU2 (Surgical services) (* attended for Minute 16/198 – Patients’ Story)

APOLOGIES: Ms K Kelly Director of Operations

Mrs H McNair Director of Nursing & Quality 16/194 APOLOGIES & WELCOME

Members and attendees were welcomed to the meeting, together with governors and staff attending as observers. Prior to the start of the main business of the meeting, the Chair welcomed Mr Sajard (Energy & Sustainability Manager), Mr Purba (Head of Estates Maintenance) and Ms Lavery (Joint Associate Director of HR&OD) to the meeting briefly. They were members of the team recently awarded the ‘most sustainable public sector organisation in health/NHS category' at this year’s Public Sector Sustainability Awards. It had been a strongly contested category and the Award was a worthy recognition of the team’s efforts and the Trust’s commitment to sustainability. The Board congratulated Mr Purba, Mr Sajard and Ms Lavery and asked them to convey their thanks to everyone involved for the hard work and commitment which had contributed to the Trust’s success.

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BoD Jan 2017: Dec Minutes PUM (p2 of 10)

16/195 DECLARATION OF INTERESTS None.

16/196 MINUTES OF LAST MEETING (16/12/P-03) The Minutes of the meeting of the Board of Directors held in public on 3rd November 2016 were received and reviewed. Two errors were noted:

• Reference to the Clinical Excellence Group should read Clinical Effectiveness Group

• Reference to “kerb scores”, should refer to CURB scores – an acronym for ‘confusion, urea, respiratory and bloods.

Subject to these corrections, the Minutes were accepted as a true record.

16/197 ACTION LOG (16/12/P-04) The action log showing progress on matters arising from the last and previous meetings held in public was reviewed and noted. Dr Jenkins confirmed that development of the statistical process control charts for mortality ratios was ongoing.

16/198 PATIENT’S STORY Ms Beasley was welcomed to the meeting, to share the story of a 79 year old patient admitted following a TIA (stroke). After her discharge, the patient’s daughter had written in to complain about the poor discharge arrangements. Prior to discharge, the care provided to her mother had been good but her discharge had been delayed by 24 hours, causing stress to her and her mother. It would doubtless also have caused considerable inconvenience to her, as she had taken time off work to oversee her mother’s transfer. Having been told previously that her mother was fit for discharge, the patient’s daughter had arrived at midday, waited until 3pm for discharge to be confirmed and then been told at 8pm that essential medication could not be provided until the next day as it was required to be in 7-days packaging (a venalink) which could not be dispensed at that time. The patient was transferred the next day albeit the discharge had been further complicated by the involvement of both Rotherham and Barnsley services. The team had since met with the complainant and had responded formally to explain the situation and offer sincere apologies. Ms Beasley explained to the Board that venalinks cannot be dispensed after 4pm due to safety issues/extra requirements. Ordinarily the venalink would have been dispensed in good time but on the planned day of discharge, the ward rounds and completion of prescriptions had been delayed due to staffing absences and high discharge numbers. On review it had also been ascertained that the patient had a venalink on admission and did not require one on discharge as she was going to a place of respite (nursing home) rather than her own home. The case had been reviewed in the Clinical Business Unit’s (CBU) governance meeting to ensure greater awareness of the requirements for venalinks and the need for clearer communications with patients and their families to explain how and when delays arose around discharge. Actions had also been taken with the ward pharmacy medical teams to ensure earlier preparation before discharge.

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Dr Jenkins queried the need to wait for a further medical review on the planned day of discharge if the patient had already been deemed medically fit. Having already been deemed medically fit for discharge, it should have been possible for the medication to have been prepared earlier in this case. Following discussion at the meeting, there was a consensus that the protocols should be revised to obviate the need for a further review on the day of planned discharge provided that the patient’s clinical condition had not changed in the interim. Dr Jenkins undertook to develop a protocol in co-operation with the Director of Nursing & Quality and Director of Operations. Ms Beasley was requested to take the Board’s message back to her team too. Before leaving the meeting, Ms Beasley was thanked for attending and for presenting an informative account of a patient’s experience and the Trust’s learning therefrom.

RJ

16/199 QUALITY & GOVERNANCE COMMITTEE (Q&G) (16/12/P-06) - CHAIR’S LOG As Ms Moore had been unable to attend the latest meeting of the Quality & Governance Committee (Q&G), Dr Jenkins presented the Chair’s Log on her behalf. Dr Jenkins advised that the Log gave a comprehensive overview of the Committee’s key discussions, including welcome assurance on complaints, which had been reinforced by the largely positive outcomes from four cases referred to the Parliamentary & Health Service Ombudsman recently. The Log also highlighted continued good progress on key safety areas such as pressure ulcers, mortality ratios and harms from falls but had identified the need for more work around VTE (venous thromboembolism) screening, which he was confident would be redressed swiftly. Dr Jenkins flagged the two policies approved by the Committee following minor updates, and adoption of the new national guidance around risk management in relation to safeguarding vulnerable adults. Additionally, the Trust’s Framework of Policies and Procedures had been revised to make the lines of responsibilities clearer. The Board noted the actions and endorsed and approved the Policies and Framework respectively.

16/200 EXECUTIVE TEAM (ET) CHAIR’S LOG Ms Wake confirmed that there had been nothing for escalation to the Board; some items had been reported to the governance committees.

16/201 SIX MONTHS UPDATE ON NURSING & MIDWIFERY (16/12/P-08) STRATEGY AND SKILL MIX Ms Bielby presented the six months update report on Nursing and Midwifery. It had been provided in a slightly different format than previously, to expand on changes in staffing reflecting national changes and the impact on new roles. Members were reminded, however, that a review of staffing levels (including fill rates) continued to be scrutinised closely at Q&G on a monthly basis. Ms Bielby also confirmed that the Trust continued to work to the agreed ratio of 1:7 registered nurses to patients generally (above the 1:8 national guide), with a higher ratio where needed in areas such as Care of the Elderly. Maternity continued to work to a different ratio (1:28) in accord with national guidance. The report also highlighted the changes introduced following the Francis Report in 2013 and the more recent Carter recommendations. Whilst the latter promoted more focus on productivity, the emphasis on safety remained. New areas in the report illustrated the Trust’s effective and efficient deployment of staff, the recording of care hours per patient per day (national requirement)

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changes around the ten expectations identified in the Francis Report, now reduced to three - right staff, right skills, right place and time – and new staffing guidance for emergency departments and community care, more on which was expected in the new year. The report also outlined initial work in readiness for the abolition of nursing bursaries in 2017 and new roles such as Associate Nurses and Assistant Practitioners. Advance Nurse Practitioners (ANPs) were now well established in the Trust in several areas and proving to be a very successful part of the nursing workforce. Ms Bielby drew attention to the skillmix reviews ongoing in several areas, particularly outpatients. These had resulted in revised job descriptions for a number of band 4 staff in several specialist teams, and a better skillmix for each service’s needs as well as some savings. A review was currently ongoing in paediatrics and two ANPs were being trained as part of the developments for this service. Ms Bielby also pointed out that the acuity review for nursing & midwifery staff had been postponed to the new year after the ward reconfigurations had been completed and settled in. Several aspects were explored further in discussion: • Mr Mapstone queried the impact on staffing or sickness absence levels with

the growing trend for longer shifts, which many nurses seemed to prefer. Ms Bielby assured the Board that staffing levels continued to be monitored daily to ensure safe staffing and sickness absence levels were also monitored regularly; any adverse indicators would be spotted quickly but nothing had been identified to date. The main downside of 12 hours shifts related to the need to cover two shifts in the event of sickness absence but this would be mitigated through bank and agency staffing.

• Mr Patton recalled the risk of upskilled staff such as ANPs being attracted to other employers after being trained by the Trust. Ms Bielby reported on a recent regional benchmarking exercise, which had shown that all ANP roles in acute services were paid on the same band. One nurse had been lost to a GP surgery but GPs were able to pay higher rates, nonetheless the attrition rate was low and the Trust would continue to work hard to retain staff through engagement and more career development opportunities.

• Ms Moore referred to the new role of Associate Nurses; she was aware of evidence from America regarding the correlation between quality of registered nursing compared to licensed practitioners and enquired about comparable data in the UK. Ms Bielby advised that this was not yet available but progress would be closely monitored. With regard to qualifications, postholders would need high levels, Maths and English and would be required to undertake a foundation degree course at University. The scope of practice would include medications etc, so the curriculum would cover this and other essential theories. Ms Dass reminded members of similar reservations with regard to roles introduced 10 years ago but now embedded into the system and working well; some changes must be embraced. Ms Wake agreed that these new roles should be embraced as another development opportunity for the unregistered workforce.

• In response to the Chairman, Ms Bielby advised that nurse staffing on the Care of the Elderly wards now had a more 50:50 registered:unregistered care staff mix. This had enabled better cover for staffing and less reliance on bank and agency support, and had helped with core care issues such as prevention of falls, feeding and hydration. With regard to the impact on orthopaedics and theatres queried by Mr Mitchell, Ms Bielby affirmed that the review of skillmix in all teams could help with staffing and recruitment,

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making the work and shift structures more appealing to candidates. As a first step, trauma would be split off from orthopaedics to help take this forward.

16/202 ADVANCE NURSE PRACTITIONER EVALUATION (16/12/P-09) Ms Bielby explained that this report focussed on the acute response team of ANPs – when fully trained, this would be a team of 13 ANPs plus the lead, providing support 12 hours/day in medicine and surgery and night support in surgery too, with plans to roll out wider and provide a 24/7 service by April 2017. The team had been launched in June 2016, supported by funding from Health Education England two years ago to enable training and developed as part of the Trust’s wider strategy on nursing and midwifery. The team’s main focus was on deteriorating patients or patients of concern, linked to the National Early Warning Scores (NEWS) system and working in close co-operation with the Intensive Treatment and Acute Medicine Units. The outcomes to date were very positive, enabling a majority of patients seen by them to be nursed in clinical areas albeit with transfers into the Critical Care Unit where needed. Qualitative feedback from the areas supported by the ANP team so far had indicated good, timely and valued performance. As indicated in the earlier report on nursing & midwifery, work was continuing to develop the role further. Ms Bielby advised that specific areas for development would include hospital at night, critical care outreach, and shared learning and education. Mr Bannister appreciated the success of the team but questioned plans to remove night nurse support from surgery as part of the continued development. Mr Mitchell had also received feedback that some support was being removed from the ward and queried the support for junior doctors However, Ms Bielby believed both issues reflected a misunderstanding; roles were changing but not being removed. She undertook to discuss this further outside the meeting to clarify the position and give assurance on continued support. Ms Wake also sought assurance that ANP out of hours support was intended to cover the whole site and Ms Bielby confirmed that this would be in place by April.

AB

16/203 FINANCE & PERFORMANCE COMMITTEE (F&P) (16/12/P-10) - CHAIR’S LOG Mr Patton presented and expanded upon the Chair’s Log from the Committee’s November meeting. He highlighted the month 7 financial position, which remained favourable to plan year to date but had been behind in terms of performance in month. Projections showed the Trust still expecting to hit the year end target but performance against the <4 hours emergency access target would be critical, with a potential penalty of up to £400,000 if not achieved. The Cost Improvement Programme (CIP) had been above target for the period and on target year to date. Mr Patton recorded thanks from the Committee to everyone involved with this achievement. Cash remained constrained, mainly due to continued debts to the Trust; these were being pursued vigorously. The capital programme continued to make good progress against the smaller scheme approved internally; national sign off of requests for wider capital programmes had not yet been received. The Committee had received an update on the winter plan, with assurance that this was being dealt with on a health economy-wide basis this year. He reminded members of questions raised last month by Mrs Brain England

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regarding GP capacity; this remained a concern and would continue to put the hospital’s capacity under pressure. The Chairman and Ms Wake advised that the Trust continued to ask for more information about how the gaps in GP cover would be addressed. It seemed that it was difficult to obtain the data and Ms Wake advised that she had escalated this nationally. In terms of performance, the improvements in cancer had been noted but the Committee remained conscious of the continued pressures on the emergency department and Trust-wide consequences. Two benefit realisation reports had been received on recent business cases implemented in cardiology and urology, showing good returns on investment and, more importantly, improvement in care and quality for patients. The Committee had also received an update on the Apprenticeship Levy, coming into force in 2017. It had been good to see the Trust’s growing understanding of the complex funding arrangements underpinning the new scheme and the obvious commitment to making it work well for both candidates and services. As listed in the Log, the Committee had received and endorsed minor updates to a number of policies too. For good order these were also ratified by the Board. In response to a question from Mrs Dean, Mr Patton referred to the Service Line Reporting (SLR) received and reviewed by the F&P Committee each month. This increasingly looked at operational profit, recognising each service as a separate business and taking account of overhead costs etc. SLR was now much more accurate and a very effective tool. He agreed that, whilst regular scrutiny should remain the remit of the F&P Committee, it would be useful to share the SLR with the Board annually to give further assurance from the Committee. The Chairman agreed that it would be useful to do so at the mid year point for assurance but not to revisit the discussions that would have been held by the Committee. Mr Wright gave further assurance that he knew the exact position of any CBU throughout the year. As an overview he confirmed that CBU1 remained in a challenging financial position, with CBUs 2 and 3 both in stronger positions against budget. In response to the Chairman’s question, he advised that the main challenges in CBU1 were around new to follow ups (costing c£200,000 and currently under review by the CBU), continued pressures on the emergency department and extra lists for endoscopy. Mr Kirton agreed that SLR data had become increasingly useful, giving a good indication of performance and quality and enabling the CBUs themselves to understand business principles better, as had been seen by the Board at the mid year review. In relation to the new to follow up ratios, Dr Atkinson gave assurance that a lot of work was ongoing to look at strategy and, where applicable, challenge contracts to be realistic recognising the growing service demands. In relation to endoscopy, Dr Atkinson advised that the CBU had responded well to the challenges it had faced and had been able to reduce and maintain waiting lists at 2-4 week waits.

add to workplan

16/204 INTEGRATED PERFORMANCE REPORT (IPR) (16/12/P-11) The month 7 IPR was received and reviewed. Whilst many of the key points had been reported in F&P and Q&G Chairs’ Logs and subsequent discussions, ET members provided more information on several key issues: Activity Mr Brewis highlighted the strong performance on cancer, particularly in referrals to treatment (RTT) and improvements in diagnostics albeit with some

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challenges on 62 days (showing signs of improvements going forward). As reported earlier, pressures continued on the <4 hours emergency access national target: 93.2% for October, 94.1% year to date and significant challenge throughout the whole of November. Nonetheless work continued to drive further improvements where possible, including changed rotas and improved primary care support (Vocare). Medicine CBU had faced a lot of work with the reconfiguration of several wards but this had progressed well with AMU moved, a new assessment centre in place and Stroke and Care of the Elderly merged on wards 19/20, and would also help deliver improvements overall. Work would continue to be supported by the A&E Delivery board too. Ms Wake Chaired this Board and outlined some of the work ongoing to gain more momentum and drive more improvements across the community. Mr Mapstone enquired if any predominant causes to the continued demand on A&E had been identified but Mr Brewis reiterated that the causes remained varied: increases in attendance, acuity, changeable patterns of demand, saturation of bed base, etc. Ms Moore also referred to working with the ambulance service (YAS), who themselves were facing huge demands, and anecdotal feedback that teams often came to Barnsley as the handover times were good although it was acknowledged that waits were unavoidable from time to time. Ms Wake had welcomed YAS representation on the A&E Delivery Board. The impact of Medworxx was also reviewed. Dr Atkinson affirmed that it had proven to be quite useful, helping the Trust to gain better understanding of patient flow. Ms Wake advised that there were not currently any plans for it to be rolled out in the community but the Trust would be ready to support this at any time if the opportunity arose. Quality Ms Bielby referenced the key points highlighted in the Q&G Chair’s Log and assured the Board that improvements in quality continued to move in the right direction. The IPR showed that complaint responses had improved and falls and repeat falls had decreased, as had hospital standardised mortality ratios. Six cases of Clostridium difficile had been reported to date, against trajectory of 13; this was a similar position to last year and remained on target for the year end albeit tight. Two serious incidents had been reported (one from September) and were subject to further review. In relation to pressure ulcers, Mrs Dean noted the increase against last year. Ms Bielby advised that the increase mainly related to grade 2 ulcers, which had been reported for root cause analyses; not many trusts did this. Workforce Mr Hickman confirmed that there were no concerns with staff turnover; appraisals remained compliant and mandatory training levels were static and sickness absence had risen slightly (the latter two possibly due to the October half term). Peaks had been noted on some issues in several particular staff groups and, as discussed in F&P, deep dives would be undertaken to drive improvements in training and any short/long term needs identified. Finance Mr Wright confirmed that, as reported in the F&P Chair’s Log, clinical income had performed well to date albeit the month had just achieved plan with a more challenging position ahead. The cash position remained challenging too. The Chairman was assured that the Trust had planned for the impact of annual leave throughout the year, with over achievement attained in the summer months to mitigate this. The Chairman pointed out that this could be interpreted to plan for maximum absence rather than maximum attendance and it was agreed that this might still need to be considered further.

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16/205 COMMITTEES IN COMMON (16/12/P-12)

Members were reminded of the current governance arrangements for the Working Together Programme (WTP), which involved the Boards of seven organisations across the region and Mid Yorkshire. The Chairman presented and expanded upon the second report on Committees in Common (CIC), which could enable named representatives from each trust to meet as a committee on behalf of their Board, with delegated authority to act on behalf of that Board. The CICs could meet in one room at the same time and respond to proposals immediately within their respective committees, on behalf of their respective trusts. The aim would be to minimise delays currently being experienced where proposals had to be referred back to each board, all of whom met at differing times. The outline of the CICs had come from NHS Improvement (NHSI initially. This was discussed at some length. Whilst no-one disagreed with the need to support a prompt decision making process, there was a general view that the Board of BHNFT met frequently enough to enable decisions to be made in a timely manner. However, it was recognised that the pace of work in the WTP was slower than wished and, potentially, the CICs could help. It was anticipated that boards should already be aware of any issues to be discussed by the CICs and thus the respective committees would have prior knowledge of their respective board’s view. As a foundation trust, the establishment of a CIC was permissible albeit some changes may be required in the Trust’s Constitution or Standing Orders etc. Each of the committees involved would be of equal standing; the decision made by any one committee would be binding upon its organisation only, each foundation trust would retain its status as a sovereign entity. In conclusion, the idea of a CIC was supported in principle but without a commitment at this stage. The Board agreed that before it could be taken forward any further it would be imperative that the operational details underpinning CICs were made clearer: what values would be involved? What changes would be needed for each organisation’s governance structure/ documents? What assurance could be received that no unannounced issues would be presented for decision by the CICs? Would/could a forward plan be developed? Was there any intention for CICs to be applied to the Sustainability & Transformation Plan (STP)? The Chair and Chief Executive would convey the Board’s position at the next WTP meeting.

SW/DW

16/206 CHAIRMAN’S REPORT (16/12/P-13) The Chairman’s report was received and noted. It provided an overview on a number of activities undertaken by the Chairman since the last Board meeting and items of interest, including feedback from national and local events and the continuing work of the Council of Governors and Barnsley Hospital Charity. Two reports were received from other members of the Non Executive Team:

• Ms Moore affirmed that the spirituality focus group was scheduled for 7th December

• Ms Dean had recently attended the NHS Providers national conference. She found it to be very useful in terms of both networking and hearing keynote messages from the Secretary of State and NHS leads.

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16/207 CHIEF EXECUTIVE’S REPORT (16/12/P-14) The Chief Executive’s report was received and noted, providing information on a number of internal, regional and national matters. Ms Moore sought more information following Ms Wake’s recent meeting with her counterpart at South West Yorkshire Partnerships NHSFT (SWYPFT). Ms Wake advised that an exec-to-exec meeting had since been held too. Overall both meetings had gone well and it was anticipated that the relationship would continue to develop as the two trusts had opportunity to work more closely together. In response to a question from Mr Mapstone regarding the latest visit from the NSHI relationship team, Ms Wake advised that the team had indicated the intention to schedule monthly meetings/conference calls with her and quarterly meetings with the wider executive team, to work alongside the Trust and support further performance improvements. Dates for the meetings were awaited. It was reiterated that the Trust’s management had made significant representations against the initial assessment of segment 3 under the new Scrutiny Oversight Framework but, even though the Trust’s good progress had been recognised by NHSI, it had not been possible to revise the rating due to the prescribed process.

16/208 QUARTERLY COMMUNICATIONS REPORT (16/12/P-15) Ms Parkes presented the report on communications and marketing for September-December 2016/17. It had been a very busy quarter for communications both externally, with the STP draft proposals being released directly into the public domain, and internally with the staff survey, NHS Change Day and flu vaccination programme to name a few of the workstreams. Work had also progressed to drive improvements to the internal and external web pages for the Trust, which would be launched in early 2017. Media had been very busy and generally positive; there had been a slight dip in November due to changes in staffing in the department but this should pick up with the new staff now in post. Ms Parkes also reported an increase in queries from the local media, many of which were not known to the Board; this had shown a marked shift in interest in the Board papers, which was likely to grow. The Board acknowledged that the latter could be challenging but the relationship with the media remained positive and the Board was committed to an ethos of transparency and openness. Ms Parkes advised that the Hospital’s Charity had also been very busy, receiving donations of over £200,000 in the quarter for the Tiny Hearts Appeal, which now totalled nearly £500,000, not counting a further pledge of £30,000 from Mr Dickie Bird. The Christmas Text appeal was proving successful already and the Trust’s first Christmas Ball was scheduled to be held on 2nd December, with nearly 200 tickets sold. Discussions had also been held with many of the generous companies, who wished to give toy donations to the Trust for the younger patients in hospital over Christmas. Not all toys could be used on site due to service restrictions. Some companies had kindly agreed to give donations to the Charity; some toys would still be welcomed and the Board also supported Ms Wake’s suggestion that those toys not deployed for the Trust’s patients could be raffled to raise funds for the Charity or with children and families less able to afford them themselves.

