1. society
2. welfare
3. healthcare
4. hospital

HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
TRUST BOARD
TO BE HELD ON 24 APRIL 2014 AT 11.00AM
THE BOARDROOM, HULL ROYAL INFIRMARY
AGENDA
1
Apologies
verbal
Chairman
2
Declaration of interests
2.1 To consider any changes to Directors’ interests
since the last meeting:
2.2 To consider any conflicts of interest arising from this
agenda
verbal
Chairman
3
Minutes of the meeting 27 March 2014
attached
Chairman
4
Action Tracking List
attached
Director of Governance
5
Matters Arising
5.1 – Briefing paper – Sir Bruce Keogh Letter March
2014
attached
Chief Medical Officer
6
Chairman’s Briefing
verbal
Chairman
7
Chief Executive’s Briefing
 Planned transfer of IT Clinical Systems
verbal
Chief Executive
8
SAFE, HIGH QUALITY, EFFECTIVE CARE
Patient Experience
verbal
Chaplain
9
Caring Report
attached
Chief Nurse
10
Nurse Staffing
presentation
Health Group Nurse
Directors
11
Quality Governance Framework
attached
Director of Governance
12
Francis Annual Report
attached
Chief Nurse
13
Setting the Standard
attached
Chief Nurse
14
DELIVERY AGAINST PRIORITIES AND OBJECTIVES
Corporate Performance Report
14.1 – RTT Recovery Plan
attached
verbal
Chief Financial Officer
Chief Operating Officer
15
Strategic Objectives
attached
Chief Operating Officer
STRONG, HIGH PERFORMING FOUNDATION TRUST
TDA Accountability Framework
16.1 – Accountability Framework
16.2 - TDA Accountability Self Certification/s
attached
attached
Director of Governance
Director of Governance
17
Board Assurance Framework
attached
Director of Governance
18
Going Concern
attached
Chief Financial Officer
16
CAPABLE, EFFECTIVE, VALUED AND COMMITTED WORKFORCE
19
Staff Survey
attached
Chief of Workforce & OD
1
20
People Strategy
STRONG RESPECTED IMPACTFUL LEADERSHIP
attached
Chief of Workforce & OD
21
Governance Statement
to follow
Chief Executive Officer
22
Standing Orders
attached
Chief Executive Officer
23
Board Committees Unadopted Minutes
23.1 - Quality, Effectiveness & Safety (17.04.14)
23.2 - Performance and Finance (24.04.14)
23.3 – Remuneration (17.04.14)
23.4 - Audit (17.04.14)
verbal
verbal
verbal
verbal
24
Any Other Business
25
Date and Time of Next Meeting:
29th May 2014, 11am – 5pm
The Boardroom, HRI
Date
30/1
2014
R Deri
√
J Hattam
√
K Hopkins
x
P Morley
√
A Pye
√
V Walker
√
D Ross
√
L Bond
√
U Vickerton
√
A Snowden
√
M Olsen
√
I Philp
√
In attendance
P Lewin
x
J Adamson
√
J Myers
√
L Thomas
√
J Hay
√
D Taylor
√
24/4
26/6
31/7
Chairman of Committee
27/2
27/3
25/9
30/10
18/12
Total
√
√
√
√
√
√
√
√
√
x
√
√
x
√
√
√
√
√
x
√
√
√
√
2/3
3/3
2/3
3/3
3/3
2/2
3/3
2/3
3/3
2/3
3/3
3/3
x
x
√
√
x
√
x
√
√
√
x
√
0/3
2/3
3/3
3/3
1/3
3/3
2
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
TRUST BOARD ACTION TRACKING LIST (April 2014)
Actions arising from Board meetings
NO
PAPER
MARCH 2014
02.03 Corporate
Performance
Report
03.03 CEO Briefing
ACTION
LEAD
TARGET
DATE
NEW
DATE
STATUS/
COMMENT
Falls information for each Health Group to be received
AP
24.04.14
Update
Invite stakeholders to present plans relating to the Better Care Fund
RT
TBA
Update
Actions complete: to be removed from the Board tracker next month
Date: Trust Board
Lead
Action
Date
March 2014
JA
Staff Survey Report to be received
On Agenda 24.04.14
MO
Referral to treatment times – recovery plan to be received
On Agenda 24.04.14
IP
Fetal remains and patient transfers – report to be received
On Agenda 24.04.14
January 2014
AP
External Review of Midwifery Staffing – Report to be received
On Agenda 24.04.14
December 2013
IP
CRES Clinical sign off – current process and the accumulative effect on quality of care
On Agenda 24.04.14
October 2013
IP
Emergency Care Model to be added to the Trust Forward Plans
Presentation 27.03.14
July 2013
LT
Meeting between the chairs of Quality Effectiveness and Safety, Performance & Finance and
Governance & Assurance to be held
NED meeting 22.05.14
Actions delegated to Committees
Performance and Finance Committee
March 2014
JM
Cancer waiting times action plan to be monitored through the Performance & Finance Committee
On P&F Agenda 24.04.14
JM
ED action plan to be monitored through the Performance & Finance Committee
On P&F Agenda 24.04.14
JH
Performance & Finance TOR to be finalised
On P&F Agenda 24.04.14
JH
Ambulance Turnaround times – report to be received
On P&F Agenda 24.04.14
Strategy to be updated following further discussion relating to the aim of becoming the safest
Hospital in England.
Governance & Assurance
Committee 22.05.14
Governance and Assurance
January 2014
LT
11
12
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
BRIEFING PAPER - SIR BRUCE KEOGH LETTER MARCH 2014
24 April 2014
2014 – 4 – 5.1
Trust Board
Reference
date
Number
Ian Philp – Chief Medical
Liz Thomas – Director
Director
Author
Officer
of Governance
Reason for the
report
The purpose of the report is to provide assurance on the arrangements
that are in place for the disposal of fetal remains and for the transfer of
patients between wards as requested in Sir Bruce Keogh’s letter March
2014.
Type of report
Concept paper
Performance
Strategic
options
Information
Business
case
Review

1
RECOMMENDATIONS
The Trust Board is asked to receive the information and decide whether any further
assurance is required.
2
Key purpose
3
4
5
Decision
Approval
Information
Assurance
Discussion


Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and
prioritised effectively

 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
Outcome 4
CQC Regulation(s)
Assurance
Ref: No
Legal advice
Framework No
BOARD/BOARD COMMITTEE REVIEW


No
This paper has not been considered at any other board committee.
13
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
BRIEFING PAPER - SIR BRUCE KEOGH LETTER MARCH 2014
1.
PURPOSE OF THE REPORT
The purpose of this briefing paper is to update the Board in relation to the
disposal of fetal remains and patient transfers as requested in Sir Bruce
Keogh’s letter March 2014.
2.
BACKGROUND
Mr Morley advised the Board at its meeting in March 2014 of the
requirement for Trust Boards to review their current policy and practice in
relation to the disposal of pregnancy losses up to and including 23 weeks
and 6 days gestation and to adopt burial and cremation as more
appropriate alternatives. In addition the Board was also requested to
review practices to ensure that transfers made for reasons other than
clinical ones are minimised and that established good practice is followed
where such moves are necessary. This includes ensuring that such
moves are properly explained to patients and their relatives.
3.
TRUST RESPONSE
Attached at Appendix 1 is the Trust’s response to how it currently
manages fetal remains.
The current position regarding the transfer of patients is contained in the
corporate performance report (page 32).
4.
RECOMMENDATIONS
The Trust Board is asked to receive the information and decide whether
any further assurance is required.
Ian Philp
Chief Medical Officer
April 2014
14
Appendix 1
Management of Fetal Remains
As a Trust we have disposed of fetal remains in a sensitive manner for many years.
In doing so we adhere to the HTA Code of Practice 5 (Disposal of Human Tissues),
sections 91-123 and Appendix A are particularly relevant here. All pre-24 gestations
are disposed of by cremation through the local crematorium (with the rare exception
of families who wish to make their own arrangements).The remains are no longer
routinely examined histologically but are retained for long enough to allow examine
where trophoblastic disease or molar change is suspected. This leads to batching of
the remains and periodic disposal.
The batched remains are placed into numbered "coffins" (boxes) and divided into
termination of pregnancies and miscarriages, and with the two groups cremated
separately. Each box contains 22 separate remains and is accompanied by an
Authority to Cremate form which details just maternal unit numbers and pathology
accession number.
There was a separate issue with disposal of ectopic pregnancies as local and
regional crematoria seemed to have differing views on this. The Crematorium
Regulations 2008 (England and Wales) allow for disposal of maternal remains at
their discretion, however, this too has now been resolved (and again in a sensitive
manner). All stillbirths and post-24 week gestations are disposed of by cremation
(unless families wish to fund a burial, where this is then facilitated through their own
Funeral Director). The Trusts sends all our failed pregnancies to an undertaker and
they are cremated. There are no ashes as there has been no significant
mineralisation of bone at these early gestations. The service batches together 22
remains at a time there are approximately 1000 termination of pregnancies and
almost as many failed pregnancies each year. As a Trust we are sensitive to
separating the failed ‘wanted’ pregnancies from the terminations. None of these
remains are incinerated through the hospital incinerator. Patients who wish to take
home their own child’s remains for disposal can do so as the law takes no interest in
the early gestations. I can confirm that we have had no incineration of stillbirth or
later fetal remains for many years.
15
16
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
CARING REPORT
Trust Board date
24th April 2014
Director
Amanda Pye – Chief Nurse
Reason for the
report
To update the Board on National Survey results, Friends and Family Test
scores, complaints, PALs and You Said We did figures.
Type of report
Concept paper
1
RECOMMENDATIONS
The Board is asked to note the contents of the report.
2
Key purpose
Information
3
4
√
Business
case
Review
Approval
Discussion
Assurance
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and prioritised
 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
All domains
CQC Regulation(s)
Assurance Framework
5
Amanda Pye – Chief
Nurse
Strategic
options
Information √
Performance
Decision
2014 – 4 - 9
Reference
Number
Author
Ref:
Legal advice
√
√
√
√
√
No
BOARD/BOARD COMMITTEE REVIEW
This report has also been received at the Quality Effectiveness and Safety Committee
17.04.14.
Care Report
Surveys
Top 20% for
10 of Cancer
patient
experience
Survey
Questions
Trend of
Increasing
engagement
On FFT 19.9%
response rate
qtr3
27 Wards
Above
National
average
FFT
Performing
about the
same in 9 out
of ten domains
in inpatient
survey
Caring Dashboard
Framework Section
RAG
Overall experience
Trusting relationships
Compassionate care
Treatment with dignity and respect
Meeting physical needs
Involvement in decision making
Framework
sections
Indicator
Risk
level
O value
E value
There are no indicators that are classified as ‘risk’ or ‘elevated risk’
Additional Information
Additional information has been included in the pack to provide a
more holistic view of the Trust’s performance. These are listed
below.
Additional Information
Friends and Family Test
National Bereavement Survey
Cancer Patient Experience Survey
Further Sources (Qualitative Information)
RAG
Report now includes
•
•
•
•
•
National Inpatient Survey Picker
National Radiology survey
National Chemotherapy survey
Updated FFT, complaints and PALs
Updated YSWD(You Said We Did) section
National Patient survey 2013/14
The National Inpatient survey will be published on the 8th April 2014. Picker
provide a number of analysis which help to direct Trusts into the main
problem areas. The charts below illustrate how the Trust is performing I
relation to last year and against other Trusts on the main questions Overall….
In comparison to other Trusts
HEY’s scores for respect and
dignity and Overall patient
experience is lower than other
trusts
In comparison to last year HEY’s
scores for respect and dignity and
overall patient experience is lower
than other trusts have declined
significantly Y/Y
NEW
National Patient survey 2013/14
NEW
The National Inpatient survey will be published on the 8th April 2014. Picker provide a number of analysis which help to direct Trusts into the
main problem areas. Picker have asked patients what is the single most important question on the national survey. The response was
overall were you treated with dignity and respect . Picker have then looked at the questions on the survey which influence the dignity and
respect score and their importance to patients. The charts below illustrate how the Trust is performing.
This chart maps the national
inpatient survey questions in
importance v HEYs scores in
each question. The top right area
is those questions we have the
biggest problem and are the most
important to patients
this is the top right corner above
enlarged. These are the questions
which really matter to patients
where we provide and a
experience worse than the Picker
average and these form a starting
point for improvement
National Patient survey 2013/14
NEW
These are the questions which patients feel are the most important when receiving a high quality patient experience and HEY currently
underperforms
Problem
Overall, did you feel you were treated with respect and dignity while you
were in the hospital?
Did you have confidence and trust in the nurses treating you?
Do you think the hospital staff did everything they could to help control
your pain?
How many minutes after you used the call button did it usually take
before you got the help you needed?
Were you told how to take your medication in a way you could
understand?
Were you involved as much as you wanted to be in decisions about
your care and treatment?
Were you given enough privacy when discussing your condition or
treatment?
Sometimes in a hospital, a member of staff will say one thing and
another will say something quite different. Did this happen to you?
Did hospital staff discuss with you whether you may need any further
health or social care services after leaving hospital? (e.g. services from
a GP, physiotherapist or community nurse, or assistance from social
services or the voluntary sector)
Did hospital staff discuss with you whether you would need any
additional equipment in your home, or any adaptations made to your
home, after leaving hospital?
In your opinion, were there enough nurses on duty to care for you in
hospital?
HEY
Picker
Average
Differenc Q68
e
Correlation
24
19
5
.913
27
24
3
.731
36
29
7
.660
25
17
8
.608
26
23
3
.599
45
43
2
.563
31
25
6
.561
33
31
2
.542
21
15
6
.524
19
17
2
.521
51
41
10
.520
National Radiotherapy Patient Experience Survey 2012/13
The National Cancer Patient Experience Survey asked one question
on radiotherapy.
“Did hospital staff do everything possible to control the side
effects of radiotherapy?”
The National Radiotherapy Implementation Group (NRIG)
commissioned a comprehensive Radiotherapy Patient Experience
Survey to allow services and commissioners to understand and take
action to improve patient experience.
48 questions were asked about their radiotherapy experience and with
over 577 responses from patients the information was robust
NEW
Would you be happy to go back to this centre again if you were
recommended radiotherapy treatment?
Overall, how would you rate your care?
Did you feel you were treated as a whole person in the clinic
generally?
The Trust was significantly above the National average in a number of
areas with 100% of patients rating their care as excellent t o good .
Parking was one of a few issues for patients and as these patient
attend on a regular basis it is likely one of their visits would have
caused this issue .
National Radiotherapy Patient Experience Survey 2012/13
What was the environment of the radiotherapy department like in
respect of: The waiting room
Overall was the amount of information given to you at the start of your
radiotherapy:
100%
Don’t know / can’t remember
80%
I was n ot given any info rma tio n at
the start o f my radiother apy
60%
Very poor didn’t help at all
Poor didn’t help much
40%
Satisfa ctory met my needs
20%
Excellent h elped with my
treatme nt
Ser ies1
0%
HEY
National
What was the environment of the radiotherapy department like in
respect of: The treatment room
If you travelled by car, was it easy to park?
National Chemotherapy Patient Experience Survey 2012/13
Were you given written information about the
chemotherapy and its side effects ?
Overall How would you rate your care ?
There were 52
questions in the
National
radiotherapy
survey 165
patients
responded and
HEY performed
well in many
areas compered
to the national
average. There
were still some
issues with
regard to
information's
patients had
received and
choice where
the patients
could receive
their therapy
100%
100%
80%
80%
Very poor
60%
60%
fair
no
Good
40%
40%
Very good
yes
Excellent
20%
0%
20%
HEY
0%
National
Before your treatment began, were you given the
opportunity to talk to someone about any of the
following issues: Emotional Concerns
100%
80%
80%
60%
60%
40%
yes
20%
0%
0%
National
Don’t Know
No
40%
20%
HEY
National
Were you given a choice about where you would have your
chemotherapy? (e.g.hospital, home, GP surgery, community
clinic)
100%
no
HEY
Yes
HEY
National
Patient Led Environment Action
Team(PLACE) September 2013
No change
PLACE for 2014 for HEY in
progress results Sept 2104
PLACE 2013 Acute/Specialist Trusts - National Average/HEY
With effect from April
2013 PLACE replaced
the Patient
Environment Action
Team
(PEAT) process as the
system for assessing
the quality of the
hospital environment,
with the aim of giving
patients a real voice in
assessing the quality of
the healthcare
environment. Guidance
documentation is
provided by the NHS
Commissioning Board.
Areas covered are
Cleanliness (including
hand hygiene),
Buildings and Facilities
(condition, appearance,
maintenance, fixtures
& fittings), Privacy &
Dignity and Food and
Hydration
100.00%
90.00%
80.00%
70.00%
60.00%
Cleanliness
Condition and Appearance
50.00%
Privacy and Dignity
40.00%
Food and Hydration
30.00%
20.00%
10.00%
0.00%
National Average
HEY Castel Hill Hospital
HEY Hull Royal Infirmary
• Inspections were undertaken at Hull Royal on 16
and 17 April and at Castle Hill on 10, 11 and 12
June.
• The Trust received a letter from the Department of
Health dated the 13th September 2013, thanking the
Trust for participating in the PLACE inspections
• An action plan to address any areas of concern has
been drafted. This will be monitored by the Facilities
Team and any issues escalated via the Health
Group Quarterly Performance Reviews.
Patient Led Environment Action
Team(PLACE)
•
•
•
•
•
No change
PLACE for 2014 for HEY in
progress results Sept 2104
Meetings will be set up with the Patient Assessors to keep them updated on the actions
taken as a result of their observations during the visits.
A PLACE evaluation workshop was held by the Department of Health on 27 August to
gather feedback on the PLACE process. It was agreed that the format of the inspections
would remain the same for 2014.
The Trust’s previous internal PEAT programme is to continue in a revised
PLACE format but inspections be undertaken on a quarterly basis and will involve our
patient assessors.
HEY in red compared to all acute trusts for food assessment
National Cancer Patient Experience Survey 2012/13
Questions where the Trust was in the lowest 20%
The Cancer Patient Experience Survey (CPES) 2012/13 follows on
from the successful implementation of the 2010 and 2012 CPES
designed to monitor national progress on cancer care.
A total of 1590 patients were included in the sample from HEY who
were allocated to 13 different cancer tumour groups.
RAG
Q12. The patient felt they were told sensitively that they
had cancer.
Q14. Patient given enough information about the type of
cancer they had
Q34. Patient given written information about the operation
Tumour Group
Breast
Colorectal/Lower Gastrointestinal
Lung
Prostate
Brain/Central Nervous System
Gynaecology
Haematology
Head and Neck
Sarcoma
Skin
Upper Gastrointestinal
Number
164
Q44. Always/nearly always enough nurses on duty
121
107
62
26
80
134
53
18**
23
Question
Q27 Hospital staff gave information on getting financial
help
Q28 Hospital staff told patient they could get free
prescriptions
Q31 Patient has taken part in cancer research
Q47 All staff asked patient what name they preferred to
be called by
Q49 Always given enough privacy when discussing
condition/treatment
71
Q50 Patient was able to discuss worries or fears with
staff during visit
Urology
75
Q54 Staff told patient who to contact if worried post
discharge
Other
69
Q57 Staff definitely did everything to control side effects
of radiotherapy
The combined results for the Trust demonstrated of the 63 survey
responses including all of the above categories four scores in the
lowest 20% performing trusts; ten scores in the highest 20% performing
trusts and the remaining scores are ranked equal to 60% of trusts.
Q60 Hospital staff definitely gave patient enough
emotional support
Q62. The doctor had the right notes and other
documentation with them
RAG
NEW
National Cancer Patient Experience Survey 2012/13
Comparison with 2011/12 Results
The Trust made significant progress from last year’s result in
the following question all other changes were not significant:
Question
Each tumour site received a rating by it patients of it overall care most
patients rated the Trust above the national average with 90% rating the
trust care as excellent/very good. Each tumour site has a breakdown
by question of its performance this will be used to improve services as
below
Next steps
Each tumour site MDT will receive a report outlining the results for
2012/13 with comparison from previous years. They will be expected
to present the results at one of their MDT meetings and develop and
action plan to improve highlighted areas of concern which will be
monitored by the Cancer Board.
Q70. Patient’s rating of care
‘excellent’/’very good’
This Trust
RAG
Q35. Staff explained how operation had gone in an
understandable way
.
Cancer type
National
Breast
92%
90%
Colorectal / Lower Gastro
92%
88%
Lung
84%
88%
Prostate
97%
87%
Brain / CNS
92%
84%
Gynaecological
88%
88%
Haematological
88%
91%
Head & Neck
94%
88%
Skin
95%
90%
Upper Gastro
87%
86%
Urological
86%
86%
Other Cancers
91%
85%
All cancers
90%
88%
Sarcoma
CQC’s National Maternity Survey 2012/13
The CQC final report is analysis of data from the Maternity Survey
2013 indicates that Hull and East Yorkshire scores within the expected
range for four areas of questioning, is worse in Antenatal care and
Labour and birth but better in antenatal check ups than other trusts in
England as can be seen from the table below.
Area of Questioning
RAG
While you were pregnant(Antenatal care)
Question
During labour, could you move around and choose the
most comfortable position?
Were you and/or your partner or a companion left alone
by midwives or doctors at a time when it worried you?
Thinking about your care during labour and birth, were
you involved enough in decisions about your care?
Antenatal Check ups
Looking back, do you feel that the length of your stay in
hospital after the birth was appropriate?
You Labour and Birth of your baby
After the birth of your baby, were you given the
information or explanations you needed?
Staff
Care in Hospital after the Birth (Postnatal care)
RAG
After the birth of your baby, were you treated with
kindness and understanding?
Feeding your baby( Postnatal care)
Care at Home after the birth
At the more granular level, the Trust performed ‘better than most
other trusts’ on the one individual questions and significantly worse
on 2 than other trust scores and about the same in 41 questions
Question
Comparison with 2010 Results
A number of questions have changed significantly since 2010
so comparing scores with those achieved in 2010 is not easy
of those that were consistent the trust had improved
significantly in 1 and worsened in 5.
.
At the very start of your labour, did you feel
that you were given appropriate advice and
support when you contacted a midwife or the
hospital?
After the birth of your baby, were you given
the information or explanations you needed?
Were you given information or offered
advice from a health professional about
contraception?
RAG
National Maternity Survey Action Plan 2013-14
The National Maternity Survey in 2013 has highlighted areas where the Trust has worsened on the previous survey and other
areas where the Trust is in the worst performing Trusts. The Trust strives to be in the best performing trusts and an action plan
has been developed to build on strengths and to improve on areas of weakness
Action
Description
2013.01.
Post Natal Care Mother not given enough information about own recovery after birth improved from 2010 score
39%
39% (was 54%) IMPROVED
De brief section highlighted in postnatal records to ask women if they would like to discuss prior to discharge often decline
at that point
All high risk / poor outcomes given de briefs about events and offered postnatal follow up at a later date
Nicky
Foster/
Angela
Rymer
2013.02.
Post Natal Care Not given enough information about emotional changes that may be experienced 42% (was 57%)
IMPROVED
SINGLE POINT OF ACCESS takes referrals from midwives direct
Perinatal mental health team work in ANC 2 days a week seeing individual women with needs
Also facilitate awareness sessions to midwives and very responsive to calls for concern and assessment if required
urgently
Antenatal Check- ups did not see the same midwife most of the time 83% (was 61%) WORSENED
Team midwifery concept explained to woman at booking for consistency women in Hull & East Yorkshire have a choice
about which location they have antenatal care names of team members on hand held records TEAM MIDWIFERY
supported by Children Centre’s and midwifery assistants
W& CH’s try to ensure the same midwife facilitates ANC in W&CH’s or link specialist midwives in diabetic / healthy life
styles / teenage pregnancy which offers consistency
42%
Zoe Dale
83%
CMS to
monitor
2013.04.
Postnatal Care Hospital stay too long or too short 31 % (was 17% ) WORSENED
Facilitate discharge in accordance with clinical need and patient choice
A Rymer will develop patient discharge lounge Jan 2014 to facilitate midwifery led discharges before 6 hours and return
next day for neonatal examination / community midwives to perform check only if capacity, training of all underway
Employment of Infant Feeding Coordinator to facilitate BFI training standards that all staff give consistent advice and
support
Rota tool to support direct care requires monitoring to ensure ratio appropriate for quality and safety S Sykes
31%
A Rymer
2013.05.
Postnatal Care – not treated with kindness and understanding 41% (was 27%) WORSENED
Trend identified in attitude and behaviours being actively managed referred to Supervision of Midwives also
ACAS training 1st and 8th Nov 2013 multidisciplinary to address harassment bullying and attitudes
41%
S Sykes
2013.03.
Score
Lead
RAG
Action
Description
Score
Lead
2013.06.
Feeding did not receive enough support and encouragement 37% (was 11% ) WORSENED
Breast feeding rates have increased
Peer support workers on postnatal wards – visible
Investment in Midwifery Support Workers for Community to undertake home visits and attend postnatal clinics Nov / Dec
2013
Frenotomy 5 people trained to support fixing and lactation prior to discharge / return for minor procedure if required
1WTE Infant Feeding Coordinator to enhance / develop and support advice to staff and women
Continue to review breast feeding rate
Postnatal at home: saw a midwife too often / too seldom 28% ( was 19%) WORSENED
Community Workforce review to determine pathway of care following risk assessment women offered postnatal care in
clinics within the demography
Review of staffing standardised resources across the patch in accordance with case load which is monitored by referral to
Direct Access monthly
Home visits arranged on clinical need ALL women have initial home visit following discharge to discuss Postnatal care
Better than national average
More choice given where to have antenatal check ups
Did not have the midwives phone number
Hospital room or ward not clean
Toilets and bathrooms not clean
Infant feeding not fully discussed when pregnant
Midwives where not aware of the medical history
Did not have confidence or trust in visiting midwives
Did not have enough help/advice about baby’s health and progress
Not given enough information or advice about contraception
37%
A Rymer
monitor
28%
CMS
S Sykes
Action
plan
workforc
e review
Trust
59%
2%
2%
4%
33%
17%
24%
24%
4%
Nat
68%
3%
5%
10%
41%
23%
30%
31%
9%
Results worse than picker average
Antenatal Care Not given choice of where to have the baby
Patient information leaflet explains choice of birth at home / hospital this can be changed by the woman at any point in her
pregnancy community midwifery accommodate requests following risk assessment at home
All midwives advised to discuss at booking and relate to midwifery led care options
Antenatal check up did not see midwife most of the time Ref : 03
Trust
25%
Nat
16%
83%
66%
Labour and Birth did not get appropriate advice from midwife or hospital
All advice is based on Hull & East Yorkshire Guidelines developed on best evidence / NICE / RCOG
Triage to be reviewed and patient telephone contact remains with notes
Labour and Birth – Concerns not taken seriously – no trends noted on Family and Friends Feedback / PALS /Complaints
29%
15%
26%
19%
2013.07.
2013.08.
2013.09.
2013.10
2013.11
2013.12
RAG
Care report Concerns, Complaints and
compliments
Less than
10% of
complaint
responses
become
seconds
56% of PALs
resolved
within 1
working days
781
complaints
MAT
64% of
complaints
upheld
Number of
complaints about
Staff attitude has
fallen by 41%
Key data
• 781 complaints in 12 months up 12% Y/Y
• Complaints about care and comfort have risen
substantially in the last 10 months
• 65% of complaints upheld
• Fewer than 10% of complaint responses
become seconds
• Number of PALS has fallen Y/Y
• 56% of PALs resolved within 1 working days
• Number of complaints about Staff attitude has
fallen by -35%
Complaints
100
2013/14
2012/13
90
86
80
74
73
75
71
70
66
62
65
62
59 59
60
59
57
52
68
66
59 58
59
53
51
50
47
Qtr 1
Qtr 2
Qtr 3
11 Mths
Total
2
0
0
2
12
16
18
59
24
22
36
113
61
75
76
255
62
78
76
278
161
191
206
707
39
40
Corporate
Functions
Clinical Support
- Health Group
30
20
Family and
Women's Health
- Health Group
10
0
A and E
Orthopaedic
s (Trauma )
Acute
Assessment
Unit
Elderly
Medicine
Obstetrics
NEW
Complaints received Monthly data
Complaint numbers have Increased y/y during the last 5 months with
an MAT now at 781. Complaints have grown in Medicine and Surgery
by 5 and 14% respectively on the latest 11 months. Treatment ( 65%) –
Outcomes/not satisfied with plan/ diagnosis-Surgery 59% of these are
the main areas of complaint growth. Clinical support has seen an
increase around treatment both outcomes and plan
Qtr 1
Qtr 2
Qtr 3
1 Mths
Total
12
20
23
63
%
change
11 mths
on 11
mths
19%
13
15
16
50
-11%
11
12
9
41
11%
9
9
19
46
12%
9
8
11
38
+9%
Medicine Health Group
Surgery - Health
Group
Totals:
% change
11 mths on
11 mths
-67%
69%
11%
5%
14%
12%
Complaint Numbers by Specialty
This shows that there is an upward trend in a number of Clinical
services including: A&E,, Elderly Medicine, Obstetrics and AAU.
These complaints relate primarily – to treatment (65%) in particular
outcomes of both surgery and treatment and the plan with Elderly
medicine growing around care and comfort. There has also been a
reduction in complaints in Orthopaedics Trauma in this period over
last year. Care and comfort complaints particularly around
assistance with nursing care and assistance with food and fluids
have increased
Complaints
NEW
Total for 11
Change over same
Months
464
period 2012/13
Communication/Record Keeping
59
-20%
Care and comfort including privacy and dignity
66
+128%
Discharge
38
-30%
Delays, waiting times and cancellations
50
-11%
Attitude
19
-35%
Themes Subject (primary)
Treatment
Upheld Complaints
Complaints are categorised when they are close as
Upheld, Partially Upheld and Not Upheld. Partially
Upheld is where for example, the treatment was
appropriate but communication and attitude were
lacking.
Resolution meetings
held (11 months to Feb
2014)
+21%
Subject and themes of Complaints
Complaints ain a number of areas have fallen
however the largest subject of treatment has seen the
biggest rise in numbers with outcome and diagnosis
showing the biggest growth. Care and comfort
complaints have risen substantially in the last 11
months when compared with the previous year this is
spread across all wards. AAU with 6 so far when
compared to 0 in the same six months last year, with
assistance with Nursing Care being the main
complaint .
Total complaints received
since April 2013 and
closed
13/14
% Upheld/Partially by
HG
13/14
Not upheld
191
72%
Partially upheld
164
Upheld
191
Totals:
546
Clinical Support
Family and Women's
Health
Medicine
Surgery
Meetings
Held
Complaints
Closed
Complaints
Reopened
%
Reopened
Corporate Functions
0
3
0
0%
Clinical Support
5
49
2
4%
Family and Women's
Health
17
108
11
10%
Medicine
47
287
24
8%
Surgery
92
289
21
7%
Totals:
126
890
54
6%
72%
60%
67%
Resolution meetings
This table identifies by Health Group the % of Re-opened
cases. Surgery has the lowest re-opened cases, this
correlates with the number of being open meetings held within
this Health Group. It is proposed that other Health Groups
offer more face to face resolution meetings to reduce the
number of cases that are re-opened
Complaints Quality Measures
The number of
complaints that
are resolved at
a local on the
first response is
an indication of
the success of
the complaints
procedure, as is
the number of
complaints that
then require
reopening and
further
resolution and
ultimately those
that are then
referred to the
PHSO
(Parlimentary
Health Service
Ombudsman)
NEW
Current Complaints Closing and Quality
measures Seconds
despite the increase in the number of
complaints the number of reopened and
ombudsman cases has fallen as a
percentage of complaints closed
Complaints reopened
Data on complaints reopened each
quarter since April 2013 shows between
15 and 20 complaints remain unresolved.
As mentioned before resolution meetings
have helped to minimise the number of
seconds as it is a good opportunity for
patients and carers to talk open and
honestly with staff about their concerns
Current Complaints Closing and Quality
measures Ombudsman
We have also seen a reduction in the
number and % of complaints that then
convert to PHSO investigations
Concerns Raised through PALs
PALs Service
An alternative
route for
members of the
public to raise
concerns is
through the PALS
service. Informal
concerns
received by the
PALS team are
not logged as
formal complaints
however, they are
recorded to
capture key areas
of concern.
Following receipt
there is a focus
on rapid
resolution of
these concerns,
with the service
directly
contacting the
person who has
raised the
concern in order
to resolve all
concerns raised.
NEW
Concerns Raised with Patient Advice
and Liaison Service (PALS)
The Trust has received 2256 PALS
concerns in the period April to Feb 2013
inclusive. This is a decrease of 5% upon
the same period during 2012-13, where
2372 concerns were received
Number of concerns reported by each Health
Groups
since April 2013 Surgery and Medicine seeing -15%
decrease on the same period last year although the
last three months have seen increases in activity
Orthopaedics (Elective)
Acute Assessment Unit
A and E
Cardiology
Elderly Medicine
Urology
Orthopaedics (Trauma )
Neurosurgery
Radiology
Ophthalmology
Neurology
11 Months
11 Months
2012/13
2013/14
127
128
124
141
92
78
89
75
66
60
96
151
110
109
107
97
96
95
92
88
87
85
% Change
19%
-14%
-12%
-24%
5%
23%
7%
23%
33%
45%
-11%
Main areas of concern for PALs.
Concerns about delays for both appointments and
results are the main growth Ophthalmology,
Radiology and Neurosurgery. With concerns about
cardiology AAU and A&E down Y/Y
PALs service levels
PALs try to resolve concerns as quickly as possible and
preferably in one day the number of working days taken to
resolve PALs concerns In the 11 months since April in 1 day
is at 56% those concerns answered within 5 working days is
79%
NEW
Ombudsman cases
The Trust has 3 open ombudsman cases a draft report has been received 12.5319, 114433 and 12.5027 are now closed not upheld.
A further Ombudsman has been received 13.5727 medical records have been sent and a copy of the complaint file.
Our Ref
Area
Issues
12.5224
First
contact
March 13
Ward 21
Nursing Care
Nutritional support
Treatment
11.4433
April 13
AAU/Ward 8
12.5319
July 13
Ward 110
11.4342
April 13
13.5727
Nov 13
Our Ref
Last
contact
August 13
Current status
Attitudes
Treatment
Treatment
Communication
LCP
Dec 2013
Not Upheld Now closed
Feb 2013
Not Upheld Now closed
Ward 15
Care and Compassion
Response letter
July 13
Ward 110
DNR and attitude
Dec 13
Upheld letter of apology actions
and Compensation to be paid
£2500
Complaint file and medical record
s sent
Area
Issues
12.5027
First
contact
Sept 13
AAU/Ward 21
13.5546
Oct 13
Ward 14
13.5362
Oct 13
Ward 26
Communication
Treatment
Treatment
Pain Control
Treatment
Complaints handling
Now closed
Complaint partially upheld letter of
apology actions
Last
Contact
Dec 2013
Current Status
Feb 2014
Further local resolution taking
place
Further local resolution taking
place
Feb 2014
Not Upheld
Examples of PALs and actions taken – February2014
ID
Concern/Action
23903 Patient was waiting to be discharged but there was a delay in the care
package being put into place by the hospital social worker. Patient's wife
was becoming increasingly distressed and wanted help in coordinating with
Discharge Liaison Services and the Ward.
24248 The patient had three appointments cancelled with the latest now on 15th
May, but as her symptoms have become worse she wanted to be seen
sooner than May.
NEW
Outcome
Complainant called to say that everything is sorted, care package is
in place and patient is to be discharged today. She expressed her
thanks for PALS assistance in bring this to a satisfactory conclusion.
An earlier appointment date was acquired by PALS with the
assistance of the Management Assistant in OP Dept.
23833 Unhappy that their appointment to see the consultant had been cancelled Appointment has been made for April.
and another appointment had not been given.
23979 The patient had several concerns over the way he had been dealt with
whilst in AAU awaiting results form an MRI.
PALS spoke at length to the unit Charge Nurse who agreed to see
the patient and his wife straight away to cover all of their concerns.
23908 Patient was concerned that a clinic letter detailing the medication to be
prescribed by her GP had not yet been sent.
Advised patient the letter had been sent to the GP on the 21
January marked unsigned to avoid delays. Suggested that the
patient check with the GP surgery again to see if it had not been
received, and if not, we would arrange for a further copy to be
faxed.
The Consultant spoke with the relative at length and answered all of
the concerns.
24054 Told to stop taking warfarin on 21 January 14 by his consultant but never
received an explanation why. Recently admitted to HRI after having a
stroke and doctors on the ward cannot understand why. His family would
like to know why he was told to stop taking Warfarin.
23904 Patient was asked to sit in the waiting room in a gown with other patients Sister has spoken with the patient and reassured her that her
that were fully clothed; the clinic was running 90 minutes late. She felt
concerns will be raised with the relevant people and suggestions
uncomfortable. Two students were present with the doctor, her consent put forward as to how we can improve.
for them to be present was not requested and she actually stated that she
did not want them there, however they remained. She felt her privacy and
dignity was compromised and is worried about attending for further scans
in the future.
Lessons Learnt
Complaints are
important
feedback for
trusts and
many
complaints
generate
actions that
need to be
completed so
active learning
is taking place.
Complaints
about attitude
basic nursing
care and
communication
require
following up to
improve
patients
experience in
the future
NEW
Actions Closed Feb 2014
Description of Complaint
Action completed
Patient was due to have an endoscopy. He had breakfast at
6am and went for his procedure. At 6pm he was returned to the
ward as wrong paperwork had been completed and therefore no
investigation had been done. Patient was diabetic and insulin
and metform
Now a consultant dedicated to the ward, which will
prevent a repeat of the patient's experience.
Saw the Neurologist at the beginning of January and told he would Corrective action already taken and patient has had
be referred for an EEG test. He has not received an appointment
investigation carried out.
to date.
Patient prescribed Ethambutol and Voriconazole for a chest
infection, despite serious side effects, these tablets were not
discontinued and patient recently lost his sight as a
consequence. Patient would lie to know why nothing was done
sooner.
Risks Vs benefits of treatment conisdered carefully.
Treatment deemed appropriate. No action
identified
Relative concerned that a lump on the patient's leg was not noticed Nurse Director has spoken to the ward sister
by staff until told by relatives and not happy with explanation given regarding her grave concerns relating to the lack of
for the lump. The patient's leg became infected and she died.
nursing care provided for the patient
Ward sister to identify training requirements for staff
Patient was unhappy with the care provided on the ward, felt
isolated and that he had been discharged too early. He was also
unhappy at the attitude of the physiotherapist.
Relative believes it was unsafe and unprofessional to undergo a
deep clean on the ward in the way it was conducted; relative
described it as 'chaos' and ultimately compromised her husband's
care.
A new system of arranging IDL's introduced to prepare
them the day before discharge negating the need for
patients to sit around waiting for medications on day of
discharge
Meeting held with CEO. No action identified.
NEW
Complaints and PALs and FFT
Changes have been put into place on all the wards identified as poorly performing and most areas have seen an
improvement in their FFT. This has seen a reduction of complaints on most of these wards. Of concern is the rise in the
number of complaints in outpatient areas this stems from appointment delays and delays in diagnosis.The next care
report will look at complaints and concerns in outpatients in more detail
Friends and family - net promoter score for bottom ten areas
Oct
Nov
Dec
Area
Ward 90
21
21
56
Acute Assessment Unit
23
44
32
ESSU (HRI Ward 8 & Ward 80)
36
52
50
Ward 21
54
47
23
Fracture Clinic
49
49
56
Ward 130W
41
72
72
Ward 19
31
69
70
Ward 33
100
67
70
Ward 9 (HRI)
55
66
95
Complaints top ten areas
Acute Assessment Unit, HRI
Accident and Emergency, other, HRI
Outpatients, CHH
Outpatients, Surgical, HRI
Ward 10, HRI
Outpatients, Medical, HRI
Ward 9, CHH
Eye Clinic, Eye Hospital
Ward 14, CHH
Outpatients, Fracture Clinic, HRI
Jan
57
13
41
35
61
53
95
80
68
Feb
52
8
51
55
58
66
88
55
28
6 mths LY 6 mths TY
28
24
PALs concerns top ten areas
21
24
Waiting list - elective
6
17
Outpatients, CHH
3
16
Outpatients, Surgical, HRI
6
15
A&E
4
14
Acute Assessment Unit, HRI
4
13
7
12
6
11
9
11
Outpatients, Medical, HRI
Eye Clinic, Eye Hospital
Cardiology Outpatients, CHH
1st Floor Orthopaedics, HRI
Trustwide
6 mths LY 6 mths TY
88
76
57
85
77
75
36
59
34
23
140
99
73
70
68
63
51
42
37
28
Friends and Family Test
Overview
The Friends
and Family
Tests have
been
introduced to
give patients
the
opportunity to
give feedback
on the quality
of care they
receive. Hull
and East
Yorkshire can
be seen to be
performing
well above
the national
average on
the Inpatient
test, and on
the A&E
section.
Since April 2013, patients have been asked
whether they would recommend hospital wards
to their friends and family if they required similar
care or treatment, the results of which have
been used to formulate NHS Friends and
Family Tests for Accident & Emergency and
Inpatient admissions.
Age distribution of FFT responses
NEW
Overall Performance
Hull and East Yorkshire Hospitals NHS
Trust scored 54 in the January A&E
Friends and Family Test, which was
below the national average 57.
However, the Trust’s response rate
5.7% was is much lower than the
national rate 17.43%. The Trust scored
81 in the latest Inpatient test, which was
above the national average of 73, this
maintained the score from December.
The response rate 41% was also above
the average of all English trusts 31%,
this suggests a continuing engagement
with the Friends and Family Tests by
staff members
The FFT was successfully launched in
maternity January scores are set out in
the table below.
Trust
National
Antenatal
60
67
Labour/Birth/ ward
78
78
Postnatal Ward
80
65
Postnatal Community services
88
75
Friends and Family Test
NEW
Accident & Emergency Performance
In January, a total of 326 people completed the
test at Hull and East Yorkshire Hospitals NHS
Trust , with 85% of patients ‘extremely likely’ or
‘likely to recommend the A&E department to
friends of family. The Trust’s score of 54 in
December is below the national average for the
month 57, with Hull and East Yorkshire lying in
the middle 50% of services eligible for the
survey nationally.
The Trust’s response rate of the A&E Friends
and Family Test is below the national average
for the 10 months and measure are being put
into place to address this using SMS
messaging to gain feedback
A&E Friends and
Family Test, April
– Jan 2014
Month
Indicat
or
A
Score
Respon
se rate
J
A
S
O
N
D
J
51
62
62
65
73
72
68
66
45
54
Eng.
49
55
54
54
56
52
55
56
56
57
HEY
3.8
4.1
7.8
10.1
10.8
6.5
9.7
8.0
4.3
5.7
Engl.
5.6
7.5
10.3
10.4
11.4
13.2
13.8
15.3
15.3
17.4
Month
Indicator
A
M
J
J
A
S
O
N
D
J
HEY
76
76
80
81
83
78
78
81
80
81
England
71
72
72
71
72
72
72
73
72
73
HEY
31.4
38.1
53.5
44.9
50.
47.3
42.4
52.7
22.7
41.0
England
21.7
24.4
27.1
27.8
28.9
29.4
30.4
31.3
28.8
31.1
Respon
se rate
J
HEY
Inpatient Friends
and Family Test,
April – jAN 2013
Score
M
Inpatient Performance
In January, 1595 people undertook the Inpatients
Friends and Family Test at Hull and East Yorkshire
Hospitals , 93% of which were ‘extremely likely’ or ‘likely’
to recommend the ward they stayed in. The Trust’s score
of 81 was above the national average of 73, and
continued a trend of being above the average
performance since the Test’s inception.
The response rate observed at Hull and East Yorkshire
Hospitals has improved over December with 41% of
those eligible replying ( national 31%)
NEW
Friends and Family Test
Wards and Specialties
39 wards at Hull and East Yorkshire Hospitals NHS Trust were included in the Jan 2013 FFT Survey. These wards experienced
varying response rates, from 100% in Ward 20 ,ccd5 AND WARD 35 to 12.% on ward 10 with 24 wards with response rates
above the 31% national average. 29 wards scored above the national average of 73, with ward 2 at Castle Hill scoring 100% for
their NPS.
There were 20 wards that scored less than the Trust-wide average of 81. Of the wards identified 6 months ago as having a poor
experience as well as above average complaints Ward 11 and 90 at HRI show good progress. Whilst Improvements are still
required on wards 8,80,21
Ward
Name
A
M
J
J
A
S
O
N
D
J
Ward 11
(HRI)
83
56
79
73
75
53
85
62
100
71
ESSU
(HRI
Ward 8 &
Ward 80)
61
66
54
44
55
51
36
52
50
41
Ward 8
(CH)
89
63
71
73
83
50
88
87
90
78
Ward 21
50
50
49
53
48
38
54
47
23
35
Ward 90
31
56
71
88
21
-12
21
21
56
57
RAG
NEW
Friends and Family Test
The introduction of the FFT test has
allowed those wards who provide a
high level of patient experience to
demonstrate their worth and give
staff the recognition they deserve
Wards with high scores in the FFT test
100
Apr
80
May
60
Jul
Jun
Aug
40
Sept
Oct
20
Inpatient recommendation trend
Percentage of patients who are extremely likely or
likely to recommend the Trust as a place to receive
treatment
0
Nov
Dec
Ward 35
(EYWD)
Ward 28 (C28
& CCMU)
Ward 32
Ward 26
Ward 27
Jan
Prompt & efficient service from booking in at reception to consultation. Excellent
service. Thank You. Fracture Clinic Feb 2014
The care this time was marvellous, medically and physically the staff excellent in
all respects Ward 60 Feb 2014
Fantastic people, every one very caring, put at ease in every department. A big
well done to all could not fault a thing keep up the good work.. Ward 35 Feb 2014
All staff very caring and efficient- excellent
Some procedures very painful and could be improved with a measure of sedation
(Sheath removal) Ward 28 Feb 2014
Excellent care was given at all times to my Dad and all the staff were always very
helpful & caring with our family. My Dad was professionally looked after at all
times. We are very greatful to all nurses & doctors Ward 32.Feb 2014
Fantastic, everyday for 6 weeks I would not change anything. To improve things I
would like to see something more to do when we are more active. Ward 26 Feb
2014
The kindness & gentle care has been friendly. It has been like a visit to a family get
together. God bless you all. Ward 27Feb 2014
NEW
Compliments Received
PALs Compliments received from April 2013
The Trust receives compliments
–
–
–
–
Corporate Functions
At ward level with cards chocolates and comments
Through the Friends and Family Test
Through the PALs team
Through the NHS Choices and patient opinion
website
HEY FFT
378
1119
Extremely
Unlikely
Unlikely
Neither
Likely or
Unlikely
36072
18
Family and Women's Health - Health Group
20
Medicine - Health Group
35
Surgery - Health Group
69
Likely
150
Compliments and FFT
–
9861
Extremely
Likely
8
Clinical Support - Health Group
Totals:
381
Total
–
–
Over 36,000 patients Extremely Likely to recommend
our services
Many compliments received through comments
Examples are on following slides
Compliments and NHS Choices
NHS Choices and Patient opinion comments are published on the NHS Choices website many of these are compliments a few examples are on the
following slides data until Feb 2014
HRI 3.0 Stars
199 ratings
CHH 4.5 Stars
129 ratings
NEW
WARD 90 You Said
We did
No access to refreshments whilst
waiting for discharge in the quiet
rooms on ward 90.
Housekeeper & nursing staff ensure
refreshments & snacks are available
at all times.
Uncomfortable chairs, shabby area to
wait in for admission or discharge.
Waiting areas decorated, easy chairs
and sofas installed. Wall mounted TV’s
to be purchased.
CCD5 CHH You Said
We did
Comments on not having a TV within
the cardiology day ward for patients.
Had 2 TV’s bought by the Welwick
Wheelers. One for the patient’s sitting
room and one for the waiting area
outside the ward. Both TV have
CD/DVD PAYERS so we will be able
to give patients information about their
procedures and life styles.
ESSU You Said
We did
Visiting times weren’t long enough.
Visiting longer times, we have now
opened visiting 9am-7pm
Signs on the ward.
They couldn't find the toilets, we have
bought picture signage
Patients crockery.
Coloured crockery to improve meal
times for patients with Dementia.
Dining Companions.
Increased amount of
Dining Companions to support feeding
Reminiscence Therapy.
Introduction of reminiscence therapy
and excepted donations of CD and
radio players
Ward 12 You Said
Patients would like hot chocolate
option for night drinks.
WARD 6/60 You Said
We did
Provided hot chocolate for night time
drinks.
We did
For February the common theme was The Estates team was contacted and
the heat on the ward - it was incredibly the radiator temperature were
hot.
adjusted and the new windows were
opened to allow air to circulate.
Ward 11 H.R.I You Said
We did
Wards too warm.
All radiators turned off and problem
escalated to estates.
Waiting too long for scans and
investigations
Kept you informed and chased scans.
EYE CLINIC You Said
Waiting in Clinic
We did
All the following have been done in an
effort to improve patient waiting times.
Introduction of weekend clinics and
the new 'scan van' for Wet AMD
(Lucentis) patients and the
appointment of new clinical staff.
Ward 30 CHH You Said
We did
Lots of telephone calls not being
answered at the nurses station with
the staff being busy washing patients.
So I ensure I spend the morning at the
nurses station answering the
telephones to save the staff keep
coming to the phones, I look at calls
missed whilst I am answering the
phone and call them back, works very
well and we have less complaints !!!
Daisy Day Unit
You Said
Waiting time of 2.5hrs was too long.
Marmalade would have been nice on
my post –op toast!
E.N.T OUTPATIENTS
HRI You Said
There should be bigger gowns
We did
Ensure patients are advised at preassessment that the operating lists
times are either 09:00-12:30 or 14:0017:30 and that their surgery will be
undertaken at any time during that
period.
Ensure patients are advised of the full
post op menu available. Marmalade
now ordered as an alternative to jam.
We did
Always 8 extra gowns available now,
and a sign in the changing
rooms encouraging patients to ask.
WARD 9 CHH You Said
Patients are persistently stating that
they are waiting long times from
pharmacy take home medications.
WARD 35 You Said
The wait for your op is boring.
WARD 10 H.R.I You
Said
Patients commented that they always
get there medicines late in a morning.
We did
We have teamed up with Pharmacy
and the junior doctors and devised a
way to identify those who may go
home the next day to ensure that their
medications are done in advance.
Ensuring that patients don't have to
wait on day of discharge.
We did
We used some money that patients
donated to purchase a TV for the
waiting room.
We did
We are changing the ward routine so
that medicine rounds will start earlier.
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
MONITOR’S QUALITY GOVERNANCE FRAMEWORK
Trust Board
date
Director
April 2014
Liz Thomas
Director of Governance
and Corporate Affairs
2014 – 4 - 11
Reference
Number
Author
Liz Thomas
Director of Governance and
Corporate Affairs
Reason for
the report
The purpose of the paper is to present the outcome of the self-assessment against
Monitor’s Quality Governance Framework
Type of report
Concept paper
Performance
Strategic
options
Information
Business
case
Review

1
RECOMMENDATIONS
The Trust Board is requested to review the outcome and confirm that further discussion will
take place on the next Board Development Day
2
Key purpose
3
4
5
Decision
Approval
Information
Assurance

Discussion
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care

 Strong, high performing FT

 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and prioritised effectively
 Delivery against our priorities and objectives

 Capable, effective, valued and committed workforce

 Strong respected impactful leadership

LINKED TO
Regulation 10: Assessing and monitoring the quality of service
CQC Regulation(s)
provision
No
Assurance Framework
Ref:
Legal advice
All
BOARD/BOARD COMMITTEE REVIEW
The Trust Board received the Board Memorandum in January 2013. It reviewed progress in
July 2013 and January 2014.
57
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
MONITOR’S QUALITY GOVERNANCE FRAMEWORK
1
PURPOSE OF THE PAPER
To present the outcome of the self-assessment undertaken by Board members individually and
support the approach to agreeing the further actions required.
2 INTRODUCTION
Monitor introduced a Quality Governance Framework in July 2010 and it became part of the
application process for aspirant Foundation Trusts in August 2010. It was included in the Compliance
Framework from April 2011 and Foundation Trusts were expected to report against it in their Annual
Governance Statement from 2012. It now forms part of the Risk Assessment Framework and will form
part of Monitor’s Governance Reviews.
The Trust Development Authority’s Accountability Framework was published on 1 April 2014. There
are two important changes relating to quality governance:
 It is proposed that the Monitor team will undertake an assessment of the Trust against the
Framework whilst it is still working with the Trust Development Authority. This will provide Monitor
with an earlier insight into aspirant trusts and should help to reduce the number of organisations
which struggle to pass the Monitor’s final assessment due to quality governance concerns. This
has already been piloted and will be phased in during 2014/15
 A single well led framework will be introduced. This will be developed and tested during 2014/15
which will aim to align the different aspects of culture, leadership and governance undertaken by
the Trust Development Authority, Monitor and the Care Quality Commission. This will bring
together the current approaches embodies in the Quality Governance Framework, the Board
Governance Assurance Framework and the Care Quality Commission’s new inspection regime to
create a single definition of success for NHS Trusts. However, in the meantime the assessments
undertaken under the existing frameworks will remain valid.
3 BACKGROUND
The Quality Governance Framework consists of 10 questions against 4 domains. The 4 domains are:

Strategy

Capabilities and culture

Process and structures

Measurement
The Trust must achieve a score of less than 4 in order to progress its Foundation Trust application
and no one area can be entirely amber-red rated. The score must be confirmed by an independent
assessor.
Information has previously been presented to the Board on the rigour with which Monitor assesses
Trusts against the Quality Governance Framework. Early applications resulted in a differentiation
between the Monitor assessment and the Trust’s self-assessment, with Monitor increasing Trusts’
scores by between 0.5 and 5.5.
4
CURRENT POSITION
Attached at appendix A is the outcome of the individual scores against each element of the
Framework. Key issues to note are:
 The overall score remains at 3.5. There has been an improvement against the Board being
aware of potential risks to quality (1A) but the score has deteriorated against the Board having
the necessary leadership skills for the quality agenda (2A)
58




The remaining five areas where the Trust previously scored 0.5 have remained at 0.5
There was consistency between Executive Director scores and Non-Executive Director scores
The greatest variation in scores was amongst the Executive Director group
The highest scores given by individuals were 6.0 and the lowest were 2.5.
4
NEXT STEPS
Monitor has produced a questionnaire for Board’s to use to help compare their quality governance
assurance activity with the domains of the Quality Governance Framework. It is proposed that this
document is used at the forthcoming Board time out in order to identify the gaps in assurance and
agree collectively the action required to reduce the scores further. In addition the Director of
Governance is attending a Foundation Trust Network event which is devoted entirely to the Quality
Governance Framework and at which speakers from Monitor and recent lessons learned will be
presented. This will also inform the Board development session.
4
RECOMMENDATION
The Trust Board is requested to note the revised scores and to agree to further discussion at the
Board development session using the Monitor questionnaire.
Liz Thomas
Director of Governance and Corporate Affairs
April 2014
59
CURRENT (individual) ASSESSMENT (April 2014)
SCORE
December 2012
(Deloitte & Trust)
0.0
Score
April
2014
0.0
Change
Mode
Average
Highest
score
Lowest
score
↔
0.0
0.3
1.0
0.0
1.0
0.5
↓
0.5
0.68
1.0
0.5
0.0
0.5
↑
0.5
0.43
1.0
0.0
The majority of NEDs and the majori
scored 0.5
0.5
0.5
↔
0.5
0.43
1.0
0.0
All NEDs scored at 0.5. There was a
scores for EDs: 0.0 (3), 0.5 (4) and 1
3A: Are there clear roles and accountabilities
in relation to quality governance?
0.0
0.0
↔
0.0
0.1
1.0
0.0
All NEDs scored 0.0. All EDs scored
the exception of three: two x 0.5 and
3B: Are there clearly defined, well understood
processes for escalating and resolving issues
and managing quality performance?
0.5
0.5
↔
0.5
0.5
1.0
0.5
All NEDs scored 0.5. The majority of
scored 0.5. Two EDs scored 1.0 and
scored 0.0.
3C: Does the Board actively engage patients,
staff and other key stakeholders on quality?
0.5
0.5
↔
0.5
0.5
1.0
0.0
All NEDs scored 0.5. The majority of
scored 0.5. Two EDs scored 1.0 and
scored 0.0.
4A: Is appropriate quality information being
analysed and challenged?
0.0
0.0
↔
0.0
0.2
1.0
0.0
All but one NED scored 0.0. One NE
0.5. The majority of EDs scored 0.0.
three EDs scored 0.5 and one ED sc
4B: Is the Board assured of the robustness of
the quality information?
0.5
0.5
↔
0.5
0.5
1.0
0.0
All NEDs scored 0.5. The majority of
scored 0.5 with one scoring 1.0 and
scoring 0.0.
4C: Is quality information used effectively?
0.5
0.5
↔
0.5
0.5
0.5
0.5
All scores were 0.5
TRUST SCORE
3.5
3.5
↔
STRATEGY
1A: Does quality drive the Trust’s strategy?
1B: Is the Board sufficiently aware of potential
risks to quality
Commentary
The majority of EDs and the majority
scored this as 0.0.
3 NEDs scored this at 1.0 and 3 NED
0.5. The majority of EDs scored 0.5.
CAPABILITIES AND CULTURE
2A: Does the Board have the necessary
leadership, skills and knowledge to ensure
delivery of the quality agenda?
2B: Does the Board promote a qualityfocussed culture throughout the Trust?
PROCESSES AND STRUCTURES
MEASUREMENT
60
61
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
FRANCIS ANNUAL REPORT
Trust Board date
24 April 2014
Director
Amanda Pye – Chief Nurse
Reason for the
report
The purpose of this annual report is to inform the Board of progress to date on
the implementation of the recommendations from the Francis Report. It sets
out the Trust’s achievements over the last year against the 109
recommendations aimed at Acute Trusts.
Concept paper
Strategic
Business
options
case
Performance
Information √
Review
Type of report
1
RECOMMENDATIONS
The Board is asked to note the contents of the report.
2
Key purpose
Decision
Information
3
4
5
√
2014 – 4 - 12
Reference
Number
Author
Caroline Grantham –
Medicines Management
Nurse
Approval
Discussion
Assurance
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and prioritised
 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
All domains
CQC Regulation(s)
Ref: N/a
Assurance Framework
No
BOARD/BOARD COMMITTEE REVIEW
Legal advice
This report has not been considered by any other Board Committee.

No
Hull and East Yorkshire Hospitals NHS Trust
Response to the Francis Report
Annual report April 2014
1. Introduction
The purpose of this annual report is to map our progress to date on the implementation of the
recommendations from the Francis Report. It sets out our achievements over the last year against
the 109 recommendations aimed at Acute Trusts and the subsequent review documents requested
by the Department of Health (DoH) which followed the Francis Report:
 Cavendish Review: An Independent Review into Healthcare Assistants and Support
Workers in the NHS and social care settings (July 2013).
 Keogh Review: Review into the quality of care and treatment provided by 14 hospital trusts
in England: an overview report (July 2013)
 Berwick Review: A promise to learn - a commitment to act Improving the safety of patients
in England (August 2013).
 Clwyd Hart Review: A review of NHS Hospitals Complaints putting patients back in the
picture (October 2013).
 HARD TRUTHS: The journey to putting patients first (November 2013)
All these national documents link to the trust’s strategic aims of:
 Delivering excellent quality outcomes
 Working in partnerships that add value and in ways that use public money wisely
 Provide assurance to our regulators and commissioners that all necessary standards are
being met.
2. Background
The failing in care at Mid Staffordshire NHS Foundation Trust between 2005 and 2009 brought
suffering to a large number of patients and may have been responsible for an unknown number of
premature deaths. An initial independent inquiry was published by Robert Francis in 2010 with the
report from the second public inquiry being published in February 2013. This final report contained
290 recommendations aimed at changing culture and practice at the Department of Health, the Care
Quality Commission, Monitor, the General Medical Council and the Nursing and Midwifery Council,
in addition to local patient & public scrutiny organisations as well as boards of acute hospitals and to
all those working in these organisation providing services to patients. Five key themes where
identified by Robert Francis QC in the report which all NHS organisations needed to action:
 Fundamental Standards
 Openness, Transparency & Candour
 Nursing Standards
 Patient Centred Leadership
 Information
3. Internal Developments
Following the publication of this report a number of actions occurred within Hull & East Yorkshire
Hospital NHS Trust:

The Senior Team met to discuss the Francis Report and agree an initial way forward, All 290
recommendations where reviewed against the criteria below.
Total
Now
Must
Partial
Sooner
Should
None
Later
Could
The senior team highlighted 27 key recommendations’ these where then scored 1 – 5 with
11 prioritised. These became HEY’s Top 11 (Appendix 1).

The Chief Nurse presented a paper to the Trust Board in April 2013 outlining HEYs response
and identifying work programmes in place prior to the publication of the Francis Inquiry and
key actions and progress since its publication. 
A master document was developed which documents each Francis recommendation; who
the recommendation is aimed; response from review documents to date and evidence to
demonstrate HEY’s compliance. For ease of reference a summary on a page of all
recommendations has also been developed (Appendix 2).

A committee was set up to review and deliver the recommendations as agreed by the Trust
Board. This meeting is chaired by the Chief Executive and meets monthly. Membership of
the Francis Committee is:
o Chief Executive Officer (Chair)
o Chief Nurse
o Chief of Workforce and Organisational Development
o Medical Director (Health Group)
o Chaplains
o Non-Executive Director
o Director of Innovation
o Representation from Hull University
o Project Lead to Chief Nurse

Five task and finish groups have been set up and they each have a set of recommendations
to consider. These groups meet monthly to review and progress their action plan. Every
month the task and finish groups report to the Francis Committee on their progress with
particular reference to the Top 27 and specifically progress made against the Top 11
recommendations. All recommendations that the task and finish groups indicated that they
have met are considered by the Francis Committee before final sign off. The master
document is then updated with the evidence to demonstrate HEY’s compliance.

A member of the Francis Committee sits on the Francis 2 Programme Board. The purpose of
the Francis 2 Programme Board is to provide seamless appropriate quality care when a
patient journey scans more than one organisation. The stakeholders who are members of
the Programme Board include the following:
 NHS Hull Clinical Commissioning Group
 NHS East Riding of Yorkshire Clinical Commissioning Group
 Hull and East Yorkshire Hospitals NHS Trust
 Humber NHS Foundation Trust
 City Health Care Partnership
 Spire Hospital – Hull and East Riding
 Hull City Council
 East Riding of Yorkshire Council
 NHS Yorkshire and Humber Commissioning Support Unit

A member of the Francis Committee also sits on the group set up by Hull University to
response to the implications of the Francis Inquiry recommendations for undergraduate
admissions, curriculum and educational programme content and delivery.
4. External Developments
Since the initial publication of Francis, several separate reviews have been published over the last
few months commissioned by the Department of Health.
These are:

Cavendish Review: An Independent Review into Healthcare Assistants and Support
Workers in the NHS and social care settings (July 2013). This review makes a number of
recommendations on how the training and support of both healthcare assistants who work in
hospitals and social care support workers can be improved to ensure they provide care to
the highest standard. It proposes that all healthcare assistants and social care support
workers should undergo the same basic training, based on the best practice that already
exists in the system, and must get a standard “certificate of fundamental care” before they
can care for people unsupervised.

Keogh Review: Review into the quality of care and treatment provided by 14 hospital trusts
in England: an overview report (July 2013) The reviews identified patterns across many of
organizations:
o Professional and geographic isolation
o Failure to act on data or information that showed cause for concern
o The absence of a culture of openness
o A lack of willingness to learn from mistakes
o A lack of ambition
o Ineffectual governance and assurance processes.
In some cases, Trust boards were shockingly unaware of problems discovered by the review
teams in their own hospitals.

Berwick Review: A promise to learn - a commitment to act Improving the safety of
patients in England (August 2013). This review highlights the main problems affecting
patient safety in the NHS and makes ten recommendations to address them. It says that the
health system must :
o Recognize with clarity and courage the need for wide systemic change
o Abandon blame as a tool and trust the goodwill and good intentions of the staff
o Reassert the primacy of working with patients and carers to achieve health care
goals
o Leaders of provider organisations should take responsibility for ensuring that
clinical areas are adequately staff taking account of varying levels of patient
acuity and dependency. The report cite recent work that operating a general
medical – surgical ward with fewer than one registered nurse per eight
patients, plus the nurse in charge may increase safety risks substantially.
o Use quantitative targets with caution - they should never displace the primary
goal of better care
o Recognize that transparency is essential and expect and insist on it
o Ensure that responsibility for functions related to safety and improvement are
established clearly and simply
o Give NHS staff career-long help to learn, master and apply modern methods for
quality control, quality improvement and quality planning. Customised training for
the entire workforce on such topics as safety science and approaches to
compassionate care and teamwork.
o Make sure pride and joy in work, not fear, infuse the NHS

Clwyd Hart Review: A review of NHS Hospitals Complaints putting patients back in
the picture (October 2013). The recommendations from this review focus on four areas for
change:
o Improving the Quality of Care
o Improving the way complaints are handled
o Ensuring independence in the complaints procedures
o Whistleblowing
In total there are approximately 24 recommendations aimed at Acute Trusts (Appendix 3). Within
HEY these recommendations will be reviewed and actioned by the Patient Experience Forum.

HARD TRUTHS: The journey to putting patients first the Department of Health’s
response to the Francis Recommendation was published in November 2013. The document
mirrors the initial response:
o Preventing Problems
o Detecting Problems Quickly
o Taking Action Promptly
o Ensuring Robust Accountability
o Ensuring Staff are Trained & Motivated
The majority of the 290 recommendations made by the Francis Inquiry have been accepted by the
Department of Health either in total or in principle and work is underway to implement them. The
summary on a page document has been coded so that the reader that see at a glance which
recommendations have been accepted, accepted in principle, accepted in part or not accepted
(Appendix 2). When a recommendation has been explicitly rejected by the Department of Health
they are taking an alternative approach that they believe is more likely to be effective in reaching the
desired outcome.
Total Recommendations
ACCEPTED = 201
PRINCIPLE = 60
ACCEPTED IN PART = 20
NOT ACCEPTED = 9
The Francis Committee has considered the recommendations / ambitions from these documents
and as appropriate has aligned them with the recommendations in the Francis Review.
Of the Top 27 recommendations selected by the Trust Board the table below shows which of these
recommendations where accepted or accepted in principle by the Department of Health.
HEY’s Top 27 or Top 11
Top 11
Francis
Recommendation
2
5
12
111
114
191
195
236
238
242
243
13
15
23
93
Hard Truths (DoH, 2013)
Accepted
Accepted
Accepted
Accepted
Accepted
Accepted
Accepted in Principle
Accepted
Accepted
Accepted
Accepted
Accepted
Accepted in Principle
Accepted
Accepted in Principle
Top 27
40
88
89
109
116
173
194
198
239
270
278
288
Accepted
Accepted in Principle
Accepted in Principle
Accepted
Accepted
Accepted
Accepted in Principle
Accepted
Accepted
Accepted
Accepted
Accepted
5. Progress to date
To date 26 recommendations have been met and signed off by the Francis Committee. HEY are
looking at their compliance against 107 recommendations in total. By April 2014 we will be
compliant with recommendation 195 (Supervisory Status for Charge Nurses). The summary on a
page document tracks progress, the recommendation number is turned blue when it has been met.
All recommendations that the task and finish groups indicated that they have met are considered by
the Francis Committee before final sign off. The master document is then updated with the evidence
to demonstrate HEY’s compliance.
5.1 Actions to date
Chief Nurse:
 Commenced monthly meeting to update our nurses on our response to Francis and
subsequent reviews.
 Big Conversation held with Student Nurse around the 6Cs held in December 13.
 Big Conversation with patients & carers took place in September 13
 Patient Experience Forum commenced.
 Intentional Rounding introduced Trust Wide in December 2013.
 Nutrition: New process of meal provision which ensures high risk patients are supported is
currently being rolled out across the organisation (Dec/Jan 14).
 Introducing a Placemat which will give usually information about the meals service but will
also state Name Nurse/Consultant.
 Relative Clinics successfully tested on one ward; wide scale test to commence in surgery
health group during May 14.
 Six Cs: included holding wide scale engagement events with our nursing teams and
development of an action plan to help deliver on issues which nursing staff identified as
important. Launched a Nursing Awards scheme
 Using 6Cs to demonstrate issues & learning from patient harm; tissue viability posters.
 Quality boards outside all of our patient areas provide transparent information on monthly
incident data: Falls, Hospital Acquired Pressure Ulcers, MRSA & C Diff. From January 14
this board will also incorporate “Days Since ….” In relation to Falls, MRSA, Hospital Acquired
Pressure Ulcers & C Diff.
 Staffing Levels: From January 2014; staffing levels will be displayed on the Quality Boards.
 Medication Safety Thermometer for Omitted Doses data was been collected monthly since
November 13.
 NEWS: introduced Trust Wide in September 13 with escalation process to critical care
outreach.
 Safeguarding Helpline.
 Speak Out Safely: Supports the Nursing Times speak out safely campaign. Hospital Control
Team Helpline: Phone line to report any urgent issues or concerns relating to patient safety.


Patient Safety Meetings: Commenced twice a day since January 14. These meetings
follow the Patient Placement Meetings at 9.30am & 3.30pm; using the information gathered
from the wards Patient Safety Briefs.
Open & Honest Care: Driving Improvement: Since November 2013 we have been one of
sixteen Acute Trust boards in the North of England who have published data on safety,
effectiveness and experience with the overall aim of driving improvement s in practice and
culture. These reports are published on our public facing website.
Staff Engagement/Culture:
 Clear vision that Great Staff leads to Great Care and a Great Future. This is supported by
five values and a set of behaviours which were selected by staff. Communicated widely:
education and development programmes, staff induction, leadership development and
reward and recognition schemes.
 Great Leaders Programme; Middle management leadership programme introduced trust
wide in October 13.
 Monthly internal ‘pulse checks’ which assess the current views and mood among our staff.
Staffing Levels
The Board has approved £500K investment to increase frontline nursing within the Medicine Health
Group to improve patient care. In addition to this the numbers of nursing staff are being closely
monitored on a monthly basis and to assist in the Trusts business planning process for 14/15 and
beyond; workforce intelligence packs have been sent to service managers. The packs include %
turnover by department, age profile and attendance by staff group.
Other:
 Dementia Programme Board
The National dementia strategy (DoH 2009) identified five areas which must be prioritised in
order to enable people to live well with dementia. To address these areas HEY has created
a Dementia programme board chaired by Dr Dan Harman, Consultant Geriatrician. The
Dementia Programme Board are working with our partners across health, social and
voluntary sectors to ensure there is a lasting improvement in the quality of care received by
patients with dementia in our organisation.

Dementia Training
Two levels of training available planned in conjunction with the education and development
department
1) A one hour session suitable for anyone who may have an interest or who may come into
contact with someone who has dementia
2) A half- day session suitable for Staff who regularly care for patients with dementia or
anyone with an interest
So far 500 members of staff have accessed the training and we have dates planned for
2014.

Butterfly Scheme
Introduced into HEY in 2013, to date we have 225 Butterfly scheme champions
5.2 Progress on TOP 27
Appendix 3 demonstrates HEY’s compliance against “TOP 27” which incorporates the DoH’s
response from Hard Truths.
5.3 Items off Track
The “TOP 11” recommendations should have been completed by the end of December 2013, the
following recommendation are off track and will be reviewed at the next Francis Committee:
 Standard 12: Discussed within Health Groups but no formal process in place for wider
learning although this has commenced; 6Cs poster on Pressure Ulcers.
 Standard 111: Need posters in all clinical areas including outpatients