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16/209 HORIZON SCANNER (16/12/P-16) Ms Parkes presented the latest Horizon Scanner and highlighted several items of interest, including the reports on contracts being awarded outside of the NHS. Ms Moore noted the reporting on hand hygiene and Mr Mapstone also flagged the data on 7 days services.

16/210 ANY OTHER BUSINESS & DATE OF NEXT MEETING a) Comments from Public observers

Mr Brannan, Partner Governor, had found the patient story to be of particular interest and had been pleased to note the Board’s instant response in securing a change of protocols to address one of the issues raised. He would welcome further feedback from the Non Executives from the Quality & Safety visits they were involved with or other reports received from staff. Whilst this could be difficult as the Chairman and Non Executives met with a lot of staff during the course of their activities, Ms Moore undertook to share more information at future Q&G sub-group meetings with the Governors. Mr Brannan shared the Board’s frustration about information not currently available on GP capacity in the community.

b) Date of next meeting The next meeting of the Board of Directors was scheduled for 12th January 2017.

There being no further business and in accordance with the Trust’s Constitution and Standing Orders, it was resolved that members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted. It was further resolved that Governors were invited to remain for the private session.

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BoD Jan 2017:Action Log (PuM)

SUBJECT: BOARD ACTION LOG

DATE: JANUARY 2017

PURPOSE:




PREPARED BY: Carol Dudley, Secretary to the Board & Governors SPONSORED BY: Diane Wake, Chief Executive PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT

EXECUTIVE SUMMARY

RECOMMENDATION(S)

The Board of Directors is asked to: a) note and approve reported progress and any verbal updates and b) review any outstanding actions

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Subject: Board Action Log Ref: BoD 17/01/P-04

Key to RAG status Action overdue or no update provided Update Provided but action not complete Update provided and action complete BoD Jan 2017: Action Log

ACTIONS ON AGENDA: Table 1 Minute

ref Meeting date Item Action Owner Due date Done Date Progress report RAG

status

- - -

ACTIONS COMPLETED & CLOSED SINCE LAST MEETING: Table 2 Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report RAG

status

16/206 December 2016

Committees in Common

Board approval in principle (final decision pending further detail) to be reported to Working Together Programme

Chairman & CEO Dec 2016 Dec 2016 Actioned: reported at

December meeting


Finance & Performance Committee

Presentation of Service Line Report to Board at mid year, to be added to workplan.

F&P Chair Dec 2016 Dec 2016 Actioned: added to 2017 workplan

ROLLING TRACKER OF OUTSTANDING ACTIONS: Table 3 red = overdue Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report RAG

status


Advance Nurse Practitioner evaluation

Support for junior doctors to be reviewed/discussed outside meeting.

Deputy Dir of Nursing Dec 2016 tba

Ongoing: Meeting scheduled 06.01.2017 however, this was cancelled due to operational pressures. Meeting to be rescheduled.

16/198 December 2016 Patient’s Story

Protocol to be revised/ developed re patients assessed as medically fit for discharge

Medical Director

March 2017 In progress: subject to further

review before finalisation.

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Key to RAG status Action overdue or no update provided Update Provided but action not complete Update provided and action complete BoD Jan 2017 Action Log / 2

Minute ref

Meeting date Item Action Owner Due date Done

Date Progress report RAG status

16/171 October 2016 Chairman’s Report

“Ambassador’s pack” to be developed for directors attending community events.

Dir of Marketing &

Comms

Early 2017 Work will commence early

2017.

16/152 September 2016

Integrated Performance Report (IPR)

Review of establishment post-reconfiguration of wards to be reported to Q&G and Board

Dir of Nursing & Quality

Early 2017

Scheduled: Report to be provided to Q&G in January 2017 and Board in February 2017.

16/104 June 2016 Integrated performance report

SPC chart for mortality ratios to be developed covering 2014-17, reflecting interventions, impact and future expectations

Medical Director & Dir

of IT

October 2016 Ongoing: work in progress

abbreviations: • BAF – Board Assurance Framework • CIP – Cost Improvement Programme • Comms – Communications • CRR – Corporate Risk Register • Dir – Director • ET – Executive Team • F&P – Finance & Performance Committee • ICT – Information & Communications Technology • IPR – Integrated Performance Report • Q&G – Quality & Governance (Committee) • SPC – Statistical Process Control (or SPCC Statistical Process Control Chart)

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BoD Jan 2017: Q&G Chair’s Log Dec 2016/ p1

REPORT TO THE BOARD OF DIRECTORS REF: BoD 17/01/06

SUBJECT: QUALITY AND GOVERNANCE ASSURANCE REPORT

DATE: JANUARY 2017

PURPOSE: Tick as

applicable Tick as applicable

For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Carol Dudley, Secretary to Board & Governors & Ros Moore, Non Executive Director/Committee Chair

SPONSORED BY: Ros Moore, Non Executive Director/Committee Chair PRESENTED BY: Ros Moore, Non Executive Director/Committee Chair STRATEGIC CONTEXT

The Quality & Governance Committee (Q&G) is one of the key committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of quality and safety across the Trust in order to provide assurance and raise concerns (if appropriate) to the Board of Directors and to make recommendations, as appropriate, on quality and safety matters to the Board of Directors.

EXECUTIVE SUMMARY

This report provides information to assist the Board on obtaining assurance about the quality of care and rigour of governance. From the Q&G Committee’s December meeting, key issues for the Board’s attention include:

• review of quality issues in the Integrated Performance Report • regular review of the Board Assurance Framework and Corporate Risk Register and reports on

Mortality Ratios and Nursing & Midwifery staffing • assurance on plans progressing with local Universities in anticipation of the abolition of bursaries

for nurse training in 2017 • overview of the benefits being realised with the introduction of 7-days specialist palliative care

since April 2016 • the annual report on Research & Development, which outlined the progress made throughout

2016, with an improved structure, new leadership and better recruitment for and participation in clinical trials

• the annual report on External Visits to the Trust • the proposed response to consultation on changes to Paediatric Surgery & Anaesthetics and

Hyperacute Stroke Service, which the Committee fully endorsed • further review of the governance structure for groups reporting into Q&G, noting the continued

progress and identifying further improvements required • endorsement of a number of policies updated by the IP&C team The Committee received a useful overview and demonstration of the VitalPAC system recently implemented on three wards (cardiology, respiratory and gastro/endoscopy), with plans for further roll out in the new year. Operating on a ‘paperless’ basis, staff on these wards have been able to switch to e-systems for patient observations, ensuring more robust completion of processes, instant upload and wider access to data, and automated calculation of observation periods and NEWS (national early warning signs) data – all contributing to more efficient and safer processes, with further developments (linked to other e-systems) in the pipeline.

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The Committee also maintained its focus on the continued high demands on A&E services. Whilst there has been no conclusive evidence to date of any adverse impact on care, a full report will be provided to Q&G in February, with triangulated validated data from incidents, complaints and harms to patients. The pressures on staff and outcomes for patients remain a concern for everyone. Staff clearly recognise that Barnsley is not unique in the pressures it faces, nevertheless, the Committee was pleased to note that staff are being offered additional support, such as debriefs after particularly pressured shifts.

RECOMMENDATION(S)

The Board is asked to review and endorse the attached Log.

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Subject: QUALITY AND GOVERNANCE ASSURANCE REPORT Ref: BoD 17/01/P-06 CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: Quality and Governance Committee (Q&G) Date: 21 December 2016 Chair: Ros Moore

Ref Agenda Item Issue and Lead Officer Receiving Body,

i.e. Board or Committee

Recommendation / Assurance/ mandate to receiving body

1 7 day services - Specialist Palliative Care (SPC)

With a team of five SPC nurses in place since April 2016, the service has been expanded to provide 7-day care. The Committee heard how this has helped to ensure that the same standard of End of Life support and care is available for patients and their families/carers – and staff – at weekends as well as weekdays. The team highlighted a number of additional benefits too, including strengthening of acute oncology and greater staff awareness. The improved service was part of the Trust’s End of Life services cited as “outstanding” in the 2015 Care Quality Commission inspection. Lead officer: Director of Nursing & Quality

Board of Directors For assurance

2 Research & Development (R&D)

The annual report on R&D illustrated the good progress achieved over the past year, with an improved structure and leadership now in place. The team has also renegotiated its position for clinical trials and already overachieved on recruitment. The R&D contribution to the Trust’s bottom line will be a focus of the next report on strategy, due to be presented to the Finance & Performance Committee in January 2017. Lead officer: Medical Director

Board of Directors

Finance & Performance Committee

For assurance

3 Integrated performance Report (IPR)

Key points from the latest IPR included: • continued improvement in complaint response times • another good month with no incidence of falls resulting in moderate

(or more) harm • seven avoidable grade 2 pressure ulcers recorded, with more work

needed on assessments. Recruitment plans ongoing to appoint more nursing support to this need and proposals mooted to run an observation exercise to identify causality of gaps in the assessment process

• C.diff at six cases to date (year end trajectory of 13) and still zero MRSA bacteraemia cases

• Increase reported in norovirus but continues to be well managed

Board of Directors For assurance and to note

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• continued good performance in mortality ratios • work continuing to ensure a return to compliance for venous

thromboembolism screening, including development of mandatory e-training for front line staff

• three medication incidents resulting in harm reported in month - the highest level for several years. No trends or commonality identified to date and assurance was received that all of the incidents would be subject to further review

• good compliance with mandatory training noted, at 87.8%. This is the highest achievement year to date and particularly encouraging in light of the continued demands and pressures on staff

• increased staff sickness levels noted, largely due to gastro Lead officers: Director of Nursing & Quality and Medical Director

4 Mortality Ratios

The latest report confirmed the Trust’s continued good performance, below national averages on all key mortality measures. Additional data on weekend mortality rates was also received, showing the marked improvement over the past few years. Focussed work was ongoing to drive improvements around sepsis. The Committee was also assured that other continuing work (including VitalPAC) would support more progress, which was essential – the Trust must not become complacent. Lead Officer: Medical Director


5 Public Consultation

The Committee reviewed and fully supported the draft response to the public consultation on Children’s Surgical Services & Anaesthetics and Hyperacute Stroke Services. It is imperative that safe services are protected across the region. Whilst the changes proposed for Hyperacute Stroke Services offer a sensible way forward, the Committee shared the concerns raised regarding the impact for Barnsley patients re the children’s surgical services on the basis currently outlined. Lead Officer: Medical Director

Board of Directors For escalation

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6 Infection Prevention & Control

As mentioned, C.diff and MRSA continue to be compliant against trajectory. Incidence of norovirus has increased but continues to be well managed on site despite prevalence in the community and higher incidence amongst staff. Several cases of flu were recorded and had added to the pressures on isolation facilities, the availability of which has been reduced with the new ward configurations but continues to be well co-ordinated. Lead Officer: Director of IP&C


7 Nursing & Midwifery

• The monthly report showed a reduction in vacancies for inpatient services albeit staffing was still facing notable pressures. Following the ward moves (now complete) new staffing models were in place in AMU and the Emergency Department; the impact would be reviewed in the new year.

• An overview of plans in progress to address changes to non medical professional training was received. Close work is ongoing with the University of Sheffield in particular to support provision of training in Barnsley for nurses following abolition of bursaries in 2017.

Lead Officer: Director of Nursing & Quality


8 External Visits

The Registers of External Visits for 2015/16 and 2016/17 were reviewed. Members noted closure on the actions for 2015/16 outcomes (all complete except one ongoing in accord with agree timings) as well as reporting on 2016/17 to date. Lead Officer: Head of Quality & Clinical Governance


9 Governance Structure review

Following initial review of the governance and reporting structure for Q&G in May, the follow up review confirmed the actions progressed to date, including review of Terms of Reference (to ensure a shared approach across all reporting groups) and review of memberships. Some work still required to support better attendance. Lead Officer: Head of Quality & Clinical Governance

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10

Board Assurance Framework (BAF) and Corporate Risk Register (CRR)

The sections of the Board Assurance Framework and Corporate Risk Register relevant to the Q&G Committee were reviewed. The Committee requested one new risk to be added. The Committee also received an analysis of the CRR, showing a 50:50 split clinical:non-clinical and the spread of risks by domain. The further analysis was appreciated and will be presented at regular intervals. Lead Officers: Executive Team


11 Policies

Approved The Committee noted three Policies updated by the IP&C Group: • MRSA Policy • MRSA Screening Policy • Viral Haemorrhagic Fever Policy Lead Director: Director of IP&C

Board of Directors For assurance and to note

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BoD Jan 2017: Mortality


SUBJECT: MORTALITY REPORT

DATE: JANUARY 2017

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Jade Booth and Dr Kieran Baker, Head of Healthcare Information and Insight Service

SPONSORED BY: Dr Richard Jenkins, Medical Director

PRESENTED BY: Dr Richard Jenkins, Medical Director

STRATEGIC CONTEXT

The Trust has a 2016/17 goal of reducing mortality rates to below 100.

EXECUTIVE SUMMARY The report provides a range of statistics on mortality rates in the Trust. Crude mortality: Latest crude mortality is 24.1 for November 2016 compared to 21.5 in October 2016. Year to date is 20.01 compared to 22.80 for 2015-16. Summary Hospital Mortality Indicator (SHMI): No new data has been released since the last report. The latest available period is April 2015-March 2016 and was 99.4. Hospital Standardised Mortality Ratio (HSMR): Latest data is to August 2016 and reports 94.9 for the preceding 12 month period. The financial year-to-date HSMR is 89.1. Disease-specific mortality: Sepsis HSMR remains elevated at 115. A case note review demonstrated that care processes are satisfactory but early antibiotic administration is less good recently and work is ongoing to address this. Pneumonia HSMR remains just above the national average at 102.2. Weekend mortality: Analysis of the last four years demonstrates dramatic improvements in HSMR and also unadjusted numbers of deaths. Summary: Overall, the different measures of mortality give a fairly consistent picture of rates just below the national average and evidence of improvement on previous years. A mortality reduction action plan is being implemented. The recent announcements from NICE on mortality will be reviewed by the Mortality Steering Group. RECOMMENDATIONS

The Board is recommended to review and receive the report.

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SUBJECT: MORTALITY RATIOS REF: BoD 17/01/P-07

1 MORTALITY STATISTICS

1.1 SUMMARY HOSPITAL MORTALITY INDICATOR (SHMI)

1.2 The latest data published in September 2016 was for the period April 2015 – March 2016 (99.4).

1.3 HOSPITAL STANDARDISED MORTALITY RATIO (HSMR)

1.4 The latest Rolling 12 Months HSMR for Yorkshire and Humber Non Specialist Trusts are presented below. The 12 Month rolling to August 16 is 94.9 and the Financial Year to date HSMR is 89.1. BHNFT figures are highlighted in peach.

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1.5 The monthly trend for HSMR is shown below. The Trust target for the 2016/17 Financial year is below 100.

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1.6 CRUDE MORTALITY RATES FOR BARNSLEY HOSPITAL NHSFT

1.7 Crude Mortality Rates (latest month November 2016) Financial Year No. of Deaths No. of Discharges* Crude Mortality

Rate per 1000 Discharges*

Weekend Crude Mortality Rate per 1000 Admissions**

2007/08 1052 37651 27.94

2008/09 1062 40028 26.53 31.28

2009/10 1072 42583 25.17 31.85

2010/11 1051 40914 25.69 30.06

2011/12 1012 42023 24.08 28.08

2012/13 1034 42588 24.28 29.13

2013/14 1021 42551 23.99 31.10

2014/15 967 41948 23.05 29.12

2015/16 982 43062 22.80 27.84

2016/17 YTD 556 27785 20.01 27.06

* Excludes Day cases, unless a death ** Deaths/Admissions on a weekend

1.8 Statistical Process Control (SPC) Chart, Crude Mortality Rate, BHNFT

1.9 Crude mortality figures show an increase in the number of deaths in the

Trust from 74 in October 16 to 84 in November 16. The crude mortality rate for October stands at 24.10.

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2. HSMR RATES FOR SEPSIS AND PNEUMONIA

2.1 The trends are expected versus actual deaths and HSMR rates for both Sepsis and Pneumonia are shown in the graphs below

2.2

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2.3

Time Period HSMR Observed Deaths Expected Deaths Low HighApril 13 - March 14 130.22 274 210 115.25 146.58April 14 -March 15 111.86 258 231 98.62 126.37April 15 - March 16 103.48 225 217 90.39 117.92April 16 - August 16 100.91 95 94 81.64 123.36

April 13 - March14 April 14 -March 15 April 15 - March

16April 16 - August

16HSMR 130.22 111.86 103.48 100.91

0

20

40

60

80

100

120

140

HSM

R

Weekend HSMR

April 13 - March14

April 14 -March15

April 15 - March16

April 16 - August16

Observed Deaths 274 258 225 95Expected Deaths 210 231 217 94

0

50

100

150

200

250

300

No

of D

eath

s

Observed v Expected Weekend Deaths

Weekend HSMR has deceased steadily from financial year 2013-2014 which was 130.22.

weekend HSMR for Current Financial year to date is 100.91.

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Bod Jan 2017: F&P Chair Log (Dec) / p1

REPORT TO THE BOARD OF DIRECTORS REF: BOD 17/01/P-09

SUBJECT: FINANCE & PERFORMANCE ASSURANCE REPORT

DATE: JANUARY 2017

PURPOSE:


applicable For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Francis Patton, Non Executive Director, Chair Finance & Performance Committee

SPONSORED BY: Francis Patton, Non Executive Director, Chair Finance & Performance Committee

PRESENTED BY: Francis Patton, Non Executive Director, Chair Finance & Performance Committee

STRATEGIC CONTEXT

The Finance & Performance Committee (F&P) is one of the key sub committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of financial matters and operational performance in order to provide assurance and raise concerns (if appropriate) to the Board of Directors and to make recommendations, as appropriate, on financial and performance matters to the Board of Directors

EXECUTIVE SUMMARY KEY: £k = thousands £m = millions

The aim of this report is to critically analyse and evaluate the financial and operational performance of the Trust in order to provide assurance to the Board. This will be accomplished by: - critically analysing and reviewing the financial performance in order to identify any

opportunities or threats - critically analysing and reviewing the Cost Improvement Programme (CIP) in order to get

assurance that it is on plan and will deliver the planned savings - critically analysing and reviewing the corporate performance in order to ensure that the Trust

is delivering the optimum performance safely and negating any penalties - reviewing business cases at the six months anniversary in order to ensure that they are

delivering planned benefits - critically analysing and reviewing the Board Assurance Framework in order to ensure any

risks to the strategic plan are identified and mitigated Month eight was our most challenging to date and the Trust achieved a year to date position £21,000 favourable to plan but £93,000 adverse in month. This included some prudent provision for penalties against the 4 hours emergency access target, although the Trust was considering an appeal in view of the performance against this target overall. Performance was good in clinical income overall albeit risks remained in relation to new to follow ups, which the Trust still hoped to be able to address in year, and Road Traffic Accident income (£269,000 down year to date but might increase). Agency pay remains good although the run rate has increased recently and is being reviewed with the Clinical Business Units (CBUs). Accruals from medical staffing were

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also under review. Cash was adverse in month 8 but slightly improved in December and January to date, following receipts against trading and part-payment of outstanding debts. Delivery of the 4 hour target continues to present a potential threat to delivery of the year end figures. In terms of the Cost Improvement Programme (CIP) month 8 showed savings of £504,478 against a planned saving of £599,026. This represents an under achievement of £94,548 in month, which has resulted in a shift in variance from a cumulative over achievement of £253,242 last month to an over achievement of £158,694 (savings year to date). In terms of maturity, 87% of schemes were at full maturity, with the remainder at maturity level 1 & 2. The CIP Steering Group is confident that the full programme would be delivered. The level of non-recurrence is currently at 40% and this was being reviewed with the intent of getting it reduced to a more acceptable level of 20-25%. Looking ahead, a CIP target of £6m for 2017-18 had been submitted to NHS Improvement in November (with a higher internal stretch target). To date 56 schemes totalling £3.035m have been identified. The CIP Steering Group has also received reports on work ongoing to identify further efficiencies. As requested by Board, the Committee reviewed the two year business plan. In setting the plan it was evident that the Trust faces a number of financial risks associated with reductions in national tariff (HRG4 +) and also local funding reductions associated with the provision of seven days services. It should therefore be noted that delivery of the financial plan will be exceptionally challenging but was signed off by the Committee. The other key issues that Board need to be aware of are

- In terms of the Winter Plan additional resources were being deployed for the Christmas and New Year periods. Significant pressures were expected over the holiday period, in light of the higher demands already being experienced and the current capacity restrictions across the borough. The A&E Delivery Board continues to address capacity availability across the health economy. Nevertheless the Trust had remained amongst the best in the region in terms of performance. The Committee commended the staff who had helped to manage the recent ward moves despite also managing the continued high service demands. The hot and cold configuration had now been established and, together with service developments such as Medworxx and VitalPAC, the Trust was better placed despite the demand pressures.

- The <4 hour emergency access target, where despite every effort to address this high demands continue and the Trust is struggling to deliver 95%.

- Workforce targets showed sickness absence at 4.6% for November. This was the highest position (by month) for 2016 but the overall year to date cumulative figure remained static at 4.12%. Gastro and D&V illnesses were the dominant factors in month; fast track services in Occupational Health which would ordinarily provide additional support had been suspended for a short time due to other demands on the service but would be resumed in January.

The Committee reviewed and endorsed a business case for a new Picture Archiving and Communications System (PACS). Due to commercial sensitivities the full business case is presented to the Board in private session and is recommended for approval The first benefits realisation report for the extended Specialist Palliative Care services was presented. With funding from the Trust, Macmillans and the Hospice, the team now comprised five specialist nurses and had been able to provide support for end of life patients throughout the week and at weekends. The expanded service had provided better support to patients and their families/carers, improved links with South West Yorkshire Partnership Foundation Trust (SWYPFT) and support to the Clinical Care and Acute Medical units too, helping to ensure the right care at the right time, in the right place as and when needed. The report provided more detailed information on other benefits, including gains for acute oncology services too. There was still scope for further development but the work to date had been very positive. Finally the Committee reviewed the Board Assurance Framework and a number of slight updates were made based on discussions at the Committee.

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RECOMMENDATIONS

This report therefore recommends that: - the Board notes the performance in month 8 and its impact on performance year to

date. The Board should also note the potential threat to yearend financial delivery from the 4 hour emergency target. the Board notes the underperformance in month of the CIP programme but that at present it is still on target to deliver the year end forecast total of £7.1m

- the Board endorses sign off of the two year business plan - the Board signs off the PACS business case - the Board notes the planning already ongoing for Winter but also the issues raised,

which could also impact on the <4 hour emergency target

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Subject: Finance & Performance Committee Assurance Report Ref: BoD 17/01/P-09

CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group Date Chair Finance and Performance Committee 24 November 2016 Francis Patton, Non Executive Director KEY: £k = thousands / £m = millions

Log Ref Agenda Item Issue and Lead Officer

Receiving Body, i.e. Board or Committee

Recommendation/ Assurance/ mandate to receiving body

1. Finance

As predicted, November had been a challenging month although the Trust had achieved a year to date position £21,000 favourable to plan (£93,000 adverse in month). This included some prudent provision for penalties against the 4 hours emergency access target, although the Trust was considering an appeal in view of the performance against this target overall. Performance had been good in clinical income overall albeit risks remained in relation to new to follow ups, which the Trust still hoped to be able to address in year, and Road Traffic Accident income (£269,000 down to date but might increase). Activity in December at the time of the meeting had been good but a dip was expected in the final week. The adverse positions on some costs were also noted, particularly in relation to new equipment which the Trust had not been able to capitalise, additional endoscopy lists and dermatology (reflecting national difficulties in recruitment, new models of working were under consideration) Other key points included: • agency pay – this remained good although the run rate had increased recently

and was being reviewed with the CBUs. Accruals from medical staffing were also under review

• the Cost Improvement Programme (CIP) – still ahead of plan at £158,000 favourable

• cash – was adverse in month 8 but slightly improved in December and January to date, following receipts against trading and part-payment of outstanding debts.

Use of the Service Level Reporting (SLR) continued within the CBUs. Lead Officer: Director of Finance

Board of Directors To note

2.

Cost Improvement Programme (CIP)

Month 8 showed savings of £504,478 against a planned saving of £599,026. This represents an under achievement of £94,548 in month, which has resulted in a shift in variance from a cumulative over achievement of £253,242 last month to an over achievement of £158,694 (savings year to date). The overall CIP forecast position was £7,054,914. In terms of maturity, 87% of schemes were at full maturity, with the remainder at maturity level 1 & 2. Leads had been tasked


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with developing the remaining or additional schemes at pace, although the CIP Steering Group was confident that the full programme would be delivered. The level of non recurrency was currently at 40% and this was being reviewed with the intent of getting it reduced to a more acceptable level of 20-25%. Looking ahead, a CIP target of £6m for 2017-18 had been submitted to NHS Improvement in November (with a higher internal stretch target). To date 56 schemes totalling £3.035m had been identified. The CIP Steering Group had also received reports on work ongoing to identify further efficiencies. Some delays in progress for both the 2016/17 and 2017/18 programmes has arisen due to current operational plans but the new calendar year, and following completion of the main commissioning contract, the Trust should be better placed to firm up the final position and future plans. Lead Officer: Director of Strategy & Business Development

3. Winter Planning

Work continues on winter planning to meet the requirements for Barnsley as a whole health economy, supported by the escalation framework to ensure good cover. Additional resources had been deployed for the Christmas and New Year periods too in services such as 111. Significant pressures were expected over the holiday period, in light of the higher demands already being experienced and the current capacity restrictions across the borough. The A&E Delivery Board continues to address capacity availability across the health economy. Nevertheless the Trust has remained amongst the best in the region in terms of performance. The Committee commended the staff who had helped to manage the recent ward moves despite also managing the continued high service demands. The hot and cold configuration had now been established and, together with service developments such as Medworxx and VitalPAC, the Trust was better placed despite the demand pressures. National changes with regard to performance reporting in A&Es have been proposed recently and a fuller report will be presented to the Committee in January. Lead Officer: Chief Executive


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4. Business Planning

The 2017/18-18/19 two year business plan was tabled. The Trust has agreed the planned two year control targets as follows: • 2017/18 – Control Total £10.061m (£10.616m less £0.55m donated funding) • 2018/19 – Control Total £9.450m. In setting the plan it was evident that the Trust faces a number of financial risks associated with reductions in national tariff (HRG4 +) and also local funding reductions associated with the provision of seven days services. It should therefore be noted that delivery of the financial plan will be exceptionally challenging. As mandated by the Board in November and December, the final plan was agreed and approved for submission on behalf of the Board of Directors. Lead Officer: Chief Executive

Board of Directors

For assurance and to note

5. Business Case

The business case for a new Picture Archiving and Communications System (PACS) was considered and endorsed by the Committee. Due to commercial sensitivities the full business case is presented to the Board in private session and is recommended for approval. Lead Officer: Director of ICT

Board of Directors For approval

6. Integrated Performance Report

As indicated above, problems continue around the 4 hour emergency access target but work is ongoing to protect patient safety and deliver improvements wherever possible. Other key points included: • Improved performance for cancer targets against all metrics with the

exception of consultant upgrade, which had not yet achieved target. • RTT (referral to treatment) continued to perform well generally. There

were some issues in urology, which might create a pressure in December but it had achieved target to date.

• DNAs (did not attend) also continued to do well. There had been a slight increase recently but performance remained below the national average. The need to take action swiftly to prevent further slippage was emphasised.

Lead Officer: Executive Team


Pack pg 38





7. Workforce

Workforce targets showed sickness absence at 4.6% for November. This was the highest position (by month) for 2016 but the overall year to date cumulative figure remained static at 4.12%. Gastro and D&V illnesses were the dominant factors in month; fast track services in Occupational Health which would ordinarily provide additional support had been suspended for a short time due to other demands on the service but would be resumed in January. The Workforce dashboard report also outlined Occupational Health’s plans to support positive health actions with the “Step into 17” campaign.

Mandatory training was at 87.75% - the best position to date. Resus Paediatrics intermediate life support training was an outlier but was only a small team and work was already underway to improve compliance. The high response rate for the latest staff survey was also highlighted at 52.8% and the Committee recorded thanks to Lesley Driver and her team, who had worked to hard to drive this. Lead Officer: Joint Assoc Directors of HR&OD


8.

7 Day Services – Specialist Palliative Care (SPC)

The first benefits realisation report for the extended SPC services was presented. With funding from the Trust, Macmillans and the Hospice, the team now comprised 5 specialist nurses and was able to provide support for end of life patients throughout the week and at weekends. The expanded service had provided better support to patients and their families/carers, improved links with SWYPFT, and support to the Clinical Care and Acute Medical units too, helping to ensure the right care at the right time, in the right place as and when needed. The report provided more detailed information on other benefits, including gains for acute oncology services too. There was still scope for further development but the work to date had been very positive. Lead Officer: Medical Director

9. ICT

The monthly report highlighted the good feedback to date for the public WiFi access, with over 200 people per day making use of it. Having originally been planned as a one week trial, there were no plans to withdraw the system at this point. Recent improvements in Lorenzo were noted, with speeds doubled albeit further work still needed. This had prompted the Trust to apply to move it to a local based solution. If agreed, this should help to improve performance further and support the new prescribing project. Lead Officer: Director of ICT


Pack pg 39





10. Board Assurance Framework

The latest iteration was reviewed and noted. Minor changes since the last iteration were noted. Lead Officer: Head of Clinical Governance & Quality


Pack pg 40

BoD Jan 2017 – IPR (Nov)

EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT REF: BoD 17/01/P-10 SUBJECT: INTEGRATED PERFORMANCE REPORT DATE: JANUARY 2017

PURPOSE:



PREPARED BY: Executive Team SPONSORED BY: Karen Kelly, Director of Operations PRESENTED BY: Karen Kelly, Director of Operations

The attached report is the latest template for the integrated performance report, to give the Board a full overview against key indicators. The report will include trends and actions needed if any indicators are non compliant.

The attached integrated performance report provides an overview of the Trust’s performance to the end of November. It identifies the current quality and performance compliance of the Trust, trends, benchmarks (where available) against other organisations in our network and actions to address non compliance against key indicators. Members are referred to the Executive Summary and are reminded that the summary and key data is also subject to close scrutiny by the Executive Team and, relevant sections, by the Finance & Performance and Quality & Governance Committees.

The Board of Directors is asked to receive and consider the contents of the report.

Pack pg 41

HSMR - Updated with Dr Foster figures

Created by: Healthcare Information and Insight Service

Title of report: Integrated Performance Report

Executive Lead: Karen Kelly

November 2016

Integrated Performance Report

Pack pg 42

Contents

Executive Summary……………………………… 3

Summary…………………………………………….. 9

Patients will experience Safe Care………. 11

Partnerships will be our Strength………. 25

People will be proud to work for us…… 26

Performance Matters………………………… 30

a) Key Performance Indicators……………… 31

b) Data Quality……………………………………… 40

c) Activity……………………………………………… 44

d) Financial Overview……………………………. 46

2 Pack pg 43

Executive Summary by Exception

Key Messages

1 Patients will experience safe care Committee: Q&G Page: 11-24

Quality & Patient Experience:-

Falls

During November the Trust received 25 new complaints bringing the year to date total to 180, with a primary focus on clinical care and treatment. This is a slight reduction

from the previous month (26) but is an overall increase from the number received at this point last year (142). The complaints were risk assessed as follows: low risk (8),

moderate risk (13), high risk (4) and extreme risk (0).

The complaints were allocated as follows; CBU 1 (12),CBU 2 (10), CBU 3 (2) and Corporate services (1).

The percentage of complaints closed within target has slightly reduced this month to 84%, previous month 86%. Year to date figure of 70% against a target of 90%. With the

exception of last month this is the highest figure this financial year.

The average number of working days taken has seen a slight increase this month to 52 from 47 in October. However again, with the exception of last month this is the lowest

figure this financial year.

5 complaints were re-opened this month; 3 in CBU 1 and 2 in CBU 2.

The number of open complaints is continuing to reduce.

Complaints

During the period 1st November 2016 – 30th November 2016 there were 73 inpatient falls reported trust wide and 21 repeat falls. The total number of inpatient falls FYTD is

504; the average number of falls FYTD is 63 a month, this is a decrease of 14% in comparison to the same period in 2015/16. The total number of repeat falls FYTD is 110; the

average number of repeat falls is 14 a month, this is a decrease of 18% in comparison to the same period in 2015/16. In November for the second month running there have

been no inpatient falls incidence that have resulted in moderate harm or above.

The Trust’s aim for 2016/17 is to reduce the total number of inpatient falls by 10% and reduce falls resulting in moderate harm and above by 15%. The Trust continues to be

on target to achieve this reduction.

Although there is a variation through the months with the number of inpatient falls that occur at the Trust, the data collected on the actual number of falls per 1,000 bed days

shows that the Trust has not deviated far from the average in November 2016 and that we remain within our set control limits indicating that there are no special causes.

The Trust is continually striving to promote patient safety and improve our patient’s experience, and the Trust’s newly appointed Falls Clinical Support Sister is due to start in

post on 16.12.2016. This newly developed post will help to promote the delivery of high quality evidence based care for patients at risk of inpatient falls.

Patients Partnerships People Performance

3 Pack pg 44


Key Messages

1 Patients will experience safe care cont. Committee: Q&G Page: 11-24Pressure UlcersNovember has seen an increase in the number of avoidable pressure ulcers across the Trust from the previous month, with 3 avoidable grade 3s, and 7 avoidable grade 2s.

The Tissue Viability team have recommenced twice weekly ward rounds on Wards 19/20/ASU to ensure the focus is on preventative measures, and this continues to show an

impact with a reduction in avoidable hospital acquired pressure ulcers within these areas. Weekly Tissue Viability ward rounds will now also take place on the escalation ward, due

to the increase in avoidable pressure ulcers.

Due to an increase in numbers on AMU, work is being undertaken to support the reduction of avoidable pressure ulcers through the implementation of a robust action plan with a

focus on the assessment and subsequent appropriate management of the patient.

Education in the form of the React to Red training programme is now being delivered by the Tissue Viability team Trust wide to ensure the focus on pressure ulcer prevention

remains a priority.


4 Pack pg 45


Key Messages

1 Patients will experience safe care cont. Committee: Q&G Page: 11-24

Safety

Medication Incident Resulting in Harm

Mortality

A&E 4 Hour Wait

There have been 2 SIs in total reported in November 2016

• 2016/28540 – Grade 3 pressure ulcer. Incident occurred in October 2016 (DTX 31297)

• 2016/28423 – Delayed diagnosis of empyema. Incident occurred in May 2016 (DTX 38055)

ED performance under achieved at 87.7% against agreed trajectory of 95%, Year To date position 93.3%

HSMR - The rolling 12 months HSMR (to August 2016 ) is 94.9, Financial Year to Date is 89.1 and the crude mortality is 21.51 for October 16.

Serious Incidents

There has been 3 medication incidents resulting in low harm;

• Known Diabetic patient missed insulin medication for approximately 36 hours resulting in BMs of 21 (DTX 32403 – ward 18)

• Cancer patient not administered analgesia on multiple occasions (DTX 32294 – AMU)

• Patient had mild reaction following Ceftriaxone being given via the wrong route. (DTX 31874 – ward 37)


5 Pack pg 46


Key Messages3 People will be proud to work for us Committee: F&P Page: 26-29

Staff Turnover

Appraisals

Mandatory Training

Sickness AbsenceSickness - Sickness has risen in month to 4.60% for November. An increase of 0.48% on October. Only Corporate Services (CBU 4) remains in amber at 3.79% . Highest levels of

sickness are in CBU 3 with 5.65% . CBU 2 moves into red at 4.36%. CBU 1 remains in red but has decreased to 4.18% . The annual percentage sickness absence rate for the

year to date remains static at 4.12%.

Appraisals Medical - Percentage of doctors (eligible for appraisal) in date for appraisal:

CBU 1 Medicine = 95.2% CBU 2 Surgery = 97.0% CBU 3 W&C & Clinical Services = 97.6%

Overall compliance is 96.5%, compliance has been achieved by all CBU’s

Appraisals Non Medical - Overall compliance is 93.9%, compliance has been achieved by all CBU’s

Mandatory Training - Overall compliance is currently 87.8%, no CBU has achieved compliance the figures are as follows; CBU1 84.5%, CBU2 88.0%, CBU3 89.4%, Corporate

services 87.8%

Staff Turnover - has decreased from last month and is within the expected range.


6 Pack pg 47

Executive Summary by Exception cont.

Key Messages4 Performance Matters Committee: F&P Page: 30-39

a) Key Performance Indicators62 Day - Urgent GP Referral to Treatment

Consultant Upgrade

Breast symptomatic 2WW

The locally agreed 62 Day Consultant Upgrade target was compliant in November at 85% although there were 3 shared pathways referred late to the tertiary centre (post Day 38)

that may be reallocated. If so, the November final position would fail at 75%. Reallocation requests have not yet been received from STH.

The breast symptomatic target remains strong and is compliant in November at 98.2% and also is on track for the Q end position.

This target was achieved in November and is also showing a compliant Q3 position to date. Anticipated reallocation of shared breaches referred after Day 38, will not

negatively impact the achievement of this target at November month end.


7 Pack pg 48

Executive Summary by Exception cont.

Key Messages4 Performance Matters cont. Committee: F&P Page: 46-49b) Financial overview

The Trust has a consolidated year to date deficit position of £5.76m that is £0.05m favourable to plan. CIP delivery for month 8 is ahead of plan year to date. Clinical

income is ahead of plan, although the activity mix is varied. Planned Sustainability and Transformation funding has been achieved for quarter 1 & 2, but only partially

accrued for months 7 & 8 due to not meeting the A&E 4 hour wait target. Other income is broadly on plan at month 8, with an adverse position on RTA income offset

by a favourable position on R&D funding and other income. Capital expenditure is £2.33m below plan. Loan drawdown to support cashflow requirements is £0.4m

lower than plan.


8 Pack pg 49

1 2 3 4 6 7 11 12 13 14 15 16 17 18 19 20

Domain April 16 Summary Target Set By Current Qtr Year to Date Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Trend

Q - FFT Positivity Rates - ED G >85%, A >=80%-85%, R <80% (> ) BHNFT 86.7% 87.8% 89.1% 90.5% 88.0% 79.6% 91.4% 81.4% 97.1% 82.6%

Q - FFT Positivity Rates - IP G >85%, A >=80%-85%, R <80% (>) BHNFT 96.9% 97.6% 96.7% 97.4% 98.7% 96.9% 98.4% 98.5% 96.9% 96.9%

Q - FFT Positivity Rates - OP G >85%, A >=80%-85%, R <80% (>) BHNFT 94.6% 94.3% 95.4% 94.4% 94.7% 94.6% 95.0% 94.8% 93.3% 93.8%

Q - FFT Positivity Rates - MAT G >85%, A >=80%-85%, R <80% (>) BHNFT 97.7% 97.9% 98.8% 98.0% 99.3% 96.8% 97.1% 97.5% 98.4% 96.7%

Q - Complaints closed within target % G >90%, A >=70%-90%, R <70% (>) BHNFT 84.8% 69.7% 35.7% 66.7% 73.5% 76.2% 76.7% 64.5% 85.7% 84.4%

Dementia - Find/Assess 90% (>) National 93.0% 94.6% 97.0% 97.0% 92.5% 95.2% 94.8% 94.0% 93.8% 92.0%

Dementia - Investigate 90% (>) National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Dementia - Refer 90% (>) National N/A 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% N/A 100.0%

Falls 785 (<) BHNFT 144 504 58 56 53 55 85 53 71 73

Multiple Falls n/a BHNFT 40 110 10 16 11 8 18 7 19 21

Falls resulting in moderate harm or above 20 (<) BHNFT 0 7 1 3 0 1 1 1 0 0

Hand washing 95% (>) National 99.7% 99.7% 99.7% 99.3% 99.4% 99.8% 99.7% 99.9% 99.7% 99.7%

Pressure Ulcers Grade 3 & 4 (Avoidable) 0 (<) BHNFT 4 15 4 2 2 1 1 1 1 3

Pressure Ulcers Grade 2 (Avoidable) 0 (<) BHNFT 8 38 3 6 5 9 3 4 1 7

Single Sex Breaches 0 (<) National 0 0 0 0 0 0 0 0 0 0

Hospital Acquired Clostridium Difficile 13 (<) NHSE 3 6 0 0 0 3 0 0 3 0

MRSA Bacteraemia 0 (<) NHSE 0 0 0 0 0 0 0 0 0 0

VTE Screening Compliance 95% (>) NHSE 94.4% 94.1% 94.7% 95.5% 95.8% 94.7% 95.1% 93.4% 89.2%

Recorded Medication Incidents 400 (<) National 60 289 41 57 36 31 41 23 26 34

Recorded Medication Errors - Causing harm 10 (<) National 3 6 0 1 0 0 1 1 0 3

Q - Never Events - Occurred in Month 0 0 0 0 0 0 0 0 0 0

Q - Never Events - Reported in Month 0 0 0 0 0 0 0 0 0 0

Q - Serious Incidents n/a NHSE 4 35 3 8 7 5 3 5 2 2

Q - Death 0 (<) National 0 3 0 2 0 1 0 0 0 0

Q - Severe 0 (<) National 0 8 2 2 0 1 1 1 1 0

Q - Percentage of Incidents Causing Harm 28% (<) BHNFT 5.7% 7.9% 7.9% 9.6% 6.3% 9.0% 6.9% 8.8% 5.7% 9.5%

Q - Total (All) 7400 (<) National 1279 4786 568 602 624 545 612 556 618 661

Q - HSMR (Rolling 12 months) Latest Data is August 2016 100 (<) National 104.6 100.1 98.7 98.8 99.8 98.3 97.1 94.9

SHMI (Rolling 12 months) Latest Data is March 2016 105 (<) National 97.8 98.6 99.4

Q - HSMR (Financial Year to date) - April 16 - August 2016 100 (<) 82.6 97.9 99.3 95.7 86.4 89.0 90.3 91.3 89.1

Duty of Candour Q - Duty of Candour Breaches 0 (<) National 0 0 0 0 0 0 0 0 0 0

Summary

Quality & Patient

Experience

Patients will experience safe care

Mortality

Patient Safety

0 (<) NHSE


9 Pack pg 50

Domain KPI Target Set By Current Qtr. Year to Date Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Trend