Standard 191: Values Based Recruitment not in place.
Standard 236: Awaiting further guidance from the Academy of Medical Royal Colleges who
are leading work to take this forward; they will produce Key Principles with worked examples
on how this can be implemented.
Standard 242: E Administration not in place.
Standard 243: E Observations not in place
Cavendish Review:
The training and support of healthcare assistants within HEY is currently being reviewed.
6. What Next.
Our “IWantGreatCare” results tell us that our patients rate, very highly, the care we provide.
Sometimes, though, our staff struggle to see themselves in the same way. Staff, underestimate the
excellent care they provide and forget that the amazing things they do every day. Therefore we plan
to hold a series of Big Conversations where we will encourage staff to talk about their stories, we
want the staff to talk about the great work that is being done within HEY and help to bring to life the
five domains that the report identified
 Standards: fundamental standards of care ‘owned’ by staff and patients
 Openness, transparency & candour: a willingness to receive & act on complaints &
feedback; transparency about performance.
 Leadership
 Compassion & care: stronger voice for nursing.
 Information: all healthcare professionals have a responsibility to help formulate measures of
the effectiveness of what they do and to make publicly available
First Big Conversation was held on the 10th January 13.
Caroline Grantham
Medicines Management Nurse
Patient Safety and Clinical Leadership
On behalf of
Amanda Pye
Chief Nurse
April 2014
The measures formulated by the National Institute for Health and Clinical Excellence should include
measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of
organisations.
The standard procedures and practice should include evidence-based tools for establishing what each
service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing
staff on wards, as well as clinical staff. These tools should be created after appropriate input from
specialties, professional organisations, and patient and public representatives, and consideration of the
benefits and value for money of possible staff: patient ratios.
It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as
well as to the numbers.
The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations should be made available to healthcare regulators through the serious untoward incident
system
in order to provide a check on the consistency of trusts’ practice in reporting fatalities and other serious
incidents.
Reports on serious untoward incidents involving death of or serious injury to patients or employees should
be shared with the Health and Safety Executive.
Provider organisations must constantly promote to the public their desire to receive and learn from
comments and complaints; constant encouragement should be given to patients and other service users,
individually and collectively, to share their comments and criticisms with the organisation.
Comments or complaints which describe events amounting to an adverse or serious untoward
incident should trigger an investigation.
Priority
HEY Top
11
109
111
The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to
be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance
and benchmarks where these exist and to demonstrate that effective risk assessments take place when
changes to the numbers or skills of staff are under consideration. It should also consider how more
outcome based standards could be designed to enhance the prospect of exploring deficiences in risk
management, such as occurred at the Trust.
Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple
gateways need to be provided to patients, both during their treatment and after its conclusion, although all
such methods should trigger a uniform process, generally led by the provider trust.
114
Priority
HEY Top 11
All the required elements of governance should be brought together into one comprehensive standard. This
should require not only evidence of a working system but also a demonstration that it is being used to
good effect.
HEY
Top
11
88
Standards should be divided into:
Fundamental standards of minimum safety and quality – in respect of which non-compliance should not
be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can
be brought against organisations. There should be a defined set of duties to maintain and operate an
effective system to ensure compliance;
Quality standards – such standards could set requirements higher than the fundamental standards but be
discretionary matters for commissioning and subject to availability of resources;
Developmental standards which set out longer term goals for providers – these would focus on
improvements in effectiveness and are more likely to be the focus of commissioners and progressive
provider leadership than the regulator. All such standards would require regular review and modification
Priority
Francis
15
40
Francis
Francis
Recommendation
89
Francis
93
Francis
Francis
Recommendation
Francis
Openness,
Transparency
& Candour
Recommendation
Task & Finish
Group
Francis
Values &
Standards
Recommendation
Task & Finish
Group
Recommendation
Openness,
Transparency
& Candour
Recommendation
Task & Finish
Group
Recommendation
Francis
Recommendation 23
Values &
Standards
Recommendation
Task & Finish
Group
Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or
some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are
entitled to receive feedback in relation to any report they make, including information about any action
taken or reasons for not acting.
Priority
HEY Top
11
Francis
Recommendation 2
Francis
Recommendation 5
Francis
Recommendation 13
Task & Finish
Group
Openness,
Transparency &
Candour
In reaching out to patients, consideration should be given to including expectations in the NHS Constitution
that:
Staff put patients before themselves;
They will do everything in their power to protect patients from avoidable harm;
They will be honest and open with patients regardless of the consequences for themselves;
Where they are unable to provide the assistance a patient needs, they will direct them where possible to
those who can do so;
They will apply the NHS values in all their work.
Francis
12
Values &
Standards
Recommendation
Task & Finish
Group
The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is
the priority in everything done. This requires:
A common set of core values and standards shared throughout the system;
Leadership at all levels from ward to the top of the Department of Health, committed to and capable
of involving all staff with those values and standards;
System which recognises and applies the values of transparency, honesty and candour;
Freely available, useful, reliable and full information on attainment of the values and standards;
A tool or methodology such as a cultural barometer to measure the cultural health of all parts of the
system
Priority
HEY Top 11
HEY’s TOP 27 Recommendation for Action
Appendix 1:
236
198
Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess
candidates’ values, attitudes and behaviours towards the well-being of patients and their basic care
needs, and care providers should be required to do so by commissioning and regulatory requirements.
Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess
candidates’ values, attitudes and behaviours towards the well-being of patients and their basic care
needs, and care providers should be required to do so by commissioning and regulatory requirements.
Priority
HEY Top
11
Every healthcare organisation and everyone working for them must be honest, open and truthful in all
their dealings with patients and the public, and organisational and personal interests must never be
allowed to outweigh the duty to be honest, open and truthful.
Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected
to double up, except in emergencies as part of the nursing provision on the ward. They should know
about the care plans relating to every patient on his or her ward. They should make themselves visible
to patients and staff alike, and be available to discuss concerns with all, including relatives. Critically,
they should work alongside staff as a role model and mentor, developing clinical competencies and
leadership skills within the team. As a corollary, they would monitor performance and deliver training
and/or feedback as appropriate, including a robust annual appraisal.
Healthcare providers should be encouraged by incentives to develop and deploy reliable and
transparent measures of the cultural health of front-line nursing workplaces and teams, which build on
the experience and feedback of nursing staff using a robust methodology, such as the “cultural
barometer”.
Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in
charge of a patient’s case, so that patients and their supporters are clear who is in overall charge of a
patient’s care.
239
In the absence of automatic checking and prompting, the process of the administration of medication
needs to be overseen by the nurse in charge of the ward or his or her nominated delegate. A frequent
check needs to be done to ensure all patients have received what they have been prescribed and what
they need. This is particularly the case when patients are moved from one ward to another or returned
to the ward after treatment
Priority
HEY Top
11
The recording of routine observations on the ward, where possible be done automatically as they are
taken; with results being immediately accessible to all staff electronically in a form enabling progress to
be monitored and interpreted. If this can not be done there needs to be a system whereby ward leaders
and named nurses are responsible for ensuring that the observations are carried out and recorded.
Priority
HEY Top
11
288
278
270
243
The care offered by a hospital should not end merely because the patient has surrendered a bed – it
should never be acceptable for patients to be discharged in the middle of the night, still less so at any
time without absolute assurance that a patient in need of care will receive it on arrival at the planned
destination. Discharge areas in hospital need to be properly staffed and provide continued care to the
patient
242
Regular interaction and engagement between nurses and patients and those close to
them should be systematised through regular ward rounds:
All staff need to be enabled to interact constructively, in a helpful and friendly fashion,
with patients and visitors.
Where possible, wards should have areas where more mobile patients and their
visitors can meet in relative privacy and comfort without disturbing other patients.
The NHS should develop a greater willingness to communicate by email with relatives.
The currently common practice of summary discharge letters followed up some time
later with more substantive ones should be reconsidered.
Information about an older patient’s condition, progress and care and discharge plans
should be available and shared with that patient and, where appropriate, those close to
them, who must be included in the therapeutic partnership to which all patients are
entitled.
Priority
HEY Top
11
As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting,
should be required to demonstrate in their annual learning portfolio an up-to-date knowledge of
nursing practice and its implementation. Alongside developmental requirements, this should contain
documented evidence of recognised training undertaken, including wider relevant learning. It should
also demonstrate commitment, compassion and caring for patients, evidenced by feedback from
patients and families on the care provided by the nurse. This portfolio and each annual appraisal
should be made available to the Nursing and Midwifery Council, if requested, as part of a nurse’s
revalidation process.
Priority
HEY Top
11
116
173
Francis
Francis
Francis
Francis
Recommendation
Francis
Francis
Recommendation
Leadership &
Foundation
Trust
Recommendation
Openness,
Transparency
& Candour
Francis
Task & Finish
Group
Recommendation
Francis
Recommendation
Care &
Compassion
Recommendation
Task & Finish
Group
Francis
Recommendation 238
Francis
Recommendation
Francis
Recommendation
Francis
Recommendation
195
Care &
Compassion
Where meetings are held between complainants and trust representatives or investigators as part of
the complaints process, advocates and advice should be readily available to all complainants who
want those forms of support.
Priority
HEY Top 11
Task & Finish
Group
Recommendation
Openness,
Transparency
& Candour
Francis
Francis
Recommendation
Recommendation 194
191
Task & Finish
Group
Recommendation
HEY’s TOP 27 Recommendation for Action
There is a need for a review by the Department of Health, the information Centre and UK Statistics
Authority of the patient outcome statistics, including hospital mortality and other outcome indicators.
It should be a routine part of an independent medical examiners’s role to seek out and
consider any serious untoward incidents or adverse incident reports relating to the
deceased, to ensure that all circumstances are taken into account whether or not
referred to in the medical records.
The Department of Health should ensure that there is senior clinical involvement in all policy decisions
which may impact on patient safety and well-being.
APPENDIX 2: Recommendations by Task & Finish Group (Blue indicates that HEY is compliant with that recommendations)
Task & Finish Group
Recommendation Number
7
8
11
14
15
98
178
5
13
23
93
2
4
1
Berwick Rec 2
Cavendish: Rec 3
Berwick: Rec 10
Berwick Rec 9
Cavendish: Rec 19
Keogh : Amb 6
Berwick Rec 2
Values &
Standards
Openness,
Transparency &
Candour
Keogh: Amb 4
Cavendish: Rec 3
Keogh: Amb 6
Berwick: Rec 4
Berwick: Rec 4
Total 14
12
40
Berwick
Rec 2/8/10
Keogh
Amb 3
160
44
58
88
89
109
Keogh
Amb 3
Keogh
Amb 3
Keogh
Amb 3
179
173
174
175
176
177
Berwick
Rec 10
Berwick
Rec 10
Berwick
Rec 10
Berwick
Rec 10
Berwick
Rec 10
110
180
111
112
114
Keogh
Amb 3
Berwick
Rec 2/3/7/8
Keogh
Amb 3
Berwick
Rec 7/8
Keogh
Amb 3
181
182
183
Berwick
Rec 10
115
255
Keogh
Amb 3
116
270
117
118
119
120
273
278
279
280
238
239
240
241
121
150
152
Total 37
143
Care &
Compassion
Keogh
Amb 2
194
197
195
198
199
Berwick
Rec 4
Berwick
Rec 3
200
207
202
208
Cavendish
Rec 11
236
Berwick
Rec 3
237
Berwick
Rec 3
242
243
256
Keogh
Amb 1
Total 20
47
Leadership &
Foundation
Trust
191
Cav
Rec 6
48
64
65
68
69
70
Keogh
Amb 2
217
218
245
72
75
74
Keogh
Amb 4
76
77
Keogh
Amb 3
Keogh
Amb 3
78
79
81
84
86
Keogh
Amb 3
204
205
Cavendish
Rec 13
Keogh
215
288
Keogh
Amb 8
Total 24
Information
36
37
244
Keogh: Amb 2
Berwick:Rec 2/7/8
Keogh: Amb 2
Berwick: Rec 7/8
Berwick:Rec 9
246
247
248
250
249
252
262
263
268
Total 12
HEY are working on 107 recommendation; this includes Top 11 & Top 27
3
6
9
10
16
17
18
Cavendish
Rec 3
Recommendations
not being actioned
33
34
35
38
39
Berwick
Rec 7/8/9
60
99
61
100
62
101
41
42
Berwick
Rec 9
63
102
66
103
67
104
19
20
Berwick
Rec 9
Cavendish
Rec 3
Berwick
Rec 9
43
45
21
46
22
24
25
26
27
28
49
50
51
52
53
54
85
87
90
91
92
29
30
31
32
Berwick
Rec 9
Berwick
Rec 9
55
56
57
59
94
95
96
97
Berwick
Rec 7/8
71
105
73
106
80
82
83
Berwick
Rec 9
Berwick
Rec 9
107
108
113
122
123
124
125
126
127
128
129
130
139
163
140
164
141
165
142
166
144
167
145
168
146
169
147
170
148
171
149
172
151
184
153
185
Berwic
k
Rec 4
Berwick
Rec 9
131
154
132
155
133
156
134
157
135
158
136
159
137
161
138
162
Cavendish
Rec 8/2
186
187
188
189
190
Cavendish
Rec 4
Cavendish
Rec 7/9/10
Cavendish
Rec 6
Cavendish
Rec 4
Cavendish
Rec 5
220
258
286
221
259
287
222
260
289
223
261
290
224
264
192
193
196
201
203
206
Berwick
Rec 4
225
265
226
266
227
267
228
269
229
271
230
272
231
274
209
210
211
Berwick
Rec 9
Cavendi
sh
Rec 15
Berwick
Rec 9
Cavendish
Rec 1
Berwick
Rec 9
232
275
233
276
234
277
212
213
214
216
219
253
283
254
284
257
285
Caven
dish
Rec 14
235
281
251
282
Appendix 3: HEY’s compliance against “TOP 27” which incorporates the Department of Health’s response from Hard Truths.
Top 11 Francis Recommendation 191:Assess nursing staff’s values, attitudes & behaviours at recruitment DoH Response: Hard Truths HARD TRUTHS ACCEPTED DoH has mandated to Health Education England (HEE) that all new NHS funded training posts incorporates testing of values‐based recruitment. NHS England is working with Health Education England and NHS Employers to support the introduction of values based recruitment & appraisal for all registered and unregistered staff. The three key objectives of HEE national values based recruitment programmes focus on: 1: Recruiting for Values in higher education institutions 2: Recruiting for Values in the NHS 3: Evaluating the impact of recruiting for values. HARD TRUTHS ACCEPTED in PRINCIPLE DoH are not mandating that ward managers must operate in a totally supervisory capacity. TOP 11 195: Supervisory Status for Charge Nurses TOP 11 236.Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient’s case, so that patients and their supporters are clear who is in overall charge of a patient’s care TOP 11 238. Regular interaction and engagement HARD TRUTHS ACCEPTED between nurses and patients and those Ward round in medicine; principles for best practice. close to them should be systematised Environments for dementia patients HARD TRUTHS ACCEPTED The Academy of Medical Royal Colleges is leading work to take this forward, they will produce Key Principles with worked examples on how this can be implemented. Evidence Project Group has been set up. Training pack developed. GAP Not in place, training for managers to commence June 14 ALL Health Groups will have supervisory Charge Nurses by April 2014. Monitored by staffing data base daily. Checked with all ward clinical areas patients are under a named consultant. Most specialities operate a Consultant of the week. Setting the Standard Medics section will monitor documentation in medical records re: Named Consultant. Relative Surgery’s commenced in some clinical areas Short notice sickness & vacancies will affect charge nurses being supervisory every shift On hold until further guidance. Need to standardize:  IDL across HG TOP 11 through regular ward rounds: *All staff need to be enabled to interact constructively, in a helpful and friendly fashion, with patients and visitors. *Where possible, wards should have areas where more mobile patients and their visitors can meet in relative privacy and comfort without disturbing other patients. *The NHS should develop a greater willingness to communicate by email with relatives. *The currently common practice of summary discharge letters followed up some time later with more substantive ones should be reconsidered. *information about an older patient’s condition, progress and care and discharge plans should be available and shared with that patient and, where appropriate, those close to them, who must be included in the therapeutic partnership to which all patients are entitled 242. In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse in charge of the ward, or his/her nominated delegate. A frequent check needs to be done to ensure that all patients have received what they have been prescribed and what they need. Dementia Training HARD TRUTHS ACCEPTED Chief Pharmacist leads on ensuring that all aspects of medicines use within its organisation are safe (RPSPS). Therefore local hospital pharmacy teams must ensure systems are in place to minimise risks to patients from medicines and working with doctors, nurses & management colleagues ensure that systems are robust and regularly monitored & audited. Local organisations must encourage a culture and systems which supports reporting & learning from medication mistakes & errors. Such systems must be set out in drug policies signed off by the Trust Board, with the board receiving regular reports on implementation and areas for improvement, together with remedial action plans. Most Charge Nurses state available at visiting and walk around patients & carer’s. Intentional rounding: introduced Trust wide in December 2013 All ward areas have access to a day rooms or Quiet rooms IDL: Nursing & Medical in Surgery only so include Nursing & medical discharge information. 
Relative surgery’s in all areas. 
Ward Rounds HEY now collecting Electronic Prescribing monthly data on Omitted doses via medication safety thermometer trust wide since November 2013: Prevalence Data HEY Drug Policy mirrors NMC guidance & GMC prescribing guidance. Setting the standard – Standard 10 reviews medicine management practices on wards & omitted doses. MOCK CQC inspection by internal pharmacy team Administration incidents report reviewed by SMPC every six months, * Supervisory Status for Charge Nurses * Weekly audits on drug charts by Charge Nurses * Intentional Rounding to be launched Trust Wide Dec 2014 * Staff (Drs, Pharmacists & Nurses report omitted doses via the incident reporting system. * Drug chart / Clinical Document prompts staff to document reasons for any omitted doses. * Drug Chart prompts good practice in prescribing: prescribers identification; no abbreviations, indication & duration for antibiotic prescribing; reconciliation. * NMC Standards for Medicines Management TOP 11 Top 11 incorporated into HEY drug policy. * Newly qualified nurses complete STEPs Programme on medicines management within first six months of qualifying. 243. E observation. If this cannot be done, HARD TRUTHS ACCEPTED NEWS has been introduced there needs to be a system whereby ward Nursing Technology Fund £100 million spread over 2 years. Trust wide (September). leaders and named nurses are responsible Three technology types: digitial pens, mobile technology & for ensuring that the observations are end of bed monitoring technologies. Funds to be NEWS was reviewed by the carried out and recorded. announced shortly Critical Care Outreach Team following introduction. This shows 96% compliance in completing observation correctly. Calls to the critical care outreach team have increased. The team’s workload has more than doubled and although it appears that unplanned critical care admissions and cardiac arrests are low it is too early to say whether this is due to the NEWS implementation. Report attached HEY current performance with observations completed correctly has increased to 94% on weekly audits 12 Reporting of incidents of concern HARD TRUTHS ACCEPTED ‐ All staff can report on relevant tp patient safety needs to be not NHS England will re‐commission the NRLS to improve its Datix only encouraged but insisted upon. Staff are entitles to receive feedback in relation to any report they make including information about any action taken or reasons for not acting. functionality uses and benefits. This will also strengthen reporting and learning from the most serious incidents, with quicker notification and feedback of the relevant lessons learnt and with efficient mechanisms for distributing incident reports to relevant organisations. ‐ Tier 2 reviews feedback ‐ policy in place ‐ Committee reports ‐ Big Conversation for Incidents in October 13 (HRI & CHH) ‐ Can report anonymously Friends & Family Test PALs posters in clinical areas TOP 11 111. Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually and collectively, to share their comments and criticisms with the organisation. TOP 11 complaints & pals team trained on SUI and Never Event criteria ‐ pals and complaints team reviewing NHS Choices ‐ investigations always take place ‐ SUIs and CIs have RCA ‐ safeguarding incidents & referrals ‐ discharge concerns Clear vision: Great Staff, 2. The NHS and all who work for it must HARD TRUTHS ACCEPTED adopt and demonstrate a shared culture in Shared core values: Great Care, Great Future. which the patient is the priority in *continue to use & prmote the core values & expectations Supported by five values TOP 11 HARD TRUTHS ACCEPTED The management of an effective system of complaints and patient feedback is a Board Level responsibility; an effective trust board will promote a culture of openness, recognise the value of patient comments and complaints and make it easy for patients, their families and carers to give feedback. An effective board will also be open about and publish regular information about the complaints it receives and the action it is taking as a result. The government wants to see every Trust make it clear to every patient from their first encounter with the hospital:  How they can complain when things go wrong  Who they can turn to for independent local support  That they have the right to go to the ombudsman if they remain dissatisfied  Details of how to contact the local HealthWatch 114. Comments or complaints which HARD TRUTHS ACCEPTED describe events amounting to an adverse The DoH strongly agrees that complaints amounting to a or serious untoward incident should trigger serious or untoward incident warrant independent local an investigation. investigation and we want to see all NHS Trusts using their statutory powers to offer this to patients. The current NHS England SI framework is a working draft and will therefore be updated and clarified in relation to this recommendation. everything done. This requires: * A common set of core values and standards shared throughout the system; * Leadership at all levels from ward to the top of the Department of Health, committed to and capable of involving all staff with those values and standards; * A system which recognises and applies the values of transparency, honesty and candour; * Freely available, useful, reliable and full information on attainment of the values and standards; * A tool or methodology such as a cultural barometer to measure the cultural health of all parts of the system for the NHS set out in the NHS constitution. *Values based recruitment *CQC core standards *New inspection regime Leadership at all levels  Effective leadership & engagement of staff  NHS leadership academy developing & implementing a programme of leadership support Information on the Attainment of the Values & Standards  Transparent approach to care  Legal changes that place a duty of candour on health care providers  New Inspection Regime Measuring Cultural Health  New Inspection regime will access the culture of the organisation  NHS boards to pay close attention to the culture of their organisation, actively dealing with cultural risks and seeking improvements in their organisational culture. The NHS constitution should be an important reference point for staff, patients with staff committed to its values. and a set of behaviours which were selected by staff. These are communicated widely and form the basis for our education and development programmes, staff induction, leadership development and reward and recognition schemes. Nursing teams: embed the Six Cs through wide scale engagement events; an action plan to help deliver on issues which nursing staff identified as important. Launched a Nursing Awards scheme which will recognise and reward nursing staff who work to the Six Cs. Great Leaders: ward sisters to understand their role in leading our values‐based system and empowering and enabling staff to deliver against our standards and objectives. Large number of staff engagement events (Big Conversations) since 2012 which have seen over 2,000 people given the opportunity to comment on and suggest new and creative ways of communicating with staff and patients as well as the importance of open and honest communication. Our Comms and Engagement strategy (2013) puts these values at its core. Established a patient panel, Installed ‘quality boards outside all of our patient areas; which provide transparent information about the performance of that area, in terms of infections, falls, pressure sores, staff attendance etc Information on our values is widely available on our Trust intranet site and is communicated in all corporate communications via – newsletters, team brief, emails etc TOP 11 The Trust has previously measured its cultural status in partnership with Denison and is running a whole organisation cultural assessment using Barratt values technique in November 2013. In addition we run monthly internal ‘pulse checks’ which assess the current views and mood among our staff. 5.In reaching out to patients, consideration HARD TRUTHS ACCEPTED should be given to including expectations Shared core values: 6Cs embedded into PDR in the NHS Constitution that: *continue to use & prmote the core values & expectations process from 2013/2014 *Staff put patients before themselves; for the NHS set out in the NHS constitution. outcomes measured *They will do everything in their power to *Values based recruitment through PDR process. protect patients from avoidable harm; *CQC core standards * They will be honest and open with *New inspection regime Focus groups “What does patients regardless of the consequences Leadership at all levels the NHS Constitution mean for themselves;  Effective leadership & engagement of staff *Where they are unable to provide the  NHS leadership academy developing & to you?” Nov13 assistance a patient needs, they will direct implementing a programme of leadership support them where possible to those who can do Information on the Attainment of the Values & Standards so  Transparent approach to care *They will apply the NHS values in all their  Legal changes that place a duty of candour on work health care providers  New Inspection Regime Measuring Cultural Health  New Inspection regime will access the culture of the organisation  NHS boards to pay close attention to the culture of their organisation, actively dealing with cultural Link HEY Values to the NHS Constitution into recruitment Values Jan 14 Need database or directory of specialist services that patients/carers can access. TOP 27 194: Annual performance review to include developmental requirements, training undertaken & demonstrate commitment, compassion and caring for patients, evidenced by feedback from patients & carers. risks and seeking improvements in their organisational culture. The NHS constitution should be an important reference point for staff, patients with staff committed to its values. 6Cs added to PDR HARD TRUTHS ACCEPTED IN PRINCIPLE DoH strongly encourage employers to use the full flexibilities in existing pay contracts so that pay progression is linked to quality of care not time services. NMC committed to introducing a proportionate & effective model of revalidation – subject to public consultation. Top 27 40: It is important that greater attention is paid to the narrative contained in for instance, complaints data as well as to the number HARD TRUTHS ACCEPTED The CQC is now making greater use of the information that it holds on complaints. The CQC already uses a range of information about complaints to inform the timing and focus of its inspections. The CQC will review how it best make use of complaints that it receives directly from individuals and the individual stories in complaints as well as the aggregated trends. Top 27 88. The information contained in reports for the reporting of injuries, diseases and dangerous occurrences regulations should be made available to healthcare regulators through the serious untoward incident system in order to provide a check on consistency of trusts practice in reporting fatalities and other serious incidents. HARD TRUTHS ACCEPTED In PRINCIPLE Information currently takes place but this information will be shared on a more regular basis under new working arrangements and will be reflected in the liaison agreement between the CQC and the HSE No robust system for collecting feedback on individual nurses query easier for specialist nurses. Family & Friends can be used if staff named and Compliments ‐ New HG Governance Report Trail during Q1 and Q2 ‐ Themes recorded ‐ Increased use of resolution meetings ‐ CLIP reports to OGC ‐ Complaints report ‐ DIGs – complaints themes ‐ Patient stories & DVDs ‐ Member of the Board reviews ever complaint and all signed off by CX ‐ Illustrating 6Cs with patient comments ‐ Patient Big Conversation RIDDORs reported to HSE then uploaded to NRLS ‐ CQC access information through NPSA ‐ NPSA uploaded weekly ‐ Quarterly RIDDOR report to the Health & Safety Ctte ‐ HSE Visit on Dermatitis ‐ Full investigation of every RIDDOR HARD TRUTHS ACCEPTED In PRINCIPLE An initial assessment of SUI should be carried out by the CQC as the specialist inspector of the health & adult social care providers with the ability to draw on the HSE expertise in investigations & prosecutions. This will be set out in the revised liaison agreement with the CQC and the HSE. TOP 27 89. Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive. TOP 27 109. Methods of registering a comment or HARD TRUTHS ACCEPTED complaint must be readily accessible and Refer to 111 easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, although all such methods should trigger a uniform process, generally led by the provider trust. TOP 27 116. Where meetings are held between HARD TRUTHS ACCEPTED complainants and trust representatives or Refer to 111 investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those forms of support. ‐ Benchmarked through DATIX (trial currently being undertaken with Birmingham University) If in relation to an employee it would be reported to HSE ‐ All SUIs go through the STIS system ‐ Patient related information is submitted via NRLS ‐ Friend’s & Family, PALs, Complaints, PALs office at CHH, can report through the intranet, message to matron ‐ policy in place ‐ relatives surgeries ‐ Learning Disabilities Nurse Advisor – provides feedback to PALs complaints process includes availably of ICAs ‐ A rep from patient experience team at all complex / difficult complaints meetings ‐ complaints/pals team have had advocacy training ‐ Chaplin and LD Nurse Advisor also act at advocates as required ‐ Trialling recoding meetings ‐ Information regarding advocacy included In Top 27 TOP 27 Top 27 complaints response letters
- Every SUI is 173. Every healthcare organisation and HARD TRUTHS ACCEPTED communicated to everyone working for them must be CQC proposed a framework for inspection which includes a persons effected honest, open and truthful in all their judgement of organisations based on their ability to - Being Open policy dealings with patients and the public, and promote an open, fair, transparent culture. Already a organisational and personal interests must requirement in professional codes of conduct and the NHS - Research & never be allowed to outweigh the duty to constitution promotes already emphasises the importance Development be honest, open and truthful of openness and honesty. - Standing Orders - LSA for Midwifery - Whistle blowing policy - Information Sharing polices - Serious Case Reviews - Complaints Process 270. There is a need for a review by the HARD TRUTHS ACCEPTED data available Department of Health, the Information The UK statistics authority is undertaking an independent ‐ ward boards publish Centre and the UK Statistics Authority of review, its findings will be studied closely in a view to help information on C.diff, the patient outcome statistics, including improve presentation of statistics to patients and the MRSA, complaints etc hospital mortality and other outcome public. ‐ performance report on intranet indicators. In particular, there could be benefit from consideration of the extent to ‐ Speciality reporting which these statistics can be published in a ‐ Quality Accounts form more readily useable by the public. ‐ Intervention Outcomes ‐ Annual Report Consultant mortality rates ‐ Confidential enquires of maternal deaths ‐ NHS Choices to be revamped in new year. ‐ Performance Report This is an action for the DH to undertaken. However, the Trust has a range of information already available to the public 278. It should be a routine part of an HARD TRUTHS ACCEPTED coroners write to the Trust TOP 27 TOP 27 independent medical examiners’s role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to ensure that all circumstances are taken into account whether or not referred to in the medical records 13.Standards should be divided into: *Fundamental standards of minimum safety and quality – in respect of which non‐compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations. There should be a defined set of duties to maintain and operate an effective system to ensure compliance; * Enhanced quality standards – such standards could set requirements higher than the fundamental standards but be discretionary matters for commissioning and subject to availability of resources; * Developmental standards which set out longer term goals for providers – these would focus on improvements in effectiveness and are more likely to be the focus of commissioners and progressive provider leadership than the regulator. All such standards would require regular review and modification. 15. All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a working system but also a demonstration that it is being used to good effect. The government intends publishing draft death certification regulations. if they have concerns and this leads to an investigation (rule 43) ‐ Medical examiner sits on SUI panels HARD TRUTHS ACCEPTED The DoH, NICE, NHS England & CQC are working on a new framework of standards. New regulations setting out fundamental standards of care will come into effect during 2014 and will apply to all providers CQC MHRA Regulatory Bodies: NMC; GMC etc CQUINNS Setting the Standard HARD TRUTHS ACCEPTED IN PRINCIPLE Quality Governance The DoH will consult on new regulations which introduce Framework fundamental standards of care and a clearer focus on Quality Accounts governance arrangements for complying with them. The CQC will consult on and issue guidance for providers which will cover all elements of governance covered by the new regulations. Subject to consultation and parliament the regulations will be put in place during 2014 and then Top 27 23.The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include evidence‐based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards, as well as clinical staff. These tools should be created after appropriate input from specialties, professional organisations, and patient and public representatives, and consideration of the benefits and value for money of possible staff: patient ratios TOP 27 198:Measure the cultural health of frontline nurses TOP 27 239. The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the middle of the night, still less so at any time without absolute assurance that a patient in need of care will receive it on implemented progressively in all sectors. HARD TRUTHS ACCEPTED The DoH have tasked NICE to set out authoritative, evidence based guidance on safe staffing by Summer 2014. The National Quality Board is publishing alongside this response a guidance document that sets out the current evidence on safe staffing and makes clear the immediate expectations on all NHS bodies what they must do to ensure that every ward & every shift has the staff needed to ensure that patients receive safe care. The NICE, NHS England, HEE and other national organisations will work together to ensure that NHS Trusts have the tools they need to make decisions to secure safe staffing and these decisions will then be subject to external scrutiny and challenge by commissioners, regulators and the public & the inspector of hospitals. HARD TRUTHS ACCEPTED Cultural Barometer evaluation of pilot in November 13. NHS England supports the use of tools such as cultural barometer and real time staff experience feedback. The friends & family test for staff will be rolled out from April 2014 HARD TRUTHS ACCEPTED Discharging patients where it is unsafe, because there is no care and support in place is clearly a matter of clinical negligence and a breach of the duty of care that professionals have towards those they care for. The DoH can see few situations where it would be reasonable to discharge a patient at night, unless it was both safe and the Acuity Tools E Rostering Skill Mix Staffing Boards on wards Acuity Daily: escalation process Incident Reporting System: Staffing Levels Service Reviews/Pathways (Chiefs) Recruitment Process: Right Skills PDR: Competence: Workforce plans Patient Safety Meeting commenced Jan 14 Not in pLace Datix: transfers/discharge after 10pm. RCA’s Transferred & discharges monitored weekly by senior nurses (Chief Nurse) TOP 27 TOP 27 arrival at the planned destination. Discharge areas in hospital need to be properly staffed and provide continued care to the patient. 93. The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence‐
based guidance and benchmarks where these exist and to demonstrate that effective risk assessments take place when changes to the numbers or skills of staff are under consideration. It should also consider how more outcome based standards could be designed to enhance the prospect of exploring deficiencies in risk management, such as occurred at the Trust express wish for the patient. HARD TRUTHS ACCEPTED IN PRINCIPLE The NHS litigation Authority will move to a new outcome focused approach. It will reduce claims by focusing members on areas which cause significant harm and in working towards improving clinical outcomes. Staffing levels will be assessed by regulators However revised pricing methodology for setting members contributions for their indemnity cover takes account of staffing & activity levels. This means that if all other factors are equal, organisations which have more staff to undertake activities with the same level of risk will pay less for their indemnity cover. Rewarding safer organisations. 288. The DoH should ensure that there is HARD TRUTHS ACCEPTED Staffing Ratios monitored on monthly basis. Risk Assessments: 1:8 Night 1:7 Day Staffing levels reported to Board via Chief Nurse. Board have invested 1 million into nurse staffing. Service Reviews /Pathways (Chiefs) Acuity Tools E Rostering Skill Mix Staffing Boards on wards Acuity Daily: escalation process via Patient Safety Meeting twice a day. Senior Nurse chairs meeting. Incident Reporting System: Staffing Levels Charge Nurses supervisory and Junior Sister role re: introduced. Recruitment Process: Right Skills PDR: Competence: Workforce plans. New starter to the Trust will commence 8hrly shifts only. Staffing levels have been reviewed by TDA Internal (includes): No GAP Identified in monitoring staffing levels No GAP Identified senior clinical involvement in all policy The DoH has put in place arrangements to ensure access to - Board members with decisions which may impact on patient clinical advice on the full range of issues it deals with. clinical background (6) safety and well‐being. - Medical Directors (4) as accountable officers - EMB - Clinical Statements of Assurance - Board and Committee arrangements (including Health Group Boards) Divisional triumvirates HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
SETTING THE STANDARD ANNUAL REPORT
Trust Board
date
Director
24th April 2014
Reason for the
report
The purpose of this annual report is to provide an overview of the Setting
the Standard results over the last 9 months since its inception in July
2013 and the work that is being undertaken to improve performance,
clinical leadership and eliminate avoidable harm.
Type of report
Concept paper
Amanda Pye – Chief
Nurse
Reference
Number
Author
1
RECOMMENDATIONS
The Board is asked to:
 note the progress made on Setting the Standard
 advise if any further information is required.
2
Key purpose
Information
3
4
√
Business
case
Review
Approval
Discussion
Assurance
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and prioritised
 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
All domains
CQC Regulation(s)
Assurance Framework
5
Caroline Grantham –
Medicines
Management Nurse
Strategic
options
Information √
Performance
Decision
2014 – 4 - 13
Ref:
Legal advice
BOARD/BOARD COMMITTEE REVIEW
This report has not been received at any other Board Committee.
√
√
√
√
√
No
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST PATIENT SAFETY AND CLINICAL LEADERSHIP Annual Report: Setting the Standard 1. Purpose The purpose of this annual report is to provide an overview of the Setting the Standard results over the last 9 months since its inception in July 2013 and the work that is being undertaken to improve performance, clinical leadership and eliminate avoidable harm which link to the trust’s strategic aims of:  Delivering excellent quality outcomes  Provide assurance to our regulators and commissioners that all necessary standards are being met. 2. Background The Setting the Standard framework was initially introduced in July 2013; following the Francis Report and subsequent reviews published by Keogh & Berwick. The framework is designed around a set of standards with the emphasis on delivering high quality safe effective care to patients, relatives and carers. The twelve standards are:  Standard 1: Patient Safety in the Environment,  Standard 2: Staffing  Standard 3: Culture  Standard 4: Respect & Dignity  Standard 5: Leadership  Standard 6: Infection Control  Standard 7: Communication  Standard 8: Record Keeping  Standard 9: Safeguarding  Standard 10: Medicine Management  Standard 11: Nutrition and Hydration  Standard 12: Pressure Ulcers The reviews are led by the Chief Nurse & Nurse Directors. The review team include the Divisional Nurses with specialist professional expertise to complete specific standards:
 Standard 6: Clinical Safety Infection Control reviewed by Infection Control Specialist Nurses  Standard 10: Medicines Management reviewed by Medicines Management Nurse  Standard 11: Nutrition: reviewed by Dieticians  Standard 12: Pressure Ulcers reviewed by Tissue Viability Nurses The Setting the Standard document has been formatted, to ensure the following:  Clear and transparent feedback for each ward  Collection and triangulation of appropriate outcome date  Ensure that reviews fit for purpose  Encompasses Ward to Board Philosophy  Reflect CQC essential standards  Reflect Bruce Keoghs reviews  Brings together all ward data collected to substantiate a ward categorisation which reflects the current standard it is at. The aim is to celebrate areas of excellent practice, identify what works well and where further improvements are needed, and a clear timescale for this to be delivered. The Charge Nurse, Matrons, Divisional Nurses and Health Group Nurse Director have receive feedback and subsequently developed action plans to improve performance where required. These action plans and reviews are monitored by the Chief Nurse. 2.1 The Setting the Standard review process.  Unannounced as per agreed time period following a review.  12 standards assessed. To meet each standard an average 80% of each standard must be achieved.  Each ward will have an assessment completed and will be accredited with a score Red to Gold. Reassessment will take place at a time interval dependent upon the results.  Following the assessment the Ward Manager and Matron will be required to formulate an action plan.  The Ward Manager and the Matron will be given two weeks to complete their action plan.  A copy of each assessment and action plan will be sent to the Divisional Nurse Manager and Nurse Director responsible for that area to approve and endorse in practice, and will be monitored through the Health Group Patient Safety Committee.  Action plans must then form part of every ward team meeting [which must be documented on monthly basis] and Ward Manager / Matron to track progress.  If the ward achieves NIL or RED then the Ward Manager will have an appraisal completed by the Divisional Nurse Manager, with clear objectives set. If the ward gets a second consecutive Red overall then the Charge Nurse/Matron will have an appraisal completed by the Nurse Director.  Progress reports will be monitored through the Patient Safety Committee.  In the absence of the Ward manager on the review a meeting will be set up to discuss any areas of concern, and agree if any further evidence available, if this is appropriate  When a ward maintains GOLD status for three consecutive “Setting the Standard” Reviews, the ward can then apply for PLATINUM STATUS. 2.2 Platinum Status When a ward maintains GOLD status for THREE consecutive “Setting the Standard” Reviews, the ward can then apply for PLATINUM STATUS. To achieve Platinum status a ward has to:  Complete seven enhanced quality standards  Produce an evidence folder demonstrating how the ward is continual delivering high quality, safe care.  The ward team will be asked to present before a Panel (Panel will consist of: Chief Nurse, Chief Executive, Non‐Executive Director & Patient Representative) once the seven enhanced quality standards have been completed. This will consist of a 30 minutes question and answer session and the panel will carry out a ward visit. The panel will then decide whether the ward achieves PLATINUM STATUS.  Any ward that holds platinum status will have a yearly review. To date two platinum standards have been devised:  Enhanced Quality Standard 1: The Clinical Area as a Learning Environment  Enhanced Quality Standard 2: Spiritual Care In progress:  Enhanced Quality Standard 3: Dementia Friendly Environment 3. Performance 2013 ‐ 2014 3.1 Performance by Clinical Area Following the reviews completed in October 2013, 32% of the total wards reviewed where classified as Red. This has subsequently reduced to 21% by the end of November 2013 (Appendix One). 12% of clinical areas are now classified as RED and 64% of areas are now classified as SILVER. Month Clinical Areas: Wards & Critical Care 49 (43) Number of: RED Wards BRONZE Wards SILVER Wards GOLD Wards March 14 6 (12%) Month RED OPD March 14 0 12 (24%) 31 (64%) 0 OUTPATIENT AREAS: 6 (27) Number of: BRONZE OPD SILVER OPD 0 5 (83%) GOLD OPD 1 (17%) So far six outpatient areas out of a total of 27 have been completed see table above for average scores. 3.2 Performance by Standard The table below show that performance by each individual standard has improved over the last nine months. The majority of individual standards are now SILVER (37%), with the number of individual gold standards increasing to 176 (30%) from 105. Month March 14 Performance by Standard: Number of Standards RED standards BRONZE SILVER standards GOLD standards standards 107 (18%)↓ 85 (15%)↑ 219 (37%)↑ Across all the Health Groups the standards which are predominately Red are: 176 (30%)↑ Standard 11: Nutrition Standard 12: Pressure Ulcers Month 1 2 Red March 14 1