Staff Turnover (Rolling 12 months) G <=10%, A >10%-11%, R >11% (<) BHNFT 17.8% 8.8% 9.3% 8.5% 9.3% 9.7% 9.6% 8.7% 9.0% 8.8%

Appraisals (Rolling 12 months) G >90%, A >=70%-90%, R <70% (>) BHNFT 188.2% 94.1% N/A 40.5% 90.9% 94.0% 94.7% 94.5% 94.2% 94.1%

Mandatory Training (Rolling 12 months) G >90%, A >=85%-90%, R <85% (>) BHNFT 174.7% N/A 86.6% 86.2% 85.5% 85.5% 86.7% 87.3% 86.9% 87.8%

Sickness Absence (Rolling 12 months)G <=3.75%, A >3.75%-4.25%, R >4.25%

(<)BHNFT 8.7% 3.9% 4.1% 3.7% 3.9% 4.6% 4.6% 3.9% 4.1% 4.6%

RTT Incomplete Pathways 92% (>) National 93.5% 94.2% 95.1% 94.3% 94.2% 94.8% 94.1% 94.2% 94.1% 92.9%

Diagnostic patients waiting more than 6 weeks 99.88% National 13 225 141 52 4 2 9 4 6 7

Q - Cancer 2 Week Waits 93% (>) National 95.3% 94.9% 93.9% 95.1% 93.3% 95.4% 95.0% 96.3% 95.1% 95.4%

Q - Symptomatic Breast 2 Week Waits 93% (>) National 97.0% 93.6% 85.3% 92.7% 95.2% 96.4% 95.5% 89.9% 95.2% 98.2%

Q - 31 Day - 1st Definitive Treatment 96% (>) National 99.4% 98.8% 98.7% 100.0% 98.6% 97.2% 100.0% 97.3% 100.0% 98.9%

Q - 31 Day - Subsequent Treatment (Surgery) 94% (>) National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Q - 31 Day - Subsequent Treatment (Chemotherapy) 98% (>) National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Q - 38 Day - Inter-Provider Transfer 85% (>) BHNFT 100.0% 82.5% 81.5%

Q - 62 Day - GP Referral to Treatment 85% (>) National 93.0% 88.9% 84.4% 79.2% 88.5% 91.4% 87.5% 93.0% 91.8% 94.1%

Q - 62 Day - Screening Referral to Treatment 90% (>) National 100.0% 98.4% 100.0% 90.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Q - 62 Day - Consultant Upgrade to Treatment 85% (>) BHNFT 83.3% 81.8% 80.0% 75.0% 90.9% 0.0% 88.9% 89.5% 81.3% 85.0%

Emergency % Patients Waiting <4 Hours 95% (>) National 93.2% 93.3% 93.0% 95.4% 95.5% 91.4% 95.3% 94.7% 93.2% 87.7%

Average Length of Stay - Elective G <=2.42, A >2.42-2.67, R >2.67 (<) BHNFT 2.29 2.14 2.33 2.34 2.50 2.08 2.27 2.87 2.86

Average Length of Stay - Non-Elective G <=3.44, A >3.44-3.69, R >3.69 (<) BHNFT 2.67 2.68 2.83 2.68 2.60 2.70 2.47 2.30 2.55

Re-admissions % BHNFT 9.6% 9.3% 9.1% 9.7% 8.9% 9.4% 9.2% 8.3% 9.8% 9.7%

Cancelled Operations - Breaches of the 28 day rule 0 (<) National 0 0 0 0 0 0 0 0 0 0

DNA Outpatient DNA Rates G <=10%, A >10%-11%, R >11% (<) BHNFT 9.5% 10.4% 11.1% 12.5% 8.3% 8.5% 8.5% 8.7% 8.7% 8.6%

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & A&E targets

which will be RED if the target is not achieved)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule

NOTE: National Indicators such as Cancer, RTT, Cancelled Ops, etc. are considered as being either Achieved or Failed. These are therefore RAG rated as Green or Red.

All other indicators are classed as Achieved or Failed with the exception of all Workforce KPIs, Average Length of Stay & DNA rates which detail the tolerances applied in the Target column.

Elective Access

Cancer

Operational

Efficiency

Performance matters - Key Performance Indicators

People will be proud to work for us

Workforce

Summary


10 Pack pg 51

1 2 3 4 5 8 18 19 20 # 22 # 24 25 26 27 39 40 41 42 43

Patients will experience safe care - "At a glance"

Target

16/17

Target

YTDNov-16

Actual

YTDTrend

YTD

Status

Target

16/17

Target

YTDNov-16

Actual

YTDTrend

YTD

Status

Friends & Family Test (Quality Strategy Goal 1) Mortality (Quality Strategy Goal 3)

Friends & Family Test - ED 85% 85% 82.6% 87.8% ↓ 87.8% HSMR Rolling 12 months (Latest data August 16) 100 100.0 94.9 94.9 ↓ 94.9

Friends & Family Test - Inpatients 85% 85% 96.9% 97.6% ↓ 97.6% SHMI Rolling 12 months (Latest data March 16) 105 105.0 99.4 99.4 ↔ 99.4

Friends & Family Test - Maternity 85% 85% 96.7% 97.9% ↓ 97.9% HSMR Year to date (Latest data August 16) 100 100.0 89.1 89.1 ↓ 89.1

Friends & Family Test - Outpatients 85% 85% 93.8% 94.3% ↑ 94.3% VTE Screening Compliance (Quality Strategy Goal 2)

April 2016 - July 2016 95% 95% 94.1% ↑ 94.1%

Complaints (Quality Strategy Goal 1)

Total no. of complaints N/A N/A 25 180 ↑ Medication Incidents (Quality Strategy Goal 2)

Complaints closed within target 90% 90% 84.4% 69.7% ↓ 69.7% Recorded Medication Incidents 400 300 34 289 ↓ 1

Complaints re-opened N/A N/A 5 22 ↓ Recorded medication errors - Causing harm 10 8 3 6 ↓ 1

Dementia (Quality Strategy Goal 1) Serious Incidents (Quality Strategy Goal 2)

Find/Assess 90% 90% 92.0% 94.6% ↓ 94.6% Never Events Occurring in Month 0 0 0 0 ↔ 1

Investigate 90% 90% 100.0% 100.0% ↔ 100.0% Never Events Reported in Month 0 0 0 0 ↔ 1

Refer 90% 90% 100.0% 100.0% ↓ 100.0% Serious Incidents N/A N/A 2 35 ↔ 1

Falls (Quality Strategy Goal 2) Incident Grading (Quality Strategy Goal 2)

No. of Falls 785 589 73 504 ↑ 1 Death 0 0 0 3 ↔ 0

No. of Multiple Falls N/A N/A 21 110 ↑ 1 Severe 0 0 0 8 ↑ 0

Falls resulting in moderate harm or above 20 15 0 7 ↔ 1 Moderate N/A N/A 8 79 ↑

Low N/A N/A 55 290 ↓

Hand washing (Quality Strategy Goal 2) 95% 95% 99.7% 99.7% ↓ 99.7% No Harm N/A N/A 598 4406 ↓

Percentage of incidents causing harm <28% 28% 9.5% 7.9% ↓ 7.9%

Pressure Ulcers (Quality Strategy Goal 2)

Grades 3 & 4 (Avoidable) 0 0 3 15 ↓ 0

Grade 2 Post (Avoidable) 0 0 7 38 ↓ 0 Patient Safety (Quality Strategy Goal 2)

Total Incidents 7400 5550 661 4786 ↑ 1

Single Sex Breaches (Quality Strategy Goal 1) 0 0 0 0 ↔ 1

Infections (Quality Strategy Goal 2)

Hospital Acquired Clostridium Difficile 13 10 0 6 ↑ 1

MSSA N/A N/A 0 6 ↑

MRSA Bacteraemia 0 0 0 0 ↔ 1

Ecoli - Total hospital N/A N/A 2 14 ↓

Patients will experience safe care - Quality & Experience Patients will experience safe care - Patient Safety


11 Pack pg 52

Patients will experience safe care (Safety)

Mortality (Quality Strategy - Goal 3: Delivering Consistently Effective Care)

HSMR rolling 12 month target

HSM

RH

SMR


12 Pack pg 53



SHIMI rolling 12 month target

Comments

HSMR

SHMI

SHM

I an

d C

rud

e M

ort

alit

yC

rud

e M

ort

alit

y

SHIMI - The latest SHIMI for Q4 2015/16 is 99.4. SHIMI has held steadily just below 100

since Q4 2013/14.

HSMR - The rolling 12 months HSMR (to August 2016 ) is 94.9, Financial Year to Date is 89.1

and the crude mortality is 21.51 for October 16.

13 Pack pg 54



Incidents (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Med

icat

ion

Inci

de

nts

- C

ausi

ng

har

m

Nev

er E

ven

ts &

Ser

iou

s In

cid

en

ts

Inci

de

nt

Gra

din

g

Pat

ien

t Sa

fety

Inci

den

ts (

All)

0

10

20

30

40

50

60

0

2

4

6

8

10

12

Total Medication Incidents Causing Harm Cumulative Target

Causing Harm Cumulative Actual

0

1

2

3

4

5

6

7

8

9

Serious Incidents Never Events SI Target Never Event Target

0

100

200

300

400

500

600

700

Actual Target

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

0

10

20

30

40

50

60

70

Pe

rce

nta

ge C

ausi

ng

Har

m

Gra

din

g

Low Moderate Severe Death % Causing Harm

14 Pack pg 55

Patients will experience safe care (Quality & Experience)

7

9

Frie

nd

s &

Fam

ily T

est

Frie

nd

s &

Fam

ily T

est


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ED Actual IP Actual OP Actual MAT Actual Target

95.5% 97% 99% 98% 97% 95% 96% 97% 93% 97% 97%

77%

96% 98% 97%

0%

20%

40%

60%

80%

100%

120%

Friends & Family Test - Inpatient Benchmarking (Latest NHS England Published Data - Sept 2016)

Peer Group Local Target

95.9% 96% 98% 99% 98% 97% 98%

95% 94% 96%

93% 95%

99% 97%

75%

80%

85%

90%

95%

100%

105%

Friends & Family Test - Maternity Benchmarking (Latest NHS England Published Data - Sept 2016)


86% 92%

81% 72%

87% 94%

88% 88% 83% 96%

83% 87% 87% 94%

85%

0%

20%

40%

60%

80%

100%

120%

Friends & Family Test - A&E Benchmarking (Latest NHS England Published Data - Sept 2016)


15 Pack pg 56



Complaints (Quality Strategy - Goal 1: Delivering Patient Centred Care)

Comments:

Co

mp

lain

tsC

om

pla

ints

Co

mp

lain

ts

During November the Trust received 25 new complaints bringing the year to date total to 180, with a primary focus on clinical care and

treatment. This is a slight reduction from the previous month (26) but is an overall increase from the number received at this point last year

(142). The complaints were risk assessed as follows: low risk (8), moderate risk (13), high risk (4) and extreme risk (0).

The complaints were allocated as follows; CBU 1 (12),CBU 2 (10), CBU 3 (2) and Corporate services (1).

The percentage of complaints closed within target has slightly reduced this month to 84%, previous month 86%. Year to date figure of 70%

against a target of 90%. With the exception of last month this is the highest figure this financial year.

The average number of working days taken has seen a slight increase this month to 52 from 47 in October. However again, with the exception

of last month this is the lowest figure this financial year.

5 complaints were re-opened this month; 3 in CBU 1 and 2 in CBU 2.

The number of open complaints is continuing to reduce.

0

5

10

15

20

25

30

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Complaints by Category

Patient Care Access, Appts, etc Communication Medical Records Medication

Falls Infection Control Infrastructure Other

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge w

ith

in t

arge

t

Complaints Closed within Target

% closed Target

0

50

100

150

200

250

300

0

5

10

15

20

25

30

Complaints & Concerns

Complaints Re-opened PALS

16 Pack pg 57



Dementia (Quality Strategy - Goal 1: Delivering Patient Centred Care)

Comments:

De

me

nti

aD

eme

nti

a -

Ben

chm

arki

ng

Dem

en

tia

- B

ench

mar

kin

g

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Find/Assess Actual Investigate Actual Refer Actual Target

87%

94% 94% 92%

95% 94% 96%

87% 86% 90%

100% 98%

75%

80%

85%

90%

95%

100%

Percentage of Cases Identified (Latest NHS England published data September 2016)

Peer Group Target

68%

100% 98% 100% 100% 100% 100% 98% 100% 100% 100% 100%

0%10%20%30%40%50%60%70%80%90%

100%

Percentage of Cases with Diagnostic Assessment (Latest NHS England

Published data September 2016)

Peer Group Target

17 Pack pg 58



Falls (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Comments:

Falls

res

ult

ing

in m

od

era

te h

arm

or

ab

ove

Falls

The number of falls reported in February remains around the same number as prior

months.

Mu

ltip

le F

alls

During the period 1st November 2016 – 30th November 2016 there were 73 inpatient falls reported trust wide and 21 repeat falls. The total number of inpatient

falls FYTD is 504; the average number of falls FYTD is 63 a month, this is a decrease of 14% in comparison to the same period in 2015/16. The total number of

repeat falls FYTD is 110; the average number of repeat falls is 14 a month, this is a decrease of 18% in comparison to the same period in 2015/16. In November

for the second month running there have been no inpatient falls incidence that have resulted in moderate harm or above.

The Trust’s aim for 2016/17 is to reduce the total number of inpatient falls by 10% and reduce falls resulting in moderate harm and above by 15%. The Trust

continues to be on target to achieve this reduction.

Although there is a variation through the months with the number of inpatient falls that occur at the Trust, the data collected on the actual number of falls per

1,000 bed days shows that the Trust has not deviated far from the average in November 2016 and that we remain within our set control limits indicating that

there are no special causes.

The Trust is continually striving to promote patient safety and improve our patient’s experience, and the Trust’s newly appointed Falls Clinical Support Sister is

due to start in post on 16.12.2016. This newly developed post will help to promote the delivery of high quality evidence based care for patients at risk of

inpatient falls.

0

10

20

30

40

50

60

70

80

90

No

. of

Falls

No. of Falls

Actual Target

0

5

10

15

20

25


No

. of

Mu

ltip

le F

alls

Multiple Falls

Actual Target

0

1

2

3

4

No

. of

Falls

Falls resulting in moderate harm or above

Actual Target

18 Pack pg 59



Pressure Ulcers (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Comments:

As stated

last

Pre

ssu

re U

lcer

s -

Gra

de

3 &

4P

ress

ure

Ulc

ers

- G

rad

e 2

Avoidable grade 2 pressure ulcers = 7

3 of the avoidable grade 2 pressure ulcers were identified on AMU, 2 on ward 18, 1 on ward 29 / 1 on ward 36. In all the incidents, there was either a lack of skin

assessment / lack of documentation regarding skin assessment or a lack of / delay in providing the patients with appropriate preventative measures.

Education in the form of the React to Red training programme is now being delivered by the Tissue Viability team Trust wide to ensure the focus on pressure

ulcer assessment and prevention remains a priority. Due to an increase in numbers on AMU, work is being undertaken to support the reduction of avoidable

pressure ulcers through the implementation of a robust action plan with a focus on the assessment and subsequent appropriate management of the patient.

Weekly Tissue Viability ward rounds will now take place on the escalation ward, due to the increase in avoidable pressure ulcers.


These were attributed to AMU, ward 29 and ward 14.

In all 3 incidents, there was a delay in providing the patients with appropriate preventative measures, despite the patients being at high risk of developing

pressure damage. There was also a delay in completing relevant documentation regarding risk and pressure area assessment on AMU

0

1

2

3

4

5

6

7

8

9

10

Grade 2 Unavoidable Grade 2 Avoidable Target

0

1

2

3

4

5

6

7

8

9

10

Grade 3&4 Unavoidable Grade 3&4 Avoidable Target

19 Pack pg 60



Infections (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Comments:

Eco

li B

acte

rae

mia

Ho

spit

al A

cqu

ired

Clo

stri

diu

m D

iffi

cile

To

xin

0

1

2

3

4

5


0

2

4

6

8

10

Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17

Hospital Acquired Clostridium Difficile Toxin (cumulative position)

Tolerance Actual

20 Pack pg 61



Nursing Staffing Fill Rate (Quality Strategy - Goal 4: Building on Capacity and Capability)

Comments:

14 92.2% 100.0% 100.0% 97.1% 2.5 1.5 Registered Nurses

17 85.3% 86.2% 96.3% 110.1% 2.8 2.0 Registered Midwives

18 75.0% 87.2% 79.0% 126.7% 3.3 2.1 Unregistered health care/midwifery care assistants

19/20 69.8% 84.9% 91.7% 130.0% 2.6 4.3 Unregistered nursing/midwifery auxiliaries.

AMU 75.2% 96.2% 94.8% 106.2% 4.3 2.8

Acute Stroke 73.6% 105.5% 71.7% 150.0% 3.1 4.1

24 100.5% 104.5% 101.7% 117.6% 4.7 3.4

28 94.5% 86.2% 101.4% 100.0% 2.5 2.6

31 84.9% 85.2% 97.5% 98.9% 3.8 3.2

34 81.6% 82.1% 97.6% 115.5% 3.3 3.0

ITU 94.4% 90.0% 94.8% - 34.8 2.7

SHDU 98.3% 70.7% 100.0% - 15.2 3.3

CCU 95.8% 102.3% 99.1% - 11.1 1.9

AN/PN 97.5% 86.9% 100.0% 90.6% 5.4 1.8

Birthing Centre 94.1% 84.7% 93.3% 84.2% 26.1 4.9

37 100.0% 100.0% 104.5% - 6.6 1.3

15 88.9% 89.6% 89.8% 84.0% 11.7 2.4

This allows for contingency plans to be made where the roster identifies that the

planned staffing falls short of the minimum requirement, for example where there are

vacant nursing posts or staff appointed have not started in post. These contingency

plans can include: moving staff from a shift which is above the minimum required

level, moving staff from another ward/area which is above the minimum required level,

or the use of flexible/temporary staffing from the Trust’s internal bank or via an

external nursing agency.

In November 2016 the overall fill rate remains fairly static and similar to last month

other than a reduction in care staff on night duty. Following the successful

reconfiguration of beds in medicine this month the skill mix requirements for care of

the elderly and stroke have been reviewed and staff who are over and above the rota

requirements have been redeployed to the escalation ward which has opened this

month. This means that there are no current vacancies in care of the elderly which was

a high risk area for vacancies for the trust. However vacancies remain predominantly in

trauma and orthopaedics, theatres and the acute medical unit, these are being closely

monitored and managed. Agency usage remains under the trust cap this month.

SpecialtyAve fill rate

Registered

Nu

rsin

g St

affi

ng

Fill

Rat

e

420 - PAEDIATRICS

Ave fill rate

Care staff

(%)

NightRegistered

Nurses/Midwi

ves

Care Staff

Care Hours Per Patient

422- NEONATOLOGY

110 - TRAUMA & ORTHOPAEDICS

192 - CRITICAL CARE MEDICINE

Day

300 - GENERAL MEDICINE

300 - GENERAL MEDICINE

320 - CARDIOLOGY

501 - OBSTETRICS

501 - OBSTETRICS

370 - MEDICAL ONCOLOGY

301 - GASTROENTEROLOGY

100 - GENERAL SURGERY

192 - CRITICAL CARE MEDICINE

Ward

name

Ave fill rate

Registered

320 - CARDIOLOGY

The Trust uses an e-rostering system with duty rosters created eight weeks in advance

to ensure the levels and skill mix of the nursing staff on duty are appropriate for

providing safe and effective care.

Ave fill rate

Care staff (%)

340 - RESPIRATORY MEDICINE

430 - GERIATRIC MEDICINE

502 - GYNAECOLOGY

BHNFT is committed to ensuring that levels of nursing staff, match the acuity and

dependency needs of patients in order to provide safe and effective care. Nurse staffing

includes:

21 Pack pg 62


Falls SPC Charts


Jan 2016 - Inpatient falls assessments provided by Falls Nurse Specialist.

April 2016 - Introduction of bed & chair alarms.

Jun 2016 - Acute Falls Assessment documentation went live June 2016 AMU - Short stay Falls assessment documentation went live June 2016 on AMAC

0

1

2

3

4

5

6

7

8

9A

pr-

15

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

All Falls per 1000 Bed Days

Number of Falls Per 1000 Bed Days Average Number of Falls Per 1000 Bed Days Improvement Trajectory Lower Control Limit

Upper Control Limit Lower Warning Limit Upper Warning Limit

* Improvement trajectory based on a 10% reduction of the average number of falls between Apr-15 and Mar-16 * Average number of falls per 1000 bed days based on caluculations from Apr-15 to present

07 Sep 2015 Introduction of: - Multifactorial Falls Assessments (MFA level 1 &2) for inpatients - Lying and Standing BP charts - Bed rail assessment charts - Medical Acute post fall assessment & Secondary fall assessment document - Updated falls careplans on Lorenzo for nursing staff - Patient and Relatives falls prevention advice available at each patients bedside - Promotion of Stickman signage (Red stickman to indicate patient has fall in hospital but now also to include patients admitted with a falls). 28 Sep 2015 - Falls Awareness Week at the Trust

Oct 2015 - Local Falls audit undertaken (including ward spot checks) - Falls Nurse Specialist Secondment commenced

Nov 2015 - Feedback to wards on spot check from local falls audit - Updated falls assessment documentation used on ITU, CCU, & SHDU (live 30.11.15) - Short stay Falls assessment documentation went live 30.11.15 on CDU,PIU,SDA, Wards 31/33/34 (daycases),Day Surgery & Endoscopy Unit

Dec 2015 - Falls Outcomes added to discharge summary letter

22 Pack pg 63


Falls SPC Charts


0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Harmful Falls per 1000 Bed Days

Number of Harmful Falls Per 1000 Bed Days Average Number of Falls Per 1000 Bed Days Improvement Trajectory Lower Control Limit

Upper Control Limit Lower Warning Limit Upper Warning Limit

* Improvement trajectory based on a 15% reduction of the average number of falls between Apr-15 and Mar-16 * Average number of falls per 1000 bed days based on caluculations from Apr-15 to present

07 Sep 2015 Introduction of: - Multifactorial Falls Assessments (MFA level 1 &2) for inpatients - Lying and Standing BP charts - Bed rail assessment charts - Medical Acute post fall assessment & Secondary fall assessment document - Updated falls careplans on Lorenzo for nursing staff - Patient and Relatives falls prevention advice available at each patients bedside - Promotion of Stickman signage (Red stickman to indicate patient has fall in hospital but now also to include patients admitted with a falls). 28 Sep 2015 - Falls Awareness Week at the Trust

Oct 2015 - Local Falls audit undertaken (including ward spot checks) - Falls Nurse Specialist Secondment commenced

Nov 2015 - Feedback to wards on spot check from local falls audit - Updated falls assessment documentation used on ITU, CCU, & SHDU (live 30.11.15) - Short stay Falls assessment documentation went live 30.11.15 on CDU,PIU,SDA, Wards 31/33/34 (daycases),Day Surgery & Endoscopy Unit

Dec 2015 - Falls Outcomes added to discharge summary letter

Jan 2016 - Inpatient falls assessments provided by Falls Nurse Specialist.

April 2016 - Introduction of bed & chair alarms.

Jun 2016 - Acute Falls Assessment documentation went live June 2016 AMU - Short stay Falls assessment documentation went live June 2016 on AMAC

23 Pack pg 64


Pressure Ulcer SPC Charts


0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

Grade 2 Pressure Ulcers per 1000 Bed Days

Total PU's Grade 2 per 1000 Bed Days Average Upper Control Limit Upper Warning Limit

* The information above represents hospital acquired, avoidable grade 2 pressure ulcers . * The average is calculated from July-15 to present.

Q1 1516 - 164 staff received training on Pressure

Q2 1516 - 130 staff received training on Pressure Ulcer Prevention and Management



Jun-16 Equipment: Implementation of the hybrid mattress system in ED / CDU (including hybrid

Oct-16 Equipment: Implementation of heel magnets / new intentional rounding charts. Education: React to Red Clinical Support Nurse commences in post .

Apr-15 Introduction of Pressure Ulcer Prevention patient information leaflet. 1st April Tissue Viability Education Nurse commences in post. w/c 13th April implamentation of the hybrid mattress system across the medical block (wards 17, 18, 19, 23, 24, AMU, CCU). Education: Tissue Viability Education Nurse commences in post to specifically deliver Pressure Ulcer Prevention and Management training for one year. Equipment: Implementation of the hybrid mattress system – wards 17, 18, 19, 20, 23, 24, AMU, CCU.

Jul-15 Documentation: New 2 part Pressure Ulcer Pathway and Pressure Ulcer Prevention and Management policy implemented. Education: 4 week intensive Pressure Ulcer Prevention and Management training wards 19 / 20

Aug-15 Equipment: Implementation of the hybrid mattress system – ward 28, 31, 32, 33, 34. Implementation of 4 bariatric hybrid mattresses Trust wide Education: Trust wide Heel Pressure Ulcer Awareness week

Nov-15 Staffing: Vacant part time TVN post (new starter to commence Feb 22nd 2016). Education: TVN / Frailty team ward round ward 19 / 20 three times weekly (from 30th November)

Feb-16 Staffing: Part time TVN commences in post (22nd Feb) .

Mar-16 Education: Tissue Viability Education Nurse finishes in post (4th March) .

24 Pack pg 65


Pressure Ulcer SPC Charts


0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Grade 3 Pressure Ulcers per 1000 Bed Days

Total PU's Grade 3 per 1000 Bed Days Average Lower Control Limit Upper Control Limit Lower Warning Limit Upper Warning Limit

* The information above represents hospital acquired, avoidable grade 3 pressure ulcers . * The average is calculated from July-15 to present.

Q1 1516 - 164 staff received training on Pressure




Jun-16 Equipment: Implementation of the hybrid mattress system in ED / CDU (including hybrid

Oct-16 Equipment: Implementation of heel magnets / new intentional rounding charts. Education: React to Red Clinical Support Nurse commences in post .

Apr-15 Introduction of Pressure Ulcer Prevention patient information leaflet. 1st April Tissue Viability Education Nurse commences in post. w/c 13th April implamentation of the hybrid mattress system across the medical block (wards 17, 18, 19, 23, 24, AMU, CCU). Education: Tissue Viability Education Nurse commences in post to specifically deliver Pressure Ulcer Prevention and Management training for one year. Equipment: Implementation of the hybrid mattress system – wards 17, 18, 19, 20, 23, 24, AMU, CCU.

Jul-15 Documentation: New 2 part Pressure Ulcer Pathway and Pressure Ulcer Prevention and Management policy implemented. Education: 4 week intensive Pressure Ulcer Prevention and Management training wards 19 / 20

Aug-15 Equipment: Implementation of the hybrid mattress system – ward 28, 31, 32, 33, 34. Implementation of 4 bariatric hybrid mattresses Trust wide Education: Trust wide Heel Pressure Ulcer Awareness week

Nov-15 Staffing: Vacant part time TVN post (new starter to commence Feb 22nd 2016). Education: TVN / Frailty team ward round ward 19 / 20 three times weekly (from 30th November)

Feb-16 Staffing: Part time TVN commences in post (22nd Feb) .

Mar-16 Education: Tissue Viability Education Nurse finishes in post (4th March) .

25 Pack pg 66


Infections SPC Charts


0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

Q1

08

/09

Q2

08

/09

Q3

08

/09

Q4

08

/09

Q1

09

/10

Q2

09

/10

Q3

09

/10

Q4

09

/10

Q1

10

/11

Q2

10

/11

Q3

10

/11

Q4

10

/11

Q1

11

/12

Q2

11

/12

Q3

11

/12

Q4

11

/12

Q1

12

/13

Q2

12

/13

Q3

12

/13

Q4

12

/13

Q1

13

/14

Q2

13

/14

Q3

13

/14

Q4

13

/14

Q1

14

/15

Q2

14

/15

Q3

14

/15

Q4

14

/15

Q1

15

/16

Q2

15

/16

Q3

15

/16

Q4

15

/16

Q1

16

/17

Rolling Annual Infection Rate - Infections as a Percentage of all Hip Operations

SSI % Last 4 Periods for Inpatient or Re-admission Average Upper Control Limit Upper Warning Limit National Benchmark

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

Q1

08

/09

Q2

08

/09

Q3

08

/09

Q4

08

/09

Q1

09

/10

Q2

09

/10

Q3

09

/10

Q4

09

/10

Q1

10

/11

Q2

10

/11

Q3

10

/11

Q4

10

/11

Q1

11

/12

Q2

11

/12

Q3

11

/12

Q4

11

/12

Q1

12

/13

Q2

12

/13

Q3

12

/13

Q4

12

/13

Q1

13

/14

Q2

13

/14

Q3

13

/14

Q4

13

/14

Q1

14

/15

Q2

14

/15

Q3

14

/15

Q4

14

/15

Q1

15

/16

Q2

15

/16

Q3

15

/16

Q4

15

/16

Q1

16

/17

Rolling Annual Infection Rate - Infections as a Percentage of all Knee Operations

SSI % Last 4 Periods for Inpatient or Re-admission Average Upper Control Limit Lower Warning Limit Upper Warning Limit National Benchmark

26 Pack pg 67


Infections SPC Charts


0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

Q1

08

/09

Q2

08

/09

Q3

08

/09

Q4

08

/09

Q1

09

/10

Q2

09

/10

Q3

09

/10

Q4

09

/10

Q1

10

/11

Q2

10

/11

Q3

10

/11

Q4

10

/11

Q1

11

/12

Q2

11

/12

Q3

11

/12

Q4

11

/12

Q1

12

/13

Q2

12

/13

Q3

12

/13

Q4

12

/13

Q1

13

/14

Q2

13

/14

Q3

13

/14

Q4

13

/14

Q1

14

/15

Q2

14

/15

Q3

14

/15

Q4

14

/15

Q1

15

/16

Q2

15

/16

Q3

15

/16

Q4

15

/16

Q1

16

/17

Rolling Annual Infection Rate - Infections as a Percentage of all Neck Of Femur Operatons

SSI % Last 4 Periods for Inpatient or Re-admission Average Upper Control Limit Upper Warning Limit National Benchmark

27 Pack pg 68


Cardiac Arrest SPC Charts


0

0.5

1

1.5

2

2.5

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Cardiac Arrests per 1000 Admissions

CAs per 1000 Admissions Average CAs per 1000 Admissions Improvement Trajectory Lower Control Limit Upper Control Limit Lower Warning Limit Upper Warning Limit

* Improvement trajectory is based on a 25% reduction of the average calculated between Oct-14 and Mar-16. * Average CAs per 1000 Admissions is calculated from Oct-15 to present.

Oct 2015 - NCAA reporting commenced - Datix reporting commenced

Apr 2016 - DNACPR audit produced and disseminated Nov 2016

- AMU Relocation - W23 relocated with W20 - New bed configuration

28 Pack pg 69

Patients will experience safe careHeatmap Nov-16

MR

SA

Bac

tera

emia

C D

iff

Falls

- N

o

Ad

vers

e

Ou

tco

me

Falls

- A

dver

se

Out

com

e

Mu

ltip

le f

alls

-

No

Ad

vers

e

Ou

tco

me

Mu

ltip

le f

alls

-

Ad

vers

e

Ou

tco

me

Med

icat

ion

Erro

rs -

No

Ad

vers

e

Ou

tco

me

Med

icat

ion

Erro

rs -

Ne

ar

mis

s

Med

icat

ion

Erro

rs -

Cau

sin

g H

arm

Nu

mb

er o

f

Seri

ou

s

Inci

den

ts

Nu

mb

er o

f

Nev

er E

ven

ts

Pre

ssu

re

Ulc

ers

Gra

de

2 (A

void

able

)

Pre

ssu

re

Ulc

ers

Gra

de

3 (A

void

able

)

Pre

ssu

re

Ulc

ers

Gra

de

4 (A

void

able

)

Inci

den

ts -

Dea

th

Inci

den

ts -

Seve

re

Inci

den

ts -

Mo

der

ate

Inci

den

ts -

Low

Inci

den

ts -

No

Har

m

Trust 0 0 56 17 15 6 21 13 3 0 0 7 3 0 0 0 5 56 599

AMU 12 2 3 3 4 1 3 1 9 102

Cardiology OPD 1

CCU 1 2

CDU 1 2 12

Chemotherapy Unit 1 1

Dermatology 2

Discharge Unit 1

Diabetes Centre 3

Escalation Ward 1 1 1 1 1 1 2 10

Emergency Department 2 1 80

Endoscopy 6

Ward 17 2 4

Ward 18 12 4 1 1 1 2 3 27

Ward 19 & Ward 20 12 5 4 3 2 1 1 12 39

Ward 23 2 3 1 1 2 4 21

Ward 24 1 1 2 6Ward 35 8 2 2 2 2 1 2 28

Breast OutpatientsBreast Outpatients 1

Day Surgery 1 12

ENT OPD 1

Fracture Clinic 4

Hospital at Night 1

ICU 2 4

ICU - Paediatric area 1

Inpatient Surgical Unit 3 1 3 5 19

Opthalmology OPD 1

Orthoptics OPD 3

Planned Investigation Unit 1

Surgical Admissions 1 6

SHDU 1

Theatres 23

Theatres recovery 1Ward 33 & Ward 34 2 2 1 1 3 22

Antenatal Day Unit 5

Childrens Assessment Unit 2

Community Midwifery 5

CSSD 1

Labour Suite 83

Laboratory Reception 1

Medical Imaging 10

Paediatric Outpatient 1

Pathology 1 2

Pharmacy 1 1

Physiotherapy 3

Postnatal/Antenatal Ward 1 1 12

Ultrasound (maternity) 1

Ward 14 1 1 1 2 14

Ward 15 1 4Ward 37 1 1 7

Chest Clinic 1

Medical Outpatients 3

Portering 1

Surgical Outpatient 1

CB

U 1

CB

U 2

CB

U 3

Co

rpo

rate


29 Pack pg 70

Patients will experience safe careThe heatmap below is designed to show the areas of greatest concern.

AMUCardiology OPDCCUCDU

Chemotherapy UnitDermatologyDischarge UnitDiabetes CentreEscalation WardEmergency Department

EndoscopyWard 17Ward 18Ward 19 & Ward 20Ward 23Ward 24Ward 35Breast OutpatientsDay SurgeryENT OPDFracture ClinicHospital at NightICUICU - Paediatric areaInpatient Surgical UnitOpthalmology OPDOrthoptics OPDPlanned Investigation Unit

Surgical AdmissionsSHDUTheatresTheatres recoveryWard 33 & Ward 34Antenatal Day UnitChildrens Assessment UnitCommunity MidwiferyCSSDLabour SuiteLaboratory ReceptionMedical ImagingPaediatric OutpatientPathologyPharmacyPhysiotherapyPostnatal/Antenatal WardUltrasound (maternity)Ward 14Ward 15Ward 37Chest ClinicMedical OutpatientsPorteringSurgical Outpatient

CB

U 1

CB

U 2

C

BU

3C

orp

ora

te


30 Pack pg 71

Patients will experience safe careHeatmap

Reporting Month: Nov-16

Executive lead : Heather McNair

Comments


These were attributed to AMU, ward 29 and ward 14.

In all 3 incidents, there was a delay in providing the patients with appropriate preventative measures, despite the patients being at high risk of developing pressure damage. There was also a delay in completing relevant documentation

regarding risk and pressure area assessment on AMU.


3 of the avoidable grade 2 pressure ulcers were identified on AMU, 2 on ward 18, 1 on ward 29 / 1 on ward 36. In all the incidents, there was either a lack of skin assessment / lack of documentation regarding skin assessment or a lack of /

delay in providing the patients with appropriate preventative measures.

Education in the form of the React to Red training programme is now being delivered by the Tissue Viability team Trust wide to ensure the focus on pressure ulcer assessment and prevention remains a priority. Due to an increase in

numbers on AMU, work is being undertaken to support the reduction of avoidable pressure ulcers through the implementation of a robust action plan with a focus on the assessment and subsequent appropriate management of the

patient. Weekly Tissue Viability ward rounds will now take place on the escalation ward, due to the increase in avoidable pressure ulcers. Pressure Ulcers

Indicator Name


31 Pack pg 72

0 1 2 3 4 5 6 18 19 20 # 22

People - "At a glance"

Target Target Actual Month

16/17 YTD Nov-16 YTD Trend Status

Workforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Sickness Absence Rate 3.75% 3.75% 4.60% 3.91% ↓ 3.91%

Staff Turnover 10% 10% 8.8% 8.8% ↑ 8.78%

Mandatory Training 90.0% 90.0% 87.8% N/A ↑ N/A

Appraisal Rates - Medical 90.0% 90.0% 96.5% N/A ↓

Appraisal Rates - Non Medical 90.0% 90.0% 93.9% N/A ↓ N/A

Appraisal Rates - Total 90.0% 90.0% 94.1% 94.1% ↓ 94.07%

People


32 Pack pg 73

People will be proud to work for usQ - Workforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Staf

f Tu

rno

ver


5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

Pe

rce

nta

ge P

osi

tivi

ty

Staff Turnover

Actual

Staff Turnover - has decreased from last month and is within the expected range.

33 Pack pg 74

People will be proud to work for usWorkforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Comments

Comments

Ap

pra

isal

sM

and

ato

ry T

rain

ing

50%55%60%65%70%

75%80%85%90%95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Mandatory Training

Actual Target


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Appraisals

Total Non-Medical Medical Target

Mandatory Training - Overall compliance is currently 87.8%, no CBU has achieved compliance the figures are as follows; CBU1 84.5%, CBU2 88.0%, CBU3 89.4%, Corporate services 87.8%

Appraisals Medical - Percentage of doctors (eligible for appraisal) in date for appraisal: CBU 1 Medicine = 95.2% CBU 2 Surgery = 97.0% CBU 3 W&C & Clinical Services = 97.6% Overall compliance is 96.5%, compliance has been achieved by all CBU’s Appraisals Non Medical - Overall compliance is 93.9%, compliance has been achieved by all CBU’s

34 Pack pg 75

People will be proud to work for usWorkforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Comments

Sick

ne

ss A

bse

nce

Sick

ne

ss A

bse

nce


1%

2%

3%

4%

5%

Pe

rce

nta

ge P

osi

tivi

ty

Sickness Absence

Actual Target

Sickness - Sickness has risen in month to 4.60% for November. An increase of 0.48% on October. Only Corporate Services (CBU 4) remains in amber at 3.79% . Highest levels of sickness are in CBU 3 with 5.65% . CBU 2 moves into red at 4.36%. CBU 1 remains in red but has decreased to 4.18% . The annual percentage sickness absence rate for the year to date remains static at 4.12%.

35 Pack pg 76

1 2 3 4 5 6 18 19 20 # 22 # 24 25 26 27 39 40 41 # #

Performance - "At a glance"

Target

16/17

Target

YTDNov-16 Actual YTD Trend

Current

Qtr

Qtr

Status

YTD

Status

Target

16/17

Target

YTDNov-16 Actual YTD Trend YTD Status

Cancer Reporting Cancelled Operations

All Cancer 2 week waits 93% 93% 95.4% 94.9% ↑ 95.3% 95.3% 94.9% % Cancelled Operations 1% 1% 0.6% 0.7% ↓ 0.7%

2 week wait - Breast Symptomatic 93% 93% 98.2% 93.6% ↓ 97.0% 97.0% 93.6% Urgent operations - cancelled twice 0 0 0 0 ↔ 0

31 day diagnostic to 1st treatment 96% 96% 98.9% 98.8% ↑ 99.4% 99.4% 98.8% Cancelled operations - breaches of 28 day rule 0 0 0 0 ↔ 0

31 day subsequent treatment - Surgery 94% 94% 100.0% 100.0% ↔ 100.0% 100.0% 100.0%

31 day subsequent treatment - Drugs 94% 94% 100.0% 100.0% ↔ 100.0% 100.0% 100.0% Theatre Utilisation

62 day urgent GP referral to treatment 85% 85% 94.1% 88.9% ↓ 93.0% 93.0% 88.9% Theatre Utilisation - Day 84.0% 78.4% ↑ 78.4%

62 day screening programme 90% 90% 100.0% 98.4% ↔ 100.0% 100.0% 98.4% Theatre Utilisation - Main 94.7% 87.9% ↑ 87.9%

62 day consultant upgrades 85% 85% 85.0% 81.8% ↓ 83.3% 83.3% 81.8% Theatre Utilisation - Trauma 98.3% 86.5% ↑ 86.5%

Breast Screening GP Referrals

Screening to offer of 1st assessment <=3 weeks (June 16) 90% 90% 100.0% 74.4% ↔ 74.4% GP Written Referrals - made 4059 33647 ↑ 33647

Screening to 1st assessment (June 16) 90% 90% 100.0% 89.6% ↑ 89.6% GP Written Referrals - seen 4362 33688 ↓ 33688

Screening to issue of normal results <=2 weeks (June 16) 90% 90% 99.9% 95.9% ↑ 95.9% Other Referrals - Made 1766 14713 ↑ 14713

GP referral rate year on year (2015/16 + 2016/17) -151 -11554 ↓ -11554

Referral to Treatment Total referral rate year on year (2015/16 + 2016/17) -22 3532 ↓ 3532

RTT Incomplete Pathways - % still waiting 92% 92% 92.9% 94.2% ↓ 93.5% 93.5% 94.2%

DNA Rates

Diagnostics New outpatient appointment DNA rate 10% 10% 8.2% 9.1% ↑ 9.1%

No. of diagnostic tests waiting over 6 weeks 0 0 7 225 ↓ ###### Follow-up outpatient appointment DNA rate 10% 10% 8.7% 9.5% ↑ 9.5%

% of diagnostic tests waiting over 6 weeks 0% 0% 0.3% 1.0% ↓ 1.0% Total outpatient appointment DNA rate 10% 10% 8.6% 10.4% ↑ 10.4%

ED Appointment Slot Issues

Percentage of patients treated in less than 4 hours 95% 95% 87.7% 93.3% ↓ 93.3% 93.3% 93.3% No. of appointment slot issues 0 0 n/a 0 ↔ 0

Emergency Department Attendances n/a n/a 6788 56191 ↓ 0 % of appointment slot issues 4.0% 4.0% n/a ↔

12 Hours Trolley Waits 0 0 0 0 ↔ 0 0

Average Length of stay (Quality Strategy Goal 3)

Ambulance to ED Handover Time Average Length of Stay - Elective 2.4 2.4 2.9 2.3 ↑ 2.29

% under 15 mins 34.9% 50.9% ↓ 50.9% Average Length of Stay - Non-Elective 3.4 3.4 2.6 2.7 ↓ 2.67

% between 15 and 30 mins 51.2% 38.1% ↑ 38.1%

% between 30 and 60 mins 6.6% 3.4% ↑ 3.4% Re-admissions

% between 60 and 120 mins 1.1% 0.6% ↑ 0.6% Percentage of re-admissions N/A N/A 9.7% 9.3% ↔

Over 120 mins (SI) 0.3% 0.0% ↑ 0.0%

% Not Recorded 5.8% 6.9% ↓ 6.9%

Total Ambulance Handovers 1761 15564 ↓ 15564

Performance - Key Performance Indicators Performance - Key Performance Indicators cont.