↔ 1↓ Bronze 5↓ 9↑ 1↓ 3↓ 3↓ 9↑ 5↑ 8↑ 3
↔ 19
↑ 24
↑ 16
↔ 30
↑ Gold 25
↑ 13
↑ 19
↑ 20
↓ 12
↓ 33
↑ 5↓ 20
↓ 3↓ 19
↑ 24
↑ 2↓ 9
↔ 9↓ Silver 1↓ Performance per Standard: Individual Standard 3 4 5 6 7 8 9 10 11
↑ 30
↑ 17
↑ 3
↔ 6↓ 25
↑ 13
↑ 24
↑ 8↓ 2↑ 11 12 25
↓ 11
↑ 25
↓ 12
↑ 10
↑ 8↑ 4↑ 2↑ 3.3 Performance by Health Group All Health Groups have improved their overall performance or maintained performance at previous level (see table below). Three Health Groups performance overall is now Silver with one Health Group maintaining their performance at Bronze. The Trust’s overall performance remains at Bronze although this has increased from 81% to 84%. Overall Performance by HEALTH GROUP Health Group November 13 March 14 82% 81% 79% 77% 81% Medicine Surgery Clinical Support Family & Women’s HEY OVERALL PERFORMANCE 82% 86% 87% 85% 84% ↔ ↑ ↑ ↑ ↑ Health Group Nov 13 Medicine Surgery Clinical Support Women & Family Overall % per Standard by Health Group 5 6 7 8 9 10 87% 85% 81% 90% 89% 84% 1 86% 2 90% 3 85% 4 89% 11 62% 12 72% Total 82% Mar 14 92%
↑ 90%
↔ 87%
↑ 90%
↑ 92%
↑ 84%
↓ 88%
↑ 83%
↓ 93%
↑ 87%
↑ 68%
↑ 73%
↑ 82%
↑ Nov 13 92% 90% 85% 97% 88% 80% 88% 81% 79% 85% 71% 71% 81% Mar 14 94%
↑ 91%
↑ 83%
↓ 98%
↑ 93%
↑ 83%
↑ 83%
↓ 88%
↑ 92%
↑ 86%
↑ 78%
↑ 83%
↑ 86%
↑ Nov 13 85% 85% 88% 98% 84% 73% 89% 80% 85% 82% 70% 77% 79% Mar 14 92%
↑ 90%
↑ 87%
↓ 100
% 95%
↓ 78%
↑ 96%
↑ 84%
↑ 92%
↑ 86%
↑ 91%
↑ 81%
↑ 87%
↑ Nov 13 86% 86% 87% 95% 88% 89% 85% 88% 94% 86% 74% 65% 77% Mar 14 90%
↑ 87%
↑ 86%
↓ 96%
↑ 92%
↑ 83%
↓ 82%
↓ 90%
↑ 92%
↓ 87%
↑ 72%
↓ 71%
↑ 85%
↑ Nov 13 88% HEY Overall % Mar 14 89% 86% 94% 87% 83% 85% 85% 87% 84% 57% 71% ↑ ↑ ↓ ↑ ↑ ↔ ↑ ↑ ↑ ↑ ↑ ↑ 92% 90% 80% 95% 93% 83% 86% 86% 93% 86% 76% 72% 4. Improvement work 4.1. Setting the Standard Committee Members of the review team meet bi‐monthly to discuss progress, pending reviews, themes and improvement work. 4.2. Improvement Work 2013 – 2014  Nutrition: New process introduced across the organisation in Jan/Feb 13. Nutrition risk assessment and care plan revised and reformatted.  Intentional Rounding: Introduced trust wide in December 2013 but the process needs embedding within the organisation; clinical areas will be monitored on this as part of the Setting the Standard review process.  Daily Ward Safety Briefings: Standardize across the organisation and introduced trust wide; patient safety issues are escalated from these briefing to the Patient Safety Meeting twice a day.  Patient Safety Meeting: commenced twice a day since January 2014.  Pressure Ulcers: Tissue Viability Nurses working with Health Groups to address their individual issues e.g. Surgery Health Group have more devised related pressure ulcers. Tissue viability risk assessment revised and care plan reformatted  Nursing documentation revised and reformatted: document reduced and all the risk assessments have been removed and will be a standalone document.  Standardize Student Booklets across all clinical areas.  Quality Boards: standardized across the organisation. (Safety Thermometer, I Want Great Care & 6Cs)  Safety Cross: for short term & long term sickness introduced  Safeguarding: New process introduced November 2013. 4.3 Improvement Work Planned 2014 – 2015  Nutrition: Large scale testing of revised nutritional risk assessment form and care plan to commence in May 2014.  Pressure Ulcers: Large scale testing of revised “Skin integrity” risk assessment and care plan to commence in May 2014.  Nursing Documentation & In patient Risk Assessments: Large scale testing of revised documentation to commence in May 2014. This will now also include section on infection control admission risk.  Mandate specific link nurses roles across the organisation with defined responsibilities  Ward Round Documentation & Process to be reviewed 5. Next steps 5.1. Clinical Areas During 2014; the Setting the Standard review process will spread to incorporate other clinical areas: Theatres & the Emergency Departments. 5.2. I Want Great Care Staff Questionnaire From April 2014 we will start to use the results from the IWantGreatCare Staff questionnaires to triangulate with Standard 3: Culture. 5.3. New Standards 5.3.1 Medical Team: A standard to review documentation by the medical team is currently being devised (Appendix 2). The standard will assess documentation by the medical team; specifically issues such as treatment 81% 84
↑ and escalation plans being in place, consent and DNAR status being recorded. As well as patient experience: does the patient know the name of the doctor responsible for their care and has their treatment plan been discussed with them. Testing of this standard will take place in April. 5.3.2. Patient Journey/Pathway: The “Setting the Standard” review document currently addresses specific issues within a clinical area e.g. Medicines Management, Record Keeping and Infection Control. These standards are then amalgamated to give each clinical area an overall performance score. The next step is how we assess and monitor our performance against specific patient pathways/ journeys through the organisation. This is important as it will allow us to measure patient experience and patient outcomes. For example: The elderly care/frail older person pathway Frail older people are at greater risk of experiencing significant harm if admitted to hospital as an emergency. Levels of avoidable harm among older people are considerably higher and qualitative feedback from this patient group or carers state that key information is not communicated across interfaces of care. Therefore; monitoring performance along this patient pathway could include:  Was the patient seen by their GP prior to admission?  If patient admitted from another care setting (Residential/Nursing Home did we received written information about the patient e.g. Patient Passport?  How long was the patient in the Emergency Department?  How soon did medicines reconciliation take place?  How many missed doses did the patient have prior to full reconciliation?  How soon after admission where all inpatient risk assessment completed?  How soon was a treatment plan & escalation plan put in place?  How many ward moves did the patient experience?  Care package to support discharge should be available within 24hrs? 6. Recommendations The Board is asked to:  note the progress made on Setting the Standard  advise if any further information is required. Caroline Grantham MEDICINES MANAGEMENT NURSE On Behalf of Amanda Pye CHIEF NURSE April 2014 Setting the Standard: Ward to Board
Via Clinical Area (MARCH 2014 Results)
Appendix 1
STANDARDS
Clinical
Area
One:
Two:
Three:
Four:
Five:
Six:
Seven:
Eight:
Nine:
Ten:
Eleven:
Management
of the Clinical
Area
Staffing
Culture
Respect &
Dignity
Leadership
Clinical
Safety
Communication
Record
Keeping
Safeguarding
Medicines
Management
Nutrition
Twelve:
Pressure
Ulcers
Overall Review
Next Review Due
AAU
H1
PHDU
H4
H40
H5
H50
H6
H60
H7
H70
ESSU 8/80
92%
100%
88%
96%
84%
100%
96%
100%
100%
96%
100%
96%↓
96%
100%
96%
92%
80%
92%
88%
100%
92%
88%
92%
92%↔
100%
100%
100%
86%
85%
100%
100%
100%
85%
57%
100%
100%↔
91%
100%
90%
100%
90%
100%
92%
100%
100%
100%
84%
91%↓
95%
100%
94%
96%
95%
96%
100%
95%
96%
100%
90%
96%↑
77%
76%
98%
92%
87%
87%
84%
85%
83%
84%
93%
82%↑
87%
81%
93%
93%
78%
87%
100%
93%
100%
100%
86%
81%↓
91%
90%
95%
86%
86%
89%
86%
92%
96%
93%
96%
81%↓
95%
100%
93%
100%
100%
96%
100%
100%
100%
91%
93%
95%↓
81%
88%
94%
83%
85%
89%
92%
93%
90%
87%
92%
81%↔
80%
52%
81%
67%
76%
67%
70%
58%
72%
79%
46%
64%↑
71%
82%
86%
75%
93%
57%
90%
73%
82%
85%
70%
82%↑
86%
83%
94%
84%
85%
83%
86%
84%
89%
88%
85%
81%↑
August 14
June 14
April 2014
May 14
August 14
July 14
October 14
July 14
September 14
October 14
April 2014
April 14
H9
H90
H10
H100
H11
H110
H12
130
ACORN
H30
H35
Rowan
Maple
Labour
C2
C8
C9
C10
C11
C14
C15
C16
C19
C20
C21
C22
C26
C27
C28
C30
C31
C32
C33
100%
100%
84%
92%
84%
100%
95%
88%
91%
100%
92%↑
100%
76%
91%
83%
88%↓
96%
95%
100%
88%↓
92%↑
80%
91%↑
92%
92%
92%↑
91%
100%
100%
96%↑
92%↑
88%
95%↑
88%
85%
81%
95%
84%
87%
100%
84%
68%
88%
86%↑
100%
91%
92%
88%
84%↓
85%
92%
84%
96%↑
93%↑
81%
88%↑
92%
70%
92%↑
84%
100%
96%
91%↓
92%↑
84%
92%↑
86%
86%
57%
85%
100%
57%
100%
86%
71%
100%
100%↔
100%
60%
86%
100%
86%↓
86%
100%
85%
86%↑
100%↔
71%
86%↑
85%
85%
86%↑
57%
85%
100%
100%↔
100%↑
57%
100%↑
100%
100%
100%
91%
91%
66%
100%
100%
100%
100%
92%↑
100%
90%
100%
92%
100%↔
100%
100%
100%
100%↑
100%↑
100%
83%↓
100%
91%
83%↓
100%
100%
92%
100%↔
100%↔
100%
100%↔
100%
91%
80%
72%
79%
95%
63%
74%
95%
95%
96%↑
100%
100%
86%
100%
80%↑
96%
100%
100%
100%↑
95%↑
84%
87%↑
100%
75%
92%↓
100%
100%
100%
87%↑
96%↑
100%
95%↑
77%
72%
77%
79%
89%
81%
60%
81%
61%
71%
72%↓
91%
94%
75%
92%
75%↑
87%
85%
80%
80%↑
73%↓
73%
74%↓
95%
87%
82%↑
74%
88%
87%
77%↓
77%↑
70%
73%↓
100%
94%
75%
92%
93%
93%
100%
81%
69%
75%
94%↑
87%
94%
75%
87%
93%↑
93%
100%
100%
80%↑
100%↑
94%
87%↔
100%
87%
81%↑
87%
86%
100%
100%↑
93%↑
93%
93%↑
92%
89%
71%
87%
74%
65%
67%
98%
82%
87%
90%↑
84%
95%
96%
97%
83%↑
82%
93%
93%
80%↑
85%↓
89%
85%↓
91%
74%
95%↑
78%
94%
85%
86%↑
82%↑
68%
85%↑
100%
80%
86%
100%
90%
90%
100%
96%
95%
91%
93%↑
91%
93%
91%
100%
82%↑
92%
100%
100%
99%↑
60%↓
95%
78%↓
94%
96%
100%↑
72%
100%
97%
87%↓
93%↑
95%
91%↑
82%
85%
81%
84%
85%
82%
91%
72%
90%
97%
94%↑
93%
85%
90%
86%
86%↑
86%
82%
83%
87%↑
80%↓
80%
88%↑
94%
81%
83%↓
95%
89%
88%
81%↑
82%↑
84%
88%↑
63%
83%
59%
79%
65%
61%
67%
68%
62%
80%
65%↓
91%
100%
NA
82%
98%↑
77%
81%
90%
67%↓
91%↑
79%
74%↑
87%
81%
66%↓
84%
80%
78%
87%↑
96%↑
97%
87%↑
96%
77%
80%
92%
54%
59%
77%
86%
48%
55%
84%↑
57%
50%
78%
80%
67%↑
89%
82%
78%
86%↑
72%↓
84%
76%↑
90%
74%
73%↓
80%
83%
60%
72%↑
74%↓
86%
84%↑
85%
86%
76%
86%
74%
72%
71%
84%
74%
87%
85%
88%
87%
91%
92%
85%
84%
88%
89%
81%
85%
84%
82%
91%
79%
84%↑
86%
89%
87%
85%
87%
87%
86%
September 14
August 2014
May 14
October 14
April 14
April 14
March14
July 14
May 2014
September 2014
June 14*
October 14
April 14
October 14
April 14
July 14
June 14
October 14
October 14
April 14
June 15
April 14
May 14
September 14
March 14
March 2014
August 14
September 14
April 2014
June 2014
July 14
September 14
July 14
STANDARDS: CRITICAL CARE
Clinical
Area
One:
Two:
Three:
Four:
Five:
Six:
Seven:
Eight:
Nine:
Ten:
Eleven:
Management
of the Clinical
Area
Staffing
Culture
Respect &
Dignity
Leadership
Clinical
Safety
Communication
Record
Keeping
Safeguarding
Medicines
Management
Nutrition
Twelve:
Pressure
Ulcers
Overall Review
Next Review Due
100%
98%
92%
90%
92%
95%
97%
96%
85%
85%
65%
85%
100%
100%
100%
100%
95%
90%
86%
91%
100%
92%
66%
100%
82%
74%
77%
86%
81%
90%
88%
90%
93%
94%
94%
92%
83%
89%
91%
83%
89%
97%
79%
76%
88%
89%
84%
87%
August 14
August 14
May 14
August 14
Overall Review Next Review Due Sept 14
December 2014
GICU1
GICU2
HDU
ICU
87%
90%
86%
87%
STANDARDS: OPD One:
Two:
Three:
Four:
Five:
Six:
Seven:
Eight:
Nine:
Ten:
Management of
the Clinical Area
Staffing
Culture
Respect &
Dignity
Leadership
Clinical Safety
Communication
Record Keeping
Safeguarding
Medicines
Management
Cardiac OPD CHH
69%
90%
71%
75%
100%
87%
75%
95%
84%
100%
Cardiac 5 Day
Ward
Cath Lab
CHH
Plastics OPD &
Clean Room
Pre – Assessment
CHH
ENT OPD
CHH
100%
100%
85%
88%
100%
91%
100%
100%
83%
94%
88%
96%
82%
90%
85%
100%
90%
82%
83%
66%
75%
97%
91%
Sept 14
91%
88%
57%
75%
66%
78%
85%
89%
100%
100%
86%
October 14
100%
80%
100%
85%
83%
79%
100%
97%
92%
91%
October 14
100%
95%
100%
87%
92%
89%
85%
100%
83%
93%
October 14
OPD
Area 100%
Setting the Standard: Ward to Board via Divisions
Health Group
STANDARDS
One:
Two: Staffing
Three: Culture
Management of
the Clinical Area
Four:
Five:
Six:
Seven:
Eight: Record
Nine:
Ten:
Eleven:
Twelve:
Respect &
Dignity
Leadership
Clinical Safety
Communication
Keeping
Safeguarding
Medicines
Management
Nutrition
Pressure Sores
Overall
Average By
Division
MEDICINE
Speciality Medicine
Wards
Speciality Medicine
OPD
Emergency
Medicine
181/12
93%
124/10
92%
45/9
83%
48/2
96%
177/26
87%
126/15
89%
66/4
94%
50/1
98%
48/6
88%
32/6
84%
17/4
80.9%
14/0
100%
88/9
90%
67/7
90%
21/3
87%
23/1
95%
168/19
89%
113/10
91.8%
34/1
97%
48/1
97.9%
319/55
85%
284/49
85%
79/12
86.8%
56/17
76%
108/17
86%
87/6
93.5%
36/4
90%
27/5
84%
1476/271
84%
826/249
76.8%
134/5
96%
425/43
90.8%
259/19
93%
204/11
94.8%
30/6
83%
66/2
97%
742/121
85%
510/78
86.7%
143/4
97%
173/31
84.8%
701/341
67%
465/171
73%
473/154
75%
256/121
67.9%
122/70
63.5%
105/32
76.6%
Health Group
Overall Averages by
Standard
398/33
92%
419/46
90%
111/16
87%
199/20
90%
363/31
92%
738/133
84%
258/32
88%
2861/568
83%
559/38
93%
1568/234
87%
1288/582
68%
834/307
73%
9596/2040
Acute Surgery
H100/C14
Health Group
Overall Averages by
Standard
165/5
97%
98/7
93%
143/9
94%
45/5
90%
165/12
93%
105/5
95%
131/22
85%
48/2
96%
43/6
87%
31/10
75%
36/6
85%
12/2
85%
83/0
100%
20/0
100%
69/1
98%
22/1
95%
161/3
98%
79/8
90%
134/10
93%
40/6
86%
210/44
82%
137/19
87%
182/40
82%
62/16
79%
1371/107
92%
327/78
80%
1058/162
86%
361/71
83%
81/5
94%
35/5
87%
80/6
93%
23/1
95%
651/99
86%
213/14
93%
542/97
84%
200/32
86%
761/201
79%
252/40
86%
523/161
76%
197/73
72%
350/92
79%
200/31
86%
271/51
84%
101/12
89%
4143/602
87%
1555/227
87%
3254/572
85%
1136/225
83%
451/26
94%
449/41
91%
122/24
83%
194/2
98%
414/27
93%
591/119
83%
3117/418
88%
219/17
92%
1606/242
86%
1733/475
78%
922/186
83%
10088/1626
Ward
Areas
114/9
92.6%
112/12
90.3%
29/4
87.8%
60/0
100%
116/6
95%
892/162
84.7%
101/8
92.6%
449/72
86%
754/69
91.6%
296/67
81.5%
3146/452
87.4%
Health Group
Averages by
Standard
92.6%
90.3%
87.3%
100%
95%
78.9%
96%
84.7%
92.6%
86%
91.6%
81.5%
87.4%
Children’s & YP
Services & H35
99/10
90%
78/9
89%
113/12
90%
72/15
82%
27/5
84%
23/3
88%
49/1
98%
38/2
95%
104/6
94%
77/9
89%
169/35
82%
175/33
84%
64/15
81%
53/10
84%
702/80
89%
554/59
90%
112/9
92%
109/8
93%
291/40
87%
165/25
86%
211/45
82%
248/128
66%
11/52
68%
95/31
75%
2052/310
86%
1687/332
83%
Health Group
Averages by
Standard
177/19
90%
185/27
87%
50/8
86%
87/3
96%
181/5
92%
344/68
83%
117/25
82%
1254/139
90%
221/17
92%
456/65
87%
459/173
72%
206/83
71%
3737/642
General Medicine
Critical Care Areas
Trauma Surgery
Specialist Surgery
Women’s Services
SURGERY
102/33
97%
58/10
85%
84/7
92%
25/4
86%
269/54
83%
CLINICAL SUPPORT
150/40
73/3
78.9%
96%
4740/1050
81%
3094/733
80%
605/52
92%
1157/205
84.9%
82%
86%
85%
Appendix Two STANDARD THIRTEEN: MEDICAL STAFF
Yes (Y) No (N) or
Not Applicable (NA)
ENVIRONMENT
Daily Consultant presence on the ward
Patients reviewed by a senior medic daily: Board Round
Ward Round
PATIENT
Did the Doctors looking after you give you an opportunity to ask questions?
Do you know which Doctor is responsible for your care?
Have the Doctors explained what they think is wrong with you and discussed your treatment plan with you?
If the patient has consented for a procedure the patient received written information.
DOCUMENTATION
Clinical Records
1
Consultant in overall charge of patient care clearly
recorded
All entries will be signed in full & dated:
Time
Date
Signature
Printed Name
GMC number
Grade
Every Clinical Sheet must bear the name of the patient,
an approved NHS identification number or date of birth,
ward & site on both sides of the record sheet if notes are
written on both sides
All entries will identify the most senior healthcare
professional present (who is responsible for decision
making) at the time the entry is made.
Treatment plan in place
Escalation Plan documented
On each occasion the consultant responsible for the
patients care changes, the name of the new responsible
consultant and the date and time of the agreed transfer of
care should be recorded
Record clearly demonstrates involvement of the patient in
Response Yes (Y) No (N) or Not Applicable (NA)
2
3
4
5
6
7
8
9
10
decisions about their care
Mental capacity documented
DNAR:
DNAR status documented
If not for DNAR the decision correctly:
recorded in Medical Notes
Discussed with patients relatives i
Form completed correctly
CONSENT
There is a record of the discussion held with the patient?
Have the following been explained to the patient :
Intended benefits
Possible risks
Alternative treatments, where these exist
Is there a record that the patient has consented to the
procedure/treatment
Has the health professional completed page one fully
Has the health professional completing the consent:
Dated the consent form
Printed their name
GMC Number
Designation
Has the form been signed by the patient
If No has the patients representatives signature been
dated?
Is the patients representatives name printed?
Is there evidence that the pink copy has been given to the
patient?
Standard Ten: Questions Scoring
RED
BRONZE
Total Yes’s
SILVER
GOLD
Total No’s
Percentage Score for this Standard
CORPORATE PERFORMANCE REPORT 2014/15
Report Month:
April 2014
CONTENTS
Page Number
Executive Summary
Executive Summary
4
Foundation Trust
Monitor Compliance Framework Scorecard
Monitor Compliance Framework Exception Report
Foundation Trust Membership
6
7
8
Quality Metrics
Quality Scorecard – Effectiveness
Exception Reporting : Mortality
Exception Reporting: Pneumonia Deaths
Exception Reporting: Maternity
Exception Reporting: Ventilator Acquired Pneumonia
Exception Reporting: Fracture Neck of Femur
Quality Scorecard – Safety
Exception Reporting: Missed Doses
Exception Reporting: HealthCare Acquired Infections
Exception Reporting: Falls
Exception Reporting: Tissue Viability
Exception Reporting: Serious Incidents
Quality Scorecard – Experience
Exception Reporting: Transfers
Exception Reporting: Quality of Life for People with Long Term Conditions (LTC)
Exception Reporting: Stroke Dashboard
Exception Reporting: Stroke
Exception Reporting: Cleanliness
Exception Reporting: CQC Intelligent Monitoring
11
13
16
18
19
20
21
23
24
26
28
30
31
32
33
34
35
36
37
Finance and Business
Financial Summary
Financial Risk Rating
Financial Risk Rating Metrics
Contracting
Cash Releasing Efficiency Savings Programme
Cash and Working Capital Management - Stock
Cash and Working Capital Management - BPCC Performance
Cash and Working Capital Management - Receivables
Cash and Working Capital Management - Payables
Capital Programme
Cash and Working Capital
Statement of Comprehensive Income
Statement of Financial Position
Bridge Analysis
40
41
42
43
44
45
46
47
48
49
50
51
52
53
Operational Delivery
KPI dashboard
Exception Report
55
59
Workforce
Workforce Progress Report
Workforce Performance - Health Group and Directorate Position Against Plan
Workforce Key Performance Indicators
73
74
75
Page 2 of 84
Appendices
Appendix A: Quality Scorecard Notes
Appendix B: Infection Control – Days Since Infection By Ward
Appendix C: CQC Intelligent Monitoring – Tier 1 indicators breakdown
Appendix D: Version Control
Page 3 of 84
EXECUTIVE SUMMARY
Quality and Safety
Mortality indicators remain on track
Fluid balance remains below target – Chief Nurse is reviewing
Cardiac arrest calls received is not on target however, further explanation is included in the report
AMI reduction in length of stay remains off track and continues to be variable month to month
Pneumonia deaths in spiked in January and have since fallen. An exception report is provided
C-Section rates year to date are above peer, Q4 showed an upwards trend
Reporting of incidents has improved, and was above Trust target in Quarter 4
VTE is currently being validated for March
C.Diff finished the year above trajectory (3 cases)
Falls – The full year is above target however the last 3 months have seen the number of falls
decrease month on month.
There has been 1 never event in March (Retained Foreign Object)
Finance
The Trust is reporting a trading surplus of £5.9m for the year end 2013/14 and in doing so has
delivered the forecast. The original plan was for a trading surplus of £7.3m , the revised forecast
and actual results therefore being £1.4m below plan.
In month the Trust has generated a surplus of £1.3m and an EBITDA of 7.6%. The year ended
2013/14 EBITDA margin was 6.2%
The current month variance against plan reflects the assumption in the original plan on funding of
£7.3m in March from CCG’s for capital.
Performance
RTT:
An RTT Recovery Plan has been submitted to the Executive Management Board and
following that the Trust Board in April to assess the options for the delivery of RTT in
2014/15.
The Trust reported 10 x 52 week waiters. A paper has been reviewed by the Performance
and Finance committee in March outlining the actions that have and will be taken.
A&E
An Emergency Department recovery plan outlining actions to be taken in 30, 60 and 90 days
has been reviewed by the Trust Board in March and the actions are being implemented.
Page 4 of 84
Cancer Waiting Times
A Cancer Waiting Times Recovery Plan has been reviewed by the Trust Board in March and
the actions are being implemented.
Workforce
At the start of the financial year the Trust was planning a reduction of approximately 140 Contracted
WTE in 13/14. This was reflected in the reduction in Contracted WTE in Q1 and Q2. However in
Q2 and Q3 the Health Groups revisited their workforce plans due to additional business cases and
additional work being undertaken. The Trust has also recently seen an increase in staffing due to
winter pressures.
The Trust over the last 12 months has increased by 0.50% in attendance, 4.7% in
mandatory/statutory training and 0.4% in retention. There has been a 5.2% decrease in appraisals
over the last 12 months. The % appraisal is excluding staff with less than 1 years service and those
who are not on AfC terms and conditions.
There are 59 open employee relations cases. In March 2014 a total of 11 cases were resolved and
16 new cases were opened.
Page 5 of 84
MONITOR COMPLIANCE FRAMEWORK SCORECARD
RISK ASSESSMENT FRAMEWORK
GOVERNANCE
INDICATORS
CQC
REGISTRATION
CNST RATING
Green
Red
Green
FINANCIAL RISK RATING
Risk Rating Score Key
1 - Highest risk - high probability of significant breach of authorisation in short-term, e.g. <12 months, unless remedial action is taken
2 - Risk of significant breach in medium-term, e.g. 12 to 18 months, in absence of remedial action
3 - Regulatory concerns in one or more components. Significant breach unlikely
4 - No regulatory concerns
5 - Lowest risk - no regulatory concerns
GOVERNANCE QUARTERLY INDICATORS (PERFORMANCE)
Monitoring
Period
Threshold
Current
Quarter
Performance
Quarterly (25%
cumulative)
54
10
94%
98.5%
98%
98.0%
94%
94.1%
85%
82.9%
90%
86.2%
96%
95.4%
93%
93.7%
93%
89.0%
Q1
Q2
Q3
Penalty Points Penalty Points Penalty Points
Jan-14
Performance
Feb-14
Performance
Mar-14
Performance
Q4
Penalty Points
3
3
4
1
100.0%
94.9%
94.9%
97.6%
98.7%
100.0%
92.6%
98.8%
97.5%
83.8%
83.6%
80.9%
89.9%
82.6%
76.9%
94.9%
96.1%
97.5%
92.1%
95.3%
95.1%
83.8%
93.1%
95.9%
13/14
Safety - Weighted 1.0
Clostridium Difficile Infection (acute acquired)
1
1
1
0
0
1
Quality - Weighted 1.0
Surgery
All cancers : 31 day wait for
second or subsequent
treatment ^
Anti cancer drug treatments
Quarterly
Radiotherapy
All cancers : 62-day wait for
first treatment ^ (ADJUSTED
FOR SHARED BREACHES)
From urgent GP referral to treatment
0
Quarterly
From consultant screening service
referral
All cancers : 31 day wait from diagnosis to first treatment ^
Quarterly
All cancers
Cancer : two week wait from
referral to date first seen
Quarterly
Symptomatic breast
1
1
0
0
0
0
0
1
0
1
1
1
Total time in A&E: % of patients who have waited less than 4
hours
Quarterly
95%
93.1%
0
1
0
94.5%
92.2%
94.4%
1
Self-certification against compliance with requirements regarding
access to healthcare for people with a learning disability
Quarterly
Meet 6 criteria
6
0
0
0
6
6
6
0
Jan-14
Performance
Feb-14
Performance
Mar-14
Performance
Q4
Penalty Points
Note: Information shown includes provisional data for latest month
GOVERNANCE MONTHLY INDICATORS (PERFORMANCE)
Monitoring
Period
Threshold
Current Month
Q1
Q2
Q3
Performance Penalty Points Penalty Points Penalty Points
13/14
Patient Experience - Weighted 1.0
Admitted
Referral to Treatment Times Non-Admitted
percentage performance
Quarterly
90%
90.5%
0
0
0
91.0%
91.5%
90.5%
0
95%
93.5%
0
0
0
95.1%
95.0%
93.5%
1
89.5%
89.6%
89.4%
92%
Incomplete
Note: Information shown includes provisional data for latest month
Key to Quarterly Risk Rating
89.4%
Risk Rating:
<1.0
>= 1.0 - < 4.0
>= 4.0
Green
Amber
Red
0
1
1
Amber
Red
Red
1
Red
From October 2013 all indicators weighted at 1.0
Page 6 of 84
MONITOR COMPLIANCE FRAMEWORK EXCEPTION REPORT
The Monitor Compliance Framework scorecard is showing as “Red” for Q4.
Provisional cancer data for March is showing the Trust failed to achieve the cancer 62 GP referral to
treatment standard and the cancer 62 day referral from an NHS screening service standard.
March provisional data also shows the ‘A&E: % of patients who have waited less than 4 hours’ failed
to achieve standard.
The 18 week wait referral to treatment – non admitted pathway and incomplete pathways also failed
to achieve the standard provisionally during March.
Page 7 of 84
FOUNDATION TRUST MEMBERSHIP
Patient and Public members
The table below details public and patient membership status as at 31 March 2014.
Constituency
Sub
Constituency
Public
East Riding 3287 3224 3226 3234 3234 3210 3223 3287 3302 3285 3309 3307
Patient
30
Apr
* 31
May
30
Jun
31
Jul
31
Aug
* 30
Sep
31
Oct
30
Nov
31
Dec
* 31
Jan
28
Feb
31
Mar
Gap
YE
Target
+9 3300
Hull
3235 3196 3198 3214 3214 3135 3168 3318 3318 3322 3376 3376
+76 3300
Total
public
6522 6420 6424 6448 6448 6345 6391 6605 6620 6607 6685 6683
+83 6600
-
2898 2855 2870 2903 2902 2855 2859 2901 2985 2958 2984 3021
+21 3000
Total
9420 9275 9303 9351 9350 9200 9250 9506 9605 9565 9669 9704 +104 9600
* The decrease in membership figures is due to a data cleanse been undertaken of the
membership database.
Number of Members
Public Membership - East Riding 2013/14
3320
3300
3280
3260
3240
3220
3200
3180
3160
Actual
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Month
Target
Number of Members
Public Membership - Hull 2013/14
3400
3350
3300
3250
3200
3150
3100
3050
3000
Actual
Target
Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
Month
Page 8 of 84
Patient Membership 2013/14
Number of Members
3050
3000
2950
2900
2850
2800
2750
Actual
Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
Month
Target
Staff members
The table below details staff membership status as at 31 March 2014.
30
Apr
31
May
30
Jun
31
Jul
31
Aug
30
Sep
31
Oct
30
Nov
31
Dec
31
Jan
28
Feb
31
Mar
Gap
YE
target
Medical
282
282
279
280
280
276
282
292
291
291
287
296
+51
245
Nursing
1098
1091
1104
1116
1116
1121
1122
1169
1169
1188
1189
1202
- 167
1369
Class
Scientific,
technical &
therapeutic
Non clinical
682
673
671
674
675
686
690
698
717
718
710
712
+147
565
1163
1154
1153
1166
1167
1174
1187
1200
1204
1203
1204
1223
-8
1231
Volunteers
123
124
127
132
132
134
135
137
138
138
145
145
+55
90
3348
3324
3334
3368
3370
3391
3416
3496
3519
3538
3535
3578
+78
3500
Dec
Jan
Total
Number of Members
Staff Membership 2013/14
3600
3500
3400
3300
3200
3100
Apr
Target
May
Jun
Jul
Aug Sep
Oct
Nov
Feb Mar
Month
Actual
Page 9 of 84
CORPORATE PERFORMANCE REPORT 2014/15
Section:
Quality & Safety
Lead Director:
Amanda Pye & Professor Ian Philp
Report Month:
April 2014
Page 10 of 84
QUALITY SCORECARD - EFFECTIVENESS
INDICATORS
2012/13
Frequency Baseline
Measure
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14 Mar-14
Q1
2013/14
Q2
2013/14
Q3
2013/14
Q4
2013/14
YTD
Actual
YTD
Target
Target*
National /
Peer
Benchmark
Effectiveness
SHMI (Validated IC publication by month)
*data available up to June 13 only
SHMI (Unvalidated HED publication)
*13/14 data available up to September 13 only
Quarterly
103.1
NQD-TDA-QA
95.4
101.0
102.3
na
na
na
na
na
na
na
na
na
99.5
na
na
na
99.5
100.0
95.2
Quarterly
103.2
NQD-TDA-QA
96.1
102.0
102.8
93.3
90.2
101.6
85.0
93.8
na
na
na
na
100.2
95.0
89.1
na
95.5
100.0
93.3
1.59%
1.57%
1.32%
1.24%
1.48%
1.27%
1.35%
1.55%
1.58%
1.65%
na
1.59%
1.35%
1.39%
1.61%
1.47%
1.25%
99.2
Crude Mortality Rate (deaths as % of spells)
Monthly
0.0
NQD-TDA-QA
1.61%
HSMR (November 12 - Ocotber 13)
Monthly
92.7
TDA-QA
93.7
88.9
100.1
83.5
85.5
91.3
83.8
91.9
90.2
na
na
na
94.0
86.8
1.1
na
89.8
Maximum Number of Days without a VAP at month end (with current YTD maximum)
Monthly
na
SD
na
na
61
65
39
54
36
53
84
95
49
na
na
65
84
95
95
VAP Bundle completion
Monthly
na
SD
22.0%
30.5%
37.8%
22.7%
25.0%
36.2%
51.4%
67.2%
49.1%
41.6%
65.7%
na
29.2%
27.1%
56.0%
51.2%
37.3%
Observations chart compliance
Monthly
97.5%
SD-QA
96.01%
96.56%
95.95%
97.33%
97.19%
93.71%
93.33%
93.34%
93.23%
91.24%
91.30%
91.41%
96.17%
96.08%
93.30%
91.32%
94.33%
95.0%
Fluid chart compliance
Monthly
89.0%
SD-QA
84.10%
84.92%
85.15%
85.35%
88.70%
79.38%
79.73%
81.10%
81.10%
79.84%
78.09%
82.09%
84.73%
84.48%
80.65%
80.01%
82.22%
95.0%
100.2
Reduce avoidable deaths
na
na
Improve Mortality in specific conditions
Reduction in HSMR for patients diagnosed with Acute Cereberal Disease (ACD) - MAT
Monthly
97.7
SD
95.4
94.7
96.0
96.0
97.0
91.5
93.2
91.8
na
na
na
na
95.4
94.8
92.5
na
85.5
82.0
na
Congestive Heart Failure (CHF): Reduction in HSMR - MAT
Monthly
108.7
SD
103.8
106.0
107.2
104.0
103.0
97.2
100.5
99.9
na
na
na
na
105.7
101.4
100.2
na
91.2
103.0
na
Acute Myocardial Infarction (AMI): Reduction in HSMR - MAT
Monthly
119.9
SD
121.5
122.2
126.1
130.0
128.0
127.2
123.5
136.8
na
na
na
na
123.3
128.4
130.2
na
141.5
134.6
na
Colorectal Surgery: Reduction in HSMR - MAT
Monthly
106.0
SD
101.5
96.4
96.8
100.0
106.0
94.5
90.6
85.1
na
na
na
na
98.2
100.2
87.9
na
78.4
159.0
na
Sepsis outcome data (HSMR) - MAT
Monthly
113.5
SD
113.0
114.0
114.0
118.5
121.6
130.7
136.3
141.2
150.6
na
na
na
114.0
130.7
150.6
na
161.2
Pneumonia Deaths
Monthly
563.0
SD-QA
50
47
52
37
30
35
30
35
38
72
56
52
149
102
103
180
534
500
500
Cardiac Arrests (calls received)
Monthly
332.0
SD-QA
22
22
26
22
18
38
16
22
28
25
28
22
70
78
66
75
289
200
200
CHF: Reduction in length of stay
Monthly
11.0
SD
9.7
9.7
11.6
11.4
9.8
9.8
9.2
9.1
15.5
12.4
7.4
na
10.3
10.3
11.3
9.9
10.7
8.4
na
CHF: Reduction in emergency readmissions
Monthly
10.8%
SD
0.00%
0.00%
25.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
na
na
8.33%
0.00%
0.00%
0.00%
0.00%
12.0%
na
AMI: Reduction in length of stay
Monthly
5.9
SD
5.1
4.9
5.6
4.0
5.0
11.6
7.5
5.5
8.3
5.3
6.8
na
5.2
6.9
7.1
6.0
7.4
4.5
na
AMI: Reduction in emergency readmissions
Monthly
14.2%
SD
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
na
na
0.00%
0.00%
0.00%
0.00%
0.00%
7.0%
na
Colorectal Surgery: Reduction in length of stay
Monthly
5.9
SD
6.0
5.4
5.6
3.4
4.1
4.3
4.7
4.2
5.1
3.7
4.7
na
5.7
3.9
4.7
4.2
4.2
5.8
na
Colorectal Surgery: Reduction in emergency readmissions (30d)
Monthly
2.0%
SD
1.56%
1.85%
1.81%
3.23%
3.73%
2.41%
2.09%
1.18%
0.65%
0.00%
na
na
1.74%
3.12%
1.31%
0.00%
1.29%
2.4%
na
NQD - National Quality Dashboard, TDA - Trust Development Authority, SD - Safety Dashboard, QA - Quality Accounts
Page 11 of 84
INDICATORS
2012/13
Frequency Baseline
Measure
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14 Mar-14
Q1
2013/14
Q2
2013/14
Q3
2013/14
Q4
2013/14
YTD
Actual
YTD
Target
Target*
National /
Peer
Benchmark
Reduce mortality following hip fracture
AMTS pre op %
Monthly
na
SD
na
na
na
na
na
na
na
na
1.00
1.00
na
na
na
na
100%
1.00
100%
na
na
na
na
na
na
na
0.92
0.92
na
na
na
na
92%
0.92
92%
100%
na
AMTS post op %
Monthly
na
SD
na
ASA Grade (as decided by an anaesthetist %)
Monthly
na
SD
na
na
na
na
na
na
na
na
0.96
0.98
na
na
na
na
96%
0.98
97%
Ortho-geriatrician review %
Monthly
na
SD
na
na
na
na
na
na
na
na
1.00
1.00
na
na
na
na
100%
1.00
100%
To theatre within 36 hours of admission 80% target
Monthly
na
SD
na
na
na
na
na
na
na
na
0.80
0.60
na
na
na
na
80%
0.60
70%
Falls and bone protection assessment %
Monthly
na
SD
na
na
na
na
na
na
na
na
1.00
0.96
na
na
na
na
100%
0.96
98%
MDT%
Monthly
na
SD
na
na
na
na
na
na
na
na
1.00
1.00
na
na
na
na
100%
1.00
100%
Emergency Readmissions within 30d
Monthly
6.9%
NQD-TDA-QA
7.04%
7.27%
6.96%
6.68%
6.95%
6.60%
6.70%
6.20%
7.20%
6.90%
na
na
7.09%
6.74%
6.70%
6.90%
6.90%
11.20%
11.13%
Emergency Adm not usually requiring Admission
Monthly
5.9%
NQD-TDA
6.35%
6.16%
5.37%
5.65%
6.34%
5.06%
5.69%
5.96%
6.09%
6.13%
5.53%
na
5.96%
5.67%
5.91%
5.84%
5.85%
9.73%
9.68%
Caesarean Section Rate - as a % of maternity spells
Monthly
23.3%
TDA
24.10%
24.60%
21.74%
25.83%
26.91%
24.00%
22.40%
24.81%
24.90%
25.30%
25.50%
26.20%
23.48%
25.58%
24.04%
25.67%
24.59%
24.10%
23.29%
Mothers requiring forceps - as a % of deliveries
Monthly
na
SD
na
na
na
na
na
na
8.10%
7.60%
8.00%
5.60%
8.60%
7.80%
na
na
7.90%
22.00%
7.62%
12.00%
Monthly
89.8%
SD-QA
90.00%
91.00%
94.00%
91.00%
90.16%
90.20%
91.21%
90.32%
90.48%
90.40%
90.90%
na
91.67%
90.45%
90.67%
90.65%
90.87%
90.0%
-
-
-
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
Complication Rate (%)
Monthly
0.99%
TDA
0.66%
0.73%
0.63%
0.68%
0.84%
0.68%
0.65%
0.70%
0.73%
0.66%
0.64%
na
0.01%
0.01%
0.01%
0.01%
0.95%
1.09%
1.08%
Misadventure Rate (%)
Monthly
0.14%
TDA
0.13%
0.15%
0.20%
0.12%
0.09%
0.13%
0.14%
0.08%
0.18%
0.15%
0.18%
na
0.00%
0.00%
0.00%
0.00%
0.15%
0.13%
0.10%
100%
100%
100%
80%
100%
100%
na
na
na
na
na
na
Reduce rate of readmission following discharge from the Trust
To improve maternity care by encouraging natural childbirth
Caring for the elderly
% of Patients with Dementia Screening
0.00%
Ensure active engagement with research
Data not collected
na
Quality Governance Indicators
NQD - National Quality Dashboard, TDA - Trust Development Authority, SD - Safety Dashboard, QA - Quality Accounts
Page 12 of 84
EXCEPTION REPORTING: MORTALITY
Mortality
National Indicator / Quality Requirement
The trust is measured against other Trusts using both the Summary Hospital
Mortality Ratio (SHMI) and the Hospital Standarised Mortality Ratio (HSMR).
Also of interest are the Risk Adjusted Mortality Index (RAMI) and the crude
death rate.
Aim: Improve SHMI rate
Owner: Chief Medical Officer, HG Medical Directors
Consequence of failure: Patient Safety, patient outcome & reputation
Summary Hospital Mortality Index (SHMI)
SHMI measures in-hospital deaths as well as deaths post discharge within 30 days. The
Trust’s nationally published Summary Hospital Mortality Index (SHMI) for July 2012 to June
2013 was 99.4 which is a decrease from the previous position of 102.5 (April 2012 to March
2013).
The Trusts’s comparative position against other trusts within Yorkshire and Humber can be
seen in the graphs below.
The Healthcare Evaluation Dataset (HED) system now enables trusts to view more timely
SHMI data on a monthly basis. It should be noted that that this is classed as unvalidated
until quarterly publication by the Information Centre (IC). The Trust’s latest rebased monthly
SHMI up to October 2013 is shown in the graphs below.
Page 13 of 84
Hospital Standardised Mortality Ratio (HSMR)
The Trust’s HSMR for November when measured as a Moving Annual Total (MAT) is 89.7.
The monthly HSMR value for the Trust for November is 90.2.
Risk Adjusted Mortality Index (RAMI)
Monthly RAMI for November 2013 is 86 against a peer position of 87. The Trust’s RAMI
calculated as a Moving Annual Total is 86.
Crude Mortality
Total number of deaths per month may be seen in the graph below. There were 209 hospital
deaths recorded for February 2014.
The following graphs show the number deaths per month as a percentage of Finished
Consultant Episodes (FCEs) and monthly discharges. Both of these graphs show a monthly
percentage and the moving annual total percentage which is calculated using the past 12
months’ worth of data. Between February 2013 and January 2014 there were 2,366 deaths
which accounts for 1.5% of discharges.
Page 14 of 84
Depth of Coding
Depth of coding at Trust level for December is shown in the table below.
2013/2014 Year to Date**
December 2013
Trust **
Trust ** CHKS Peer
CHKS Peer
Average
Average
All FCEs
4.4
4.5
4.8
4.4
Inpatient FCEs
5.4
5.6
5.9
5.5
Zero Days Length of Stay (including day
3.5
3.8
3.6
3.4
cases)
Deaths
9.4
9.6
8.2
9.7
** (Data source: CHKS. Green rating indicates at, or better than, CHKS peer position and amber indicates below
peer position)
Acute Trust Quality Dashboard
The Acute Trust Quality Dashboard provides an assessment of quality across 5 domains of
the NHS Outcomes Framework.
Section 1 relates to Preventing people from dying prematurely
The dashboard provides an overview of Trust performance against national mean, as well as
against expected performance.
Data from Stethoscope (last updated 31/3/2014)
Page 15 of 84
EXCEPTION REPORTING: Pneumonia Deaths
The chart below shows number of patients who died as a percentage of the number of patients discharged coded
with Pneumonia as primary diagnosis – as well as the number of deaths of patients due to Pneumonia.
Pneumonia deaths as % of discharges of all patients coded with Pnuemonia
(also showing actual number of deaths with Pneumonia as primary cause of death)
45.00%
80
40.00%
70
Pneu Deaths act
35.00%
60
50
25.00%
40
20.00%
30
15.00%
10.00%
20
5.00%
10
0.00%
0
Actual number of deaths
deaths as % of discharges
Avg Pneu Deaths %
30.00%
Upper control limit
Lower control limit
all Pneu Death%
Trend Line Showing
change in Pneu
Deaths%
February 2014 follows the trend of decreased deaths occurring in February following spikes in December and
January (January only this year).
As can be seen deaths as percentage of discharges has been falling since 2010 – illustrated by the trend line.
There has been a statistically significant change in the average percentage of deaths - occurring in July 2013
(from 25.7% of all pneumonia discharges to 21.3% of all pneumonia discharges).
The latest data shows the actual number of deaths of patients with Pneumonia peaked in January and has since
fallen.
Further analysis of Pneumonia is below;
Page 16 of 84
Page 17 of 84
EXCEPTION REPORTING: Maternity
Maternity
Trust Development Agency Indicator
The Trust should be providing a high quality service
Aim: Maintain a high quality service
Owner: Chief Nursing Officer, Relevant HG Nursing Director
Consequence of failure: Patient Safety
Activity October 2013
Number of Births (per month)
October 2013
November 2013
Goal
Red Flag
Status
Status
Status
Status
Status
6300 (525)
600
484
422 
December 2013
510
January 2014
423
February 2014
412
March 2014
452
90%
85%
88%
85%
Status
> 95%
<90
86.00%
86.0% =
Booking over 13 weeks within 2 weeks
95%
<90%
100.00%
100.0% =
100.0% =
100.0% =
100.0% =
100.0% =
Caesarean Section
<25%
>25%
22.10%
23.9% 
24.9% 
25.3% 
25.5% 
26.2% 
Instrumental Birth
<12%
>12%
8.10%
7.6% 
8.0% 
5.6% 
8.6% 
7.8% 
Workforce
Goal
Red Flag
98
<60
107
101 =
98 
98 =
98 =
98 =
Midwife/Birth ratio
<1:30
>1:40
35
35 =
35 =
35 =
35 =
35 =
Supervisor to midwife ratio
<1:15
>1:20
17
15 
13
13 =
13 =
13 =
Maternal Morbidity
Goal
Red Flag
Eclampsia
2
0
0=
0=
0=
0=
ICU Admissions in Obstetrics
0
1
1=
1=
0 
1
Blood transfusions (>4 units)
0
1
0
0=
0=
0=
0
0=
0=
0=
0=
0=
1
0
0=
0=
0=
Direct access before 12+6
Weekly hours of Consultant cover on LW
Post-Partum Hysterectomies
Neonatal Morbidity
Number of cases of meconium aspiration
<6 cases in any two
month period
>6 cases in any two
month period
Number of cases of hypoxic encephalopathy(grades 2 &3)
1
0
1
1=
1=
<1%
>3%
0%
0% =
0% =
1% 
0 
0=
Massive PPH >2 litres
<10/month
>12/month
3
8
7
1
7
5
Shoulder Dystocia
<6/month
>10/month
5
2
4
2
4
4=
>20
10
12 
12 =
9
12 
7
4
3
1
2
2=
4
Goal
Risk Management
Failed Instrumental Delivery
3rd/4th Degree Tear
Complaints
Number of Complaints
Red Flag
<20
Goal
Red Flag
<10/month
>10/month
The Trust has two red indicators in the following areas;
Direct Access to Midwives – recommended that women book within 12weeks and 6
days gestation. Direct Access phone line has been re-advertised in Health
Centres/GP Surgeries/Children’s Centres. There appears to be no themes as to why
women not accessing the service.
Caesarean Section - the rate continues to rise and the Labour Ward Forum is
monitoring this closely.
The Trust has an amber indicator in the following area;
Midwife to birth ratio 1:35. The service has implemented other support staff to
release midwifery time these include Data Inputters/Maternity Support Workers and
ward Hygienists. Agreement for active recruitment to midwifery posts for leavers in
place to maintain this ratio
The birth rate as a trend is reducing month on month. The total births for 2013-14 was 5,666
which is a reduction on the previous year 2012-13 of 5,729.
The Instrumental birth rate demonstrates a declining trend.
Page 18 of 84
EXCEPTION REPORTING: Ventilator Acquired Pneumonia
(VAP)
Castle Hill Hospital VAP bundle performance
GICU2 – January
Elevation of Bed 45degrees
Sedation Hold
Gut Protection
Subglottic Suction
Cuff Pressure
Chlorhexidine Prescription
Oral Hygiene 4 hourly
Ventilator Tubing Check
Humidification Check
All Bundle elements met
No data taken
28
28
28
28
26
28
28
28
28
28
26
0
Last VAP
03/02/2014
100%
100%
100%
93%
100%
100%
100%
100%
100%
93%
0
Hull Royal Infirmary VAP bundle performance
HRI ICU & HDU – January
Elevation of Bed 45degrees
Sedation Hold
Gut Protection
Subglottic Suction
Cuff Pressure
Chlorhexidine Prescription
Oral Hygiene 4 hourly
Ventilator Tubing Check
Humidification Check
All Bundle elements met
No data taken
71
62
44
64
62
66
66
66
66
65
39
5
Last VAP
25/02/14
87%
62%
90%
87%
93%
93%
93%
93%
92%
55%
7%
Combined HRI & CHH VAP bundle performance
99
Last VAP
25/02/2014
Elevation of Bed 45degrees
90
91%
Sedation Hold
72
73%
Gut Protection
92
93%
Subglottic Suction
88
89%
Cuff Pressure
94
95%
Chlorhexidine Prescription
94
95%
Oral Hygiene 4 hourly
94
95%
Ventilator Tubing Check
94
95%
Humidification Check
93
94%
All Bundle elements met
65
66%
5
5%
Combined HRI & CHH - December
No data taken
No new data is provided this month.
Page 19 of 84
EXCEPTION REPORTING: Fracture Neck of Femur
Fracture Neck of Femur
We were unable to report activity in February 2014 as the data was not available.
The data for March 2014 has not been completed yet (due to clinical commitments of the staff).
160
12
148
82
66
50
3
3
Reason not achieved
– medical reasons
Reason not achieved
– awaiting further
imaging
Reason not
achieved- failure to
be seen by orthogeriatrician within 72
hours
Reason not achieved
– theatre capacity
Best practice not
achieved
Best practice tariff
achieved
No of patients where
data has been
captured
No. of patients where
the data has not
been captured yet
No. of patients to be
audited
The following activity has been provided for Q4
10
The service strives to deliver to best practice tariff and reports that the primary barriers to delivering
this are theatre capacity and bed availability.
Page 20 of 84
QUALITY SCORECARD - SAFETY
INDICATORS
2012/13
Frequency Baseline
Measure
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Q1
2013/14
Q2
2013/14
Q3
2013/14
Q4
2013/14
YTD
Actual
YTD
Target
Target*
National /
Peer
Benchmark
SAFETY
Patient Safety Aggregated Score - Data not collected
-
-
-
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
% of Patients Receiving 'Harm Free' Care
Monthly
92.3%
NQD-TDA-QA
92.08%
94.61%
94.13%
94.13%
94.59%
93.34%
95.33%
95.15%
94.98%
95.20%
95.46%
95.90%
93.60%
94.01%
95.16%
95.52%
94.57%
93.0%
Remain in the upper quartile for PSI reporting with a ratio of PSI reported per 100
admissions being greater than 7
Monthly
6.8
SD
6.25
6.35
6.40
6.38
6.46
6.23
6.52
6.37
7.25
6.59
8.16
7.54
6.33
6.36
6.71
7.40
6.70
7.0
Total Incidents
Monthly
10457
SD
813
848
833
896
816
802
901
824
929
910
1022
991
2494
2514
2654
2923
10585
Total Moderate, Severe or Death Incidents (cat 3,4,5)
Monthly
497
SD
27
38
39
43
39
37
51
47
54
73
69
41
104
119
152
183
558
Serious Incidents (SUIs) per 1,000 bed days
Monthly
0.0
NQD-TDA
0.0
0.0
0.1
0.1
0.1
0.0
0.1
0.1
0.1
0.3
0.2
0.2
0.0
0.1
0.1
0.2
0.1
Serious Incidents (SUIs) actual number
Monthly
11
SD
0
0
2
2
3
0
4
3
2
9
6
5
2
5
9
20
36
CAS Alerts
Monthly
92
TDA
4
12
14
39
17
6
15
15
16
8
11
25
30
62
46
44
182
CAS Alerts Closed
Monthly
na
SD
3
6
12
34
23
12
7
21
13
11
4
na
21
69
41
15
146
Missed Doses on Wards (experimental statistic ALL wards)
Monthly
119
SD
4
12
12
10
7
14
14
14
12
12
10
12
28
31
40
34
133
Medication Errors in Pharmacy (experimental statistic)
Monthly
197
SD-QA
13
14
9
25
16
23
18
27
22
16
33
31
36
64
67
80
247.0
Monthly
91.9%
TDA-QA
93.19%
92.09%
92.26%
95.48%
95.10%
96.28%
96.05%
96.35%
95.63%
95.08%
95.48%
94.90%
92.52%
95.62%
96.01%
95.14%
94.84%
General Safety
0.6
93.1%
0.6
na
Improve Safety of prescribing
179
179
Reduce incidence of healthcare acquired VTE
VTE Risk Assessment
95.08%
95.67%
Reduce incidence of healthcare acquired infections
MRSA Bacteraemia
Monthly
6
SD-QA
0
0
1
0
0
0
1
0
0
0
0
0
1
0
1
0
2
0
0
C Difficile Infections
Monthly
58
SD-QA
5
6
6
6
4
2
8
4
6
3
3
4
17
12
18
10
57
54
54
Infections (CDI, E Coli, MRSA Bact. & MSSA) per 1,000 bed days
Monthly
0.5
NQD-TDA
0.5
0.6
0.6
0.6
0.7
0.5
0.7
0.5
0.8
0.3
0.5
0.5
0.6
0.6
0.7
0.4
0.6
Urinary Catheter Infections
Monthly
1.3%
SD
1.2%
0.7%
1.2%
1.7%
0.9%
0.6%
1.2%
0.5%
0.3%
0.6%
0.3%
0.5%
3.0%
3.2%
2.0%
1.4%
0.8%
WHO Surgical Checklist Compliance
Monthly
99.7%
TDA
100.00%
100.00%
100.00%
100.00%
99.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
99.67%
100.00%
100.00%
99.92%
100.00%
Never Events per 1,000 bed days
Monthly
0.0
NQD-TDA
0.00
0.00
0.00
0.00
0.03
0.00
0.03
0.00
0.00
0.03
0.00
0.03
0.00
0.01
0.01
0.02
0.01
0.0
Never Events actual number
Monthly
3.0
SD
0
0
0
0
1
0
1
0
0
1
0
1
0.00
1.00
1.00
2.00
4.00
0.0
Surgical Never Events actual number
Monthly
3.0
SD-QA
0
0
0
0
1
0
0
0
0
1
0
1
0
1
0
2
3
0
Falls
Monthly
2313
SD-QA
175
186
197
195
176
176
182
155
207
203
178
158
558
547
544
539
2188
2245
2245
Falls resulting in Harm (cat 3)
Monthly
50
SD
2
4
3
3
5
7
1
4
9
9
4
1
9
15
14
14
52
50
50
Falls resulting in Severe Harm or Death (cat 4 or 5)
Monthly
0
SD
1
0
0
2
0
0
1
0
0
5
2
0
1
2
1
7
11
0
0
1.3
1.4
Improve theatre safety for patients
0.1
Reduce the number of falls in hospital
NQD - National Quality Dashboard, TDA - Trust Development Authority, SD - Safety Dashboard, QA - Quality Accounts
Page 21 of 84
INDICATORS
2012/13
Frequency Baseline
Measure
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14 Mar-14
Q1
2013/14
Q2
2013/14
Q3
2013/14
Q4
2013/14
YTD
Actual
YTD
Target
Target*
National /
Peer
Benchmark
Pressure damage
Grade 2 Pressure Ulcers
Monthly
297
SD-QA
24
28
30
15
23
13
17
13
23
22
10
17
82
51
53
49
235
Grade 3 Pressure Ulcers
Monthly
3
SD-QA
0
0
0
0
0
0
1
0
1
0
0
0
0
0
2
0
2
0
0
Grade 4 Pressure Ulcers
Monthly
2
SD-QA
0
0
0
2
0
0
0
0
0
0
1
0
0
2
0
1
3
0
0
5
2
5
6
1
7
4
9
1
2
3
11
12
20
6
49
50
50
0
85.53%
Deep Tissue Injury
Monthly
30
SD
4
Unstageable Pressure Ulcers
Monthly
44
SD-QA
6
3
3
7
1
2
5
3
1
4
1
3
12
10
9
8
39
Bed Occupancy
Monthly
86.5%
NQD-TDA
91.01%
88.95%
86.81%
86.81%
86.57%
91.28%
91.89%
88.38%
84.43%
83.85%
84.22%
83.41%
87.58%
87.77%
88.15%
83.81%
86.80%
88.73%
Nurses to Bed Ratio
Monthly
1.59
NQD-TDA
1.59
1.63
1.62
1.63
1.64
1.63
1.61
1.64
1.56
1.57
1.57
na
1.61
1.64
1.60
1.57
1.61
1.99
na
Monthly
0.13
NQD-TDA
0.13
0.12
0.13
0.12
0.13
0.13
0.12
0.13
0.14
0.12
0.13
na
0.13
0.13
0.13
0.13
0.13
0.18
0.18
Organisational Indicators
Doctor to Patient Ratio
(Spells used as the denominator for internal measurement)
NQD - National Quality Dashboard, TDA - Trust Development Authority, SD - Safety Dashboard, QA - Quality Accounts
Page 22 of 84
EXCEPTION REPORTING: Missed Doses
Page 23 of 84
EXCEPTION REPORTING: Healthcare Acquired Infections
SPC Chart of the number of C.Difficile infections showing the average and upper control limit – note
step change and the outlier in June 2011.
Page 24 of 84
SPC Chart of the number of MRSA Bacteraenmia infections showing the average and upper control
limit.
The infection control committee has reviewed the action plan for C.Difficile. The committee will now
take forward reviewing MSSA and E.Coli.
Page 25 of 84
EXCEPTION REPORTING: Falls
Medicine Health Group
There has been a small increase (128 to 133 respectively) between February and March in the
number of falls recorded. The majority of falls reported did not result in injury or harm although there
were 2 incidents rated as moderate severity where patients suffered lacerations.
Clinical Support Health Group
In Clinical Support 28 falls were recorded during the month of March 2014. 12 of which occurred on
Ward 2, which has now joined the Health Group. We are undertaking some targeted work in this
area with 2 of the Ward Sisters/Charge Nurses being part of the Trust Falls Group.
Family and Women’s Health Group
Family & Women’s Health Group reported 6 patient falls within March 2014. Only 1 incident
caused injury which resulting in minor harm to the patient (cuts and bruising). One incident was a
near miss with no injury to the patient and the further 4 were no injury to the patients.
Surgery Health Group
The number of falls reduced between February and March 2014 by 15 falls from 64 to 49.
A review of incidents reported as injury or harm has shown an decrease of 43% in March 2014 from
January 2014. There was a spike in falls in February due to a number of confused patients on C15
Urology who fell multiple times despite appropriate measure being in place to reduce the risk.