36 Pack pg 77

Performance Matters (KPIs)Operational Efficiency

7

9

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

Ave

rage

Len

gth

of

Stay

Bre

ast

Sym

pto

mat

ic

Re

-ad

mis

sio

ns

Can

celle

d O

per

atio

ns


0.8% 0.8%

1.1%

0.4% 0.6%

0.4% 0.5% 0.6%

0.0% 0.0% 0.0% 0.0%

0.5%

1.0%

1.5%

2.0%

0

1

2

3

28 Day Breaches Target % Cancelled Ops 2015/16

0.00

1.00

2.00

3.00

4.00

5.00


Average Length of Stay (Quality Strategy - Goal 3: Delivering Consistently Effective Care)

Elective Non-Elective Elective Target Non-Elective Target 2015/2016 Elective 2015/2016 Non Elective

9.1%

9.7%

8.9%

9.3% 9.2%

8.3%

9.7% 9.7%

0.07

0.08

0.09

0.1

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Re-admissions %

37 Pack pg 78

Performance Matters (KPIs)


87.83% 82.94% 83.71% 80.84% 82.40% 82.58% 83.48% 77.24% 84.60% 79.23% 86.09%

Thea

tre

Uti

lisat

ion

GP

Re

ferr

als

DN

A R

ates

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Theatre Utilisation

Day Main Trauma 2015/2016

0.00%

5.00%

10.00%

15.00%

DNA Rates

New Follow Up

Total Target

2015/2016 Total DNA's

0

1000

2000

3000

4000

5000

6000

GP Referrals Made & Seen

15/16 Made 15/16 Seen 14/15 Made 14/15 Seen

38 Pack pg 79



Diagnostics

Comments:

Dia

gno

stic

Tes

ts o

ver

6 w

eek

s (D

M0

1)

4.3%

1.5%

0.1% 0.1% 0.4%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

0

20

40

60

80

100

120

140

160


Pe

rce

nta

ge o

ver

6 w

ee

ks

No

. ove

r 6

we

eks

Target Actual Actual 2015/2016

39 Pack pg 80



Regulatory Performance - ED

A&E All Types Benchmarking

A&E benchmarking

Quarter 3

Current

Position %YTD %

85.06% 88.19%

91.10% 92.61%Doncaster & Bassetlaw

92.75%89.07%

A&

E 4

Ho

ur

Wai

tA

&E

4 H

ou

r W

ait

- B

en

chm

arki

ng

Sheffield Teaching

Rotherham

Barnsley

85.42% 90.95%

0

500

1000

1500

2000

2500 No. Ambulance Handover Times (pre-validated YAS)

No. under 15 mins No. between 15 & 30 mins

No. between 30 & 60 mins No. between 60 & 120 mins

No. over 120 mins Not recorded

0

1000

2000

3000

4000

5000

6000

7000

8000

86%

88%

90%

92%

94%

96%

98%

100%

Within 4 Hours Total Attendances

Target % Achievement

78%

80%

82%

84%

86%

88%

90%

92%

94%

96%

Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16

A&E Benchmarking All Types

Doncaster & Bassetlaw Barnsley Rotherham Sheffield Teaching

40 Pack pg 81



Regulatory Performance - 18 Week Referral to Treatment

As stated

RTT 18 Week Performance - November 2016 Unvalidated Position

Specialty <18 >18 Total %

General Surgery 1752 174 1926 91.0%Urology 700 148 848 82.5%Trauma & Orthopaedics 1508 113 1621 93.0%ENT 1015 70 1085 93.5%Oral Surgery 921 37 958 96.1%General Medicine 74 5 79 93.7%Gastroenterology 677 28 705 96.0%Cardiology 624 44 668 93.4%Dermatology 1124 81 1205 93.3%Respiratory 280 32 312 89.7%Rheumatology 215 3 218 98.6%Geriatric Medicine 266 9 275 96.7%Gynaecology 770 10 780 98.7%Other 767 63 830 92.4%Total 10693 817 11510 92.9%

Co

nsu

ltan

t 1

8 W

eek

Ref

erra

l to

Tre

atm

ent

Incompletes - Target 92%

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Pe

rce

nta

ge P

osi

tivi

ty

Non-Admitted Pathways

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Incomplete Pathways

Actual Target

75%

80%

85%

90%

95%

100%A

pr-

16

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Pe

rce

nta

ge P

osi

tivi

ty

Admitted Pathways

Actual Target

41 Pack pg 82



Regulatory Performance - Cancer

31

Day

- S

ub

seq

ue

nt

Tre

atm

en

t (S

urg

ery

)

31

Day

- T

arge

ts

Bre

ast

Sym

pto

mat

ic

All

Can

cer

2 W

ee

k W

aits

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Pe

rce

nta

ge P

osi

tivi

ty

31 Day Diagnostic to Treatment

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Pe

rce

nta

ge P

osi

tivi

ty

31 Day Subsequent Treatment (Drugs)

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Pe

rce

nta

ge P

osi

tivi

ty

31 Day Subsequent Treatment (Surgery)

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Target

42 Pack pg 83




Comments

Can

cer

Pe

rfo

rman

ce b

y Tu

mo

ur

Site

62

Day

Can

cer

Targ

ets

62

Day

- S

cre

en

ing

Pro

gram

me

November (pre-validation) has shown a compliant position across all national Key Performance Indicators. Breaches of the ‘62

Day GP referral to treatment target’ were seen across the Gynaecology (2 x shared), Upper GI (1 x shared) and Breast (1 x local)

pathways. Breach analysis reveals varied reason including unexceptional pathways (no stand out delays), capacity at STH; and

some patient choice elements. Of the shared pathways, 2 were referred late to STH (> Day 38) and may be fully allocated back

to BHNFT. 1 pathway was referred < Day 38 and STH will be asked to accept the full reallocation of this pathway. Following

reallocation – the target would remain compliant in November.

The locally agreed Consultant Upgrade target is currently showing as compliant but would be adversely affected by

reallocation of shared breaches of which 3 pathways were referred late. This reallocation would render the target non-

compliant at 75%.

Prolonged pathways

Root Cause Analysis of all pathways exceeding 104 days is routinely undertaken and circulated through clinical teams for input,

oversight and comment. Specifically the MDT Leads are asked whether the prolonged nature has negatively impacted the

patient’s clinical outcome. So far, reviews of pathways have not revealed any evidence of this.

75%

80%

85%

90%

95%

100%A

pr-

16

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Urgent GP Referral to Treatment

Actual Target

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Screening Programme

Actual Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Consultant Upgrades

Actual Target

43 Pack pg 84




Graph to follow

Comments

Can

cer

Shar

ed

Pat

hw

ay P

erf

orm

ance

In November 22/27 pathways were referred to the tertiary centre by the required Day 38. Whilst this does not meet the 85% monthly target the Q position remains positive and the

position is more consistently strong. Of the 5 pathways referred late - there was 1 x Head +Neck, 1 x Upper GI and 3 x Lung. Late referrals will not necessarily result in a breached pathway.

However, of the 6 shared breaches in November (both GP 62 Day and Consultant Upgrades), 5 were referred late and risk full reallocation to BHNFT.

The Cancer Waiting Times Improvement Plan is now underway with a specific focus on achieving the 28 day diagnostic target as mandated by the national cancer strategy. This requires

95% of patients to be given a cancer diagnosis or have cancer excluded by Day 28 following GP referral (by 2020). Work to achieve this will positively impact shared pathway performance

as will see an improvement to the diagnostic and staging phase of pathways. Updates against this plan will be given to Board each month.

44 Pack pg 85



Regulatory Performance - Breast Cancer Screening

Comments:

Scre

en

ing

to is

sue

of

no

rmal

re

sult

s

<=2

we

eks

Scre

en

ing

to 1

st a

sse

ssm

en

t

Scre

en

ing

to o

ffe

r o

f 1

st a

sse

ssm

en

t

<=3

we

eks

30%

40%

50%

60%

70%

80%

90%

100%P

erc

en

tage

Po

siti

vity

Actual Target

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Target

45 Pack pg 86

Performance Matters Data QualityUncoded Episodes (As at 14th December 2016)

Treatment Specialty September October November December Total Specialty October November December Total

ACCIDENT AND EMERGENCY 38 65 103 3 3

ANTICOAGULANT SERVICE 4 8 12

BREAST SURGERY 3 3 41 41

CARDIOLOGY 10 34 44 6 34 40

CLINICAL HAEMATOLOGY 8 44 52 6 12 18

CLINICAL ONCOLOGY 3 3 7 6 13

COLORECTAL SURGERY 2 4 6 3 5 1 9

DERMATOLOGY 68 34 102 1 14 3 18

DIABETIC MEDICINE 1 20 21 2 2

DIAGNOSTIC IMAGING 0 33 33

ENDOCRINOLOGY 14 9 23 1 4 16 21

ENT 4 4 8 7 28 35

GASTROENTEROLOGY 2 24 84 110 7 24 31

GENERAL MEDICINE 126 272 398 15 15

GENERAL SURGERY 48 76 124 5 5

GERIATRIC MEDICINE 6 6 6 2 8

GYNAECOLOGY 14 74 88 2 2

NEONATOLOGY 4 7 11 1 2 3

OBSTETRICS 15 55 70 4 4

OPHTHALMOLOGY 116 46 162

ORAL SURGERY 0

PAEDIATRIC CYSTIC FIBROSIS 0

PAEDIATRIC ENT 2 4 6

PAEDIATRICS 10 101 111

PAEDIATRIC T&O 0

PAEDIATRIC OPHTHALMOLOGY 1 2 3

RESPIRATORY MEDICINE 13 77 90

RHEUMATOLOGY 3 3 CommentsStroke Medicine 2 16 18

TRAUMA AND ORTHOPAEDICS 10 83 93

UROLOGY 4 36 40

VASCULAR SURGERY 0

WELL BABIES 7 10 17

BLANK SPECIALTIES 21 57 78

Total 2 0 565 1226 1793

DIABETICS CENTRE

Missing Outcomes (As at 9th December 2016)

DERMATOLOGY

CARDIOLOGY

ANTICOAGULANT

ANTE-NATAL

AMU

MAIN OPD

GENMED

GENERAL SURGERY

GASTROENTEROLOGY

DVT

PHYSIOTHERAPY

PAEDIATRICS

OMFS

NEW STREET

WARD 24

UROLOGY

PRE-ASSESSMENT

RESPIRATORY MEDICINE

Uncoded Episodes - All episodes for January, February, March, April, May, June, July, August &

October have been coded.

There are 2 for September 2016, 565 for November 2016 & 1226 for December 2016.

Overall there are 1793 uncoded episodes for 16/17.


46 Pack pg 87

Performance Matters A

dm

itte

d P

atie

nt

Car

e C

DS

Barnsley is currently unable to flow the RTT patient pathway data in the APC & OP datasets, hence the

reduced data quality score.

Ad

mit

ted

Pat

ien

t C

are

CD

SA

dm

itte

d P

atie

nt

Car

e C

DS


99.6% 99.3% 98.4% 98.3%

94.7%

90.9%

96.6%

98.2%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Doncaster &Bassetlaw

SheffieldChildren's

SheffieldTeaching

Rotherham Barnsley RDASH St Luke'sHospice

NationalAverage

Area Team

Data validity summary average of all fields in SUS Dashboard April-August 2016

99.8% 99.6% 99.9% 99.8% 99.6% 99.6%

0.0%

99.2% 99.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Barnsley SheffieldTeaching

Doncaster &Bassetlaw

St Luke's Hospice Area TeamAverage

NHS Number

100.0% 100.0% 100.0% 100.0% 100.0% 99.9%

0.0%

99.9% 100.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Barnsley SheffieldChildren's

SheffieldTeaching

Rotherham Doncaster&

Bassetlaw

RDASH St Luke'sHospice

NationalAverage

Area TeamAverage

Registered GP Practice 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%

99.8% 99.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

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90.0%

100.0%

Barnsley Sheffield Teaching Doncaster &Bassetlaw

St Luke's Hospice Area TeamAverage

Postcode


47 Pack pg 88

Performance Matters Data Quality - Secondary Uses Service (SUS) Dashboard

Ou

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99.9% 99.8% 99.9% 99.9% 99.7%

0.0%

99.4% 99.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

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SheffieldTeaching

Rotherham Doncaster &Bassetlaw

RDASH NationalAverage

Area TeamAverage

NHS Number 100.0% 100.0% 100.0% 100.0% 100.0%

0.0%

99.8% 100.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

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80.0%

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100.0%


SheffieldTeaching

Rotherham Doncaster&

Bassetlaw


Area TeamAverage

Registered GP Practice

100.0% 100.0% 100.0% 100.0% 100.0%

0.0%

99.8% 99.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%


SheffieldTeaching



Area TeamAverage

Postcode

95.3% 100.0% 100.0% 99.4% 98.5%

0.0%

97.1% 99.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

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BarnsleySheffield Children'sSheffield TeachingRotherhamDoncaster & BassetlawRDASHNational AverageArea Team Average

Attendance Outcome

48 Pack pg 89

Performance Matters

Q - Data Quality - Secondary Uses Service (SUS) Dashboard

Acc

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nt

& E

me

rge

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me

rge

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99.2% 99.6% 99.4%

83.8%

97.6% 96.4%

97.9%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%


SheffieldTeaching


NationalAverage

Area TeamAverage

NHS Number

95.1%

100.0% 100.0%

98.5%

99.9%

98.8%

99.6%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%


SheffieldTeaching


NationalAverage

Area TeamAverage

Registered GP Practice

99.9% 100.0% 100.0%

98.3%

100.0%

99.3%

97.8%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%


SheffieldTeaching


NationalAverage

Area TeamAverage

Postcode 100.0% 100.0% 100.0%

99.0%

99.9%

97.8%

95.9%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%


SheffieldTeaching


NationalAverage

Area TeamAverage

Attendance Disposal

49 Pack pg 90

Performance MattersActivity

15/16 16/17 16/17

Actual Plan Actual Variance %

Elective Day cases 15,693 16,180 16,324 144 1%

Elective Inpatients 2,790 2,885 2,795 -90 -3%

Elective Total 18,483 19,065 19,119 54 0%

Non Elective 23,736 23,495 23,095 -400 -2%

Maternity Pathway 4,192 4,244 4,498 254 6%

A&E Attendances 53,820 55,013 56,197 1184 2%

Outpatients 160,831 165,403 174,362 8959 5%

* Please note excess bed days are not included in these figures. 2016/17 Activity Plan

2016/17 Activity Actual

2015/16 Outturn

2016/17 Activity Plan 2016/17 Activity Plan

2016/17 Activity Actual 2016/17 Activity Actual

2015/16 Outturn 2015/16 Outturn

Act

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Obstetric outpatient attendances are excluded as they are covered by the Maternity Pathways

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50 Pack pg 91

Performance MattersActivity

2016/17 Activity Plan 2016/17 Activity Plan

2016/17 Activity Actual 2016/17 Activity Actual

2015/16 Outturn 2015/16 Outturn

Comments:

2016/17 Activity Plan

2016/17 Activity Actual2015/16 Outturn

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Main areas of overperformance are Outpatients and A&E. Main area of underperformance is Non-Elective Inpatients.

Outpatients:- areas of underperformance with the highest variances (against aggregated attendances and procedure plans) in

Gynaecology -1329, Clinical Heamatology -456, Ant-Coagulant Service -1764 and Breast Surgery -365. Overperforming are

Cardiology 1326, Diabetic Medicine 1792, T&O 1972 and Gastroenterology 1703.

Non-Elective Inpatients:- General Medicine, Paediatrics, General Surgery, Clinical Haematology & Cardiology are the main areas

of underperformance.


0

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51 Pack pg 92

Performance - "At a glance"

Month

Plan

Month

Actual

Variance

%Variance Plan YTD

Actual

YTD

Variance

%Variance

Month

Plan

Month

ActualVariance % Variance Plan YTD

Actual

YTD

Variance

%Variance

ACTIVITY LEVELS (PROVISIONAL) £'000 £'000 £'000 £'000 £'000 £'000

Elective inpatients 385 386 0.26% 1 2,885 2,795 -3.12% -90 EBITDA 313 276 11.82% -37 -931 -1,045 -12.24% -114

Day Cases 2,158 2,117 -1.90% -41 16,183 16,324 0.87% 141 Depreciation -403 -385 4.47% 18 -3174 -3082 2.90% 92

Non-elective inpatients 2,941 2,883 -1.97% -58 23,511 23,142 -1.57% -369 Restructuring & Other -14 -69 -392.86% -55 -198 -212 -7.07% -14

Outpatients 21,841 22,276 1.99% 435 142,155 150,247 5.69% 8,092 Financing Costs -189 -201 -6.35% -12 -1511 -1422 5.89% 89

A&E 6,634 6,790 2.35% 156 48,379 49,408 2.13% 1,029 SURPLUS/(DEFICIT) -293 -379 -29.35% -86 -5,814 -5,761 0.91% 53

'Clinical' Activity

Other (excludes direct access tests) 11,623 11,029 -5.11% -594 86,055 83,967 -2.43% -2,088 SOFP £'000 £'000 £'000 £'000 £'000 £'000

Total activity 45,582 45,481 -0.22% -101 319,168 325,883 2.10% 6,715 Capital Spend -725 -277 -61.79% 448 -4,695 -2,365 -49.63% 2,330

Inventory 2,161 1,918 11.24% 243

CIP £'000 £'000 £'000 £'000 £'000 £'000 Receivables & Prepayments 8,586 15,124 -76.15% -6,538

Income 203 323 59.11% 120 1,187 1,579 33.02% 392 Payables -12,959 -13,357 3.07% 398

Pay 166 86 -48.19% -80 994 666 -33.00% -328 Accruals -2,529 -5,316 110.20% 2,787

Non-Pay 230 96 -58.26% -134 1,391 1,485 6.76% 94 Deferred Income -583 -604 3.60% 21

Total CIP 599 505 -15.69% -94 3,572 3,730 4.42% 158

Cash & Loan Funding £'000 £'000 £'000 £'000 £'000 £'000

INCOME £'000 £'000 £'000 £'000 £'000 £'000 Cash 1,527 369 -75.83% -1,158

Clinical (Activity) 9,460 9,901 4.66% 441 73,833 75,958 2.88% 2,125 Loan Funding -48,050 -47,631 0.87% 419

Other Clinical 4,258 4,626 8.64% 368 33,672 34,368 2.07% 696

CQUINS 289 289 0.00% 0 2,312 2,312 0.00% 0 KPIs

Risks & Penalties 0 -93 -93 0 -611 -611 EBITDA % 1.98% 1.67% -15.89% -1.98% -0.75% -0.83% -10.11% -0.08%

Non Recurrent Income 142 155 13 1,134 1,337 203 Deficit % -1.86% -2.29% -16.97% -0.32% -4.70% -4.57% 2.80% 0.13%

Other 1,633 1,667 2.08% 34 12,649 12,638 -0.09% -11 Receivable Days 16.7 29.3 -76.15% -12.7

Total income 15,782 16,545 4.83% 763 123,600 126,002 1.94% 2,402 Payable (excluding accruals) Days 63.7 65.7 3.07% 2.0

Payable (including accruals) Days 76.2 91.8 20.56% 16

OPERATING COSTS £'000 £'000 £'000 £'000 £'000 £'000 Use of Resource metric 3 3 0.00% 0

Pay -10,344 -10,684 -3.29% -340 -82,976 -84,154 -1.42% -1,178

Drugs -1,241 -1,147 7.57% 94 -9,948 -9,311 6.40% 637

Non-Pay -3,884 -4,438 -14.26% -554 -31,607 -33,582 -6.25% -1,975 Consolidated

Total Costs -15,469 -16,269 -5.17% -800 -124,531 -127,047 -2.02% -2,516 excl charity

Payable days are total op exps, less total pay, add back lead units and agency control total

Payables are Trade & Other only

Performance - Financial Overview Performance - Financial Overview


Page 52 of 55 Pack pg 93

Performance Matters - Finance

November 2016 Summary

Summary Performance:


Commentary Key to RAG Rating The RAG rating applied to Variance % is based on the following criteria: • Green equating to 0% or greater • Amber behind plan by up to 5% • Red greater than 5% behind plan

The key points derived from this table are as follows: • Total activity is favourable to plan year to date excluding Direct Access. The main driver is overperformance on Outpatient activity. Direct Access tests were excluded from the Other

activity because large variances in these figures skew the overall activity variance.

• CIP achievement is favourable to plan by £0.015m. Income and non pay schemes are ahead of plan.

• Clinical activity based income is £2.13m favourable to plan before risks and penalties. The main variances are Outpatients income £0.9m favourable to plan,Elective income £0.7m favourable. Other clinical income is £0.7m ahead of plan.

• Other income is broadly to plan.

• Operating costs are adverse to plan. Pay is £1.18m adverse. Agency costs covering vacant posts create a cost pressure, although the costs year to date are significantly lower than at this point last year.