2 ‘moderate’ incidents were reported:
One incident was reported by Orthopaedics and relates to an unwitnessed fall. Patient fell on
the way to the WC and felt the bones in her operative leg may have moved. X-Rays
undertaken revealed displaced previous fracture. Patient transferred to HRI Orthopaedics
trauma for treatment.
Unwitnessed fall on Acute Surgical floor resulted in skin tear to arm. Feedback to tier 2
reviewer requesting confirmation or downgrading of level of harm.
Page 26 of 84
Critical
Care
Acute
Found on floor, cause unknown
Controlled fall
Fall from bed
Fall from chair
Fall from commode
Fall from standing
Fall from toilet
Slip, trip or fall from different
levels
Slip, trip or fall on dry floor
Trip/fall over object
Totals:
Specialist
Trauma
Total
3
1
1
2
0
5
3
0
1
2
0
0
0
1
0
0
0
0
4
0
1
5
2
0
4
0
3
2
1
4
0
1
8
3
8
4
2
15
5
1
0
0
15
1
1
6
1
0
13
0
0
15
2
1
49
This continues to be monitored by the Falls Group
Trust
The Trust total falls can be seen below – the SPC chart shows the upper and lower control limits
and the average for the period. Note the step change that occurred in January 2012.
Page 27 of 84
EXCEPTION REPORTING: Tissue Viability
Tissue Viability
Safety Improvement Measures
Pressure Ulcers
Aim: Reduce the incidence of the various grades of pressure ulcers that are
hospital acquired.
Owner: Chief Nursing Officer, Tissue Viability Team, Relevant HG Nursing
Director
Consequence of failure: Patient Safety
Medicine Health Group
During March there were 8 reported pressure ulcers (all of which were Grade 2) which is a 100%
increase in reported pressure damage (Grade 2 and above) from February (4 reported)
Clinical Support Health Group
There have been 2, one on Ward 2 and one on Ward 33. The Root cause analyses for these are
being undertaken by the Sisters in those areas supported by the Matron and the learning and
actions will be discussed with the ward teams.
Family and Women’s Health Group
There was one incident reported on Ward 16 but following a review the Ward sister and the Tissue
Viability Link Nurse for the ward it was found not to be a Grade 2 pressure sore and was recoded to
Misc Wound.
Surgery Health Group
19 pressure ulcer incidents were reported by the Health Group in March 2014, 11 incidents were
reported as Grade 2 pressure ulcer incidents. 10 incidents have been finally approved, 2 of which
were reported as unavoidable Grade 2 pressure ulcers.
9 incidents are currently being investigated:
2 x Unstageable
7 x Grade 2
1 finally approved incident was reported as device related.
Regular reminders are sent out to those wards reporting pressure ulcer incidents regarding the
timeliness of investigation and the importance of including the RCA in DATIX.
Actions continue as indicated on last Board Report.
Trust
There was an increase of hospital acquired pressure ulcers this month. The tissue viability team
continue to work with the health groups to achieve a downward trajectory for hospital acquired
pressure ulcers.
The Trust total pressure sores (split by grade) can be seen below – the SPC chart shows the upper
and lower control limits and the average for the period. Note the step changes in the average
number of grade 2 pressure.
Page 28 of 84
.
Page 29 of 84
EXCEPTION REPORTING: SERIOUS INCIDENTS
Serious Incidents by Month declared (as at 2nd April 2014)
Serious Incidents Declared 2013/14
10
9
8
7
6
5
4
3
2
1
0
Serious Incidents declared in March 2013
There have been 1514 Incidents reported within the month of March 2014.
Five Serious Incidents have been declared within the month of March.
Date Opened
Nature of SUI
28/02/14
Fall resulting in Fractured Neck Of Femur
06/03/14
Maternal Death
04/03/14
Delayed Diagnosis
12/03/14
NEVER EVENT: RETAINED FOREIGN OBJECT
26/02/14
Unexpected Death (Inpatient)
The spike in January is following the retrospective review of Critical Incidents leading to improved
reporting.
The Board is asked to note that April’s Serious Incident figures will be reported in the April
Corporate Performance Report.
Page 30 of 84
QUALITY SCORECARD - EXPERIENCE
INDICATORS
2012/13
Frequency Baseline
Measure
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14 Mar-14
Q1
2013/14
Q2
2013/14
Q3
2013/14
Q4
2013/14
YTD
Actual
YTD
Target
Target*
National /
Peer
Benchmark
71.0
72.0
EXPERIENCE
Friends and Family Test (net promoter scores)
Monthly
45.5
NQD-TDA
72.3
73.9
76.7
80.5
83.0
78.0
78.0
81.0
80.0
81.0
81.0
na
75.0
81.0
80.0
81.0
79.0
-
-
-
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
na
Reduction in Clinics Cancelled with less than 4 weeks notice
Monthly
1025
SD
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Reduction in Operations cancelled on the day
Monthly
796
SD
86
64
na
na
na
na
na
na
na
na
na
na
150
na
na
na
150
Reduction of avoidable inpatient transfers, in particular patients who are moved more than
2 times
Monthly
470
SD-QA
47
41
28
30
31
43
57
56
38
41
41
46
116
104
151
128
499
375
375
Reduction of avoidable inpatient transfers after 10pm (all movements)
Monthly
2436
SD-QA
204
195
150
114
152
161
170
168
163
188
193
177
549
427
501
558
2035
1461
1461
Reduction in the number of patients on the delayed discharge list
Monthly
2756
SD-QA
357
382
320
396
346
315
347
367
362
393
299
307
1059
1057
1076
999
4191
1904
1904
Reduction in the number of patients with a length of stay greater than 50 days.
Monthly
610
SD-QA
53
50
46
51
45
47
45
45
41
49
47
na
149
143
131
96
519
635
635
Mixed Sex Accomodation Breaches (non-clinical)
Monthly
8
TDA
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
1
0
% Adults Admitted as an Emergency
Monthly
10.3%
NQD-TDA
9.78%
9.01%
8.28%
8.94%
8.14%
9.00%
8.79%
9.44%
8.26%
8.71%
8.60%
8.00%
9.03%
8.69%
8.82%
8.43%
8.74%
6.17%
6.10%
% Under 19s Admitted as an Emergency
Monthly
6.0%
NQD-TDA
4.01%
4.85%
7.68%
3.66%
5.58%
9.28%
5.21%
4.22%
3.98%
4.44%
5.65%
4.48%
5.38%
6.23%
4.44%
4.83%
5.18%
5.93%
5.41%
Quarterly
na
na
na
na
na
na
98.01%
na
na
94.97%
na
na
na
na
na
na
na
96.49%
Use of feedback from real time patient experience project
Data not collected
na
Reduction in patients suffering a bad experience dealing with the Trust
Quality of Life for People with LTC
Cleanliness/PEAt survey
Quarterly figures from National Specifications for Cleanliness
na
Improve our customer service and become a more caring organisation
complaints per 1000 episodes
Monthly
4.9
SD
3.9
3.8
4.5
5.2
4.8
4.5
4.6
5.7
5.3
6.3
5.6
6.5
4.1
4.9
5.2
6.1
5.1
complaints/PALs 'staff attitude'
Monthly
225
SD
19
27
19
22
20
17
24
17
16
24
21
16
65
59
57
61
242
Complaints
Monthly
759
TDA
51
51
59
73
61
58
64
74
68
87
70
85
161
192
206
242
801
Complaints about nursing staff
Monthly
100
SD
4
2
7
14
11
16
19
15
19
14
14
15
13
41
53
43
150
2.7
263
na
263
NQD - National Quality Dashboard, TDA - Trust Development Authority, SD - Safety Dashboard, QA - Quality Accounts
Page 31 of 84
EXCEPTION REPORTING: Transfers
Clinical Support Health Group
All transfers are reviewed weekly and validated by the Matron or Divisional Nurse manager. In
March, there were no patients transferred or discharged after 2200hrs. There were 6 patients
transferred more than twice, 5 for clinical reasons and therefore appropriate, 1 being transferred
to create capacity for the medical bed base.
Family and Women’s Health Group
Only one incident was recorded on Datix (13 March) – Ward 16 – patient transferred after
10pm.
Medicine Health Group
Records of patients that move wards after 10, are discharged after 10pm and have more
than 2 ward transfers for non-clinical need are validated by the Matrons and Charge Nurses
on a weekly basis and any learning from these reviews is cascaded to the ward teams.
During March within the medicine bed base there were 57 patients transferred after 10 pm.
Of these 12 patients transferred for clinical reasons and 45 patients were transferred for nonclinical reasons.
There were 17 discharges from the wards after 10pm. Transport delays were the main
reported issue
Surgery Health Group
Transfers are reviewed and validated on a weekly basis by the DNMs and Nurse Director to
ensure that all patient transfers are related to the clinical requirements of the patient.
A review of March 2014 patient transfers has shown that the majority of patients who were
transferred more than twice were predominantly in the same speciality and were carried out
in order to ensure that the service had sufficient bed capacity to maintain a seamless service
and were EMSA compliant. All transfers of patients undertaken between 10.00pm and
6.00am by the health group have been reviewed. All transfers were undertaken for clinically
need of the patient.
Action
An exception report will be continually provided to the Board, and monitored at health Group
level
Page 32 of 84
EXCEPTION REPORTING: Quality of Life for People with
Long Term Conditions (LTC)
Page 33 of 84
STROKE DASHBOARD
Page 34 of 84
EXCEPTION REPORTING: Stroke
Stroke
The Trust should be providing a high quality service - this involves meeting
key targets for admissions and ward stays
Aim: Maintain a high quality service
Owner: Chief Nursing Officer, Relevant HG Nursing Director
Consequence of failure: Patient Safety, Cost Implications
STROKE EXCEPTIONS (METRICS)
The refreshed stroke metrics will confirm achievement against 90% length of stay on stroke ward
and the patients admitted directly to the stroke ward in 4 hours via ED following further validation.
Following validation we will be able to demonstrate year compliance against all targets within the
stroke metrics.
To summarise, data is not complete at this point and the dashboard should not be taken as a final
position of March’s performance. Work continues on the development of the Stroke Database,
which will lead to an improvement in Stroke Data Quality.
Page 35 of 84
EXCEPTION REPORTING: Cleanliness
NATIONAL SPECIFICATIONS FOR CLEANLINESS
13 WEEK AUDIT SUMMARY JANUARY TO MARCH 2014
SITE
Hull Royal Infirmary
Castle Hill Hospital
OVERALL REPORT SCORE
MINIMUM SCORE
REQUIRED*
AVE 13 WEEK SCORE
29/12/13 - 23/03/14
85.5%
84.7 %
85.1 %
97.51 % ↑
97.75 % ↑
97.48 % ↑
These scores are the combined domestics, catering, nursing and estates element scores. The
minimum scores are determined by a calculation of the combined risk category minimum scores and
the percentage of risk areas at each site.
SUMMARY COMMENT AND ACTIONS
Domestic cleaning service exceeded minimum standards throughout.
Ward Kitchens – ongoing daily cleaning issues. Management are working closely with staff to
resolve these issues. Monitoring Officers currently audit these areas more frequently to ensure
improvement.
Patient Equipment - has fallen below the National Standard required during this quarter on a
number of wards at both sites. Monitoring rechecks will be carried out in areas that continue to fall
short of standards.
Theatres at both sites also fell below standard. Meeting arranged to discuss and resolve ongoing
problems.
Queens Centre - windows reported as dirty. Taken up with PFI FM provider.
Page 36 of 84
EXCEPTION REPORTING: CQC Intelligent Monitoring
Page 37 of 84
The full breakdown of the Tier one indicators can be found in appendix C.
Page 38 of 84
CORPORATE PERFORMANCE REPORT 2014/15
Section:
Finance and Business
Lead Director:
Lee Bond
Report Month:
April 2014
Page 39 of 84
FINANCIAL SUMMARY: YEAR TO 31 MARCH 2014
Page 40 of 84
FINANCIAL RISK RATING
Page 41 of 84
FINANCIAL RISK RATING METRICS
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CONTRACTING
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CASH RELEASING EFFICIENCY SAVINGS PROGRAMME
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CASH AND WORKING CAPITAL MANAGEMENT - STOCK
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CASH AND WORKING CAPITAL MANAGEMENT - BPPC PERFORMANCE
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CASH AND WORKING CAPITAL MANAGEMENT - RECEIVABLES
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CASH AND WORKING CAPITAL MANAGEMENT - PAYABLES
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CAPITAL PROGRAMME
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CASH AND WORKING CAPITAL
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STATEMENT OF COMPREHENSIVE INCOME
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STATEMENT OF FINANCIAL POSITION
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BRIDGE ANALYSIS (Excluding Impairment)
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CORPORATE PERFORMANCE REPORT 2014/15
Section:
Operational Delivery
Lead Director:
Morag Olsen
Report Month:
April 2014
Page 54 of 84
PERFORMANCE INDICATORS
Missing Data:
Page 55 of 84
30 day Emergency Readmissions – data source is CHKS, January performance is the latest confirmed position available.
Missing Data:
Termination of Pregnancy – latest available data is January provisional performance
PPCI – Latest confirmed position available is January.
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Missing Data:
OP New to Follow up, Average Length of Stay, Daycase Rate, Basket of 25 and OP Did not Attend rate – Data source is CHKS, latest available data
is February.
Page 57 of 84
Page 58 of 84
EXCEPTION REPORT
National Indicators
1.0
RTT Waits: admitted trust-level %
90% of patients to have a maximum time of 18 weeks from point of referral to first definitive
treatment for admitted pathways in aggregate.
The Trust delivered the aggregate standard in March at 90.52%. There are 5 specialties failing to
deliver the 90% standard in March. Validation of the pathways will be ongoing, with the final month
end position uploaded to the Department of Health on 17th April. Therefore the position and
specialties under-achieving is subject to change.
Cardiothoracic Surgery – 81.8%
Ear, Nose & Throat (ENT) – 77.8%
Neurosurgery – 76.7%
Plastic Surgery – 85.7%
Urology – 87.8%
An RTT recovery paper has been produced with options for discussion and agreement at the
Executive Management Board and Trust Board in April.
2.0
RTT Waits: non-admitted trust-level %
95% of patients to have a maximum time of 18 weeks from point of referral to first definitive
treatment for non-admitted pathways in aggregate.
The Trust has not delivered against the aggregate standard at the end of March at 93.52%. There
are 8 specialties failing to deliver the 95% standard in March. Validation of the pathways will be
ongoing, with the final month end position uploaded to the Department of Health on 17th April.
Therefore the position and specialties under-achieving is subject to change.
Cardiology – 92.6%
Cardiothoracic Surgery – 90.5%
Dermatology – 89.6%
Gastroenterology – 83.7%
General Surgery – 84.8%
Neurosurgery – 93.7%
Plastic Surgery – 93.7%
Trauma and Orthopaedics – 90.9%
Urology – 83.5%
An RTT recovery paper has been produced with options for discussion and agreement at the
Executive Management Board and Trust Board in April.
Page 59 of 84
3.0
RTT Waits: incomplete pathways trust-level %
92% of patients to be currently waiting for treatment less than 18 weeks at the end of the
month on an incomplete pathway (combined of non-admitted and admitted pathways) in
aggregate.
The Trust has failed to achieve the aggregate standard in March at 89.4%. Currently there are 11
specialties failing to deliver the 92% standard in March. Validation of the pathways will be ongoing,
with the final month end position uploaded to the Department of Health on 17th April. Therefore the
position and specialties under-achieving is subject to change.
Cardiology – 88.3%
Cardiothoracic Surgery – 82.3%
Dermatology – 90.7%
Gastroenterology – 83.3%
General Surgery- 85.2%
Neurosurgery – 91.5%
Ophthalmology – 90.2%
Plastic Surgery – 84.8%
Thoracic Medicine – 82.9%
Orthopaedics – 87.5%
Urology – 78.4%
The National Intensive Support Team is working with the Trust to review management of Referral to
Treatment and whether the recovery plans are robust. A report is due from them early April with
recommendations for the Executive team.
An RTT Recovery plan is being developed in readiness for Executive Management Board and Trust
Board with options for changes in approach taken for recovery.
18 Weeks RTT - Incomplete Pathways - Backlog Trajectory
4500
4000
3500
3000
2500
2000
1500
1000
Actual
Trajectory
30/03/14
23/03/14
16/03/14
09/03/14
02/03/14
23/02/14
16/02/14
09/02/14
02/02/14
29/01/14
19/01/14
12/01/14
0
05/01/14
500
Fixed Trajectory
Page 60 of 84
4.0
Total time in A&E: % of patients who have waited less than 4 hours
95% of patients to have a maximum waiting time of four hours from arrival to admission,
transfer or discharge.
March, Quarter 4 and the full year has failed to achieve the 95% standard.
A presentation was made to the Trust Board in March 2014 which outlined the 30, 60 and 90 day
actions being taken to achieve the 95% target sustainably.
For week commencing 7th April performance is at 97.4% with April to date at 93.1% (data as at 11th
April).
ED 4hr Wait Performance (HRI & ERCH)
100.0%
98.0%
96.0%
94.0%
92.0%
90.0%
88.0%
% of patients seen in < 4 hours - Type 1&3
5.0
31/03/14
17/03/14
03/03/14
17/02/14
03/02/14
20/01/14
06/01/14
23/12/13
09/12/13
25/11/13
11/11/13
28/10/13
14/10/13
30/09/13
16/09/13
02/09/13
19/08/13
05/08/13
22/07/13
08/07/13
24/06/13
10/06/13
27/05/13
13/05/13
29/04/13
15/04/13
01/04/13
86.0%
Trajectory/Operational Standard (95%)
Breast Symptomatic 2 Week Wait
93% of all referrals with breast symptoms (where cancer is not suspected) to be seen within
14 days
The Trust is currently achieving against this standard at 95% in March but has under-achieved in
Quarter 4 at 91.6%.
5.1
Family & Women’s HG
Due to the significant number of breaches of this standard in January the Quarter 4 position has
not been recovered. The Health Group have implemented a number of actions which have
shown sustained improvement with delivery shown in February and March.
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6.0
Cancer 62 Days: GP referral to Treatment
85% of all urgent GP referrals for suspected cancer to be treated within 62 days
National submission of Open Exeter is unadjusted position
Monitor performance shows an adjusted position following repatriation of late
referrals to the referring organisation
March provisional performance is showing under achievement at 80.9% (adjusted) and 78.3%
(unadjusted). Due to the early point in the month this position is likely to change. Quarter 4
performance is under-achieving at 82.8% and there is significant risk that this will not achieve in
quarter 4. Tumour sites that are under-delivering against the standard in March are:Colorectal Surgery – 73.9% (3 breaches)
Lung – 76.7% (3.5 breaches)
Sarcoma – 50% (1 breach)
Skin- 75% (1.5 breaches)
Upper GI Surgery – 68.4% (3 breaches)
Urology – 79.1% (7 breaches)
The CWT Recovery plan was presented to the Trust Board in March 2014 and outlined a number of
actions that are being taken to improve compliance with the 62 day standard. A stretch target has
been implemented to deliver 90% compliance for all GP suspected cancer referrals direct to HEY to
be treated within 62 days. This is monitored weekly via a new Cancer Dashboard that is distributed
to all MDT teams.
7.0
Cancer 62 Days: NHS Cancer Screening Referral Service
90% of all referrals from a Cancer Screening service to be treated within 62 days
The provisional March performance at Trust level is showing an under-achievement at 87.3%
(adjusted) and 83.1% (unadjusted). Due to the early point in the month this position is likely to
change prior to the final uploaded position at the beginning of May. Quarter 4 performance
(adjusted) is showing under-achievement at 85.1%.
There are 9 confirmed breaches in quarter 4:Breast – 8
Bowel – 1
The CWT Recovery plan was presented to the Trust Board in March 2014 and outlined actions that
are being taken to improve compliance with the 62 day screening standard.
In terms of securing the position sustainably, particularly in the Breast MDT, the follow actions have
been identified:
A plan to secure additional capacity long-term
Enhanced management involvement in the tracking and escalation process.
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8.0
Cancer 31 Days: Primary
96% of all patients to be treated by surgery within 31 days from the decision to treat
The provisional March performance at Trust level is showing achievement at 97.5%. Quarter 4
performance is showing under-achievement at 95.7%, and there is a risk that this will not be
recovered for the quarter. The final upload and confirmed position will be available at the beginning
of May.
The tumour sites with breaches in Q4 include:Breast – 94.3% (7 breaches)
Colorectal – 93.1% (6 breaches)
Skin – 90.1% (8 breaches)
Urology 95.6% (7 breaches)
In terms of delivering a sustainable position, there are two areas needing further improvement,
Urology and Colorectal. The issue in Urology is capacity as highlighted under the 62 day target
commentary. Colorectal performance has deteriorated significantly in Q4 and this appears to be
mainly a failure of tracking and escalation. The team have taken action to rectify this and
improvement is being monitored via the weekly oversight meetings.
9.0
Over 52 Week Waiters
Zero tolerance of Referral to Treatment waits over 52 weeks at the end of each month.
At the end of March the Trust will be reporting 10 over 52 week waiters. The upload is due to the
Department of Health on 17th April and therefore this is a provisional position.
1 x ENT
2 x Urology
1 x Plastic Surgery
6 x Dermatology
A recovery paper was presented to the Performance and Finance Committee in March 2014 which
outlined a number of actions being taken to improve performance against this standard. Most of the
actions have already been implemented. The further actions planned are:Health Groups to provide assurance that actions previously taken as outlined re accurate
recording of clinic outcomes and robust tracking and escalation avoiding pathway delays
are in place for all specialties.
Full validation of all patients on the PTL, supported by the Performance Team.
Health Groups to follow up any PTL inaccuracies detected via audit with individuals and
teams concerned and provide assurance any problems have been rectified.
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10.0 Number of diagnostic waits > 6 weeks
Less than 1% of patients are waiting longer than 6 weeks for a diagnostic test (15 key
diagnostic tests) at the end of each month.
The position for the Trust at the end of March is 48 top 15 diagnostic test breaches which equates to
0.69% and therefore the Trust achieved against this standard. The breaches reported were:25 x CT Scan
18 x MRI
3 x Cystoscopy
1 x Gastroscopy
1 x Urodynamics (Gynaecology)
10.1
Clinical Support HG
The MRI and CT departments have seen a considerable increase in referrals and are now
showing a year on year increase of 20% growth. This has been due to a combination of
acute inpatient requests and routine 18 week patients. In order to mitigate this situation a
mobile privately provided scanner has been ordered for a period of 3 months to increase
capacity and clear backlogs. The winter funding that allowed the scanners to operate 12
hour days / 7 days per week is to continue and will be funded through recurring monies.
10.2
Surgery HG
The breaches in Surgery HG occurred for a number of reasons. One patient was clinically
unfit when he attended prior to the breach date and has been redated for April. One patient
did not have mental capacity to consent to the procedure when they attended in March and
they have been reappointed for April. Two patients breached as there was a delay in
processing the request for the procedures. This is being investigated by the Health Group to
find the root cause of this.
10.3
Family & Women’s HG
The breach in Gynaecology occurred as the patient was unfit when they attended prior to
their breach date. The patient has been reappointed for April.
11.0 Cancelled Operations Re-booked within 28 days breaches
All patients who have operations cancelled, on or after the day of admission (including the
day of surgery), for non-clinical reasons to be offered another binding date within 28 days,
or the patient’s treatment to be funded at the time and hospital of the patient’s choice.
There were 2 patients not reappointed within 28 days in March in Cardiothoracic Surgery.
11.1
Surgery HG
One patient has been cancelled in January and February due to the lack of the required
valve. The patient was treated in March. The second patient was cancelled both in January
and February due to lack of ICU capacity and has now been treated in March. The CTS
RTT Recovery Plan outlines actions required for additional theatre sessions, evening out
demand for ICU throughout the week and an increase in ICU staffing.
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12.0 30 day Emergency Readmissions
Less than 6.4% of patients to be readmitted as an emergency within 30 days of being
discharged from hospital.
Data source CHKS January 2014 is the latest available position and shows an under-achievement
at 6.9%. Health Group performance is detailed below:Clinical Support – 7.0%
Family & Women’s – 4.8%
Medicine – 13.0%
Surgery – 4.5%
12.1
Medicine HG
Work is ongoing to develop services that are responsive to the needs of patients, particularly
those with long term conditions. Medicine recognises that these patients often are those
readmitted to hospital. There is an established project board looking at the development of
the heart failure pathway and this work is in conjunction with community partners. There is
similar work ongoing for the development of the COPD pathway.
Page 65 of 84
Local Contract Indicators
13.0 Recording of compliance with patient handover arrangements in
A&E
March performance is reported at 76% of all handovers happening within 15 minutes and the
average handover time is 12.44 minutes.
Performance throughout March continued to be impacted on due to the higher than
predicated ED patient attendances and surges in activity. This combined with the period
following the ambulance strikes in March led to a high volume of ambulance arrivals into
Initial Assessment in a very short period of time. This impacted on the ability of ED to
respond and triage patients in a timely manner.
An agreement in place that all GP walk in referrals go direct to AAU.
The paediatric screen has now been installed and throughout March the impact of this
should be reflected in the recording of paediatric ambulance arrivals.
14.0 Provider failure to ensure that “sufficient appointment slots” are
made available on the Choose and Book system
Less than 0.04 slot issues per successful direct booking on the national Choose and Book
system.
Performance in February was over the contract standard at 0.19. March performance has not yet
been published. The top 5 specialties with appointment slot issues in February are:Services
Children's & Adolescent
Neurology
2 week wait
Gynaecology
Ophthalmology
14.1
Total ASI’s
147
129
97
94
89
Medicine HG
Currently issues in Neurology, however, the new Registrar rota is available and slots are
being booked into. There should be 200 Registrar slots per month, however, with annual
leave, this amount to 100 slots. There is a new consultant commencing on the 23rd March,
and the Locum Consultant who was leaving at the end of March is now staying for an
additional few weeks. There will also be 2 consultants returning in April.
The Health Group will review the total capacity and put additional slots on if necessary.
14.2
Family & Women’s HG
Ophthalmology
The proportion of patients unable to be secure an appointment slot via Choose and Book
has reduced significantly but still remains a matter of concern. Capacity is reviewed by the
service team on a weekly basis and actions agreed to address shortfalls where required.
Page 66 of 84
Paediatric Medicine
The failure to appoint a Consultant Paediatric Locum in November 2013 and the transfer of
the Paediatric Allergy service from CSS Health Group at the same time has put pressure on
the General Paediatric Service which has translated into higher than planned numbers of
patients going onto the ASI. Additional capacity continues to be created with existing
Consultants undertaking extra clinics at weekends. The service will be interviewing at the
beginning of April for 2 Consultant posts both of which will add additional General Paediatric
capacity into the system.
Gynaecology
In Gynaecology there was a shortfall in new out-patient slots in February 2014 due to gaps
in the middle grade rotas. Clinic capacity was provided in March through the conversion of
under-utilised colposcopy capacity and backfill of existing clinics by two locum consultants
who were appointed in January.
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Internal Measures
15.0 Number of clinics cancelled <4 weeks’ notice period
It has been agreed that clinics cancelled with less than 4 weeks’ notice should achieve a percentage
improvement on 12/13 base line.
The Trust saw 52 clinics cancelled at less than 4 weeks’ notice in March. This is a reduction on the
same period last year. The number by Health Group:
Clinical Support – 8
Family & Women’s – 13
Medicine – 13
Surgery - 18
Clinic Cancellations <4wks notice - by month of cancelled clinic
2012/13 - 2013/14
140
120
100
80
60
40
20
0
apr
may
jun
jul
aug
sep
2012-13
15.1
oct
nov
dec
jan
feb
mar
2013-14
Clinical Support HG
Clinics were cancelled through short term annual leave and sickness although the number of
patients affected was less than expected. The Clinical Director for the service is to be tasked
with reducing unnecessary cancellations and this will be monitored through the Health Group
performance committee.
15.2
Family & Women’s HG
The number of clinics cancelled with under 4 weeks’ notice continues to be monitored as
speciality level.
15.3
Medicine HG
There were 13 clinic cancellations with less than 4 weeks’ notice in March for the Medicine
Health Group.
From the outpatient transformation steering group, some further analysis of clinic
cancellations by specialty, including patients affected by the clinic cancellations has been
shared. This is informing ongoing work to ensure that patient administration are aware of
Page 68 of 84
their responsibilities to escalate any cancellation requests with less than 4 weeks’ notice to
the appropriate management teams. This will be a regular agenda item at the weekly
Business Manager/Patient Administration meeting.
As stated before, the Medical Director for the Health Group has to authorise any such
cancellations.
15.4
Surgery HG
There has been a month on month reduction in cancelled clinics in the Surgery HG. As
previously noted, this is primarily due to priority given to non-elective and surgical
procedures or urgent outpatient appointments e.g. two week waits.
16.0 Average time in days of clinical correspondence awaiting typing
The internal standard for typing of clinical correspondence is to achieve an average in all specialties
of 7 days. This is measured using the G2 Digital Transcription system. Trust performance is
currently 23 days. Performance by Health Group shows:
Clinical Support – 23 days
Family & Women’s – 21 days
Medicine – 20 days
Surgery – 26 days
16.1
Medicine HG
Clinical correspondence remains an issue in the Medical Health Group. A breakdown of the
number of letters and the length of wait by days by Consultant has been circulated to all
Consultants in the Health Group. This will be part of the regular information provided to
clinicians to enable the managers to work closely with the clinical teams to reduce risk and
ensure that processes are managed across specialties rather than silo working
16.2
Surgery HG
The Surgery HG average time for typing of clinical correspondence in March is 26 days. A
trajectory has been implemented in the Surgery HG to monitor backlogs at specialty level.
Team working has been implemented across the HG to improve backlogs in long-waiting
specialties. The HG is also looking to bring in some agency staff, short term, but to date
there has been nobody available. Another option to be explored is outsourcing some work,
again short term and an update on this option will be given next month.
16.3
Family & Women’s HG
The current average for typing of clinical correspondence within F&WHG is standing at 17
days. The current backlog stands at 2979. Protected typing time is in place in all areas and
as a result the length of wait has reduced over recent months. Processes in all areas are
being looked at to find any areas of improvement and the G2 improvements are underway in
all areas now. Recruitment into 3 vacant Band 2 positions has been filled and successful
candidates are to attend the May induction. This will allow for further improvements.
16.4
Clinical Support HG
The most recent audit of waiting times shows Clinical and Medical Oncology at 2 days,
Clinical haematology at 7 days but with a plan to reduce this to 2 days with the next two
weeks. Infectious Diseases are at 3 days.
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17.0 Theatre Utilisation
Theatre utilisation remains a primary concern for the Surgery Health Group.
The Health Group has undertaken some detailed work with the Information Services department
looking at a variety of different time points that are recorded during a patient’s pathway. Rather than
crudely looking at start and finish times, the Health Group aspire to move to a metric that is based
on timings that occur within these global timeframes e.g. time sent for to arrival in Theatre, Arrival in
Theatre to Arrival in anaesthetic room, etc.
The audit of Plastic Surgery has commenced.
The table below shows performance using existing metrics.
18.0 Emergency Department – Clinical Quality Indicators
18.1
Timeliness – Time to initial assessment (95th percentile)
Performance at the 30th March has reduced again from 21 minutes to 16 minutes against a
15 minutes indicator. It is anticipated that with the ongoing pilot of the RAT performance will
continue to improve.
The process for recording initial assessment times for paediatric ambulance arrivals has
been reviewed and amended, it is anticipated this will provide an improvement in
performance
18.2
Timeliness - Time to treatment in department (median)
Performance at 30 March is reported as 85 minutes against a 60 minutes indicator.
The Rapid Assessment and Triage (RAT) model continues to be piloted now running
Monday to Friday with a dedicated senior doctor led team which runs from 08.00 until 18.00
and dedicated nursing lead. There is also a RAT assistant to assist with portering duties.
The ED has experienced cumulative impact of exceptionally higher than average
attendances combined with restricted timely access to bed capacity. This has impacted on
longer waits for time to see doctor during March.
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18.3
Patient Impact – Unplanned re-attendance rate
March has seen a slight increase to 5.59% from 5.44%. – cross agency work is ongoing.
18.4
Patient Impact – Left department without being seen
Performance continues to be delivered at 1.53% against the 5% indicator.
Page 71 of 84
CORPORATE PERFORMANCE REPORT 2014/15
Section:
Workforce
Lead Director:
Jayne Adamson
Report Month:
April 2014
Page 72 of 84
WORKFORCE PERFORMANCE REPORT
Purpose of Report
1.
To provide Performance and Finance Committee with the final position on workforce
performance and issues for the financial year 2013/14 as at 31st March 2014.
Background
2. Hull and East Yorkshire Hospitals NHS Trust employs 8,206 staff and is the 5th largest NHS
Trust in the Yorkshire and Humber region. As the Trust is a large employer within the region
and in order to achieve our vision, it’s vital that the organisation manages its people against a
range of workforce measures that ultimately will demonstrate whether the workforce is effective,
efficient, and delivers quality services.
Workforce Dashboard
3. The Trusts current performance against plan and budget can be seen below. Since the
beginning of the financial year the Trust has increased its contracted WTE by 77.3 WTE. The
Trust had seen a reduction of 51.1 WTE at the end of Q2, however in Q3 and Q4 the Trust
increased its Contracted WTE by 128.4 WTE.
4. At the start of the financial year the Trust was planning a reduction of approximately 140
Contracted WTE in 13/14. This was reflected in the reduction in Contracted WTE in Q1 and Q2.
However in Q2 and Q3 the Health Groups revisited their workforce plans due to additional
business cases and additional work being undertaken. The Trust has also recently seen an
increase in staffing due to winter pressures.
5. The Trust has four key performance indicators; attendance, retention, appraisal and
mandatory/statutory training. Performance against each individual indicator by Health Group
and Directorate is shown below. The Trust over the last 12 months has increased by 0.50% in
attendance, 4.7% in mandatory/statutory training and 0.4% in retention. There has been a 5.2%
decrease in appraisals over the last 12 months. Please note that the % Appraisal is excluding
staff with less than 1 years service and those who are not on AfC terms and conditions.
6. In three key performance indicators the Trust has improved performance on the position from 12
months ago. Training has seen the greatest improvement in the Trust total and Attendance is
the only key performance indicator which is green. Appraisals had met the key performance
indicator target in November 13, however has been steadily decreasing since then. This is due
to the impact of national changes in AfC terms and conditions. As a result of these changes
appraisals have been rescheduled, which is due to the new approach being linked to
incremental progression. Therefore employees appraisals will be in line with their incremental
dates. Consultant/SAS appraisal has increased by 24.4% over the last 12 months.
7. There are 59 open employee relations cases. In March 2014 a total of 11 cases were resolved
and 16 new cases were opened. The employee relations case which has been open the longest
is a grievance. This case has been open since the 26/02/13. During the financial year the Trust
has made progress in closing the oldest employee relations cases. In April 13 the longest open
case was a grievance which had been open since the 01/12/10.
Recommendations
8.
The Performance and Finance Committee is requested to note the workforce performance for
the financial year 13/14.
Page 73 of 84
WORKFORCE PERFORMANCE - HEALTH GROUP AND
DIRECTORATE POSITION AGAINST PLAN AND BUDGET
Workforce Performance - Health Group and Directorate Position Against Plan and Budget
Contracted WTE
Trust Total
Actual Contracted WTE as at Projected Contracted WTE
31/03/13
as at 31/03/14
6686.8
6545.0
The projected Contracted WTE as at 31/03/14 is the figure submitted to the Trust Development Authority.
This includes a 43.6 WTE reduction associated with QIPP.
Clinical Support Services
Family & Women's Health
Medicine
Surgery
Corporate Directorates
Infrastructure & Development
Trust Total
Baseline Contracted WTE as Actual Contracted WTE as Contracted WTE Change
at 31/03/13
at 31/03/14
YTD 2013/14
1817.3
1813.7
-3.6
894.2
897.6
3.4
1268.4
1277.9
9.5
1774.3
1820.3
46.0
456.4
499.9
43.5
476.2
454.7
-21.6
6686.8
6764.1
77.3
Total Pay Position
Total Pay Budget YTD
2013/14 (£000's)
Clinical Support Services
Family & Women's Health
Medicine
Surgery
Corporate Directorates
Infrastructure & Development
71,638
42,163
56,761
87,662
13,486
13,310
Total Pay YTD 2013/14
Variance YTD 2013/14
(£000's)
(£000's)
72,610
972
41,788
-375
56,390
-371
91,689
4,027
14,002
516
12,904
-406
69,247
40,061
53,017
85,132
12,977
11,577
Variable Pay Spend YTD
Total Pay YTD 2013/14
2013/14 (£000's)
(£000's)
3,363
72,610
1,727
41,788
3,373
56,390
6,557
91,689
1,025
14,002
1,327
12,904
Total Pay by type
Fixed Pay Spend YTD
2013/14 (£000's)
Clinical Support Services
Family & Women's Health
Medicine
Surgery
Corporate Directorates
Infrastructure & Development
Total Financial Position
Clinical Support Services
Family & Women's Health
Medicine
Surgery
Corporate Directorates
Infrastructure & Development
Total Pay and Non Pay
Actual Pay and Non Pay
Variance YTD 2013/14
Budget YTD 2013/14 (£000's) Spend YTD 2013/14 (£000's) (£000's)
113,120
114,852
1,732
53,214
53,484
270
78,504
78,979
475
115,302
122,687
7,385
28,863
28,862
-1
36,362
36,355
-7
Comments
All positive variances are over plan or budget.
The Contracted WTE figure is from ESR and the Trust has increased by 77.3 WTE.
Total Pay Position has been provided by Finance. NB This information does not include additonal activity/income over the period.
Total Financial Position has been provided by Finance. NB This information does not include additonal activity/income over the period.
Page 74 of 84
WORKFORCE KEY PERFORMANCE INDICATORS
% Attendance - Target 96.1%
Position as at
31/03/14
Position as at
31/03/13
Clinical Support Services
Family & Women's Health
Medicine
Surgery
Corporate Directorates
Infrastructure & Development
Trust Total
96.75
95.95
95.83
95.61
97.96
95.25
96.15
96.26
94.12
95.41
95.77
97.22
94.55
95.65
% Change from 12
Trend
months
0.49
1.83
0.42
-0.16
0.74
0.70
0.50
% Attendance
100.00
%
98.00
96.00
94.00
Position as at 31/03/14
92.00
Health Group
Infrastructure &
Development
Corporate
Directorates
Surgery
Medicine
Family & Women's
Health
Clinical Support
Services
90.00
Position as at 31/03/13
Target 13/14
% Retention - Target 93%
Position as at
31/03/14
Position as at
31/03/13
Clinical Support Services
Family & Women's Health
Medicine
Surgery
Corporate Directorates
Infrastructure & Development
Trust Total
91.9
91.7
90.9
92.7
93.8
95.7
92.3
90.8
90.2
92.2
94.2
89.1
92.1
91.9
% Change from 12
Trend
months
1.1
1.5
-1.3
-1.5
4.7
3.6
0.4
100.0
98.0
96.0
94.0
92.0
90.0
88.0
86.0
84.0
82.0
80.0
Corporate
Directorates
Infrastructure &
Development
Health Group
Surgery
Medicine
Family &
Women's Health
Position as at 31/03/14
Clinical Support
Services
%
% Retention
Position as at 31/03/13
Target 13/14
Page 75 of 84
% Appraisal - Target 85%
Position as at
31/03/14
Position as at
31/03/13
Clinical Support Services
Family & Women's Health
Medicine
Surgery
Corporate Directorates
Infrastructure & Development
Trust Total
77.8
63.8
68.7
60.8
74.8
74.7
69.9
Position as at
31/03/14
74.0
77.7
73.2
74.2
75.1
82.5
75.1
Position as at
31/03/13
Consultant/SAS Appraisal
69.8
% Change from 12
Trend
months
3.8
-13.9
-4.5
-13.4
-0.3
-7.8
-5.2
% Change from 12
Trend
months
45.4
24.4
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
Health Group
Infrastructure &
Development
Corporate
Directorates
Family &
Women's Health
Medicine
Surgery
Position as at 31/03/14
Clinical Support
Services
%
% Appraisal
Position as at 31/03/13
Target 13/14
% Mandatory/Statutory Training - Target 85%
Position as at
31/03/14
Position as at
31/03/13
Clinical Support Services
Family & Women's Health
Medicine
Surgery
Corporate Directorates
Infrastructure & Development
Trust Total
81.7
79.2
72.7
75.8
81.3
91.3
79.0
78.6
71.6
73.0
72.5
67.2
80.8
74.3
% Change from 12
Trend
months
3.1
7.6
-0.3
3.3
14.1
10.5
4.7
100.0
90.0
80.0
70.0
60.0
50.0
40.0
Corporate
Directorates
Infrastructure &
Development
Health Group
Surgery
Medicine
Family &
Women's Health
Position as at 31/03/14
Clinical Support
Services
%
% Mandatory/Statutory Training
Position as at 31/03/13
Target 13/14
Page 76 of 84
Employee Relations
Employment Cases
Open Cases as at
31/03/14
Grievances
Bullying/Harassment
Capability
Disciplinary
Staff Appeals Against Dismissal
Mediation – Bullying/Harassment
Tribunal
Trust Total
Employment Cases
6
8
9
36
0
0
0
59
Cases Resolved in
March 14
Grievances
Bullying/Harassment
Capability
Disciplinary
Staff Appeals Against Dismissal
Mediation – Bullying/Harassment
Tribunal
Trust Total
Health Group
Cases Resolved in
March 14
0
0
0
10
0
0
1
11
Open Cases as at
31/03/14
0
0
0
10
0
0
1
11
1
1
3
10
0
0
1
16
26/02/2013
05/07/2013
01/06/2013
09/04/2013
0
0
0
26/02/2013
Most
Recent
Case Start
Date
20/03/2014
25/03/2014
20/03/2014
28/03/2014
0
0
0
28/03/2014
Average Number of Median Number of
Days to Resolve
Days to Resolve
Cases
Cases
0
0
0
0
0
0
180
113
0
0
0
0
20
20
166
106
Cases Resolved in
March 14
10
3
18
20
3
5
59
Clinical Support Services
Family & Women's Health
Medicine
Surgery
Corporate Directorates
Infrastructure & Development
Trust Total
New Cases in March Oldest Case
14
Start Date
New Cases in March Oldest Case
14
Start Date
3
0
2
5
0
1
11
3
2
1
10
0
0
16
05/07/2013
25/11/2013
26/02/2013
09/04/2013
09/07/2013
10/06/2013
26/02/2013
Most
Recent
Case Start
Date
25/03/2014
20/03/2014
13/03/2014
28/03/2014
21/01/2014
21/02/2014
28/03/2014
Staff Survey
Objective
Ref
Staff reporting good communication
between senior management and
staff
KF21 (%)
Trust Score 2012
Trust Score 2013
Trend
National
Average
29%
32%
37%
Staff recommendation of the Trust as
a place to work or receive treatment KF24 (out of 5)
3.21
3.41
3.72
Staff motivation at work
3.67
3.73
3.82
KF25 (out of 5)
Page 77 of 84
CORPORATE PERFORMANCE REPORT 2014/15
Section:
Appendices
Report Month:
April 2014
Appendix A: Quality Scorecard Notes
Effectiveness
Missing Data
SHMI - validated quarterly position - HED 8 month delay on release
SHMI - monthly position - HED 5 month delay on release
HSMR monthly position - HED 4 month delay on release
specific conditions - all HSMR indicators - HED 4 month delay on release
Emergency Readmissions within 30 days - CHKS 2 month delay on release
Emergency Admissions not usually requiring admission - CHKS 2 month delay on release
VAP Bundle data - 1 month delay
Dementia Screening - March unavailable until mid month
Complication Rate - CHKS 1 month delay on release
Misadventure Rate - CHKS 1 month delay on release
Hip Fracture data - currently awaiting latest information
HED - national benchmarking system
CHKS - national benchmarking system
Safety
Missing Data
VTE risk assessment - waiting for validated data
WHO surgical checklist compliance - waiting for data
Experience
Missing Data
Friends and family Test - February data not available until early April
Delayed Discharges - awaiting latest information
Reduction in number of patients with LOS>50days - CHKS 1 month delay on release
HED - national benchmarking system
CHKS - national benchmarking system
Appendix B: Days Since Infection by Ward
Updat ed: 14/ 04/ 2014 11:08:05
Table showing days between Last positive episode (using date of sample) and
date of last Table update (14/04/2014 11:08:05)
All information is taken from the Infection Prevention and Control data software system.
Ward Name
Clostridium
difficile
ECOLI Bacteraemia MRSA Bacteraemia MSSA Bacteraemia
CHH Ward 2
661
545
CHH Ward 8
1073
157
CHH Ward 9
55
161
2008
CHH Ward 10
581
138
1228
51
CHH Ward 11
1488
46
2254
254
CHH Ward 14
179
53
838
91
CHH Ward 15
527
6
895
408
CHH Ward 16
784
373
90
CHH Ward 19
51
224
410
CHH Ward 20
1306
910
2098
1459
CHH Ward 21
119
264
1771
170
CHH Ward 22
279
198
CHH Ward 26 (Cardiothoracic surgery)
1020
7
CHH Ward 27 (Cardiothoracic)
1055
142
CHH 28 (CMU Cardiology)
558
1559
1645
322
CHH Ward 30
298
407
310
310
CHH Ward 31
121
79
1226
713
CHH Ward 32
322
121
428
117
CHH Ward 33
20
15
1921
168
CHH Short Stay Critical Care Unit (CGICU2)
CHH Teenage & Young adult cancer centre
CHH General Intensive Care Unit (1)
1557
311
116
938
1625
51
607
105
786
713
58
401
157
657
1804
1242
HRI Ward 1
278
747
HRI Ward 4
95
49
HRI Ward 5
336
297
1090
176
HRI Ward 6
141
151
1876
30
HRI Ward 7
229
122
66
HRI Ward ESSU - (Ward 80)
371
232
840
HRI Ward ESSU - (Ward 8)
114
45
HRI Ward 9
301
179
471
180
HRI Ward 10
301
108
1563
214
HRI Ward 11
530
138
1111
HRI Ward 12
872
95
2096
36
HRI Ward 100
154
50
186
167
HRI Ward 110
166
717
2283
952
CHH Cardiac Monitoring Unit
1846
698
1378
HRI Ward 31, Maple Ward
1028
HRI Ward 32/33 (Beech and Rowan)
HRI Gynaecology Ward 34
HRI Ward 40 Neurosurgery High Dependency Unit
34
423
HRI Ward 120
HRI Ward 130 West
836
1422
837
584
1175
1662
833
HRI Ward 50
88
24
984
HRI Ward 60
287
261
1349
73
HRI Ward 70
50
128
827
830
HRI Ward 90
307
231
895
HRI Acute Assessment Unit
459
184
171
HRI Eye Ward (Ophthalmology Ward)
HRI General High Dependency Unit
1362
17
7
67
249
HRI Neonatal Intensive Care Unit
231
HRI Paediatric High Dependency Unit
52
2055
350
32
593
1620
HRI Respiratory HDU
HRI Ward 130 East
1532
2254
HRI Labour & Delivery Suite
HRI Short Stay Ward
10
46
HRI Haemodialysis Unit
HRI Intensive Care Unit
959
33
265
39
07/08/2013 14:39:21. Document saved to : http://intranet/infectioncontrol/xls/DaysBetweenAlertsByWardHealthGroupxls.xls
207
Appendix C – CQC Intelligent Monitoring Tier 1 indicators breakdown
Appendix D: Version Control
Date
June 2013
June 2013
October 2013
January 2014
January 2014
Description
Lead
Quality and Safety section developed and included in the Corporate Performance Report.
Exception based reporting has also been included.
Operational Delivery section scorecard has been revised and developed with new NTDA
requirements and key local contract indicators. Commentary is now exception based
reporting.
Quality and Safety section revised to include the following new indicators VAP Bundle, Sepsis
Bundle, Stroke Bundle.
Quality and Safety section revised – quality scorecards revised, exception reporting also
revised.
Executive Summary added
AP/RON
MO/LT
AP/RON
AP
MO/LT
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
STRATEGIC OBJECTIVES
Trust Board
date
Director
24 April 2014
Reference
2014 – 4 - 15
Morag Olsen – Chief
Operating Officer
Author
Morag Olsen – Chief
Operating Officer
Reason for the
report
To set out the Trusts strategic objectives for 2014/15.
Type of report
Concept paper
Strategic
options
Performance
Information
1
Business
case
 Review

RECOMMENDATIONS
The Board is asked to accept the revised Strategic Objectives for 2014/15.
2
3
Key purpose
Decision
Approval
Information
Assurance
5
Discussion
Delegation
STRATEGIC OBJECTIVES




4

Safe, high quality effective care
Strong, high performing FT
Creating and sustaining purposeful partnerships
Efficient economic use of resources – targeted and prioritised
effectively



 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
All domains
CQC Regulation(s)
Assurance
Ref:
Framework No
BOARD/BOARD COMMITTEE REVIEW
Legal advice




No
This paper has not been considered by any other Board committee
Strategic Objectives for 2014/15
1.0
Overview
In order to set the Trusts strategic objectives for the forthcoming year, it would seem prudent
to also address the main areas of focus for the organisation in order to deliver the said
objectives over that period of time. To this end following the Board discussion in February,
the Executive team have reviewed the existing strategic objectives to assess whether they
were fit for purpose for the forthcoming year within the ever changing environment of the
NHS. Following that review the strategic objectives that are proposed for the following 12
months are listed below.
In order to set these objectives within a level of context, the Executive team have also
outlined a brief oversight of the strategies that they will be bring to the Board over the course
of the year for ratification, as it is expected that they will start to define the direction of travel
for future years and the delivery of the Trusts aspirations as we move forward.
2.0
3.0
Proposed strategic objectives for 2014/15

To improve health and reduce harm towards becoming the safest hospital in England
by 2017

To be recognised nationally as a Trust that consistently delivers results that place us
amongst the best performing hospitals in the country.

To be recognised nationally as a Trust, which offers excellent, integrated and
accessible care for the communities that it serves; through working in partnership
with local, national and international providers and commissioners.

To develop leaders throughout the organisation that are focused on delivery high
quality, patient centred care

Efficient and economic use of resource to ensure that the services provided by the
Trust are of the highest quality and remain financially sustainable.

Improving services by actively engaging and listening to patients, carers and families

Capable, effective valued and engaged workforce.
Supporting Strategies focus our delivery of the strategic objectives
Over the course of the year the following strategies will be presented by the relevant
Executive Directors to the Board to aid the development of the above. Whist the aim
of the strategies will obviously focus on delivery of change over a longer time period,
it is foreseen that the above strategic objectives will focus the organisation in the right
direction of travel for the future.
3.1
The main strategies that will drive our future direction of travel are:
3.1.2 Clinical Quality Strategy
Our Clinical Quality Strategy is intended to revitalise our clinical, research and educational
activities to position Hull and East Yorkshire Hospitals NHS Trust as a leading University
Teaching Hospital delivering the best possible care to the people of Hull and the East Riding
of Yorkshire and the Humber. Our ambitions are founded on a belief that there is a latent
potential in our organisation, and a belief amongst our staff that we can contribute to the
renaissance of the region as Hull becomes the UK City of Culture in 2017; a City of Culture
as well as a City of Care
The top priority in our Clinical Quality Strategy will be the safety of our patients, which is
captured in our ambition to be amongst the safest hospital in England by 2017. The Strategy
will be built on seven pillars:
1. Patient safety and effectiveness
2. Improving our tertiary services
3. Sustainable secondary care services
4. Local partnership working
5. Research and innovation
6. Education and training
7. Clinical leadership development.
3.1.3 Financial Strategy
The Finance Strategy moving forward will be a supportive strategy positioned around
ensuring service and organisational survival. The strategy will have a number of strands to it
that in one sense will be about supporting the clinical strategies to ensure we have robust
business delivery models at a service level, and, that these aspirations are reflected in the
estates strategy. It will also enhance the linkages between the delivery model and the clinical
strategies right through to a focus on cash, liquidity and the strength of the balance sheet, as
failure to do this will threaten the whole.
3.1.4 People’s Strategy
‘The People Strategy has been developed around 6 strategic workforce themes to focus our
priorities, and inform where activity is best concentrated and to generate annual delivery
plans.
The themes are: Leadership capacity and capability
 High performance and culture of excellence
 Employee engagement and recognition
 Workforce learning and development
 Diverse and healthy organisation
 Modern, fair and affordable employment package
Success for the Trust in the end will depend less on our structures, systems and processes,
but more on the way that our employees work effectively within them. What we offer our
employees as part of our written and ‘psychological’ contract and how we communicate and
engage employees will set the tone and culture for our organisation. It will enable the Trust
to overcome the challenges we face together and provide safe and quality outcomes for
patients.
Our core values remain and we will build on the people management successes of the past.
This People Strategy also takes account of expected changes in the environment and the
future aspirations of the Trust.’
3.2
All of the above will be underpinned by our performance management strategy that
allows the Board and the Executive to hold the organisation to account for delivery.
3.3
It should also be noted that there are other strategies such as the Estates Strategy
that will need to be refreshed following the development of the above, to ensure that
we have facilities to meet the needs of our patients and the services as we move
forward.
During the course of the year and in line with our Foundation Trust application, the Trusts
Integrated Business Plan will also need to be updated. Our aim is to ensure that as we move
forward this five year plan will be clearly linked the above strategies and the ongoing work of
the Clinical Services Strategy, together with the developing strategies of local
commissioners around service provision for the population.
4.0
Conclusion
In conclusion, the redefining of our strategic objectives to meet the needs of the organisation
at this time does appear appropriate, as the organisation has moved forward since the
objectives for 2013/14 were developed some three years ago. It should be noted however
that there may need to be further refining once the supporting strategies to have been
developed and ratified by the Board.
The Board is asked to accept the revised Strategic Objectives for 2014/15.
Morag Olsen
Deputy Chief Executive / Chief Operating Officer
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
TDA 2014/15 ACCOUNTABILITY FRAMEWORK
Trust Board
date
Director
24th April 2014
Liz Thomas – Director of
Governance
Reference
Number
Author
2014 – 4 – 16.1
Liz Thomas – Director
of Governance
Reason for the
report
To highlight to the Board the requirements set out in the Accountability
Framework for NHS Trusts.
Type of report
Concept paper
Strategic
options
Information √
Performance
Business
case
Review
1
RECOMMENDATIONS
The Trust Board is requested to:
 discuss the requirements of the Accountability Framework
 agree to change the Corporate Performance Report so that it reflects new
reporting requirements
2
Key purpose
Decision
Information
3
4
√
Discussion
Assurance
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and prioritised
 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
All domains
CQC Regulation(s)
Assurance Framework
5
Approval
Ref:
Legal advice
BOARD/BOARD COMMITTEE REVIEW
This report has not been considered at any other Board Committee.
√
√
√
√
√
√
No
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
DELIVERING FOR PATIENTS: THE 2014/15 ACCOUNTABILITY FRAMEWORK FOR NHS
TRUST BOARDS
1.
PURPOSE OF THE PAPER
To highlight to the Board the requirements set out in the Accountability Framework
for NHS Trusts.
2.
INTRODUCTION
The Accountability Framework was first published in April 2013. It is the document
that sets out the requirements that the Trust will need to meet in 2014/15 and the
relationship that the Trust Development Authority (TDA) will have with the Trust. The
Framework has been updated to take account of a number of new roles, policies and
processes that have been introduced over the last 12 months. This has included the
Chief Inspector of Hospitals inspection programme, the implications arising from Mid
Staffordshire and the related Keogh, Berwick and Clywd-Hart enquiries.
3
ACCOUNTABILITY FRAMEWORK
The Accountability Framework is attached at Appendix A. The document is divided
into 4 sections. The first section provides the introduction and context. Key messages
from the remaining three sections are set out below:
3.1 Oversight and escalation
 Quality metrics have been updated and aligned with the 5 domains used by
the Care Quality Commission
 The thresholds for calculating the overall financial risk rating have been
updated so that a Trust with a forecast deficit or a significant deterioration in
surplus will be red rated overall
 A sustainability score will be introduced later in 2014/15 once the five year
plans have been submitted and reviewed by the TDA
 Escalation scores have been aligned to ensure consistency with the Care
Quality Commission’s approach to assessing risk through its intelligence
monitoring system. The TDA will explore during 2014/15 a reduction in the
autonomy of NHS Trusts at higher levels of escalation, particularly on financial
matters. Escalation scores will be refreshed on a monthly basis using only
publically available information
 Trusts will be required to provide more detailed workforce data and will be
mandated to use the national workforce assurance tool. The Board will be
expected to demonstrate compliance by submitting information about how
they have put into practice the nine expectations set out in the Guide to
nursing, midwifery and care staffing capacity and capability
 There are requirements relating to data quality which include review by
internal audit, inclusion of a waiting list management review by external audit
every 3 years and maintaining and publishing a clear patient access policy.
 There are disclosure requirements relating to Information Governance
following the To Share or not to Share report (September 2013)
3.2 Development and Support
This section of the Accountability Framework sets out a range of support
mechanisms to enable Trusts to deliver high quality sustainable services.
 The Trust is required to submit a Development and Support Plan to the
Trust Development Authority plan by the end of September 2014