• Non-pay costs total are £1.98 adverse to plan, which links to activity.

• EBITDA is £0.01m below plan.

• Depreciation, restructuring and finance costs are £0.17m favourable to plan in total.

• The overall deficit is £0.05m favourable to plan.

• Capital expenditure is £2.33m favourable to plan.

• Inventory is £0.24m below plan.

• Total receivables incl. prepayments are £6.5m adverse to plan. Action is being taken to address this position.

• Total payables incl. accruals are £3.19m favourable to plan .

• Deferred income is slightly ahead of plan.

• Cash is £1.16m adverse to plan.

• Debtor days are 29.3 year to date, which is 12.7 days adverse to plan.

• Payable days 65.7 year to date which is 2 days higher than plan (down from 8.5 days at month 7). Payable days have been calculated excluding accruals, because whilst accruals include certainties in respect of future payments, the timing of these payments is uncertain.

• The Use of Resource metric is a 3 at month 8.


Performance Matters (Financial Overview)

Comments:

Clinical income per day - this is above plan for November 2016

Act

ual

Inco

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An

alys

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Inco

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Pe

r D

ay

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Income analysis - this graph analyses the split of income on a monthly basis and

demonstrates the variability of clinical income.

Pay as a % of clinical income is above plan for November 2016


0

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CIP Actual CIP Plan

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Actual Income Analysis

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Performance Matters (Financial Overview)


Comments:

CIP is ahead of plan at month 8.

Age

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Agency monthly spend - Total agency spend ytd is £3.22m. Agency expenditure is

reviewed in depth.

Deficit trend analysis - this graph highlights the gap between plan and actual at month 8.

Currently the Trust deficit is below plan.

0

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Deficit Trend Analysis

Deficit Plan Deficit


REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT REF: BoD 17/01/11 SUBJECT: BREATHE 2025 CAMPAIGN DATE: JANUARY 2017

PURPOSE:



PREPARED BY: Dr Richard Jenkins, Medical Director SPONSORED BY: Dr Richard Jenkins, Medical Director PRESENTED BY: Dr Richard Jenkins, Medical Director STRATEGIC CONTEXT

The Trust has a strategic aim to work in partnership with other local organisations in the interests of improving the health of people in Barnsley.

EXECUTIVE SUMMARY The prevalence of smoking in Barnsley is higher than the Yorkshire or England average and rates of smoking related illness are also high. Breathe 2025 is a Yorkshire and Humber wide initiative to reduce smoking rates and inspire a smoke-free generation by 2025. The engagement of organisations across the region is important to ensure this is achieved and as an NHS Foundation Trust, we have the opportunity to support this important public health initiative. The campaign has asked that organisations formally sign up to the goals of the programme which have been circulated to Board members separately. In addition to the organisational commitment, Board members may wish to make a personal pledge to support Breathe 2025. Further information is available on the link: http://breathe2025.wpengine.com/wp-content/uploads/2014/12/Breathe-2025-partners-document.pdf

RECOMMENDATIONS

The Board is asked to formally commit to support the Breathe 2025 campaign.

Pack pg 97

http://breathe2025.wpengine.com/wp-content/uploads/2014/12/Breathe-2025-partners-document.pdf

http://breathe2025.wpengine.com/wp-content/uploads/2014/12/Breathe-2025-partners-document.pdf

Pack pg 98

REPORT TO THE BOARD OF DIRECTORS REF: BoD 17/01/P-12

BoD Jan 2017: Chairman

SUBJECT: CHAIRMAN’S REPORT

DATE: JANUARY 2017

PURPOSE:




PREPARED BY: Stephen Wragg, Chairman SPONSORED BY: PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT

EXECUTIVE SUMMARY

CONCLUSION AND RECOMMENDATION(S)

The Board of Directors is asked to: a) receive, note and support this report b) invite and note any further reports on their activities from the wider Non Executive

team.

Pack pg 99


Subject: CHAIRMAN’S REPORT Ref: BoD/17/01/P-12 1. INTRODUCTION

1.1 This report is intended to give a brief outline of some of the work and activities undertaken as Trust Chairman over the past month and highlight a number of items of interest.

1.2 The items reported are not shown in any order of priority.

2. TRUST POSITION 2.1 Our financial position continues to improve through very tight controls of our costs and

an increase in activity. We must continue to make real progress to meet our control totals so that we can contribute to the overall NHS savings and to the Sustainability & Transformation Plan (STP). Our record on patient safety will continue to give confidence to the population of Barnsley and our key stakeholders that care will not be compromised and we will continue to improve our current position. I will keep reiterating this message as I think it should be constantly in people’s minds. Whilst we are bringing about our return to stability, we will not compromise on quality of care and patient safety.

2.2 We also continue to give confidence, in difficult circumstances, to our staff that the Trust is doing everything it can to improve patient experience and the quality of care our patients receive. Our hospital is very busy and it is important that we continue to recognise this, and the hard work our staff put in on a daily basis, and pay tribute to all our staff for their valued work and their efforts to conceive new ideas to deliver better care.

2.3 We must continue to be conscious of the ongoing pressures on the hospital, including activity and cost improvement plans. It is essential we keep on track to return to financial balance whilst protecting the quality of our services for our patients and meaningful staff engagement.

3. COUNCIL OF GOVERNORS 3.1 The Council of Governors’ Quality & Governance Sub-Group met on 7 December,

where the Chair of the Trust’s Quality and Governance committee answered questions about the Trust’s current performance.

3.2 On 14 December the Council of Governors’ General Meeting took place. The meeting elected Annie Moody as Lead Governor, ratified Trevor Smith as Deputy Lead Governor, and elected Tony Dobell to the Nominations Committee. Thank you to everyone who expressed interest in these positions, it is reassuring that Governors continue to support the Trust in every way.

3.3 The following were elected as new Public Governors for the coming term:

• Michelle Bailey

• Andrew Bogg

• Alan Higgins

• Karen Kanee 3.4 Tony Dobell and Jacky O’Brien were re-elected Public Governors for a further term.

Pack pg 100


4. NEWS & EVENTS 4.1 On 7 December I underwent a Health & Wellbeing check in our Occupational Health

department. This is being made available to all our staff and looks at both physical and mental health.

4.2 On 11 December I was delighted to attend the Andaluvian Order of the Buffalo meeting to receive a cheque for the Tiny Hearts Charity.

4.3 On Saturday 17 December I was pleased to attend the Millhouse Green Male Voice Choir Christmas concert who presented a cheque to the Tiny Hearts Appeal...

5. BARNSLEY HOSPITAL CHARITY 5.1 The generosity of local people and the support for our Charity continues to grow. The

work done by the fundraising team is spreading our message throughout the borough and this has resulted in continued increase in donations to the Charity, which allows it to continue to deliver its aims.

5.2 The latest figures for the year were not available at the time of writing but as we closed the calendar year I was pleased to note the latest donations for 2016/17:

o Total donations (all funds) 1st April to 30th November £368,025.72 o Other income 1st April to 30th November £8,906.17 o Legacies 1st April to 30th November £10,447.82 o Tiny Hearts balance as of 5th December £454,396.77

5.3 Toy Donations – Even with our communication regarding not having a Toy Appeal and instead requesting donations to the Text Appeal, there was a huge amount of Toys donated to the Children’s ward to the point that Ward cupboards were completely full to the brim and we needed to make use of the old PAL’s office next to reception in the run up to Christmas. This did cause disruption to the wards, especially where people were bypassing the charity and going directly to the ward. However the Charity was able to intercept some of the Toy Appeals and take some of the pressure off the Play leaders.

5.4 The Charity also had two corporate supporters who, instead of bringing toys, raised funds for the Tiny Hearts Appeal. XPO Logistics raised £550 and we are awaiting news from Halifax in Barnsley, both are new supporters but pledged to support the charity on a long term basis.

5.5 We also had a number of departments around the Hospital fundraising for the charity, many choosing to donate to the Charity in lieu of Christmas Cards as well as raffles and dress down fundraisers.

5.6 A number of people outside the hospital also supported festive fundraising for the Charity over the Christmas period as well as donating in lieu of Christmas Cards

Stephen Wragg CHAIRMAN January 2017

Pack pg 101

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT REF: BoD 17/01/P-13 SUBJECT: CHIEF EXECUTIVE’S REPORT DATE: JANUARY 2017

PURPOSE:



PREPARED BY: D Wake, Chief Executive SPONSORED BY: D Wake, Chief Executive PRESENTED BY: D Wake, Chief Executive STRATEGIC CONTEXT

To report particular events, meetings or publications that the Chief Executive would like to bring to the Board’s attention.

EXECUTIVE SUMMARY This report is a brief summary of key meetings and events attended by the Chief Executive.

RECOMMENDATIONS

The Board of Directors is asked to receive and note this report.

Pack pg 102

Subject: CHIEF EXECUTIVE’S REPORT Ref: BoD 17/01/P-13

1. STRATEGIC CONTEXT 1.1 This report is intended to give a brief outline of some of the key activities undertaken

as Chief Executive since last month’s report and highlight a number of items of interest.

1.2 The items below are not reported in any order of priority.

2. SUSTAINABLE TRANSFORMATION PROGRAMME (STP) 2.1 The Chief Executive attended a Finance Oversight Group on 13 December 2016. This

group took account of NHS England’s analysis of the STP plans. 2.2 The Chief Executive attended the South Yorkshire & Bassetlaw (SYB) Sustainability

and Transformation Collaborative Partnership Board on 16 December 2016. Updates on draft local Place plans were presented by the STP Clinical Commissioning Groups and also received from the regional collaboratives.

3. ACUTE CARE FEDERATION AND WORKING TOGETHER PROGRAMME (WTP) – CHIEF EXECUTIVES/CHAIRS MEETING – 5 DECEMBER 2016 3.1 The WTP continues to work alongside the STP. The meeting received an update on a

range of workstreams and developments supporting service improvements. Further national response to the STP is expected in the New Year.

4. OVERVIEW & SCRUTINY COMMITTEE – 6 DECEMBER 2016 4.1 On 6 December 2016 BHNFT and other local health partners were invited to attend

the Overview and Scrutiny Committee at Barnsley Council in order to update members on the South Yorkshire STP. Bob Kirton, Director of Strategy and Business Development, attended on behalf of the Chief Executive.

4.2 Papers were presented by the Clinical Commissioning Group (CCG) and questions were addressed to all partners. A number of issues were raised by members, including plans to address the shortfall in funding with increased demand, detailed plans on how demand would be reduced, and how consultation will work with local communities.

5. HEALTH & WELLBEING BOARD – 6 DECEMBER 2016 5.1 The meeting continued its overview of the local input into the strategic planning and

also received updates from Healthwatch and other aspects of partnership working across the community.

6. NHS IMPROVEMENT SYSTEM WIDE LEADERSHIP SEMINAR – 8 DECEMBER 2016 6.1 This was one of a series of high level interactive seminars for NHS Board members,

including leadership challenges of maintaining operational standards under financial pressures.

7. A&E DELIVERY BOARD – 15 DECEMBER 2016 7.1 This Board is Chaired by the Chief Executive, with membership from across the health

economy. The A&E Improvement Plan (NHS Improvement document) continues to be developed with partner organisations, along with an operational pressures escalation framework. The meeting provides a useful opportunity for all organisations to share activity and performance updates and progress opportunities for partnership working.

Pack pg 103

8. ACCOUNTABLE CARE PARTNERSHIP BOARD – 15 DECEMBER 2016 8.1 The five member organisations continue to meet to progress the development of

accountable care in Barnsley. This meeting focussed on proposals for leadership and the expansion of Right Care Barnsley.

9. GP FEDERATION OPERATIONAL BOARD – 21 DECEMBER 2016 9.1 The meeting was attended by Bob Kirton, Director of Strategy and Business

Development. This Board oversees the operational performance of the federation, is chaired by Dr Mistry and has representation from across the Federation and partner organisations.

9.2 An overview was given on the Federation’s strategy with key themes of co-operation, innovation and aspiration. Key work includes implementation of the GP forward view, continuation of the “Made in Barnsley” programme, linking to schools to support young people develop educationally and vocationally, and I Barnsley (2278 consultations given in 2016, up to November). A presentation was given on workforce, the Federation has secured the employment of 12 GPs since April.

Pack pg 104


BoD Jan 2017: CoG (Dec)

SUBJECT: COUNCIL OF GOVERNORS

DATE: JANUARY 2017

PURPOSE:




PREPARED BY: Carol Dudley, Secretary to the Board & Governors SPONSORED BY: Stephen Wragg, Chairman PRESENTED BY: Stephen Wragg, Chairman STRATEGIC CONTEXT

The role and responsibilities of the Council of Governors and the Board’s responsibilities of working with and providing support to the Council.

EXECUTIVE SUMMARY

The attached papers from the Council of Governors illustrate a small part of how the Council of Governors continues to hold the Non Executive Directors to account. The meeting agenda and Minutes evidence information provided by the Board to the Governors, and the Board’s listening and responding to questions and comments from the Governors.

CONCLUSION AND RECOMMENDATION(S) The latest agenda (from General Meeting held in December 2016) and approved minutes (October 2016) are attached, to illustrate how the Board and Governors continue to work together to support development of services to patients. They also reflect some – but not all – of the ways in which the Governors and Board meet the requirements:

- for the Board of Directors to listen to and take account of the view of the Council of Governors

- to provide both information and training to governors - for the Council of Governors to hold the Non Executive Directors to account - Governors’ responsibilities for appointment of the Non Executive Directors and External

Auditors

The Board is asked to receive and note this report.

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COUNCIL OF GOVERNORS – DECEMBER 2016 REF: CG/16/12/04.b

MINUTES OF A GENERAL MEETING OF THE COUNCIL OF GOVERNORS HELD ON 19th OCTOBER 2016, 5.30PM

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL Present: Mr P Ardron Partner Governor, Sheffield Universities Ms K Armitage Public Governor, Barnsley Public Constituency

Mr D Brannan Partner Governor, Voluntary Action Barnsley Mr A Dobell Public Governor, Barnsley Public Constituency

Mrs J Gaines Public Governor, Barnsley Public Constituency Mr A Grierson Public Governor, Barnsley Public Constituency

Mr P Lleshi Partner Governor, Barnsley Together Mr S Long Public Governor, Barnsley Public Constituency Ms A Moody Public Governor, Barnsley Public Constituency Ms G Morritt Staff Governor, Nursing & Midwifery Mrs J O’Brien Public Governor, Barnsley Public Constituency Mr H Patel Public Governor, Barnsley Public Constituency Cllr J Platts Partner Governor, Barnsley MBC Mr R Raychaudhuri Staff Governor, Medical & Dental Mrs C Robb Public Governor, Barnsley Public Constituency Mr F Skorrow Public Governor, Barnsley Public Constituency Mr R Slater Public Governor, Barnsley Public Constituency Mr S Wragg Trust Chairman

In attendance: Ms J Clark General Manager, Clinical Business Unit (CBU) 2 Ms C Dudley Secretary to the Board & Governors Mr S Judge Service Lead, Barnsley Assistive Technology Team

Ms K Kelly Director of Operations Apologies: Ms J Bleasdale Co-opted Governor

Mrs P Buttling Public Governor, Barnsley Public Constituency Ms G Cockerline Staff Governor, Non Clinical Support Mr A Conway Staff Governor, Volunteers

Mr M Jackson Partner Governor, Joint Trade Unions Committee Mr B F Leabeater Public Governor, Barnsley Public Constituency Mr C Millington Partner Governor, Barnsley Clinical Commissioning Group

Mr L Pryor Partner Governor, Barnsley College Mr T Smith Public Governor, Barnsley Public Constituency Mr J Unsworth Lead & Public Governor, Barnsley Public Constituency

CG/16 68 APOLOGIES & WELCOME

The Chairman welcomed Governors, Directors and members of the public to the meeting. Mrs Kelly was attending on behalf of the Chief Executive. It was noted that Mr Judge, attending to provide an update on Assistive Care Technology at Barnsley Hospital (BHNFT) would arrive at c6pm. It was agreed that the agenda should be re-ordered to accommodate this. Apologies were noted as above.

Action

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CoG Dec 16: Mins 10 2016/ page 2 of 8

The Chairman reported the recent resignation of Mr Steenson, Public Governor, due to pressure of work. A note of thanks for his contribution to date had been sent on behalf of the Council of Governors.

CG/16 69 COMMENTS FROM THE PUBLIC None.

CG/16 70 DECLARATIONS OF INTEREST The Chairman declared his interest in the review of the Terms and Conditions of Service for the Non Executive team (agenda item 10). He reminded the meeting that, in the absence of the Lead Governor, another Governor would be required to Chair discussions of this item in accord with the Trust’s Constitution. Mr Dobell advised that, from discussions at the Governors’ pre-meeting, he had been nominated to take the Chair for this item. Cllr Platts and the Chairman declared their involvement with the Accountable Care System shadow board.

CG/16 71 MINUTES OF LAST MEETING (Enc 4)

The Minutes of the General Meeting held on 17th August 2016 were reviewed and accepted as a true record.

CG/16 72 MATTERS ARISING With reference to Minute 16/57, the Chairman confirmed that, following Governors’ approval, the proposed changes to the Trust’s Constitution had also been approved by the Board. The revised Constitution had been adopted and a copy submitted to NHS Improvements (NHSI) as required under the Provider Licence. It was also confirmed that a programme of Governors’ visits had been established, the first of which was scheduled for 16th November. Governors wishing to participate were asked to confirm their interest to Ms Dudley. Mr Dobell raised a point from the Governors’ pre-meeting regarding the Sustainability & Transformation Plan (STP). Governors were concerned about the lack of information available publically despite the impact on patients both locally and nationally. The Chairman acknowledged Governors’ concerns, which reflected discussions by the Board of Directors’ and similar criticism in recent press reports. Plans were still at a very early stage of development, with nothing yet sufficiently worked up to share more widely. He gave assurance that he and the Chief Executive had made, and would continue to make strong representation from the perspective of Barnsley people and patients. Patient care remained at the top of the Board’s agenda and all Directors were very conscious of the current health equalities in the region. All other issues arising from the Minutes were integral to the agenda.

ALL

CG/16 73 CHAIRMAN’S REPORT (Enc 7) The Chairman’s report was received and noted. It provided commentary and updates on a range of activities, items of interest and Board activities since the last General Meeting. Several issues were highlighted:

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• progress of the annual elections to the Council of Governors. A note of appreciation was recorded for Mr Unsworth and Mr Leabeater, who had confirmed that they would not be seeking re-election. Both were thanked for their valued contribution to the Council and the wider Trust. Thanks were also extended to other Governors facing the end of their current term of office in December, all of whom were encouraged to seek re-election for a further term. Governors were urged to speak to friends and colleagues too, to encourage them to consider standing for election as well;

• invitations for expressions of interest from public Governors for the role of the Lead Governor, Deputy Lead Governor and the Nominations Committee;

• news from the Charity, including an update on the Zombie Run, which had been re-introduced this year for 29th October, and an extremely generous donation recently given to the Tiny Hearts Appeal unanimously;

• a reminder of the annual invitation for Governors to participate in the Board’s meeting on 3rd November.

The Chairman and Mrs Kelly were pleased to report on the Trust’s successful bid for Ophthalmology services at Barnsley Hospital; the contract was due to start in 2017.

ALL

Public Govs

CG/16 74 LEAD GOVERNOR’S REPORT (Enc 8) Mr Brannan presented the Lead Governor’s report on behalf of Mr Unsworth, Lead Governor. The report highlighted Mr Unsworth’s support for the recommendations of the Nominations Committee and his concerns regarding the STP, as raised by Mr Dobell earlier. Mr Unsworth had lobbied his MP and urged others to consider doing so too. It was suggested that Governors might also wish to liaise with their counterparts at other Trusts. Mr Raychaudhuri expressed concerns regarding the impact on staff and the meeting agreed it was imperative that they were considered in all planning for the future. It was further agreed that development of the STP was a critical issue for everyone. Its main aim was to deliver efficiencies across the NHS and improve effectiveness of services in every region. It would have a huge impact on the hospital, its staff and the local economy. The Chairman confirmed that some aspects of the plan had been discussed by the Board in private and challenges made in relation to some of the assumptions to date. It would continue to be discussed at every meeting and Governors were reminded that they would be able to participate fully in both the public and private discussions of the Board at its next meeting. The Chairman also highlighted the importance of ensuring that the STP was supported by robust governance and briefly outlined a proposal for introduction of “Committees in Common”. This would be subject to further consideration by each of the trusts involved in the South Yorkshire & Bassetlaw STP, which encompassed 17 organisations across the footprint. He emphasised that the Non Executive Directors – and hence the Board – would remain accountable to Governors at all times and assured the meeting that both Governors and the Board would be kept as informed as possible.