There will be support for challenged health economies to produce
effective strategic plans
The document sets out the TDAs approach to improving leadership
capacity. Support will be available for a number of leadership groups
including Boards, Chairs, Non-Executive Directors, clinical leaders,
operational leaders etc
A Patient Experience Development Framework has been developed to
support Trusts to carry out an organisational diagnostic against a set of
criteria that defines those organisations that consistently improve patient
experience
A website is being developed by the TDA to support Trusts in analysing
information
3.3 Approvals model for the FT and transactions pipelines and capital investment
 A single framework for assessing provider leadership is to be introduced
 An updated Foundation Trust approvals model is presented
 The assessment of a Trust against Monitor’s Quality Governance
Framework will be brought forward to the TDA stage of a Foundation
Trust application so that any quality issues are identified earlier.
 Historic Due Diligence will be replaced with an Independent Financial
review
 Public and patient involvement will be embedded more thoroughly in the
process
 Capital investments approvals will be required to demonstrate consistency
with the Trust’s clinical services strategy and engagement with clinical
staff
 There is now a requirement to achieve a “good” or “outstanding” rating
from the Chief Inspector of Hospitals assessment to proceed to
foundation trust status
4
RECOMMENDATION
The Trust Board is requested to:
 discuss the requirements of the Accountability Framework
 agree to change the Corporate Performance Report so that it reflects new
reporting requirements
Liz Thomas
Director of Governance
April 2014
Trust Development Authority
Delivering for Patients:
the 2014/15 Accountability Framework
for NHS trust boards
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Foreword
As we move into 2014/15, the leadership
challenge for NHS providers remains very
significant indeed. Improving quality for patients
at a time of growing financial constraint is an
increasingly demanding goal for NHS trusts,
one which we must take on at a time when the
scrutiny applied to the NHS is rightly very intense.
The Accountability Framework for NHS Trust
Boards sets out how the TDA will work alongside
NHS trusts to meet this challenge.
The refreshed Framework reflects some of the changes we
have seen in the past year, including the development of the new
Chief Inspector of Hospitals regime and the “special measures”
process. It also reflects out learning from our first year supporting
NHS trusts and the feedback we have received on our approach.
Our approaches to measurement, intervention and support have
all been adapted to reflect these changes.
The purpose of the Accountability Framework remains a simple
one: to articulate in one place all of the key policies and processes
which govern the relationship between NHS trusts and the
TDA. The Framework sits alongside our planning guidance and
covers our approach to measuring and overseeing NHS trusts;
to escalation and intervention; to the provision of support for
improvement; and to the way we move NHS trusts towards a
sustainable future.
Secondly, our approach is more closely aligned than before with
that of our partners, particularly regulators and commissioners.
So our oversight metrics are aligned with those used by CQC,
while our approvals process has been aligned to clarify the
respective of roles of Monitor, CQC and the TDA. And much of our
development work will be undertaken in partnership with other
bodies. As we come to understand the new system, it is more
evident than ever that these partnerships are critical to our success.
But while much of the detail has changed, the core principles
underpinning our Accountability Framework remain consistent.
Firstly, the Framework aims to be holistic and integrated, setting
out in one place of all our key policies and supporting a single
conversation between the TDA and NHS trusts.
Thirdly, our clear focus on quality is stitched throughout the
Accountability Framework. It sits at the heart of our oversight
and approvals models and it is central to our development work.
However, it is important that alongside our focus on quality,
a focus on financial discipline and value for money is retained.
Improving quality at the same time as maintaining financial control
represents a more difficult equation than ever for NHS providers,
but it is an equation we must continue to solve.
And finally, focussing on developing and supporting our trusts
remains a key priority for the TDA. The challenge of moving
towards sustainability is not about quick fixes, but rather a longterm process of improvement, based on a deep understanding
of organisational needs. So we want more than ever to focus on
support and development and on improving culture, leadership
and governance in NHS trusts.
I hope this Accountability Framework provides a useful guide
to the way our organisations work together over the coming year
and, as ever, I would welcome feedback so that we can continue
to develop and improve.
David Flory
Chief Executive
2
contents
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
The context for NHS trusts
Introduction
The role of the NHS TDA
Measurement of progress
on quality, finance and
sustainability
Developments since the
2013/14 Accountability
Framework
Approach to the 2014/15
Accountability Framework
Escalation and Intervention
Other areas of TDA
oversight of NHS Trusts
The importance of
development for NHS trusts
Understanding
development needs
Meeting development
needs
• Theme One:
Improving Leadership
• Theme Two:
Improving quality
• Theme Three:
Support for challenged
organisations
• Theme Four:
Support for higher
performers
Reviewing development
needs
Context
Changes to the foundation trust assessment process
Overview of the revised foundation trust assessment process
Taking forward sustainable solutions: the transactions
approval process
Sustainable capital investments
Capital Investment approvals
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
introduction
and context
The context for NHS trusts
1.1
The period ahead is likely to prove very challenging for the NHS as a whole, and particularly for provider
organisations. The emphasis on providing high quality care for patients has rightly never been greater;
the many lessons from the Mid Staffordshire Inquiry and the development of the new regime of the
Chief Inspector of Hospitals demonstrate the urgency of the quality agenda. Meanwhile, the financial
pressures facing providers are becoming ever more acute, with a 4% annual efficiency requirement
likely for the foreseeable future and the introduction of the Better Care Fund from 2015/16. Continuing
to deliver high quality care within available resources, to do more and better with less, is therefore an
increasing challenge for providers and the boards that oversee them.
1.2
Securing Sustainability, the planning guidance for NHS trust boards, was published in December and
set out the scale of this challenge and the need for local health systems to work together to deliver
effective operational and strategic plans to meet future needs. This refreshed Accountability Framework
sets out the other key elements of the TDA’s relationship with NHS trusts and the approach we will take
to our collective business in 2014/15.
The role of the NHS TDA
1.3
While the system in which NHS trusts operate is highly complex, the role of the NHS TDA and its
relationship with NHS trusts remains a simple one. The TDA oversees NHS trusts and holds them to
account across all aspects of their business, while providing them with support to improve services and
ultimately achieve a sustainable organisational form. The relationship is holistic and combines a hard
edge of accountability with a clear role in providing support and development. Hence the objectives
of NHS trusts and the TDA are one and the same, and your success is our success. Figure 1 below
captures all of the core elements of the relationship between NHS trusts and the TDA.
1.4
In delivering their responsibilities, both NHS trusts and the TDA work in a much broader environment
and interact with a range of other bodies. It is increasingly apparent in the new system that joint
working and effective partnerships are critical to all aspects of business, both at local and national level.
1.5
Commissioners play a key role across the NHS in setting the shape and pattern of services and
overseeing the delivery of services through their contractual relationship with providers. NHS trusts and
the NHS TDA therefore work closely with local clinical commissioning groups and with NHS England
at regional and national level both on the planning of services and on the day-to-day delivery of
contractual requirements. While NHS trusts are responsible to commissioners through their contracts
for the service they deliver, their accountability to the NHS TDA is broader and covers all aspects of their
business, as shown in Figure 1.
4
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
1.9
Figure 1: NHS TDA relationship with NHS trusts
NHS TDA (through local Delivery & Development Team)
Operations
•Access
•Capacity
•Winter
•Comms
Quality
•Experience
•Safety
•Mortality
•CQC/CIH
•System role
Finance
Planning
Governance
Sustainability
Development
•In-year
•Contracting
•Capital
•Cash
•2-year
operational
•5-year
strategic
•Development
•Health
economy
•Appointments
•Board relations
•Exec HR
•Comms
•FT application
•Transactions
•Service change
•Prof leadership
•Talent mgmt
•Governance
•Delivery
Developments since the 2013/14 Accountability Framework
1.10
The NHS TDA published its first Accountability Framework for NHS trust boards at the
beginning of April 2013, in line with the TDA taking on its full powers. Since then a number
of important developments have taken place which affect the work of NHS trusts and
the TDA. First, and most significant, the new health system has been operating for a year
and much has been learnt both nationally and locally about roles and responsibilities and
dynamics and behaviours within that system. The TDA has also been working alongside
NHS trusts and has gathered feedback on its role and processes.
1.11
Secondly, a number of new roles, policies and processes have been introduced since April
2013. Most notably, the first Chief Inspector of Hospitals has been appointed and his work
on the programme of new inspections has begun in earnest across all sectors of the NHS.
The need for a “Good” or “Outstanding” rating from the Chief Inspector to proceed to
foundation trust status has been set out, significantly changing the standards required for
moving to FT. And the inspections overseen by Sir Bruce Keogh early in 2013/14 have led to
the introduction of the “special measures” process to secure rapid improvement in a small
number of provider organisations with significant quality problems.
1.12
Thirdly, the implications of the Mid Staffordshire Inquiry are now clearer than they were a
year ago, and a number of related inquiries have been completed, each with significant
implications for NHS providers. These include the Keogh review, Professor Don Berwick’s
review of patient safety, the Cavendish review on healthcare support workers and the ClywdHart review into improving the patient complaints procedure. The National Quality Board has
also recently published important guidance for providers on maintaining safe staffing levels.
1.13
All of these and many other changes over the past year have had a significant impact on
the environment for NHS providers, meaning there is a clear need to refresh and update the
different processes within our Accountability Framework.
NHS Trust
1.6
1.7
1.8
NHS England has a number of roles in addition to the direct commissioning of certain
services. The NHS TDA works with NHS England in its assurance role regarding clinical
commissioning groups to provide joint support in resolving issues that span whole health
economies or local areas. Our organisations also work together at a national level on key
strategic projects to ensure that the system works to provide high quality, sustainable services
for patients.
The Care Quality Commission regulates the quality of services provided by NHS trusts and
through the Chief Inspector of Hospitals is the ultimate arbiter of the quality of care. The role
of the NHS TDA is to support NHS trusts and hold them to account for making improvements
to the quality of services, both pro-actively and in response to the findings of the Chief
Inspector. So while the Chief Inspector judges the quality of services and identifies where
improvement is needed, the role of the NHS TDA is to ensure that NHS trusts fix problems
and improve standards.
Monitor licenses existing foundation trusts and makes the final decision on whether
applicant NHS trusts meet the standards for FT status. The NHS TDA’s role is to support NHS
trusts in developing sustainable services and moving through the FT application process by
meeting the necessary standards for quality, finance and governance. Monitor also advises
the NHS TDA on the impact on choice and competition of transactions involving NHS trusts,
and assesses transactions involving NHS foundation trusts.
The TDA also works with a range of other bodies which interact with NHS trusts, including
Health Education England, the General Medical Council, Nursing and Midwifery Council
and other professional regulators, NICE, the Health and Social Care Information Centre, the
NHS Leadership Academy and the Department of Health. While the number of different
bodies which interact with NHS providers is significant, the role of the NHS TDA as the
point of accountability for NHS trusts across all aspects of their business provide some clarity
in this highly complex environment.
5
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Approach to the 2014/15 Accountability Framework
1.14
1.15
Despite these many changes, the purpose and structure of the Accountability Framework
remain consistent. Put simply, the Accountability Framework sets out the key rules,
processes and commitments which underpin and define the relationship between NHS
trusts and the NHS TDA. The document aims to provide a clear, concise and integrated
account of all the key things that NHS trust boards need to be aware
of in doing business with the TDA.
1.16
The structure of the 2014/15 Accountability Framework also remains consistent: the
planning guidance, already published, sets out the different plans that are required from
NHS trusts and how the NHS TDA will assure those plans. 2-year operational plans are due
at the beginning of April, 5-year strategic plans by 20 June, and Development Support Plans
by the end of September. The planning process provides the foundation for the other aspects
of the Accountability Framework.
1.17
The oversight process (Chapter 2) sets out what we will measure and how we will hold
trusts to account for delivering high quality services and effective financial management.
For 2014/15, the TDA’s quality metrics have been adjusted to improve alignment with the
CQC’s Intelligent Monitoring process. It also sets out how we will score and categorise
NHS trusts and a clearer approach to both intervention and support for organisations at
different levels of escalation. Finally, the oversight section covers other rules and processes
which apply to NHS trusts in areas such as appointments, remuneration, data quality and
information governance.
1.18
The development section (Chapter 3) describes the TDA’s approach to understanding
the evolving development needs of NHS trusts, particularly through the production
of Development Support Plans to complement trusts’ operational and strategic plans.
This section also sets out the TDA’s approach to development and areas where development
support will be targeted during 2014/15. This includes support for challenged health
economies to produce effective strategic plans, greater support for boards and leaders across
the trust sector, and a refreshed approach to support for aspirant FTs, delivered in partnership
with the Foundation Trust Network. The TDA recognises the importance of providing effective
support for NHS trusts and will seek to increase the emphasis on this area during 2014/15.
1.19
The approvals section (Chapter 4) sets out the TDA’s approach to assuring foundation trust
applications, transactions proposals and capital schemes. This section clarifies the new role of
the Chief Inspector of Hospitals in the FT assessment process, and sets out the ambition for
a single framework for assessing provider leadership to increase alignment between current
regulatory and assessment processes.
1.20
Each section is underpinned by more detailed guidance and templates where these are
needed. Taken together, the different processes brought together in the Accountability
Framework aim to provide some clarity for NHS trusts in the increasingly complex and
demanding environment in which they operate.
The principles underpinning the Accountability Framework remain consistent with those
set out last year, highlighting the continuity in the approach taken by the NHS TDA.
So the principles which continue to drive our work are:
•
Every interaction we undertake has an impact on the quality of care patients
receive – our focus on quality improvement remains central to the work of the
NHS TDA
•
One model, one approach – the NHS TDA is a national organisation and the
approach set out in the Accountability Framework will be applied consistently to
NHS trusts across England and across all sectors of care
•
Clear local accountability for delivery – the accountability for all aspects of
NHS trust business remains with the board of the trust, held to account and supported
by the TDA
•
Openness and transparency – being open and candid publicly about the quality of
care remains central to the TDA’s approach
•
Making better care as easy to achieve as possible – working with partners to create
the right environment for change remains a central challenge both locally and nationally
•
Working supportively and respectfully – the TDA recognises the very significant
challenges faced by NHS trust boards and therefore aims to work supportively and
respectfully at all times
•
An integrated approach to business – the TDA remains committed to aligning all the
different aspects of its business with NHS trusts through a single set of processes, as set
out in this Accountability Framework.
6
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
oversight
and escalation
Introduction
2.1
The Oversight model describes how the TDA will work with NHS trusts on a day-to-day basis,
within a clear and unambiguous framework. It describes the expectations we have of NHS trusts
to deliver high quality services for the communities that they serve. It sets out how we will measure
progress, how we will judge performance, how we will intervene where it is necessary to do so,
and other rules and policies which will govern our day-to-day relationship with NHS trusts.
2.2
The overall TDA approach to oversight remains consistent for 2014/15, with a clear focus on quality,
delivery and sustainability. In holding organisations to account we will act in accordance with the
principles set out in the Introduction to this Framework and in particular, we will always seek to be:
•
•
•
Proportionate and consistent
Open and transparent
Respectful and supportive
2.3
For the sake of clarity and consistency, it is critical that we set out the nature of our oversight
relationship with trusts. It is important to reiterate that our role in ensuring that patients receive a
standard of care consistent with their rights – as set out in the NHS Constitution – requires a proactive
approach. The TDA will not wait for concerns to become apparent through monthly reporting, but
will build effective relationships with trusts to ensure that any issues can be identified and addressed
as quickly as possible.
2.4
The key changes to the Oversight model for 2014/15 reflect the changing environment described
above and in particular the need to ensure alignment with other national bodies. They reflect the
findings of the Mid Staffordshire Public Inquiry and in particular the emergence of the new Chief
Inspector of Hospitals’ regime.
2.5
The next sections sets out an overview of the Oversight Model for 2014/15, covering:
•
•
•
Measurement of progress on quality, finance and sustainability
Escalation and intervention
Other areas of oversight
Measurement of progress on quality, finance and sustainability
2.6
The overall approach to measuring and tracking NHS trust performance remains consistent with last
year’s Accountability Framework. There are a number of domains each with an associated set of
indicators. Performance against these indicators will determine a score for each domain. These domain
scores in turn contribute towards an overall Escalation score for each NHS trust.
7
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
2.7
Figure 2 sets out an overview of the key elements of the Oversight model.
2.8
For 2014/15, the Quality domain has been aligned with the new CQC regime and the
domains of its Intelligent Monitoring system. As well as contributing to a consistent
assessment of quality nationally, this approach also ensures continued alignment with
the NHS Constitution and the NHS Outcomes Framework.
2.9
There has also been a change to the way the escalation scores will work for next year:
for 2014/15 NHS trusts will be scored using escalation levels 1 to 5, as it was last year,
but the key change will be that escalation level 1 will now be the highest risk rating with
level 5 the lowest. This is to ensure consistency with the CQC’s approach to assessing
risk through its Intelligent Monitoring system.
2.10
Whilst the Oversight and Escalation model will be closely aligned with the CQC’s Intelligent
Monitoring system, there will remain a number of differences which reflect the different roles
of the two organisations. As the regulator and final arbiter of quality, the CQC model is based
on a broad and comprehensive set of indicators which are used to highlight where a trust
is an outlier compared to its peers. In order to be effective in its oversight and performance
management of trusts, the TDA needs a narrower set of metrics, all of which can be updated
frequently so that changes in performance can be identified and addressed promptly. The
TDA also has a role in ensuring that trusts deliver on commitments made to patients in the
NHS Constitution, such as maximum waiting times, and must be able to monitor whether
trusts are meeting these standards.
2.11
The Quality, Finance and Sustainability scores will primarily be rules-based using a set of
thresholds for each indicator. Scores will be aggregated to the overall domain level according
to performance against each indicator, individual indicator weightings and where appropriate
override rules in extreme cases of poor delivery against key indicators such as mortality.
A supporting guidance document will supplement the Accountability Framework and will
contain all the detailed information about our scoring methodology.
2.12
In addition, and consistent with our current approach, the overall escalation score will
be subject to a moderation process led by the directors of delivery and development
supported by business and quality directors to determine the level of risk and appropriate
level of intervention for each organisation. The results of the rules-based scores will be
supplemented with softer intelligence from a range of third party reports including CQC
warning notices. Consideration will also be given to any future risks faced by trusts.
2.13
Escalation scores will be refreshed on a monthly basis using only publically available information.
This will ensure that all the supporting data and analysis are able to be shared openly, consistent
with our commitment to transparency. A timetable setting out the monthly business rhythm for
the oversight process is contained within the supporting guidance document.
2.14
The TDA will take a proactive approach to managing the quality of services delivered by
trusts. Whilst the oversight model will be based on published data, where there are concerns
regarding the performance of a trust, TDA staff may require more frequent information
relating to a limited number of key metrics.
2.15
Further detail on the main domain headings of Quality, Finance and Sustainability
is set out below.
Figure 2: Key Elements of the Oversight Model
Moderation including
CQC Rating warning
notices and third
party report
Overall Escalation
Score (1 to 5)
Quality Score
(1 to 5)
Finance RAG
Assessment
Sustainability
Score (1 to 5)
Caring Score
(1 to 5)
Effective Score
(1 to 5)
Responsive Score
(1 to 5)
Safe Score
(1 to 5)
Well-led Score
(1 to 5)
8
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Quality
2.16
2.17
For 2014/15, we will align the domains we use in our assessment of quality with the
5 domains used by CQC in their regime for assessing the quality of services: Caring,
Effective, Responsive, Safe and Well-led.
There is no intention for Oversight to attempt to replicate the CQC risk ratings, rather
Oversight will use a sub-set of the indicators used by CQC. In developing this list of indicators
we have also taken into consideration:
•
•
•
•
•
2.18
2.19
NHS Constitution standards;
Measures used by Monitor in their Risk Assessment Framework;
Measures required to be published in NHS trust Quality Accounts, reflecting
the NHS Outcomes Framework measurements;
Measures for which data is routinely available;
Measures which are part of the current Oversight and Escalation and are considered
worth retaining.
Figure 3 details the indicators that will be used in each of the 5 domain areas. An assessment
will be made against each indicator, usually on a monthly basis depending on the regularity
of information being available. Using thresholds, individual indicator weightings and override
rules, an overall domain score will be calculated. These 5 domain scores will then be used to
calculate an overall score for Quality.
2.22
Delivery against these categories will be RAG rated using agreed thresholds but only the
RAG rating for in-year delivery will be used in the assessment of the overall escalation score.
2.23
The indicators that make up the in-year financial delivery domain have been reviewed and
a revised set of indicators are included in Figure 3. The thresholds for calculating the overall
financial RAG rating have also been updated so that any trust with a forecast deficit or a
significant deterioration in surplus will be red rated overall.
2.24
Supporting guidance will be available via the TDA website, including detailed indicator
descriptions and clarification of how the individual indicator RAG ratings and overall in-year
financial delivery RAG rating is calculated.
Sustainability
2.25
Securing Sustainability – Planning guidance for trust boards 2014/15 to 2018/19 set out
for the first time a framework to enable NHS trusts to look in more depth at how they plan
to deliver high quality services in a sustainable way, not just over the coming year but over
the next five years.
2.26
The ultimate goal of the NHS TDA is to support organisations to deliver high quality services that
are clinically and financially sustainable, and thereby become foundation trusts or implement a
suitable alternative solution. The five year plans submitted by trusts are critical to this work.
2.27
In assessing the plans of NHS trusts, the TDA will consider the credibility of the assumptions
made by the NHS trusts before determining whether to support their plan. Our assessment
of the credibility of plans, will focus on five broad areas of assurance:
Supporting guidance will be available via the TDA website and will provide indicators
definitions, data sources and indicator constructions along with detailed scoring rules.
It will also set out the indicators which have been added or removed from last year and
the rationale behind these decisions.
•
•
•
•
•
Finance
2.20
2.21
The underpinning business plan that supports an NHS trust’s sustainability is as important
as the delivery of high quality services as it helps ensure that effective care can be delivered
well into the future.
As in last year, NHS trusts will be monitored against two financial categories:
•
•
In-year financial delivery;
Monitor Risk Assessment Framework – Continuity of Service.
2.28
Clinical and workforce strategy
Financial and business strategy
Future commissioning and service strategy
Securing a sustainable organisational form
Leadership capability and capacity.
It is the intention that following the assessment of five year plans by the TDA it will be
possible to develop a score for the Sustainability domain which will in turn feed through
to the overall escalation level for the trust. This will happen later in 2014/15 once the five
year plans have been submitted and reviewed by the TDA. Until this approach has been
refined, the sustainability of a trust will feed into the escalation scoring system through the
moderation process outlined above.
9
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Figure 3: Proposed indicators for Monthly Oversight and Escalation
Caring
Well-led
Effective
Safe
Inpatient scores from Friends and Family Test
NHS England inpatients response rate from
Friends and Family Test
Summary Hospital Mortality Indicator
(HSCIC Published data)
CDIFF
NHS England A&E response rate from Friends
and Family Test
Hospital Standardised Mortality Ratio
(DFI Quarterly)
Data Quality of trust returns to the HSCIC
Hospital Standardised Mortality Ratio
– weekend
A&E scores from Friends and Family Test
Complaints – rate per bed days, MH contacts
or calls to ambulance services
Inpatient Survey: Q68 Overall I had a very poor/
good experience?
Community Mental Health : Q45 Overall, how
would you rate the care you have received in
the last 12 months?
Mixed Sex Accommodation Breaches
NHS Staff Survey: Percentage of staff who
would recommend the trust as a place of work
NHS Staff Survey: Percentage of staff who
would recommend the trust as a place to
receive treatment
Trust turnover rate
Trust level total sickness rate
Total trust vacancy rate
Temporary costs and overtime as % total paybill
Percentage of staff with annual appraisal
MRSA
Never Event incidence
Medication errors causing serious harm
Percentage of Harm Free Care
Hospital Standardised Mortality Ratio
– weekday
Maternal deaths
Deaths in low risk conditions
Proportion of patients risk assessed for
Venous Thromboembolism (VTE)
Emergency re-admissions within 30 days
following an elective or emergency spell at
the trust
IAPT – The proportion of people who complete
treatment who are moving to recovery
Serious Incidents
Proportion of reported patient safety incidents
that are harmful
CAS alerts
Admissions to adult facilities of patients who
are under 16 years of age (Number)
Continued on next page >>
10
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Figure 3: Proposed indicators for Monthly Oversight and Escalation (continued from previous page)
Responsive
Responsive
Finance
Proportion of patients spending more than
4 hours in A&E
Urgent operations cancelled for a second time
Bottom line I&E position – Forecast compared
to plan
RTT waiting times for admitted pathways:
percentage within 18 weeks
RTT waiting times for non-admitted pathways:
percentage within 18 weeks
RTT waiting times incomplete pathways
RTT over 52 week waiters
Diagnostic waiting times: patients waiting over
6 weeks for a diagnostic test
Proportion of patients receiving first definitive
treatment for cancer within 62 days of referral
from GP
Proportion of patients receiving first definitive
treatment for cancer within 62 days of referral
from screening
Proportion of patients receiving first definitive
treatment for cancer within 31 days of decision
to treat
Proportion of patients receiving subsequent
treatment within 31 days (Drug)
Proportion of patients receiving subsequent
treatment within 31 days (Surgery)
Proportion of patients receiving subsequent
treatment within 31 days (Radiotherapy)
Proportion of patients not treated within
28 days of last minute cancellation due to
non-clinical reasons
Bottom line I&E position – Year to date actual
compared to plan
Certification against compliance with
requirements regarding access to health care
for people with a learning disability
Actual efficiency recurring/non-recurring
compared to plan – Year to date actual compared
to plan
The proportion of those on Care Programme
Approach(CPA) for at least 12 months
Actual efficiency recurring/non-recurring
compared to plan – Forecast compared to plan
A Who had a CPA review within the last
12 months
B Having formal review within 12 months
C Receiving follow-up contact within 7 days
of discharge
Admissions to inpatient services who had access
to Crisis Resolution/Home Treatment teams
Forecast underlying surplus/deficit compared
to plan
Forecast year end charge to capital resource
limit
Is the Trust forecasting permanent PDC for
liquidity purposes?
Meeting commitment to serve new psychosis
cases by early intervention teams (Number)
Category A8 Red 1 calls
Category A8 Red 2 calls
Category A call – ambulance vehicle arrives
within 19 minutes
12 hour trolley waits in A&E
Mental health delayed transfers of care
Proportion of patients seen within 14 days of
urgent GP referral
Proportion of patients with breast symptoms
seen within 14 days of GP referral
11
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Escalation and intervention
2.29
2.30
The measurement and monitoring process described above will continue to place each
NHS trust in one of five oversight categories, based on their scoring against the various
oversight domains, relevant views of third parties such as the CQC, and the judgement of
the TDA. The following table sets out the five escalation levels that will apply, including the
characteristics of organisations at each level of escalation, the nature of likely interventions,
and the support available to trusts to help them to improve.
Table 1 below aims to provide more clarity for NHS trusts about what it means to be at
each level of escalation, and to ensure greater consistency in our approach to intervening
and supporting NHS trusts. The table also clarifies that escalation level 1 and the “special
measures” designation are one and the same thing.
2.31
Trust boards should be clear that they at all times remain responsible for ensuring that
effective governance and assurance arrangements are in place within their organisations.
The purpose of the oversight model is to provide assurance regarding trusts’ performance
to the TDA and does not affect the overall accountability of trust boards.
2.32
The special measures process will apply to NHS trusts which have serious failures in their
quality of care and / or financial performance, along with concerns that the trust’s existing
leadership cannot make the necessary improvements without intensive oversight and
support. Special measures can be triggered by the NHS TDA following a recommendation
from the Chief Inspector of Hospitals, or whenever the TDA judges it is necessary.
Organisations placed in special measures because of concerns about the quality of care
will require a successful re-inspection by the Chief Inspector in order to exit special measures.
2.33
Organisations in special measures will be subject to a set of specific interventions designed
to rapidly improve the quality of care. The NHS TDA will intensify its engagement with and
oversight of the NHS trust, and trusts will be held to account through regular board-to-board
meetings. While the interventions and support brought to bear during the special measures
process will reflect the circumstances and needs of the trust, there are a small number of
interventions which will apply to every provider placed in special measures. These are:
•
The development of a clear, published Improvement Plan to address the issues
raised, with clear timescales for improvement.
•
The appointment of an improvement director who will act on behalf of the
NHS TDA. They will have a presence on the ground for, on average, two days a week.
They will work with NHS trusts and their partners to support improvement and to
monitor progress against the action plan.
•
The appointment of a partner organisation to provide support and expertise in
improvement. Partner organisations will be selected on the basis of their strength in
relevant areas of weakness in the NHS trust or foundation trust in special measures.
•
The capability of the trust’s leadership will be reviewed and changes to the
management of the organisation could be made, if needed, to ensure that the board
and executive team is best placed to make the required improvements.
2.34
As the table below sets out, these and other measures can also be used by the TDA for trusts
at levels 2 and 3 of escalation. While trusts in special measures will be subject to all of the
processes set out above, the deployment of interventions at lower levels of escalation will
reflect the particular needs and circumstances of the trust.
2.35
Special measures will be a time-limited period, the expectation being that trusts – with
the support of the TDA – will make the necessary improvements within 12 months. From
this year, a similar approach will be taken to trusts in escalation levels 2 & 3: trusts will be
expected to develop and execute a time-limited improvement plan that will enable them to
return to escalation level 4 or 5. Once a trust achieves escalation level 5 it is anticipated that
its foundation trust application or transaction will be completed within 12 months.
2.36
At all levels of escalation, the TDA can consider supplementing the interventions below with
additional processes, for example reviews of particular services areas or financial systems.
In addition, the TDA will explore during 2014/15 a reduction in the autonomy of NHS trusts
at high levels of escalation, particularly on financial matters.
2.37
In its approach to escalation and intervention, the TDA will always seek to balance hardedged intervention with the provision of appropriate support and development. This is clear
in the table below and more detail on support available for NHS trusts, including support
targeted at challenged organisations, is set out in Chapter 3.
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Oversight
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Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Table 1: TDA Oversight Categories for 2014/15
1
2
Name
Characteristics of
a trust in this category
Intervention
Support
Accountability
Special
Measures
The organisation has significant delivery issues,
including clinical and / or financial challenges;
the clinical concerns may be serious and / or
the in-year financial challenges may be greater
than planned; the TDA has limited confidence
in the board’s current capacity to deliver
improvement without additional external
support and challenge.
Trust would be subject to all of the following:
Support focussed on rapid quality
improvement and /or financial turnaround.
Support will include:
Through board-to-board meetings.
The organisation has significant delivery
issues, including clinical and / or financial
challenges; the TDA has concerns about
the board’s capacity to deliver improvement
and is therefore keeping progress under
close review, with the potential to deploy
external interventions.
Trust required to produce an Improvement
Plan and may be subject to:
Intervention
• Improvement plan;
• Capability review;
• Board-to-board meetings;
• Potential loss of autonomy;
• Further reviews as needed.
• Capability review;
• Board-to-board meetings;
• Potential loss of autonomy;
• Further reviews as needed.
• Improvement director;
• Partnering with high performer.
Support focussed on rapid quality
improvement and /or financial turnaround.
Support can include:
Through TDA director of delivery
and development (with possibility of
board-to-board meetings).
• Improvement director;
• Partnering with high performer.
3
Intervention
The organisation has some delivery issues,
including clinical and / or financial challenges;
the TDA has confidence in the board’s
capacity to deliver improvement and continue
its journey to sustainability.
Interventions likely to be focussed on
supporting improvement in particular areas,
but broader intervention can be deployed.
Support focussed on improvement on specific
issues and early development of foundation
trust application.
Through TDA portfolio director.
4
Standard
Oversight
The organisation has limited or no delivery
issues; the TDA has confidence in the board’s
capacity to deliver any improvements needed
and make significant progress towards
sustainability.
No interventions likely at this level of
escalation, but standard TDA oversight
processes continue.
Support focussed on movement through
the foundation trust application or alternative
sustainability plan.
Through TDA Delivery
and Development team.
5
Standard
Oversight
The organisation has developed a sound
FT application and received a ‘Good’ or
‘Outstanding’ rating from the CIH; the
TDA has confidence in the board’s capacity
and expects a sustainable solution to be
delivered quickly.
No interventions likely at this level of
escalation; standard oversight processes
continue but frequency may reduce.
Support focussed on finalising foundation trust
application or alternative sustainability plan.
Through TDA Delivery
and Development team.
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Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Other areas of TDA oversight of NHS Trusts
Human Resources
2.38
2.39
The NHS TDA has an important relationship with trusts in relation to certain workforce
and human resources issues.
2.40
The NHS TDA has responsibility on behalf of the Secretary of State for making chair and
non-executive appointments to NHS trusts, for ensuring chairs and non-executives have
appropriate training and support, and for the suspension and dismissal of chairs and nonexecutives when this is required. Policies relating to these processes will be available on the
TDA website. More detail on support for chairs and non-executives is set out in Chapter 3.
2.41
The TDA also has a key role in oversight of executive appointment, remuneration and
severance decisions. The key elements of this are as follows:
In addition to the core measurement, scoring and escalation processes set out above,
there are a number of other areas where the NHS TDA has oversight of NHS trusts.
For clarity and completeness, these areas are set out below, along with a summary of our
expectation of NHS trusts. The key areas are:
•
•
•
•
Human resources decisions;
Workforce assurance mechanisms;
Data quality;
Information governance.
2.42
•
A senior member of TDA staff must be invited to act as an external assessor when
NHS trusts make director appointments.
•
The NHS TDA will agree annual performance assessments for NHS trust chief executives.
•
The NHS TDA has a role in ensuring senior pay levels are proportionate and may
from time to time request pay data from trusts in order to respond to DH and wider
government pay queries. As part of this, the NHS TDA must agree remuneration rates
for senior appointments made by NHS ambulance trusts and community providers.
•
The NHS TDA must agree any “off-payroll” senior appointments, including any
appointments to roles with significant financial responsibility, whether interim or
substantive.
•
The NHS TDA must approve proposed severance arrangements for any directors
in NHS trusts and for any non-contractual severance arrangements at any grade.
Contractual terminations for non-director staff in excess of £100k also require NHS TDA
Remuneration Committee approval.
Details of the NHS TDA’s role in appointment, remuneration, performance assessment and
severance decisions was set out in writing for NHS trusts in guidance sent out to chairs, CEOs
and HRDs in June 2013. This is being updated and will be on the TDA website from April
2014. Further information about the role of the NHS TDA in executive HR decisions by NHS
trusts can be found in the supporting guidance published alongside this document.
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Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Workforce Assurance
2.43
In light of the increased focus on workforce next year, e.g. through the National
Quality Board’s A guide to nursing, midwifery and care staffing capacity and capability
we are taking steps to enhance our oversight of key workforce metrics in 2014/15.
As such, trusts will be required to provide more detailed workforce data, including funded
workforce establishments, temporary staffing usage and vacancy rates. In recognition of the
need for effective triangulation between finance, activity, quality and workforce, we have
also continued to develop the national workforce assurance tool.
2.44
All NHS trusts have access to this tool free of charge. It will be the primary method by which
the TDA will support and challenge trusts on the triangulation of their plans as part of this
year’s planning round and on the in-year delivery of workforce and finance metrics (including
the delivery of safe staffing) through our core oversight processes.
2.45
For the coming year we are mandating all NHS trusts to actively use the tool to complement
existing workforce reporting processes and to inform future planning cycles. Support
packages are available to trusts to support them in maximising the benefits of the tool.
2.46
To further evidence application of the NQB guidance NHS trusts will be asked to demonstrate
compliance by submitting information about how they have put into practise the nine
expectations for provider organisations as set out in the Guide to nursing, midwifery and
care staffing capacity and capability.
Data Quality
2.47
2.48
Following the publication of the recent NAO report into elective waiting times in the NHS,
it is clear that more robust assurance processes need to be established with respect to the
systems that are in place to ensure data quality.
2.49
In line with the recent correspondence with trusts on this matter, NHS trusts should therefore
ensure they are undertaking the following best-practice actions:
•
Reviewing data quality annually though their internal audit programme;
•
Ensuring checks of waiting list management are undertaken through the external audit
programme at least every 3 years;
•
Deploying Intensive Support Teams where the organisation continues to have difficulty
with waiting list management issues and/or where emerging problems are detected;
•
Maintaining and publicising a clear patient access policy.
The NHS TDA will continue to provide support for trusts in this area, in particular working
with NHS trusts to understand and implement best practice. If any problems with the
data quality of patient access procedures are brought to our attention we will consider
commissioning independent reviews. In serious cases, such reviews could inform actions
taken in relation to the wider governance of organisations.
Information Governance
2.50
Following the Government’s response to the Caldicott 2 report, To Share or not To Share in
September 2013, the NHS TDA requires each NHS trust to provide details of data breaches in
both their annual governance statement and in their annual report. NHS trusts are expected
to log and summarise any such data security breaches or lapses including the advice of
the Caldicott Guardian and any issues that are significant enough to warrant reporting to
the Information Commissioner. NHS trusts should also detail how they will manage and
mitigate risks in this area and how they measure compliance beyond the requirements of the
Information Governance toolkit.
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Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
development
and support
The importance of development for NHS trusts
3.1
NHS trusts provide a wide range of services for patients across England, from the most specialised
hospital care to a diverse range of community services. The role of the NHS TDA is to hold NHS
trusts to account but at the same time to support them to maximise their potential for delivering
high quality sustainable services. Every organisation has development needs, and for NHS trusts the
extremely challenging environment that they face means that those development needs are likely to
be both far-ranging and critical to the success of the trust.
3.2
Providing support for NHS trusts is part of the core business of the NHS TDA. Much of that support
can be provided through our day-to-day interactions, drawing on expertise from within the NHS TDA.
In addition, the TDA has sought to provide a range of additional programmes to support priority
development areas. To date this has included:
•
A tailored programme of support from the NHS Leadership Academy to provide a board
assessment and diagnostic process for a group of NHS trusts. This support was delivered to 8 NHS
trusts during 2013/14.
•
Programmes of support for improvement in a range of high priority areas, including emergency
access, elective access and patient experience.
•
Support for aspirant foundation trusts to progress through the FT assessment process, provided in
partnership with the Foundation Trust Network.
•
The pairing of trusts within the special measures framework with high performing organisations to
support improvement.
3.3
We recognise, however, that more needs to be done, both to increase the emphasis on development
in our core relationship with NHS trusts, and to expand the additional support that can be drawn upon.
So for 2014/15 we will build on this initial work in order to establish a broader framework of support
for NHS trusts. We will further develop this framework in light of the outcomes of the development
planning process which concludes in September 2014.
3.4
It is important to acknowledge that individual NHS trusts are at different points on their journey to
sustainability, with some trusts now moving at pace towards FT status whilst others face much more
complex challenges. The NHS TDA’s approach to development seeks to reflect the range of needs for
these organisations.
3.5
Understanding the needs of each of our trusts and how they can best access the various development
opportunities is central to our approach. The TDA’s local portfolio teams will work with individual trusts
focusing on three key steps: understanding development needs; ensuring needs are met; and regular
review of development plans. This ongoing process of support is set out in Figure 4 below.
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Introduction
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Oversight
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Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Figure 4: Overview of the TDA Approach to Development Support for NHS Trusts
Understanding Development Needs
•
TDA reviews existing trust Development Plans for first
two quarters of 14/15 to ensure immediate requirements
are being met
•
NHS trusts work to ensure a Development Support plan is in
place by the end of September, working alongside and assured
by TDA Delivery & Development teams
•
TDA reviews aggregate plan for the trust sector to ensure that
development needs can be met
Understanding development needs
3.6
In 2013/14, we started the process of ensuring that the assessment of development needs
for NHS trusts was an on-going, joint process between NHS trusts and the NHS TDA, recognising
that development needs will change over a period of time.
3.7
A strong development plan is a critical enabler for the creation a successful organisation.
For the planning process in 2014/15 to 2018/19, we have asked that boards of NHS trusts provide
a more detailed development plan to be submitted by September 2014. This is so that it can take
account of the operational and strategic plans developed by the trust, linking development with
core business needs.
3.8
The TDA will work with individual trusts to understand what their development needs are and
how they can best be met. Local Delivery and Development teams will lead this process, as part
of their core relationship with NHS trusts. Once all plans have been submitted and agreed, the
TDA will review the overall development needs of the trust sector and enhance its development
offer as required.
3.9
In the period prior to the submission of this year’s detailed development plans we will continue to
work with trusts building on the existing knowledge we have about their needs.
Meeting Development Needs
•
Where possible support is provided through day-to-day
interactions with NHS TDA
•
Where needed, NHS trusts access additional support with
the TDA programme grouped under four key themes:
–
–
–
–
Improving leadership
Quality improvement
Support for challenged trusts
Support for high performers
Meeting development needs
3.10
Some of the support required by NHS trusts can be provided directly by local teams within the NHS
TDA; some will be met by drawing on the additional development programmes set out below; and in
some cases bespoke further support may need to be commissioned.
3.11
Looking forward, the key elements of the national development offer for NHS trusts in 2014/15 are:
Review and Planning for Development Needs
•
Sign off process for the detailed plan and associated
development plan
•
Development Plans reviewed by Delivery and Development
teams as part of the oversight process
•
Ongoing review of development offer by TDA following
submission of all plans in September 2014
•
•
•
•
3.12
Improving leadership
Improving quality
Support for challenged providers
Support for high performers
Figure 5 sets out the key elements of each of these aspects of the development offer:
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Introduction
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Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Figure 5: Scope of the 2014/15 TDA development offer
3.13
Supporting key
groups: finance,
operations,
communications
Theme one: Improving leadership
Clinical
leadership
Partnering for
improvement
Benchmarking
and measurement
for improvement
Chair and CE
development
NHS Futures
Local planning
support
Quality
improvement
series
Board
leadership
Aspirant FT
programme
Improving quality
Improving leadership
Targeted at
higher performers
Targeted at
challenged providers
Below is an outline of the individual programmes sitting beneath each theme.
3.14
Strong and effective leadership within organisations from the “board to the ward” is essential to
drive improvement, and the delivery of safe and sustainable services. Good leadership leads to a
good organisational climate and good organisational climates lead via improved staff satisfaction and
loyalty to sustainable high performing organisations.
3.15
Effective governance, culture and leadership are central to the new inspection regime of the Chief
Inspector of Hospitals through the “Well-led” domain, as well as Monitor’s assessment process for
aspirant foundation trusts. Ensuring effective leadership is therefore critical to the success of all NHS
trusts.
3.16
The NHS TDA recognises the need for effective support both for boards and for key leadership
groups. Alongside the support already available from the NHS Leadership Academy, the TDA will be
working during 2014/15 to strengthen its offer to leaders within NHS trusts.
3.17
Figure 6 below outlines the broad approach which will be applied to supporting leaders.
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Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Figure 6: NHS TDA Approach to Improving Leadership Capacity
Support for NHS trust boards
Capability and
Capacity Building
Connecting with
Senior Leaders
For particular leadership groups and
across the NHS trust sector as a whole
Bringing leadership groups together
in networks and through conferences
and targeted seminars
3.19
Boards are critical to the success of NHS trusts and developing the capability and capacity of boards
is therefore a key priority. Much support for boards can be provided through the core relationship
between NHS trusts and the TDA, and many boards will already have development programmes in
place. However, the TDA will make the following additional support available for NHS trust boards
during the coming period:
•
Working with the NHS Leadership Academy, the TDA will seek to continue the successful
programme of intensive diagnostic processes for NHS trust boards,
•
Working with the Foundation Trust Network, the TDA will pilot a re-focused programme
for aspirant foundation trusts with a particular focus on improving board governance,
•
Working with CQC and Monitor, the TDA will seek to develop a “well-led framework” for
NHS providers, clarifying and aligning the requirements of NHS boards. The framework can
then be used to commission specific reviews to test and improve governance.
TDA Leadership Approach
3.18
Day to Day Support and
Guidance for Leaders
Strategic and
Operational Reviews
Through the core relationships
between the TDA and NHS trusts
To improve capacity and capability
with NHS trusts, where needed
The NHS TDA will seek to apply this approach across its leadership activities, and will
trial the approach in its work to build communications and engagement capacity during
2014/15. The sections below set out the different aspects of our approach to providing
support for particular leadership groups within NHS trusts.
Support for chairs and non-executives
3.20
The TDA recognises the critical and very challenging role which chairs and non-executives play in
providing leadership for NHS trusts. The role of non-executives is under particular scrutiny following
the Mid Staffordshire Inquiry and the Keogh review, and the need to provide appropriate support and
development for this group of leaders is therefore pressing.
3.21
The NHS TDA will be facilitating regional networking events for NHS chairs to provide an opportunity
to hear from speakers across a range of issues and also meet and network with their peer group.
These networks will provide a foundation upon which specific arrangements for supporting and
developing the chair community will be built. It is proposed that the first events will take place
quarterly, starting in the spring of 2014. We will also look to develop networks for chairs across
particular sectors of care (e.g. ambulance or community providers) and for chairs with common
interests (e.g. newly appointed chairs).
3.22
In addition, chairs and non-executives have access to a range of support services to ensure they can be
effective in their roles as soon as possible. These include an immediate induction programme provided
by the HFMA in conjunction with the TDA and other partners. Annual events will be held, mentoring
arranged and appraisal programme in place to support the development of individual NEDs.
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and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Support for chief executives
Support for finance and business leaders
3.23
3.26
The TDA recognises that excellent financial management is key to the provision of
sustainable services. The financial challenge is greater than ever before and finance
directors and their teams need to support their clinical colleagues to use resources as
intelligently as they can to achieve better care for patients.
3.27
To this end, the TDA has joined forces with the 5 other national heads of the NHS finance
profession to initiate ‘Future Focussed Finance’, a vision for the whole of NHS finance
to aspire to over the next 5 years. The priority areas for staff development subject to
consultation during 2014 are ‘Securing Excellence’, ‘Knowing the Business’ and ‘Fulfilling
Our Potential’ and these will be supported by a new Health Business Foundation.
The TDA will continue to bring together NHS trust chief executives regularly at regional
and national events to network, share intelligence and provide peer support. In addition,
the NHS TDA is exploring a series of one day events for chief executives in response to an
identified need for focussed events on key topics. These would be co-sponsored by Monitor,
and the Foundation Trust Network. Where appropriate, sessions will also be made available
to chairs. The programme will consist of a number of sessions across the year using a hybrid
of speakers and action learning sets. The first sessions are scheduled for early in 2014/15.
Support for clinical leaders
3.24
3.25
The challenges of being a clinical leader in the environment we face today have never
been greater. The clinical directorate of the TDA will continue to engage with and support
individual clinical leaders in NHS trusts in a range of ways, including:
•
One-to-one support and coaching for individual medical and nursing directors
•
Establishing networks and action learning sets with particular groups of directors
linking with other organisations where helpful, such as the Faculty of Medical
Leadership and Management (FMLM), the Nursing and Midwifery Council (NMC)
and others
•
Development support for aspiring clinical leaders, building on the success of the
TDA’s recent programme for aspiring nursing directors, delivered with the support
of the NHS Leadership Academy
•
Using our national reach to help facilitate specialist advice on key topics and/or
peer review
•
Thematic events and workshops to support sharing of good practice on particular
issues such as those we have held on patient experience and safe staffing.
We will also continue to support organisations to deliver high quality services, including
by providing professional assessment on recruitment panels and advice with preparing job
specifications, and by supporting with the planning and delivery of service improvements
such as safe staffing reviews and mortality governance.
Support for operational leaders
3.28
The TDA recognises the key role which chief operating officers and their teams play in
the success of NHS trusts. As a group, operational leaders have not always received the
same support and development as other leaders, despite the critical role that they play.
The NHS TDA will therefore be seeking during 2014/15 to develop a package of support
for operational leaders to help them to achieve success and to increase capacity in this
essential area.
Support for communications and engagement leaders
3.29
Now more than ever it is crucially important that NHS trusts engage effectively with a
range of stakeholders. Good relationships with patients, staff, the public and other
stakeholders give organisations the opportunity to understand what is working well,
what could be improved and to build trust in their services. Doing this effectively means
action can be taken promptly to improve the standard of services or experience offered
to patients where it falls short.
3.30
Central to this is ensuring excellent capability of communications teams in all NHS trusts.
To support trusts to develop their communications capability the TDA has a development
programme focussed on building trust, confidence and respect in the NHS locally and
developing better relationships with all stakeholders.
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3.31
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
The development work in this area will act as a pilot for the four-part approach to
improving leadership capacity set out at Figure 6. It will include the opportunity for
aspiring leaders to work towards an accredited qualification, secondment opportunities,
mentoring arrangements and a comprehensive training programme. This all sits alongside
the day-to-day support and advice offered to NHS trusts, as well as more tailored,
in-depth support offered to overcome specific challenges.
Theme two: Improving quality
3.32
3.36
Alongside that, we have developed a Patient Experience Development Framework to
support trusts to carry out an organisational diagnostic against a set of criteria that
defines those organisations who consistently improve patient experience. Both the Patient
Experience Development Framework and the Patient Experience Headlines tool have
been co-produced with trusts and they will be available to trusts via a dedicated patient
experience page (password protected) on the TDA website.
3.37
The effective management of medicines is a critical part of any organisation’s approach to
maintaining and improving quality. To support and challenge trusts on this the TDA has
developed a framework for medicines optimisation and pharmaceutical services which is
based on nationally recognised standards and good practice guidance. The framework
not only enables individual organisations to self-assess against areas of good practice,
but also facilitates shared learning, co-production of support materials and collaborative
improvement.
3.38
NHS trusts have made significant reductions in healthcare associated infections over the
last few years but maintaining and building on these improvements remains a real
challenge that we are committed to supporting NHS trusts to achieve. To this end, our
heads of infection prevention and control in every region work closely with trusts to
support and challenge them on delivery of improvements ranging from:
Alongside our work to provide support and development for boards and leaders in
NHS trusts, we will continue to work with NHS trusts in key areas where there is a
particular need or opportunity to drive improvements to services.
Quality improvement events
3.33During 2013/14, the TDA undertook a successful programme of events focussed on
improving quality in key areas. The events brought NHS trusts together to learn about
and share best practice, to benchmark and compare performance, and to plan for
improvement. Our 2013/14 programme focussed on improving emergency access,
improving elective access, and improving patient experience.
3.34
Feedback from NHS trusts has indicated that these events have provided a helpful focus
for their quality improvement efforts and given valuable access to best practice and
comparative data. The TDA will therefore continue this programme during 2014/15
and will be working with NHS trusts to identify suitable themes for future events. To date,
the following topics have been agreed for the 2014/15 programme:
•
Providing routine information and advice through day to day interactions and
networks such as directors of infection prevention and control (DIPC) forums
•
Hands on support through targeted infection and prevention control visits to trusts,
working in close collaboration with key partners such as CCGs, NHS England and
Public Health England, to support and challenge improvement
•
•
•
•
Facilitating peer review of trust approaches to share learning
•
Supporting with recruitment and job specifications to support capacity and capability
•
Holding workshops for directors of infection prevention and control and other key
professionals, often working with partners in the system, to help facilitate sharing of
good practice.
Safe staffing, in light of the National Quality Board’s recent guidance on this issue
Ambulance trust performance, in light of continuing challenges in this area
Meeting the cancer waiting time standards, supporting delivery in this priority area.
Broader improvement support
3.35
In addition to these focused events, the NHS TDA clinical directorate will work with trusts on
specific clinical issues. We continue to work with trusts to support improvements in patient
experience and have developed a Patient Experience Headlines benchmarking tool. This
brings together a range of key patient experience indicators (e.g. national surveys, friends and
family test, complaints, CQC ratings) in a single ‘at a glance’ dashboard to provide trust with
rounded view of their performance and the ability to benchmark against others.
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Introduction
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Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Access to Intensive Support Teams
3.39
In order to support trusts with specific operational challenges the TDA, working with
NHS Improving Quality, will provide access to a range of activities that support the delivery
of improvement. This includes:
•
•
Bespoke support through the Emergency Support Team (EST). The EST can work
with health communities to support changes in practice to deliver best practice
emergency pathways and sustainable services.
Bespoke support through the Elective Intensive Support Team. The team can provide
support in relation to elective pathways including cancer services to deliver change
in quality of service provision and sustainability. The approach as outlined above.
Benchmarking and Analysis
3.40
The need for better access to benchmarking data was the most consistent development
need identified by NHS trusts during the 2013/14 planning round. To help to address
this, the NHS TDA has developed its information provision and performance framework
which includes a number of high level dashboards. These dashboards include a range of
topic areas such as clinical access performance, quality, ambulance, activity and finance.
Workforce dashboards are also being developed in the light of the safe staffing guidance.
3.41
With the move to an Oversight model based on published data it will now be possible to
share benchmarked performance against all of the indicators in Oversight which should
significantly help organisations to identify where they are outliers and for the TDA to
help develop exemplar sites. The aim for the coming year is to introduce a website that
will allow easy access for NHS trusts to all of the analytical tools and supporting analysis
developed by the TDA, such as the Patient Experience Headlines tool.
3.42
3.43
The approach to benchmarking will be based on a number of key principles:
•
•
•
•
That no new data collections should be initiated
That data should be easy to drill down into
To allow for peer group comparisons
To include operational as well as financial information wherever possible.
These principles have informed the development of the Reference Costs Benchmarking
Tool, which is currently being piloted. Information collected in the reference cost
submission varies according to the type of service so different approaches to benchmarking
have been developed for acute, mental health and community services. NHS trusts are
encouraged to feed-back to the TDA regarding the existing benchmarking tools. This
feedback will be essential in refining these and other benchmarking tools.
Theme three: Support for challenged organisations
3.44
Some of the support provided by the NHS TDA will focus in particular on organisations
with serious challenges, including those with internal difficulties and those with strategic
challenges across their local health economy. During 2014/15 that support will include:
Partnership for Improvement
3.45
As part of the special measures process, the TDA has put in place arrangements during
2013/14 for some of the most challenged NHS trusts to be paired with high performing
NHS organisations to receive improvement advice and support. This development offer
has generally been successful in ensuring NHS trusts have access to best practice, advice,
support and coaching as they undertake challenging processes of improvement. Support
has been targeted at areas of particular need and engagement has been led by the most
senior leaders of the high performing trusts.
3.46
The NHS TDA will continue to make this support available during 2014/15 for all NHS trusts
in special measures, and will consider developing the partnership approach to support
other NHS trusts where this is needed.
Support for planning in challenged health economies
3.47
The NHS TDA recognises that the requirements of this year’s planning process are
particularly demanding, notably the requirement for commissioners and providers to
produce 5-year strategic plans. Working with NHS England and Monitor, the NHS TDA has
therefore commissioned tailored support for 11 of the most challenged health economies.
External advisors will be appointed to support the planning process in each of these areas,
working alongside local organisations to facilitate the production of effective 5-year plans.
The support will be put in place for the period of April to June 2014/15 and will benefit
21 NHS trusts across a number of health economies.
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2014/15 Accountability Framework
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01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Theme four: Support for higher performers
NHS Futures programme
3.48
3.51
While many NHS trusts face significant challenges, a number of our organisations are
much further on their journey to sustainability and close to achieving foundation trust
status. It is important that the NHS TDA provides support for these organisations to achieve
their ambitions and improve further. The programme below will be one element of our
support for higher performing NHS trusts during 2014/15.
•
•
•
•
•
•
Aspirant foundation trust programme
3.49
3.50
The NHS TDA has been working with the Foundation Trust Network (FTN) during 2013/14
to refresh the long-standing programme of support for aspirant foundation trusts. The TDA
and FTN have agreed to pilot a revised approach to providing support for aspirants with a
greater focus on tailored and individual support. The revised programme will include:
•
Smaller intensive good practice workshops for aspirant FTs, in addition to the existing
broader conference and briefing programme
•
More one-to-few support for aspirants, in particular from authorised FTs,
•
A greater focus on improving quality governance, a key area of focus for Monitor’s
assessment programme
•
A greater focus on improving non-executive capacity to provide effective challenge,
another key element of the assessment process
Following on from the successful NHS Futures conference last November, the NHS TDA is
working alongside NHS England and Monitor to identify high-performing health economies
with the potential to achieve rapid transformational change. The proposed change is
centred on implementation of the 6 characteristics of future care identified by NHS
England. These are:
3.52
Patients empowered in their own care
Wider primary care, provided at scale
A modern model of integrated care
Access to the highest quality urgent and emergency care
A step-change in the productivity of elective care
Specialist services concentrated in centres of excellence
The NHS Futures work will seek to support a small number of health economies in
implementing changes in these areas by providing expert advice and access to national and
international best practice. The learning will then be spread across the rest of the sector to
support improvement across the NHS.
Reviewing Development Needs
3.53
This section has set out our broad approach to development and some of our aspirations
for providing specific development support during 2014/15. Building the continuing review
of development needs into regular interactions between NHS trusts and the NHS TDA will
be a core objective during 2014/15. The submission of detailed development plans during
2014/15 requires both proactive review and interaction between Delivery and Development
teams with trusts.
3.54
Where a trusts needs cannot be met by the NHS TDA or through the programmes
described above, bespoke approaches will be considered to meet the needs of those trusts.
The revised programme will be piloted during the first part of 2014/15, to coincide with a
number of aspirant trusts receiving the outcome of their Chief Inspector of Hospitals visits.
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2014/15 Accountability Framework
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approvals
model
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Context
4.1
The aspiration of the NHS TDA remains a simple one: to support NHS trusts to deliver high quality,
sustainable services for the patients and communities they serve. The provision of services that are
clinically and financially sustainable remains the basis for becoming a foundation trust or a suitable
alternative solution. However, the environment for achieving sustainable solutions has become even
more challenging as the Introduction to this document sets out.
4.2
The 5-year plans which NHS trusts are developing for submission in June 2014 will bring into sharp
relief the challenges of achieving sustainability in the current environment. However, we also expect this
element of the planning process to bring fresh impetus to the pursuit of sustainability by NHS trusts as
local health economies agree new and more radical approaches to meeting the challenges ahead.
4.3
It remains vital that as NHS trusts move towards a sustainable form – whether that is through a
successful foundation trust application or through a transaction – the TDA has assurance that there
is a clear plan in place to maintain the delivery of sustainable, high quality services. This section of
the Accountability Framework therefore sets out a refreshed approach to approving foundation trust
applications and proposed organisational transactions.
4.4
To support trusts on their journey towards sustainability, the NHS TDA will retain its role in relation to
capital investments and proposed disposals. Guiding principles and details of the approvals process for
capital investments are set out below.
Changes to the foundation trust assessment process
4.5
With the introduction of the requirement for a full inspection by the Chief Inspector of Hospitals, the
number of organisations moving through the FT assessment process slowed significantly during 2013
as the new inspection regime was implemented. However, with the inspection regime now up and
running, both acute and non-acute organisations are beginning to move through the process once
again. While the hiatus in the approvals process has been regrettable, it was necessary to ensure that
the quality of care is truly embedded in the assessment process.
4.6
Over this period we have been working with Monitor and CQC to streamline the assessment process
and make more effective the process for developing NHS trusts on their journey to FT status, building
on the important lessons from the Mid Staffordshire Public Inquiry about the need for close cooperation between regulators and the need for a consistent focus on the quality of care provided.
4.7
Whilst the fundamental requirements for FT status as set out in Monitor’s Guide for Applicants
remain consistent – centred on high quality services; sound strategic and business planning and strong
governance and leadership, we have worked to ensure that the assessment process can, in future,
work in a more effective way.
24
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
4.8
The approach set out below builds on the existing process, adding further assurances on the
quality of services into the approvals process. It also recognises the critical role which partner
organisations play in the approvals process and the importance of early and meaningful
engagement with partners to ensure sustainability.
4.9
This updated approvals model confirms that:
•
NHS trusts will work with the NHS TDA to ensure they are ready for the
assessment process and are providing high quality services underpinned by a strong
business plan. The NHS TDA will provide development and support for NHS trusts,
alongside its routine oversight, to help them prepare for the assessment process;
•
A key part of the formal assessment process will be a comprehensive
inspection of the trust by the Chief Inspector of Hospitals. Aspirant trusts will
be inspected alongside other organisations as part of the Chief Inspector of Hospital’s
routine programme. Once the CQC’s new ratings system is fully rolled out, an overall
rating of ‘Good’ or ‘Outstanding’ will be required to pass to the next stage of the
assessment process. In the meantime, the Chief Inspector of Hospitals will indicate in
the inspection report whether a trust’s application should proceed;
•
•
4.10
Trusts that meet the CQC’s requirements will quickly move forward in the
application process, culminating in consideration by the NHS TDA board.
The board will assess the organisation’s overall readiness for FT status, including its
business plan, FT application and external quality assurance reports. If the NHS TDA
board is satisfied that the trust is ready to proceed then it will offer its support, on behalf
of the Secretary of State, for the organisation to move to Monitor for assessment. The
NHS TDA will aim to reach a decision on applications as soon as possible after the CQC
report is published and will aim to give that approval within six weeks of publication,
even where that requires the NHS TDA to hold a special board meeting. Organisations
already with Monitor for assessment will receive their CQC inspection during the
Monitor phase and will not be required to go back to the NHS TDA for approval;
Figure 7: Summary of Revised Foundation Trust Approvals Process
TDA works
with NHS trust
to undertake
diagnostics
and formulate
development plans.
Development of FT
application begins.
d
e 1:
Stag nosis an
g
n
a
Di aratio
prep
TDA works
with NHS trust
to undertake
diagnostics
and formulate
development plans.
Development of FT
application begins.
t
e 2:
Stag lopmen ce
e
v
De assuran
and
TDA board reviews
full application
– including CIH
rating – and takes
decision on whether
to support referral
of application to
Monitor.
e 3:
al
Stag approv
A
TD referral
and
Monitor assesses
application and
takes decision
on whether to
authorise the
trust to become a
Foundation Trust.
itor
Mon ssment
e
ass e
stag
On-going improvement and development process between the NHS TDA and the NHS trusts;
trust remains part of TDA’s oversight regime until authorisation as an FT takes place.
Monitor will then undertake its assessment process as set out in the Guide for
Applicants to determine whether the organisation should be authorised as a
foundation trust. Monitor has agreed that they will normally aim to reach a decision
on an application within four to six months of receiving a referral from the NHS TDA.
A summary of the revised approach to the approvals process is set out in Figure 7 below:
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2014/15 Accountability Framework
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4.11
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
The work that we have done wih Monitor and CQC has also considered some of the
more detailed elements of the assessment in order to streamline and align them as effectively
as possible. Changes we have agreed include:
•
•
Bringing forward Monitor’s assessment of quality governance so that it takes
place at an earlier stage in the process. The existing Monitor team will undertake this
assessment while the trust is still working with the NHS TDA to develop its application.
This will provide Monitor with an earlier insight into aspirant trusts and should help to
reduce the number of organisations which struggle to pass Monitor’s final assessment
due to quality governance concerns. This approach has already been piloted and will be
phased in during 2014/15 in line with available capacity;
Developing a single well-led framework to align the different assessments of
culture, leadership and governance undertaken by the NHS TDA, Monitor and CQC.
This will bring together the current approaches embodied in the Quality Governance
Framework, the Board Governance Assurance Framework and the CQC’s new
inspection regime to create a single definition of success for NHS trusts. We will
develop and test the new framework during 2014/15 but in the meantime assessment
undertaken under the existing frameworks will remain valid;
•
Streamlining the different aspects of financial assessment, replacing Historic
Due Diligence with an Independent Financial Review. This will ensure that
assessments occur at the most appropriate point in the process, reduce the need for
repeat assessments and add as much value as possible. Similarly, the framework will be
finalised and tested during 2014/15;
•
Embedding public and patient involvement more thoroughly into the process
by broadening the basis of the public engagement and consultation that trusts
undertake. Trusts must demonstrate that they have sought feedback from the public
regarding the quality of their services, and that this feedback is being used to make the
necessary improvements.
4.12
The core standards required to achieve foundation trust status are not changing but the way
in which they are assessed is being streamlined. The NHS TDA will adopt a flexible approach
as these new tools are being implemented, so that trusts that have recently carried out
assessments using existing tools will be able to continue with their applications, provided that
the necessary criteria have been met.
Overview of the revised foundation trust assessment process
4.13
The model in Figure 8 summarises in more detail the NHS TDA process for the development
and assurance of foundation trust applications. It provides NHS trusts and NHS TDA staff
with a clear and transparent process that will be used to support NHS trusts to achieve the
ambition of becoming foundation trusts.
4.14
The guidance should be read in conjunction with the accompanying TDA supporting
guidance and Applying for NHS Foundation Trust status: Guide for Applicants which sets
out in full the NHS foundation trust application process. In contrast this document sets out
the specific steps the NHS TDA will take to gain assurance about the clinical and financial
sustainability of applications.
4.15
The NHS TDA’s role is to ensure, on behalf of the Secretary of State, that aspirant FTs are
ready to proceed for assessment by Monitor. In line with the recommendations of the Francis
Inquiry, the achievement of FT status will only be possible for NHS trusts that are delivering
the key fundamentals of clinical quality, good patient experience and national and local
standards and targets, within the available financial resources.
4.16
With the Chief Inspector of Hospitals being the arbiter of whether those fundamental
standards are being delivered, the role of the NHS TDA in relation to quality has shifted from
assessment to development. The approach to development set out in this Accountability
Framework shows how the NHS TDA will work closely with trusts to support their
preparations for inspection and approval. This will help to ensure that not only are services
for patients safe, effective, caring, responsive and well-led but also clinically and financially
sustainable.
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2014/15 Accountability Framework
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4.17
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
The NHS TDA will follow a development, application and approval process that involves
the following three stages:
•
Stage 1: Diagnosis and preparation: This stage involves the trust and the NHS TDA
establishing a baseline of the quality, safety and sustainability of the aspirant foundation
trust. Baseline performance will be established in relation to quality through a TDAled desktop review; board and quality governance through trust self-assessments;
and finance through phase 1 of the Independent Financial Review. These baseline
reviews will inform action and development plans for trusts to support continuous
improvement. The preparations for public consultation will need to be strengthened in
line with the response to the Francis Inquiry, to ensure that trusts are explicitly asking
about the quality of the care they provide. Stage 1 culminates in the decision, agreed by
the applicant and the NHS TDA, to proceed to public consultation on the application;
•
Stage 2: Development and assurance: This stage involves the submission of key
documents to the NHS TDA and the testing and scrutiny of trust plans and personnel.
It includes a focused period of improvement and support based on the action
and development plans produced in Stage 1. Stage 2 currently includes a Monitor
assessment of quality governance arrangements and an external assessment against
the Board Governance Assurance Framework; though over time, these assessments
will be made against the new framework for well-led providers. This stage also includes
Phase 2 of the Independent Financial Review and, critically, initiating the process that
will conclude with a comprehensive inspection by the Chief Inspector of Hospitals.
Stage 2 culminates in the decision, following the NHS TDA readiness review, to proceed
to consideration for approval by the NHS TDA board;
•
Stage 3: Approval and referral to Monitor: This stage involves the consideration
of the application, including the results of the inspection by the Chief Inspector of
Hospitals, at a formal board to board meeting followed by the NHS TDA board. Stage
3 culminates in the decision by the NHS TDA board about whether the trust is ready to
undergo a detailed assessment by Monitor.
4.18
NHS TDA Delivery and Development teams will oversee the work on an FT application and
ensure that NHS trusts have the support in place to move through the different stages of the
processes. The overall model is set out in Figure 8.
4.19
Further details and templates for the development, application and approval process for FT
applications are set out in supporting guidance to accompany the Accountability Framework.
The supporting guidance and tools will be posted on the NHS TDA website and updated as
required to assist in the development of successful applications.
4.20
If NHS trusts encounter difficulties during the application process, an assessment will be
made on a case-by-case basis about the elements of the assurance process that will need
to be repeated.
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2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Figure 8: Stage 1 – Diagnosis and preparation (see Supporting Guidance for detail; time periods are illustrative)
1
Month
Introductory
meeting
2
3
4
Initial board interviews
and board observation
Desktop review of quality: Establish baseline and
agree any areas for development/support
Latest CQC Intelligence Monitoring information, key indicators
across the five CIH quality domains, any relevant third party
reports e.g. from Quality Surveillance Groups
Maintain TDA support and development
5
6
Decision point:
TDA Director of Delivery
and Development signs
off documents and
supporting strategy for
public consultation
External support for improving Quality Governance if required
Outcome
Stage 1 culminates in
the decision, agreed
by the applicant and
the TDA to proceed to
public consultation on
the application
External support for improving Board Governance if required
Initial interviews with commissioners, Health Education
England, Local Education and Training Board
Independent Financial Review Phase 1 by independent accounting firm
Begin production of key documents alongside
Board Governance Assurance Framework and Quality
Governance Framework self-assessments
The Trust maintains focus on quality, delivery and sustainability and, as part of ongoing
oversight, completes self-certifications as laid out in TDA Accountability Framework
Formal submission of
key FT application
documents to TDA
including supporting
strategy for public
consultation on proposed
FT application
Move to Stage 2
TDA action
External inputs
NHS Trust action
Decision point
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2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Stage 2 – Development and assurance (see Supporting Guidance for detail; time periods are illustrative)
7
Month
8
9
Maintain TDA support and development, eg including further desktop review of quality if needed.
TDA Medical Director/Nurse Director meet with trust.
Observation of trust board and sub-committees
TDA assesses inputs to readiness review
10
Outcome
Readiness review meeting
Decision point: Internal
TDA Sustainability Steering
Group agrees to proceed
to readiness review
Letters from stakeholders, trust solicitor and auditor
Quality Governance review by Monitor in advance of referral
Stage 2 culminates
in the decision,
following the TDA
readiness review to
proceed to a full and
final assessment by
the TDA board
Independent Financial Review Phase 2 by independent accounting firm
External assessment of Board Governance Assurance Framework
Minimum 12 week public consultation (approximately months 7–9)
Trust develops further iterations of key documents including Integrated Business Plan
and Long Term Financial Model
Delivery of FT action plans by trust with updates to the TDA
Process for inspection
by Chief Inspector of
Hospitals commences
Trust make final
submissions of key
products to inform
TDA sign-off to proceed
to final assessment
by TDA board
Move to Stage 3
TDA action
External inputs
NHS Trust action
Decision point
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2014/15 Accountability Framework
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01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Stage 3 – Approval and referral to Monitor (see Supporting Guidance for detail; time periods are illustrative)
11
Month
12
TDA Executive Team
TDA review of final assurance documents
including review of follow up action
from Readiness Review
Quality summit following inspection
by the Chief Inspector of Hospitals
Trust refreshes final documentation
in light of feedback
TDA prepares final set of
documents for board-toboard and TDA board
Report by Chief Inspector
of Hospitals published
Board-to-board
Outcome
Decision point:
TDA board decides on
referral to Monitor
Stage 3 culminates in
a decision by the TDA
board on whether the
applicant is ready to
proceed to assessment
by Monitor
Submission to Monitor
of FT application
TDA action
External inputs
NHS Trust action
Decision point
30
2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Taking forward sustainable solutions: the transactions approval process
4.21
The NHS TDA is responsible for ensuring that all NHS trusts achieve a sustainable
organisational form. Where a trust cannot achieve sustainability as a foundation trust
in its current form, a range of transactions will be considered to achieve sustainability.
4.22
This section summarises the standardised NHS TDA process for the development and
assurance of NHS trust plans to achieve high quality, safe, sustainable services through
a transaction.
4.23
A transaction may take different forms but always involves a transfer in the ownership
of assets and liabilities and/or a business/service from one organisation to another.
In the NHS many transactions have taken the form of mergers (e.g. between NHS trusts)
or acquisitions (e.g. by an FT of an NHS trust).
4.24
A description of the different forms of transactions is included in the supporting guidance
that accompanies this framework. Whilst all transactions are different, in every case where
a transaction involves the acquisition of an NHS trust, the NHS TDA is the vendor in the
transaction, with responsibility for overseeing and assuring all aspects of the process.
4.25
This Accountability Framework confirms the clear set of principles that will be used to
assist local teams in following best practice and achieving good value for money in the
transfer of an NHS asset/business to a new owner.
4.26
Further work is underway to ensure alignment of the TDA and Monitor assurance process in
relation to transactions involving FTs and the results will be incorporated in the accompanying
supporting guidance. This is in light of the proposals on which Monitor is currently consulting
to increase their involvement at an early stage in transactions involving FTs.
4.27
The transaction process for NHS trusts is structured around the following four gateways,
illustrated in Figure 9:
•
Gateway 1 – Entering the transactions pipeline: This gateway is when the
NHS TDA starts the transaction process, because the trust is not able to achievable
foundation trust status in its current form. The Gateway 1 review will include
consideration of the alternatives to pursuing a transaction within the context of the five
year plan for the trust. Trusts unable to demonstrate a viable FT solution to the NHS
TDA will enter the ‘transactions pipeline’.
•
Gateway 2 – Agreeing the form of procurement: This gateway is when the NHS
TDA takes a decision about the appropriate form of procurement. An option appraisal
will be carried out to assess the range of alternative procurement approaches, the
transaction types will be evaluated and the strategic marketing approach of the NHS
TDA will be considered in order to secure best value from the transaction. This may
include issues of timing and commissioner strategy associated with significant service
changes that are required.
•
Gateway 3 – The choice of preferred solution: This gateway is when the decision is
made to proceed with a preferred solution following the procurement process. The first
step is to gain approval from the TDA board for the preferred solution arising from the
procurement. This would be followed by the detailed development of a business case,
the clinical and quality strategy, competition assessments, a Long Term Financial Model,
letter of commissioner and clinical support, signed Heads of Terms including agreed
funding commitments and an outline implementation plan. Once sufficient assurances
are in place, the TDA board will be asked to approve the completion of Gateway 3.
•
Gateway 4 – Decision to implement the preferred solution: After all the
due diligence, legal, commercial and external reviews (including Monitor, and the
Competition and Markets Authority if necessary) have been concluded, this gateway
is the final decision-making step. It includes finalised contract terms or a Transaction
Agreement setting out the final arrangements for implementing the transaction.
This is equivalent to a ‘Full Business Case’ described in the DH Transactions Manual and
culminates in the NHS TDA’s recommendation to the Secretary of State to make the
legal changes necessary to finalise the transaction.
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2014/15 Accountability Framework
for NHS Trust Boards
01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
4.28
NHS TDA Delivery and Development teams will oversee the transactions process for
NHS trusts and ensure that trusts have access to the support needed to move through
the different elements of the process. The overall approach is set out in Figure 9.
4.29
As needed during the transaction process, Health Gateway reviews will be commissioned
by the NHS TDA, tailored to the specific timetable for each transaction, to gain assurance
about the robustness of the project management processes.
4.30
Further details of the procurement, decision-making and approval process for transactions
are set out in the supporting guidance to accompany the Accountability Framework which
will be posted on the NHS TDA website. The lessons from previous and existing transactions
will continue to be used by the NHS TDA to inform and develop its approach as vendor to
future transactions.
4.31
4.32
4.33
The NHS TDA board is clear that a transaction must only be pursued if it can be shown to
improve the quality of healthcare available to patients and value for money for the taxpayer.
These benefits are likely to be both in terms of improving current standards of care to
patients and financial benefits.
Before embarking on a transaction approach, it is therefore essential that local stakeholders
(especially NHS commissioning bodies) and the NHS TDA board have assurance that the
transaction is the most beneficial way to improve the quality, delivery and sustainability of
services for the local population.
While a transaction process is underway for the future, it is vital that the NHS trust board
retains its focus on present-day delivery. This means driving forward improvements in the
quality and safety of services, managing within the resources available and continuing to seek
sustainable solutions for services. Whatever the transaction solution in the future, the trust
board, staff and stakeholders need to continue to make every effort to resolve the underlying
problems that have led to the transaction proposal. This focus on improvement now will also
help to ensure the success of the transaction in the future.
Figure 9: Overview of the Transactions Process – Key Decision Points
Gateway 1:
Entering the
transactions
pipeline
Gateway 2:
Agreeing the
form of
procurement
Gateway 3:
The choice
of preferred
solution
Gateway 4:
Decision to
implement the
preferred solution
• A decision that a
trust is not going
to be able to
develop a viable
FT application,
without a
transactions
partner
• A decision on
the procurement
route to find
a transaction
partner
• A decision on
the preferred
solution
• Full Business
Case following
external
assurance
(e.g. NHS
England,
FT board,
Monitor,
competition
authorities)
• Grounded in
strategic and
operational plans
• Entry Gateway
• Options
appraisal
• Business case
• Final approval by
Secretary of State
NHS trust board retains its focus on the quality and safety of services
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2014/15 Accountability Framework
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01
02
03
04
Introduction
and context
Oversight
and escalation
Development
and support
Approvals model for the FT and transactions
pipelines, and capital investment
Sustainable Capital Investments
Capital Investment Approvals
Capital Investment: Guiding Principles
4.38
The NHS TDA has the responsibility for approving all significant capital investments proposed
by NHS trusts up to a limit that has been delegated to the NHS TDA by the Department of
Health – a key element of helping to ensure NHS trusts are sustainable in the medium-to long
term. Capital investment and disposal proposals over a value of £50m will require NHS TDA,
Department of Health and HM Treasury approval for all stages of the business case.
4.39
When assessing investment proposals the TDA will consider whether they are consistent
with the trust’s clinical strategy, and ensure that they clearly demonstrate a high level of
engagement with the clinical staff within the organisation and the wider health economy
where applicable. We will look closely at the quality, safety, productivity, affordability, value
for money and workforce implications associated with any investment proposal, as well
as ensuring that any applications help ensure the sustainability of the wider local health
economy. Importantly, we will also closely examine whether the NHS trust has the resource
and capacity to deliver the investment programme it is proposing within a realistic timescale.
4.40
Capital Investment Loans will be available to NHS trusts to support capital investment.
Applications for capital investment loans will need NHS TDA review and approval before they
are passed on to the Independent Trust Financing Facility for final approval. Details of the NHS
TDA’s process for NHS trusts to access capital investment loans is set out in separate NHS TDA
financing guidance.
4.34
The NHS TDA requires NHS trusts to adhere to the Department of Health (DH) Capital
Investment Manual in the production of capital investment business cases. In line with
the DH Capital Investment Manual, the TDA requires that all business cases are based upon
the five-case model for business case production Each investment proposal must therefore
cover the following aspects:
•
•
•
•
•
4.35
4.36
4.37
strategic;
economic;
financial;
commercial;
management.
The NHS TDA will require assurance that a capital investment business case has been
through an appropriate level of scrutiny and governance within the NHS trusts proposing
the investment, before the case is submitted to the NHS TDA.
Detailed guidance for NHS trusts regarding the NHS capital regime, capital business case
approvals and funding application process has been produced and issued to organisations.
The detailed operating guidance covers:
•
background and details of the NHS capital regime including technical financial
guidance;
•
delegated limits for NHS trusts for capital investment business case approvals.
NHS trusts have the authority to approve capital business cases within agreed thresholds
before NHS TDA approval is required;
•
a summary of the expected key stage documentation and associated information
requirements that NHS trusts must comply with when submitting capital business cases
to the NHS TDA for approval. All NHS trusts will be required to submit a business case
and a business case checklist in a prescribed format;
•
capital planning requirements.
Recommendations from the directors of delivery and development will be made for capital
business case investment proposals put forward by NHS trusts within their portfolio to the
NHS TDA approving officer or group in line with the NHS TDA approvals process.
33
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
TRUST DEVELOPMENT AUTHORITY SELF CERTIFICATIONS
Trust Board
date
Director
24 April 2014
Reason for
the report
The purpose of the paper is for the Trust Board to consider and agree the
self certification return to the Trust Development Authority for March 2014
Type of report
Concept paper
Director of Governance
and Corporate Affairs
(Liz Thomas)
Reference
Number
Authors
2014 – 4 – 16.2
Liz Thomas
Strategic
options
Information
Business
case
Review
1
Performance
√
RECOMMENDATIONS
The Trust Board is requested to review the evidence supporting the return, consider
risks and agree the declaration.
2
Key purpose
3
4
Decision
Approval
Information
Assurance
Discussion
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and prioritised
 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
All domains
CQC Regulation(s)
Assurance Framework
Yes
5
√
Ref:
Legal advice