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CG/16 75 CHIEF EXECUTIVE’S REPORT (Enc 9) On behalf of the Chief Executive, Mrs Kelly presented the report and expanded on several items, including:

• an update on stroke services; there had been some confusion among staff and the public on this issue. Mrs Kelly assured Governors that the Trust was not stopping stroke services at Barnsley or closing the unit. The service provision had been restructured to ensure continued safe services were available on site and/or in co-operation with partners, and plans were ongoing for substantive recruits to the service at Barnsley;

• the “hot and cold” reconfiguration work continued. The teams involved had been pleased with the developments and progress to date despite the current pressures on services;

• the Trust had recently been recorded as top performer in A&E nationally for two weeks. Mr Skorrow reported on his own recent experience when a member of his family had been admitted as an emergency. The care and support received had been fantastic and timely. He was conscious that transfer to a ward had been past the 4 hour trigger, which he felt was unfair as the essential treatment had been administered in good time and it seemed wrong that the late transfer, entirely due to lack of an available bed on AMU, might contribute to a financial penalty against the Trust. Mrs O’Brien also queried the impact of patients waiting to be collected by family or for transfer to other hospitals, who might wait over the 4 hours. Mrs Kelly advised that whilst all such cases could be counted as a breach if they went over the trigger period, patient safety remained the key criteria for services. It was also acknowledged, however, that the 4 hour target served as a direct indication of how the hospital was working in terms of patientflow, pressures on discharges, demands on community services etc. The Chairman affirmed that the views expressed regarding the unduly harsh nature of the emergency access target were shared and had been voiced by a lot of trusts and by NHS Providers. At Barnsley, a lot of work was still ongoing to improve patientflow, including introduction of a new primary care service on site, which was proving effective. Mr Ardron also reported on pressures on the ambulance services and plans to train paramedics to become advance paramedic practitioners. This new role would enable more patients to be treated in their home and not brought into hospitals although it would also bring other challenges in terms of affordability.

Mr Ardron also referred to section 2 of the Chief Executive’s report, regarding the Trust’s bid for the Associate Nurse Pilot. He clarified that the application had not gone to the University of Sheffield; it was a joint application by the Trust with the University and had been submitted to NHSI.

CG/16 76 ASSISTIVE CARE TECHNOLOGY (ACT) (presentation) Mr Judge was pleased to provide an update on the work of the Assistive Care Technology team at Barnsley Hospital. The presentation (copy attached) included an interview with a client, showing how an integrated system had been developed enabling the client to communicate and interact with his family and friends and control his environment through a simple foot switch. This was a good illustration of the aims and benefits of ACT. Mr Judge outlined a number of other services provided to help a wide range of people across the region, providing individual solutions and supporting the team’s mission statement “to engineer independence in communications

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and controls”. Governors were referred to the ACT team’s website to see more examples of their work and support for clients. Mr Judge advised that ACT at Barnsley had been one of the first technical and communications services established in the country. The team worked across a range of specialities to support patients and had helped to develop the national specifications for ACT, most of which were client home based (or other own environment). The team helped to maintain systems as well as focus on innovation and development. Following a successful bid, the team had received £3.8 million funding from NHS England and expanded its service to provide ACT across the whole of Yorkshire & the Humber. The team’s growth had been in three stages and was now in the final stage ensuring provision of service across the whole of the region. Staffing had been scaled up accordingly in terms of its size and skills and larger, improved office/manufacturing space had been obtained on site. The team continues to be involved with a lot of research & development work, which had also helped to enhance the team’s reputation and appeal to more specialist staff. More information on this aspect of its work can be found on the team’s website. At the close of Mr Judge’s presentation, the Governors gave a spontaneous round of applause in recognition of the team’s great work In response to questions from Governors, Mr Judge advised that:

• referrals were received from all areas, primarily through Learning Disability services and occupational therapists. Links were also being developed to increase training and awareness across the community.

• The team worked closely with Sheffield Hallam and other universities on a range of developments. A recent example included collars for people with motor neurone disease to support their heads and improve their control of equipment.

• The latest funding had been for an initial three years, with negotiations underway for future contracts. As the key provider of the service to date the team was hopeful that the contract would be renewed but was by no means complacent.

• The service made a valued financial contribution to the Trust albeit patient service remained the priority. The feedback from service users was very positive.

The Chairman affirmed that the ACT team provided truly person centred, bespoke care. He offered to arrange visits to the department and this was quickly accepted by the Governors. Cllr Platts suggested it might be useful to arrange a presentation to the Health & Well Being Board (H&WB). This was widely supported and she undertook to liaise with the H&WB meeting organisers. Before Mr Judge and Ms Clark left the meeting, both were thanked for attending the meeting and Mr Judge in particular was thanked for his and his team’s obvious passion and dedication to a superb service.

CED

JP

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CG/16 77 NOMINATIONS COMMITTEE (Enc 10) The Chairman stepped out of the room and Mr Dobell assumed the Chair. Three members of the Nominations Committee were present: Mr Brannan, Mr Leabeater and Mr Raychaudhuri. As requested by the Council of Governors at the last meeting, the Committee had revisited the annual review of the terms and conditions of service (T&Cs) for the Non Executive team, including the Chairman. At the last General Meeting, several Governors had requested a more significant uplift be considered in recognition of the Non Executive team’s input and to bring them more in line with market forces. When revisiting the benchmarking data, the Committee had taken account of the date of the information, some of which was nearly two years old, and latest available information. Consequently the recommendation had been revised to propose an uplift above the Agenda for Change 1% basic levy and nearer to – but still below – national and regional averages for both Non Executive Directors and Chairs, namely Non Executive Director rates to be increased to £12,500 pa and the Chairman’s to be increased pro rata to £41,625 pa. The Committee did not feel it appropriate to suggest any larger uplift at this time. As Chair, Mr Dobell acknowledged that a review of T&Cs would always be contentious but asked Governors to consider the revised recommendations, which had acknowledged their concerns regarding the level of remuneration. After careful deliberation, the recommendations were approved unanimously. Mr Wragg rejoined the meeting and resumed the Chair.

CG/16 78 SUB-GROUP REPORTS (Enc 11) The submitted report provided by Mr Brannan, for the Finance & Performance Sub-group (FPSG), and Mr Dobell, for the Quality & Governance Sub-group (QGSG0, was received and reviewed. Progress from the latest sub-group meetings was noted. On behalf of the QGSG Mr Dobell recorded a note of thanks to Ms Feerick, Head of Clinical Governance & Quality, and Mrs Pell, Head of Patient Experience, for their contribution to the meeting and to Ms Moore for her report on activities from the Board’s Quality & Governance Committee. The Chairman highlighted some key dates from the report, including the opportunity for Governors to receive flu jabs, the joint meeting with the Board on 3rd November and the Christmas Ball on 2nd December, tickets for which would be on sale shortly. The Chairman explained that the Ball was the first event of its type held by the Trust; it would be a celebratory evening and raise money for the Charity. Mrs Kelly also flagged the Riff Raff play being held at the Barnsley Civic on 5th December. The play was being staged by hospital staff and would also raise funds for the Charity.

CG/16 79 BOARD OF DIRECTORS (Enc 12) The agenda (October), Minutes (September), latest Integrated Performance (IPR) and Horizon Scanning reports presented to the Board of Directors meeting held in public on 6th October 2016, were received and noted. A report on the Working Together Programme (WTP) Commissioners’ consultation proposals for Children’s Surgery/Anaesthesia and High Acuity

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Stroke services was also included. The report gave a link to the full consultation details, with further information on how Governors could respond and dates for consultation events being held across the region. With regard to the IPR, Mr Skorrow was conscious that much of the report would be re-presented at sub-groups and queried if the copy presented at General Meetings was sufficient and could obviate duplication of paperwork. The suggestion was appreciated, however, with the sub-groups meeting on a different schedule to General Meetings the data would be out of date in some instances if not reissued for the sub-groups. Mr Skorrow also pointed out that the key for the IPR indicated that cancer and A&E ratings were measured as green or red only (no option for amber) but the report showed an amber rating in month for both indicators. Mrs Kelly confirmed that this had been an error; she had met with the team who developed the IPR each month and it would be corrected in the next issue. Ms Armitage highlighted the capital programme currently awaiting national approval. She was conscious of the national drivers to curtail capital spending and queried if these had contributed to the delays. The pressures on NHS funding was acknowledged although Mrs Kelly advised that the Trust was reviewing its immediate needs against capital requirements, as some could be authorised internally against a smaller budget and were essential to progress plans such as the hot and cold project, equipment purchases and estates maintenance.

CG/16 80 ISSUES RAISED BY GOVERNORS It was confirmed that all issues raised in the Governors’ pre-meeting had been covered in earlier discussions. It was agreed that the pre-meeting continued to be useful and effective.

CG/16 81 ANY OTHER BUSINESS a) Microphones

Mrs Bevis, a member of the public, asked speakers at the meeting to make better use of the microphones available on the tables as it had been difficult to hear those seated along the sides. The Chairman undertook to encourage more use of the audio system.

b) Move to private session It was resolved that representatives of the press and other members of the public be excluded from the final part of the meeting having regard to the confidential nature of the business to be transacted. The outcomes would, however, be reported in the next publically issued Minutes.

CG/16 82 PRIVATE SESSION Claims Before moving to the business of the private agenda, Mr Grierson referred to a recent press report about a female patient who had won a significant compensation claim following a double mastectomy. The Chairman assured Governors that the Trust continued to strive to eradicate mistakes and improve patient safety; it reviewed all such incidents to identify and act upon any learning to help avoid recurrences. This approach was highlighted at Board each month, when Directors received patients’ stories – both positive and negative.

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The Chairman stressed that generally such issues could be raised in public, reflecting the Trust’s ethos of openness and transparency. Non Executive Appointments The Council received and reviewed the recommendations for the appointment of two new Non Executive Directors, following interviews held on 29th September 2016. The roles had attracted a strong field of applicants, eight of whom had been invited for interview. The full scope of the appointment process had been reported previously and had been carried out in accordance with both national guidance (from Monitor/NHSI) and the Council of Governors’ mandate to the Nominations Committee. The process had been supported throughout by the Trust’s HR leads. The Committee recommended that the appointments be offered to Ms Keely Firth and Mr Philip Hudson, with effect from 1st January 2017. The Chairman briefly outlined the background and experience of both candidates. Several Governors had been involved with the stakeholder assessment groups held on the day as part of the appointment process and affirmed their support for the Committee’s recommendations. In conclusion the recommendation to appoint Ms Firth and Mr Hudson as Non Executive Directors at BHNFT with effect from 1st January 2017, was approved unanimously. The appointments would be for an initial term of office of up to three years. The Chairman undertook to contact the candidates and make the offers (subject to usual clearance checks) on behalf of the Council of Governors as soon as possible.

CG/16 83 CLOSE OF MEETING As a closing observation, Mr Brannan highlighted some key points from the meeting’s discussions: the Trust’s achievement as top performer in A&E for two weeks, the great work of the ACT team – not just in Barnsley but across Yorkshire & the Humber, and data in the IPR showing the Trust’s good management of agency spend. The Chairman also flagged the good progress on did not attend (DNA) rates which were being sustained at below national averages, improved performance in cancer and good feedback from patients. In addition, Mr Skorrow recalled the award presented by CHKS earlier in the year for being one of the top 40 hospitals. It was agreed that, whilst there was always room for further improvement, these and other factors reflected a lot of good work in a comparatively small district general hospital. It was agreed that the good news should be shared across the community by Governors. Mrs Kelly also affirmed that the Trust would continue to put teams forward for awards wherever possible to ensure that staff’s good work was recognised externally too. The estates team had recently been nominated for a national environmental award. The date of the next General Meeting was confirmed for 14th December 2016, 5.30-7.30pm. There being no further business, the meeting closed at 7.25pm.

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XX Reference – 2016/17

REFERENCE SECTION

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XX Reference – 2016/17

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BoD 2016.17 - Reference

SCHEDULE OF ACRONYMS

Additional acronyms may be added as appropriate/on request

A A&E Accident and Emergency A4C / AfC Agenda for Change

ACCEA Awards Committee for Clinical Excellence Awards

ACE Acute Care of the Elderly ACO Accountable Care Organisation ACP Advance Clinical Practitioners ACS Additional Clinical Services ACS Accountable Care System ADS Annual Development Session AEC Ambulatory Emergency Care AHP Allied Health Professions AHSN Academic Health Science Network AKI Acute Kidney Injury AMAC Ambulatory Medical Assessment Clinic AMU Acute Medical Unit AN Ante Natal ANP Advance Nurse Practitioner AOA Annual Organisational Audit AQuA Advancing Quality Alliance

ARCP Annual Review of Competence Progression

AUP Acceptable Use Policy B

BAEM British Association of Emergency Medicines

BAF Board Assurance Framework BBE Bare below the elbows BCCG Barnsley Clinical Commissioning Group BFI Baby Friend Initiative

BHNFT Barnsley Hospital NHS Foundation Trust

BHSS Barnsley Hospital Support Services BMA British Medical Association BMBC Barnsley Metropolitan Borough Council BMJ British Medical Journal BoD Board of Directors BWCC Barnsley Women and Children’s Centre C CAP Community Acquired Pneumonia CAPEX Capital Expenditure CASU Controls Assurance Support Unit CAUTI Catheter-Associated Urinary Tract

Infection CBU Clinical Business Unit CCG Clinical Commissioning Group CCU Coronary Care Unit C.diff Clostridium Difficile CD / CDs Clinical Director(s) CDU Clinical Decision Unit CE / CEO Chief Executive / Chief Executive Officer

CEMACH Confidential Enquiry into Maternal and Child Health

CHAI Commission for Health Audit and Improvement

CHD Coronary Heart Disease CHI Commission for Health Improvement

CHKS CHKS – name of company providing statistical/benchmarking data

CIP Cost Improvement Programme (also known as efficiency programme)

CLAHRC Collaboration for Leadership in Applied Health Research and Care

CLAUDE Clinical Audit Data Base CMO Chief Medical Officer CMT Clinical Management Team CNST Clinical Negligence Scheme for Trusts CoE Care of Elderly COG Council of Governors Comms Communications COO Chief Operating Officer COPD Chronic Obstructive Pulmonary Disease

COSHH Control of Substances Hazardous to Health

CPA Clinical Pathology Accreditation CPD Continuing Professional Development CPE Clinical Performance & Effectiveness

CPEC Clinical Performance & Effectiveness Committee

CPMS Central Portfolio Management System CPT Capital Planning Team CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation

CRR Corporate Risk Register CRS Commissioner Requested Services CSSD Central Sterile Services Department CSU Clinical Service Units CT Control Target CWT Cancer Waiting Times D D1 Discharge Form DB Designated Body DBS Disclosure & Barring Service DDA Disability Discrimination Act Do ICT Director of ICT DoH Department of Health DoN&Q Director of Nursing and Quality DHSC Directorate of Health & Social Care DH / DoH Department of Health

DIPC Director of Infection Prevention & Control

DNA Did Not Attend DNAR Do Not Attempt Resuscitation DOC Duty Of Candour DPM Department of Psychological Medicine DNR Do Not Resuscitate DSEU Day Surgery & Endoscopy Unit E EBA Employer Based Awards

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BoD 2016/17 - Reference

EBITDA Earnings before interest, taxes, depreciation and amortisation

ECIST Emergency Care Intensive Support Team

ECN Emergency Care Network ED Emergency Department EDD Estimated Date of Discharge EDS2 Equality Delivery System ENT Ear, Nose & Throat EOL End of Life EPAP Emergency Pathway Action Plan EPR Electronic Patient Records EqIA Equality Impact Assessment ESR Electronic Staff Record ET Executive Team EWS Early Warning Score EWTR European Working Time Regulation F F&P Finance & Performance

FABULOS Fluids, Antibiotics, Blood Cultures, Urine, Lactate, Oxygen, Sepsis Six

FBC Full Business Case FCE/FCSE Finished Consultant Episode FFCE First Finished Consultant Episode FFT Friends and Family Testing FPPR Fit & Proper Persons Requirement FPSG Finance & Performance Sub-Group FT Foundation Trust FTN Foundation Trust Network FQA Framework of Quality Assurance G GMC General Medical Council GP General Practitioner GUM / GU Med Genito-Urinary Medicine

H H&S Health & Safety H&WB Health & Well Being

HAPPY Harmonised Approval Process Pan Yorkshire

HASU Hyper Acute Stroke Services HCA Health Care Assistant HES Hospital Episode Statistics HSE Health & Safety Executive HDU High Dependency Unit HR Human Resources HRG Health Resource Group (finance) HSC Health Service Circular HSMR Hospital Standardised Mortality Ratio I I&E Income and Expenditure ICU Intensive Care Unit (also known as ITU)

IFRS International Financial Reporting Standards

IG Information Governance IP In Patients IIP Investors in People IHP Improving Hospital Partnerships IPC Infection Prevention & Controls IPR Integrated Performance Report IR1 Incident Reporting form

IRMER Ionising Radiation - Medical Exposure Regulations

ISS ISS Mediclean – cleaning contractors at the Trust

IT Information Technology

ITU Intensive Therapy Unit (also known as ICU)

IV Intravenous IWL Improving Working Lives J

JNCC Joint Negotiating and Consultation Committee

JTUC Joint Trade Union Committee KL K 000s (thousands) KPI Key Performance Indicator LA Local Authority LAC Local Awards Committee LCRN Local Clinical Research Network LDP Local Development Plan LHC Local Health Community LIA Listening into Action LIFT Local Improvement Finance Trust LINks Local Involvement Networks LOS Length of Stay LPMS Local Portfolio Management System LRC Learning and Resource Centre LTC Long Term Conditions M M Million(s) M&S Medical & Surgical MAG Model Appraisal Guide MAJEX Major Incident / Major Exercise MAT Maternity MDA Medical Devices Agency MDT Multi-Disciplinary Team

MHRA Medicines &Medical Healthcare Regulatory Agency

MIG Medical Interoperability Gateway

MINAP Myocardial Infarction National Audit Programme

MRI Magnetic Resonance Imaging MTAS Medical Training Application Service MYH Mid Yorkshire Hopsitals N

NCEPOD National Confidential Enquiry into Perioperative Deaths

NED Non Executive Director NEL Non-Elective NEWS National Early Warning Score NHS National Health Service NHSE National Health Service England NHSE National Health & Safety Executive

NHSLA National Health Service Litigation Authority

NCISH National Confidential Inquiry into Suicide and Homicide

NICE National Institute for Clinical Excellence NIMG NICE Initiation and Monitoring Group NIHR National Institute for Health Research NPAT National Patients Access Team NPSA National Patient Safety Agency NRLS National Reporting & Learning System NSF National Service Framework O OBC Outline Business Case

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BoD 2016/17 - Reference

ODP Operating Department Practitioners OH Occupational Health OHW Occupational Health & Wellbeing

OJEC Official Journal of the European Communities

OMFS Oral & Maxillofacial Surgery OP Outpatients

OPERA Older Persons Early Rehabilitation Assessment

OPT Operational Performance Team OT Occupational Therapy PQ PA Professional Activities (4 hours)

PACS Picture Archiving & Communications Systems

PALS Patient Advice & Liaison Services PAS Patient Administration System PBR / PbR Payment by results (tariff system) PCT Primary Care Trust PEAT Patient Environment Action Team PEG Patient Experience Group PGME Post Graduate Medical Education PIU Planned Investigation Unit

PLACE Patient Led Assessment of the Care Environment

PLICs Patient level Information & Costing systems

PN Post Natal PPI Public & Patient Involvement PR Public Relations PRASE Patient Reporting & Action for a Safe

Envrioment PROMS Patient Reported Outcome Measures PSB Patient Safety Board PSM Patient Services Manager PTS Patient transport services

QA Quality Assurance or Quality Account

QGSG Quality & Governance Sub-Group

QIPP Quality Innovation Prevention & Productivity

R R&D Research and Development RAF Risk Assessment Framework RAG Red Amber Green (risk ratings)

RATS Remuneration and Terms of Service

RCA Route Cause Analysis RCN Royal College of Nursing

RCPCH Royal College of Paediatrics and Child Health

RCP Royal College of Physicians

RDASH Rotherham Doncaster & South Humber NHS Foundation Trust

RFF NHS Trust identification code (Barnsley)

RFT Rotherham Hospital NHS Foundation Trust

RHQ NHS Trust Identification Code (Sheffield)

ROCA Register of Controls Assurance RPST Risk Pooling Assessment for Trusts

RST Revalidation Support Team RTT Referral to Treatment S SABS Safety Alert Broadcast System SALT Speech and Language Therapy SAS Staff and Associate Specialist SAU Surgical Administration Unit

SCH Sheffield Children’s Hospital NHS Foundation Trust

SDA Surgical Decision Area SHA Strategic Health Authority SHDU Surgical High Dependency Unit

SHMI Summary Hospital-level Mortality Indicators

SHO Senior House Officer SI Serious Incident SID Senior Independent Director SIFT Service Increment for Training SLA / SLAM

Service Level Agreements / Service Level Agreement Monitoring

SLR Service Line Reporting SOA Strategic Options Analysis SORP Statement of Recommendation Practice SoS Secretary of State SPA Supporting Professional Activities SPC Statistical Process Control SpR Specialist Registrar SRG System Resilience Group SSD Sterile Services Department SSDG Senior Strategic Development Group SSR Strategic Services Review

STEIS Strategic Health Authority Executive Information System

STH Sheffield Teaching Hospitals NHS Foundation Trust

STP / S&T Sustainability & Transformation Plan

SWYPFT South West Yorkshire Partnership Foundation Trust

SY&B South Yorkshire and Bassetlaw TUV T&C Terms & Conditions TDA NHS Trust Development Authority

TIGER The Information Governance Education Recognition Award

TTO Tablets to Take Out

TUPE Transfer of Undertakings (protection of Employment)

TWWMIB Together We Will Make It Better UGI Upper Gastro Intestinal VDI Virtual Desktop Infrastructure VTE VenousThrombo-Embolism WXYZ WCA Wider Controls Assurance WLI Waiting List Initiative Wte whole time equivalent

WTP Working Together Programme/ Working Together Partnership

Y&H Yorkshire & the Humber YTD Year to Date YE Year End

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a meeting of the board of directors will take …2. to review the register of interests and receive...

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