√
√
No
F3 and F4
BOARD/BOARD COMMITTEE REVIEW
The self-certifications have not been considered by a Board Committee
113
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
TRUST DEVELOPMENT AUTHORITY (TDA) SELF CERTIFICATIONS
1.
PURPOSE OF THE PAPER
The purpose of the paper is for the Trust Board to consider and agree the selfcertification return to the Trust Development Authority (TDA) for March 2014.
2.
BACKGROUND
The TDA’s role is to ensure, on behalf of the Secretary of State, that aspirant Trusts
are ready to proceed for assessment by Monitor. Two returns are submitted monthly.
One relates to compliance with a series of Board Statements (appendix 1) and the
second relates to a number of Monitor license conditions (appendix 2).
3.
SELF CERTIFICATION – RETURN FOR NOVEMBER 2013
3.1
Compliance with the Board Statements
The Trust has been declaring a risk to Board statement 10 (plans in place are
sufficient to ensure ongoing compliance with all existing NTDA targets) since
September 2013. The Board is requested to consider the March 2014 return,
specifically:
 Board Statement 10
Monitor’s Guide for Applicants and it Risk Assessment Framework have been
reviewed to provide further guidance to the Board for agreeing this statement.
Monitor’s Guide for Applicants requires applicant Trusts to provide direct
evidence of achievement of access and outcome metrics and appropriate action
plans to ensure compliance going forward. This includes historic track record of
achievement with expected trajectory and action plans to address
underperformance. Monitor considers the ability of NHSFTs to meet selected
national standards for access and outcomes to be an important indicator of the
effectiveness of the organisation’s governance. Historic performance is used as
a proxy to inform the level of risk going forward. A governance concern is
triggered in the Risk Assessment Framework if:
 Three consecutive quarters’ breaches of a single metric or service
performance score of 4 or greater
 Breaching pre-determined annual C difficile threshold
 Breaching the A&E waiting times target in two quarters over any four quarter
period and in any additional quarter over the subsequent three quarters.
The Trust has four consecutive breaches of Monitor’s target for C difficile and for
62 day cancer target. In addition it also has a service performance score of
greater than 4.
On the basis of the information provided above it is proposed that the Trust
should declare that it is non-compliant with the statement for the year ending
March 2014.

Board Statement 12
At its March 2014 meeting, the Trust Board agreed to declare a risk to this
Statement due to uncertainty about the plans for filling the two vacancies on the
Board. Since then Dr Hopkins has been appointed as Acting Chairman by the
Trust Development Authority. There remains one Non-Executive Director
vacancy.

Other Board Statements
The Board is requested to consider whether there have been any other changes
which would prevent the Board continuing to declare compliance with the
remaining 12 statements as set out in Appendix 1.
114
3.2
Compliance with Monitor’s licence requirement for Trusts
The Trust has confirmed compliance with the relevant license conditions since their
introduction. Attached at Appendix 2 is the evidence which supports compliance with
the license conditions.
4.
RECOMMENDATION
The Trust Board is requested to:
 Review the Board Statements, particularly statement 10 and 12 and determine the
submission for March 2014.
 Review the evidence to support the license requirements and advise of any issues
which would indicate non-compliance
Liz Thomas
Director of Governance and Corporate Affairs
April 2014
115
No
1
NHS TRUST DEVELOPMENT AUTHORITY BOARD STATEMENTS
Appendix 1
Statement
Comment
The Board is satisfied that, to the best of its
Improving quality of care
knowledge and using its own processes and
 Quality and Safety Strategy with annual targets for
having had regard to the TDA’s oversight model
improvement
(supported by Care Quality Commission
information, its own information on serious
Monitoring
incidents, patterns of complaints, and including
 Quality dashboards in corporate performance report
any further metrics it chooses to adopt), the trust
 Scrutiny by Quality & Effectiveness Committee
has, and will keep in place, effective arrangements  Scrutiny by Clinical Quality Committee
for the purpose of monitoring and continually
 Friends and Family results
improving the quality of healthcare provided to its  Board reports – nurse staffing, Francis, external
patients.
agency visits
 CQC action plans for Medicines Management,
Care and Welfare and Safeguarding
 Improving patient survey results
 Directors ‘concerns’ list
 Setting the Standard/internal CQC inspections/
PLACE
 Board walkrounds
Independent assurance:
 Deloitte review of quality Governance arrangements
(score of 3.5) December 2012
 Internal Audit reports:
- SUIs – significant assurance - April 2013
- Clinical Assurance Statements – significant
assurance January 2013
- Compliance with CQC - significant assurance
August 2013
- Board monitoring and reporting – significant
assurance August 2013
 Internal audit report: significant assurance August
2013
 CQC compliance issues - medicines management =
minor impact, safeguarding = moderate impact,
Care and Welfare minor impact with action plans in
place
 Internal CQC inspections programme
2
The Board is satisfied that plans in place are
sufficient to ensure ongoing compliance with the
Care Quality Commission’s registration
requirements.
3
The Board is satisfied that processes and
Responsible Officer provided assurance to the
procedures are in place to ensure all medical
Governance & Assurance Committee in January
practitioners providing care on behalf of the trust
2014 that the Trust was meeting the requirements.
have met the relevant registration and revalidation
requirements
The Board is satisfied that the trust shall at all
Audit Committee February 2014 – recommendation to
times remain a going concern, as defined by the
be made to the Board that the Trust continues to be a
most up to date accounting standards in force
going concern.
from time to time.
The Board will ensure that the trust remains at all
NHS Accountability Framework – Quality
times compliant with the NDTA accountability
Governance, Finance, Delivering Sustainability –
framework and shows regard to the NHS
Self Certifications completed monthly.
Constitution at all times.
All current key risks to the NTDA Accountability
 BAF risk – current rated at 16 (Likelihood 4 x
framework have been identified (raised either
Severity 4 Major)
internally or by external audit and assessment
 Action plans in place for national targets not
bodies) and addressed – or there are appropriate
currently being met
action plans in place to address the issue - in a
timely manner.
The Board has considered all likely future risks
As above
with the NTDA accountability framework and has
 IBP/LTFM risks, BAF risks, forward plan risks
reviewed appropriate evidence regarding the level
of severity, likelihood of a breach occurring and
the plans for mitigation of these risks to ensure
continued compliance
4
5
6
7
116
No
8
Statement
The necessary planning, performance
management and corporate and clinical risk
management processes and mitigation plans are
in place to deliver the annual operating plan,
including that all audit committee
recommendations accepted by the board are
implemented satisfactorily
9
An Annual Governance Statement is in place, and
the trust is compliant with the risk management
and assurance framework requirements that
support the Statement pursuant to the most up to
date guidance from HM Treasury (www.hmtreasury.gov.uk).
The Board is satisfied that plans in place are
sufficient to ensure ongoing compliance with all
existing targets as set out in the relevant NTDA
oversight model; and a commitment to comply with
all known targets going forwards.
Governance Statement in place. Considered by Audit
Committee and approved by the Board in April 2013.
2013/14 Statement due to be considered by the Audit
Committee in April 2014.
The trust has achieved a minimum of Level 2
performance against the requirements of the
Information Governance Toolkit.
The Board will ensure that the trust will at all times
operate effectively. This includes maintaining its
register of interests, ensuring that there are no
material conflicts of interest in the board of
directors; and that all board positions are filled, or
plans are in place to fill any vacancies.
Level 2 achieved.
Audit for 2013/14 assessment underway
10
11
12
13
14
Comment
 BGAF independent report Oct 2012
 Board Committee arrangements (P&F)
 Audit Committee recommendations follow up
arrangements
 Half year review of trust Forward Plan (Oct 2013)
Declared as a ‘ risk’ in TDA self certification – due to
return to compliance in Q1 2014/15
 Register of interest in place

– Directors declaration considered at the start of

each Board meeting
 Directors interests disclosed in Trust Annual Report
 Register of gifts and hospitality reviewed by Audit
Committee
The Board is satisfied that all executive and nonIndependent assurance
executive directors have the appropriate
 BGAF Finnamore report Oct 2012
qualifications, experience and skills to discharge
 Deloitte Quality Governance Framework review –
their functions effectively, including setting
score 0 (green) leadership
strategy, monitoring and managing performance
and risk, and ensuring management capacity and
capability
The Board is satisfied; that the management team BGAF Finnamore report Oct 2012
has the capacity, capability and experience
necessary to deliver the annual operating plan;
and the management structure in place is
adequate to deliver the annual plan.
117
Appendix 2
MONITOR’S NHS PROVIDER LICENSE
Section
General
Conditions
Pricing
No
G4
Name of Condition
Fit and proper
person
G5
Monitor guidance
G7
Registration with
the Care Quality
Commission
G8
Patient eligibility
and selection
criteria
P1
Recording of
information
P2
Provision of
information
P3
Assurance report
on submission to
Monitor
Detail
Applies to Governors and Directors
 Licensee must ensure that its contracts of service with its Directors
contain a provision permitting summary termination in the event of
the Director being or becoming an unfit person
Executive Director contract considered at the Remuneration
Committee in December 2012. Summary termination clause
included (section 16.4)
 An unfit person is an individual who: has been adjudged bankrupt,
has an arrangement with creditors and has not been discharged,
convicted in the preceding 5 years of any offence and a sentence of
imprisonment for a period of not less than 3 months, has an
unexpired disqualification order under the Company Directors’
Disqualification Act 1986.
An unfit person can also be a body corporate
Register of Directors – no declarations made

Licensees must have regard to guidance issued by Monitor
Corporate Performance Report – performance against Monitor Risk
Assessment Framework presented and continuity of service risk
rating and liquidity days adopted. Publication list containing recent
Monitor publications (also included in KPMG technical update to
Audit Committee). Monitor guidance incorporated into TDA
Accountability Framework and self-certification returns. Regular
review against Monitor Quality Governance Framework. Adherence
to pricing license requirements (see below).
 Trust must be registered at all times with the Care Quality
Commission so that it can lawfully provide services authorised to be
provided by the License
 If the registration is cancelled Monitor must be notified
Confirmation of the Trust’s registration with the CQC is available
on the CQC website. The Trust’s registration number is 1162315202
 The Licensee must set transparent eligibility and selection criteria,
apply the criteria in a transparent way to people who have a choice,
publish the criteria in such a manner to make them readily accessible
by any persons who could be reasonably be regarded as likely to
have an interest in them
 “Eligibility and selection criteria” means criteria for determining
- whether a person is eligible, or is to be selected, to receive health
care services provided by the Licensee
- if the person is selected, the manner in which the services are
provided to the person
The Trust publishes the services that it provides on its internet
site. There are no services that are age specific. The Trust has an
equality and diversity programme of work to ensure that the
potential for discrimination is minimised.
 Licensee must obtain, record and maintain sufficient information
about the costs which it spends in the course of providing services
 The Licensee must use the cost allocation methodology and
procedures set out in Monitor’s Approved Guidance (Approved
Reporting Currencies)
 Information required to be collated will extend to sub contracts (
threshold to be defined by Monitor)
 Records under this Condition must be kept for 6 years
The Trust complies with Monitor’s guidance. Service line reporting
introduced..
 Requirement to provide information to Monitor
We would comply with a request from Monitor to provide them with
information.
 Monitor can request an assurance report which has to
- be prepared by someone approved in writing by Monitor or
qualified to act as an auditor of an NHSFT
118
Section
Choice &
competition
Integrated
Care
No
Name of Condition
P4
Compliance with
the National Tariff
P5
Constructive
engagement
concerning local
tariff modifications
C1
The rights of
patients to make
choices
C2
Competition
oversight
IC1
Provision of
integrated care
Detail
- provides a true and fair assessment and meets Conditions P1
and P2
We would comply with a request from Monitor to provide an
assurance report.
 Except as approved in writing by Monitor, the Licensee will only
provide healthcare services for the NHS at prices which comply or
are determined in accordance with, the national tariff published by
Monitor
Confirmation received from Finance Directorate that the Trust
complies with this requirement
 The Licensee must engage constructively with Commissioners in
reaching agreement in any case in which it is of the view that the
price payable for the provision of a service for the purpose of the
NHS in certain circumstances should be the price determined in
accordance with the national tariff for that service subject to
modifications
The Trust would follow Monitor’s guidance on local tariff
modifications
 Subsequent to a person becoming a patient of the Licensee and for
as long as he or she remains such a patient, the Licensee shall
ensure that at every point where that person has a choice of provider
under the NHS Constitution or a choice of provider conferred locally
by Commissioners, he or she is notified of that choice and told where
information about that choice can be found.
 The information must not be misleading or unfairly favour one
provider over another
 The Licensee cannot offer or give gifts in kind, pecuniary or other
advantages as inducements to refer patients or commission services.
Monitor’s guidance indicates that in the vast majority of cases the
onus is on the GP to offer choice at a point that a referral is made
to the Trust. The issue for the Trust is Consultant to Consultant
referrals (internal and external). The March 2014 Corporate
Performance Report identified a patient requesting to be referred
to another organisation (p65) which was complied with.
 The Licensee may not enter into or maintain any
agreement/arrangement (or engage in other conduct) which has the
object or effect (or would likely to have) of preventing, restricting or
distorting competition in the provision of NHS health care services –
to the extent that it is against the interest of people who use health
care services.
The Board has approved a Joint Declaration with York, NLAG to
work together collaboratively. Arrangement will be established to
ensure that Competition Law is not breached.
 The Licensee shall not do anything that reasonably would be
regarded as against the interests of people who use health care
services by being detrimental to integration with others, to achieve
- improvements in the quality of care or the efficiency of their
provision
- reducing inequalities in respect of access
- reducing inequalities in respect of outcomes
 The Licensee must have regard to guidance issued by Monitor with
regard to actions or behaviours that might be regarded as against the
interest of people who use health services
The Board has approved a Joint Declaration with York, NLAG to
work together collaboratively. The Board Development programme
in 2013/14 involved presentations from a number of our
stakeholders. Opportunities for joint working are in place at both
operational and strategic level.
119
120
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
BOARD ASSURANCE FRAMEWORK 2013/14
Committee Date
24th April 2014
Director
Director of Governance &
Corporate Affairs
Reason for the
report
The purpose of the paper is to provide the Trust Board with a progress report on
the Board Assurance Framework risks and to seek approval for proposed
changes to one risk. The Trust Board will also be asked to consider the strategic
risks for 2014/15.
Type of report
Concept paper
2014 – 4 - 17
Reference
Number
Author
Mark Green
Head of Risk, Resilience
& Safety
Strategic
options
Information
Performance
Business
case
Review

1
RECOMMENDATIONS
 Review the rating and relativity of risks on the Board Assurance Framework
 Approve the proposals for changes to risk rating (R1) as detailed in Section 4
 Consider the strategic risks for inclusion on the 2014/15 Board Assurance Framework
 Decide if any further information and/or actions are required
2
Key purpose
3
4
5
Decision
Approval
Information
Assurance

Discussion
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT



 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and prioritised effectively 


 Delivery against our priorities and objectives

 Capable, effective, valued and committed workforce

 Strong respected impactful leadership
LINKED TO
Regulation 10: Assessing and monitoring the quality of service
CQC Regulation(s)
provision
Assurance Framework No
All
COMMITTEE REVIEW
Ref:
Legal advice
No
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
BOARD ASSURANCE FRAMEWORK (BAF) QUARTER 4 2013/14
1. PURPOSE OF THIS REPORT
The purpose of the paper is to:
 Set out the status of the Board Assurance framework at Year End
 Seeks approval of a proposed changes to one of the ratings
 Present a revised framework for consideration
 Identifies some key risks for 2014/15 to enable the Board Assurance
Framework to be populated
2. BACKGROUND
The Board Assurance Framework (BAF) provides the Trust with a comprehensive
method for the effective and focused management of its strategic risks. Through the
BAF the Board gains assurance that The strategic risks are being managed
appropriately, identifies which of the organisation’s strategic objectives may be at
risk because of inadequacies in the implementation and effectiveness of controls
and identifies where the Trust has insufficient assurance.
3. OVERVIEW OF THE BOARD ASSURANCE FRAMEWORK 2013/2014
The table below provides an overview of all BAF risks at the end of Quarter 3
2013/14, prior to any recommendations considered in this report.
Figure 1: The BAF Risk Overview (as of end Q3 2013/14)
BAF Ref:
8
Care
FT
Moderate
9
C2 risk
management
F5 BGAF
Partnerships
P2 functional
relationships
Resource
12
C1 patient
safety
C3 staff
motivation
C4 Patient
experience
F1 CQC
F2 QGF
P3 health
partnerships
High
16
Total
20
4
F4 TDA
Accountability
Framework
F6 Lorenzo
deployment
F3 national
targets
6
P1 tertiary
services
3
R1 capital
programme
Objectives
R2 CRES
2
O1 clinical
service
strategy
Workforce
W2 mandatory
training
W3 PDR’s
1
W1 visions &
values
W4 workforce
strategy
Leadership
Total
15
2
6
8
4
L2 strong
leadership
L3
distributed
Leadership
3
L1 High
performing
Board
2
3
2
Appendix 2 details the movement in the Board Assurance Framework as proposed
by the Risk Owners in the Quarter 4 assessment.
23
3.1 Issues to highlight from the above table are:
 There are 2 risks rated at 20 (although there is a proposal to decrease R2 in Q4)
 The biggest risk remains the failure to deliver national targets
 The strategic objective with the greatest number of risks is high performing
Foundation Trust
 All the risks to leadership have been rated high and have remained a high
throughout 2013/14
 There are no low level risks
4. KEY FINDINGS OF Q4 REVIEW
The BAF contains 23 principal risks which all have an allocated Lead Director.
Only one risk is proposed to change this quarter. This relates to the delivery of the
financial plan. A surplus of £5.9m was delivered at year end. Therefore the risk
owner proposed that the year–end risk rating is reduced to reflect the delivery of the
financial plan to a risk rating of 5 (rare x catastrophic).
5. Risks for inclusion in the 2014/15 Board Assurance Framework
The Board Assurance Framework for 2014/15 will need to be presented at the next
meeting of the Board in May 2014. The following areas are proposed:









Addressing the outcome of the Chief Inspector of Hospitals inspection
Meeting the requirements of the TDA 2014/15 Accountability Framework
Board development
Potential impact of Better Care Fund
Financial risks disclosed in Operating Plan
Delivery of the People Strategy
Quality Governance Assurance Framework
Pathways of care (NLAG/York)
Patient experience.
6. Revised BAF format
The Trust Board is asked to consider the attached BAF template for use in 2014/15
(appendix 4). The proposed template should make the management and
understanding of the BAF simpler.
7. Recommendation
The Trust Board is requested to:
 Review the rating and relativity of risks on the Board Assurance Framework
 Approve the proposals for changes to risk rating (R2) as detailed in Section 4
 Consider the strategic risks for inclusion on the 2014/15 Board Assurance
Framework as detailed in section 5.
 Consider the use of the proposed BAF template for 2014/15
 Decide if any further information and/or actions are required
Mark Green
Head of Risk, Resilience & Safety
January 2013
Appendix 1
2013/14 Board Assurance Framework Q4
C – Safe, high quality, effective care
BAF
Lead
Principal Risk
Ref
C1
Chief Medical
Officer
There is a risk that
the Trust's Patient
Safety agenda is
not established in
all areas.
Initial
Risk
Score no
controls
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
16
(L=4
x
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
9
(L=3
x
S=3)
9
(L=3
x
S=3)
Overall
progress
with
actions
Source
of
assura
nce
Gaps
in
assur
ance
Targe
t Risk
9 (L=3
x 3)
4
D
Lead Commentary
There is significant progress in the development
of an integrated clinical governance team, which
supports the revised integrated governance
committee structure. Funding has been secured
for the appointment of a Clinical Director of
Patient Safety.
The Trust has set an objective to be amongst
the ‘Safest Hospital in England’ by 2017. In
support of this the Trust will visit areas of good
practice both nationally and internationally in
order to identify and implement best practice.
The recent review of 71 Critical Incidents has
identified that the Trust has under reported
Serious Incidents. This will be improved by the
revised SI management process. The Executive
Directors will review all Critical Incidents on a
quarterly basis.
Work is progressing to improve the
understanding and performance regarding
Mental Capacity Act Depravation of Liberty
Safeguards.
The Trust was non-compliant with the 3 CQC
standards prior to the Chief Inspector of
Hospitals visit in February 2014. The three non
compliance areas were medicines management,
safeguarding and acre and welfare.
Whilst the Trust is above trajectory for C.Difficile,
the Trust benchmarks well with peers regarding
reduction rates.
Mortality rates have improved significantly and
the Trust is no longer a negative outlier.
Night cover for RMO’s remains a major risk to
patient safety
The Trust has declared 4 Never Events in
2013/14. In addition there has been an increase
in the number of Serious Incidents reported in
Q4 as a consequence of the strengthened
reporting procedure.
The risk owner recommends no change to the
risk rating from the previous assessment
C – Safe, high quality, effective care
BAF
Lead
Principal Risk
Ref
C2
Director of
Governance
and Corporate
Affairs
There is a risk that
effective risk
management
systems are not
established &
maintained in all
areas of the Trust.
Initial
Risk
Score no
controls
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
12
(L=4
x
S=3)
9
(L=3
x
S=3)
9
(L=3
x
S=3)
9
(L=3
x
S=3)
9
(L=3
x
S=3)
Overall
progress
with
actions
Source
of
assura
nce
3
Gaps
in
assur
ance
B
Targe
t Risk
6 (L=2
x
S=3)
Lead Commentary
3 of the 4 Health Groups are risk defined whilst
one Health Group remains at risk managed.
Internal CQC inspection is now embedded with
regular reports being presented at Governance
& Assurance Committee.
There is a revised committee structure with the
Clinical Quality Committee presiding over safety,
and effectiveness which is not yet fully
embedded.
The Trust has strengthened it process for the
reporting of Serious Incidents. This also includes
regular reporting to Executive Management
Board and a weekly appraisal to the Directors
The Risk Owner recommends no change to the
risk rating from the previous assessment
C3
Chief of
Workforce &
Organisational
Development
There is a risk that
staff report poor
satisfaction, lack of
motivation &
management
support.
16
(L=6
x
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
2
B
8
(L=2
x
S=4)
A new simplified paper based Appraisal process
launched in April 2013, receiving excellent
feedback regarding a far simpler more easily
understood process. An electronic Appraisal
system is to be available for 2014/15. For Q4
2013/14 the Appraisal performance was at
69.9% which is below the Trust target of 85%
and a decrease in performance as of the outturn
for Q3.
Good results from the Link Listeners programme
with 120 staff volunteering to become Link
Listeners. Annual Link Listener Event held in Q2
2013/14.
Third wave of Pioneer teams was launched at
th
the Trust Innovation Day 27 September and
continues to progress well. The forth wave of
pioneering teams has now commenced.
The results of the national staff survey are due in
Q4 2013/14. The Trust had good response rate
to the national survey with a 52% return
In the National Staff Survey 2012/13 the Trust
has improved in 5 areas and stayed the same in
the other 22. An action is currently being
developed to address the areas requiring
strengthening.
“Keep it going” events have been launched to
support the ongoing Pioneering teams, providing
support and leadership in the achievement of
their project objectives.
A staff, family and friends test is being
developed to replace the Pulse Check
The Risk Owner recommends, that whilst there
is improvement being made there should be no
change to the risk rating from the previous
assessment
C – Safe, high quality, effective care
BAF
Lead
Principal Risk
Ref
C4
Chief Nurse
There is a risk that
patients receive &
report poor
experience.
Initial
Risk
Score no
controls
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
16
(L=4
X
S=4)
16
(L=4
x
S=4)
12
(L=3
X
S=4)
12
(L=3
X
S=4)
Q4
2013/
14
Overall
progress
with
actions
Source
of
assura
nce
2
Gaps
in
assura
nce
C
Targe
t Risk
8
(L=2
x
S=4)
Lead Commentary
Complaints and PALs have increased in the
latter part of 2013/14 with complaints
increasing 13% on a MAT to 789 PALs
contacts are up 2% to 2820 on a MAT.
The National Maternity Survey has reported
and an action plan to tackle areas of weakness
in Ante natal Labour and birth and Post natal is
being drawn up.
The Trust held its first Patient panel in
December where senior leaders listened to a
large group of patients about patient care and
how they could help improve services for
others.
In January we held the first ‘Through their
eyes’ patient forum. These are held monthly
and there are open for all to attend to listen to
a patient/carers story who have received
treatment at HEY.
The Clwyd Hart report - A Review of the NHS
Hospitals Complaints System - Putting
Patients Back in the Picture, October 2013
action plan has been developed and is being
discussed by the Trust Board.
In December we introduced the consultant
feedback and validated 394 doctors onto the
IWANTGREATCARE website. All doctors are
to receive 100 business cards to get them
started on gathering patient’s feedback.
Figures for Friends and Family for the period
up to February 2014 shows the all Wards
achieving over 20%. ED still remains an
outlier with a low response rate and this is in
keeping with the national picture. The Trust is
trialling an SMS initiative in order to improve
the A&E response rate. Trust has a NPS
score of 81 for inpatients and a response rate
of 41% with 56000 trust responses for 2103/14
so far.
The Inpatient Survey suggests that there is no
continuous improvement on previous survey
results.
The Risk Owner recommends no change to
the risk rating from the previous assessment
F – Strong, high performing FT
BAF
Lead
Principal Risk
Ref
F1
Director of
Governance
and Corporate
Affairs
There is a risk that
the Trust will fail to
maintain full
compliance with
CQC registration
standards.
Initial
Risk
Score –
no
controls
16
(L=4
X
S=4)
Q1
2013/
14
12
(L=3
x
S=4)
Q2
2013/
14
12
(L=3
x
S=4)
Q3
2013/
14
12
(L=3
x
S=4)
Q4
2013/
14
12
(L=3
x
S=4)
Overall
progress
with
actions
Source
of
assura
nce
2
Gaps
in
assur
ance
B
Targe
t Risk
4
(L=1
x
S=4
Lead Commentary
On June 12th – 15th, 2013 the Trust received
an unannounced responsive review by the
CQC, focusing on 5 outcomes at the HRI and
CHH. The Trust was non-compliant with
outcome 9 – medicines management which
has a minor impact on patients
An unannounced responsive review by the
CQC occurred in October 2013. The outcome
of the review was that the Trust was noncompliant with outcome 7- safeguarding and
outcome 4- care and welfare.
The draft report from the Chief Inspector of
Hospitals inspection team visit in February has
been received. The Quality Summit is
scheduled for 2nd May 2014
The Risk Owner recommends no change to
the risk rating from the previous assessment
F2
Director of
Governance
and Corporate
Affairs
There is a risk that
Monitor will score
the Trust greater
than 3.5 against
Monitor's Quality
Governance
Framework.
16
(L=4
X
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
2
B
4
(L=1
x
S=4)
A paper was presented at the July 2013 Trust
Board and with a further update at the January
2014 Trust Board.
The Trust Board in March 2014 received a
presentation detailing the outcome of the
recently conducted individual assessment
against the Monitor Quality Governance
Framework. The outcome of the selfassessment was that the score remained at
3.5
The Risk Owner recommends no change to
the risk rating from the previous assessment
F – Strong, high performing FT
BAF
Lead
Principal Risk
Ref
F3
F4
Chief
Operating
Officer
Chief
Executive/FT
Project
Director
Initial
Risk
Score –
no
controls
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
There is a risk that
the Trust will fail to
meet key national
targets which are a
requirement of the
TDA 'Toward High
Quality Sustainable
Services’ Planning
guidance for Trust
Boards for 2013/14
and Monitor's
Compliance
Framework
2013/14 which
requires a minimum
achievement of an
amber/green rating.
20
(L=4
X
S=5)
20
(L=4
x
S=5)
20
(L=4
x
S=5)
20
(L=4
x
S=5)
20
(L=4
x
S=5)
There is a risk that
the Board is unable
to meet the
requirements of the
NHS TDA
Accountability
Framework.
20
(L=4
x
S=5)
Overall
progress
with
actions
Source
of
assuran
ce
Gaps
in
assura
nce
Targe
t Risk
Lead Commentary
3
C
8
(L=2
x
S=4)
For Q4 the Trust failed in the delivery of the
A&E 4 hours wait target. Although at this stage
the Trust may not achieved all of the RTT and
Cancer targets for Q4.
A recovery action plan for the RTT is required.
The Board will be updated in April 2014.
The Risk Owner recommends no change to
the risk rating from the previous assessment.
16
(L=4
x
S=4)
16
(L=4
x
S=4)
16
(L=4
x
S=4)
16
(L=4
x
S=4)
4
D
8
(L=2
X
S=4)
The Trust is self-certifying on a monthly basis
to the TDA.
 Compliance with licence conditions – the
Trust is fully compliant
 Board statements. The Trust has
identified a risk in relation to meeting
Board statement 10 that all plans are
sufficient to meet all existing targets and
statement 12 which refers to Board
appointments as set out in the TDA
oversight model
This TDA rates the Trust on a monthly basis
and our current rating is 4 – Material issue.
F – Strong, high performing FT
BAF
Lead
Principal Risk
Ref
F5
Chief
Executive
There is a risk that
the Trust will not
meet all elements
of the Board
Governance
Assurance
Framework.
Initial
Risk
Score –
no
controls
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
16
(L=4
X
S=4)
8
(L=2
X
S=4)
8
(L=2
x
S=4)
8
(L=2
x
S=4)
8
(L=2
x
S=4)
Overall
progress
with
actions
Source
of
assura
nce
2
Gaps
in
assur
ance
B
Targe
t Risk
8
(L=2
x
S=4)
Lead Commentary
Previous reports identified that the Trust
needed to improve its working relationships
with its partners. The CCG’S have disestablished the Strategic Partnership Board.
There are outstanding assurances with the
Hull and the East Riding Health and Wellbeing
Boards
The clinical alliance between HEY, York,
NLaG and local GP’s continues to strengthen.
There is now an established Strategic
Partnership Board and the Chief Executive
Officer Breakfast Meetings.
F6
Chief
Executive /
Director of IT
There is a risk that
the Trust will not
deploy Lorenzo
phase 1 across the
Trust ensuring that
patient safety,
service users and
user functionality
are not
compromised
20
(L- 5
X
S=4)
New risk
16
(L-=4
X
S=4)
16
(L-=4
X
S=4)
3
C
8
(L=2
x
S=4)
This risk was not formally reviewed in Q4 with
the Risk Owner
The Risk Owner recommends no change to
the risk rating from the previous assessment
P – Creating & Sustaining Purposeful Partnerships
BAF
Lead
Principal Risk
Initial
Ref
Risk
Score –
no
controls
P1
Chief
Executive
To maintain Cancer
Centre status & to
retain all appropriate
tertiary services as
described in the SCG
prescribed service
specifications.
15
(L=3
x
S=5)
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
15
(L=3
x
S=5)
15
(L=3
x
S=5)
15
(L=3
x
S=5)
15
(L=3
x
S=5)
Overall
progress
with
actions
Source
of
assura
nce
5
Gaps
in
assur
ance
E
Targe
t Risk
10
(L=2
x
S=5)
Lead Commentary
The SCG specifications have been published
mandating how services will be provided. The
Trust has undertaken assessments against the
prescribed service specifications and have
identified that some cancer services are at
risk.
Derogation of Specialist Services for 2014/15
has been provided, this is based on the
population served at present not meeting that
as determined in the SCG contracts
Working together for our Future, Clinical
Conference, 8th November 2013, hosted by
Hull & East Yorkshire Hospitals NHS Trust and
York Teaching Trust NHS Foundation Trust
The Trust has an intent to collaborate with
NLaG and York.
P2
P3
Chief Medical
Officer
Chief Medical
Officer
There is a risk that
the Trust will fail to
establish & maintain
functional
partnerships.
There is a risk that
the Trust will fail to
develop health
economy level
partnerships
12
(L=3
x
S=4)
16
(L=4
x
S=4
9
(L=3
x
S=3)
12
(L=3
x
S=4)
9
(L=3
x
S=3)
12
(L=3
x
S=4)
9
(L=3
x
S=3
12
(L=3
x
S=4)
9
(L=3
x
S=3
12
(L=3
x
S=4)
4
3
D
D
6
(L=2
x
S=3)
9
(L=3
x
S=3)
This risk was not formally reviewed in Q4 with
the Risk Owner
Relationships/partnerships have been
established with the CCGs and CSU. The
Trust has established partnerships with
Healthwatch and the Local Authority. The
Executive Directors led by the Chief Executive
Officer are working in partnership with other
Trusts to consider future configuration.
Partnerships with the Area Team and
Specialist Commissioning Groups are in their
early stages of development.
The Risk Owner recommends no change to
the risk rating from the previous assessment
Controls are either in place or imminent,
however they have yet to become established.
The Risk Owner recommends no change to
the risk rating from the previous assessment.
R – Efficient, economic use of resources – targeted & prioritised
BAF
Lead
Principal Risk
Initial
Q1
Ref
Risk
2013/
Score –
14
no
controls
R1
R2
Chief of
Infrastructure
&
Development
Chief
Finance
Officer
There is a risk that
the capital
programme may not
be delivered in line
with identified
priorities
That the Trust will not
achieve its Financial
Plan as approved by
the Board of
Directors and the
TDA.
16
(L=4
X
S=4)
25
(L=5
x
S=5)
8
(L=2
X
S=4)
20
(L=5
x
S=4)
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
12
(L3
x
S4)
12
(L3
x
S4)
12
(L3
x
S4)
20
(L=5
x
S=4)
20
(L=5
x
S=4)
5
(L=1
X
S=5)
Overall
progress
with
actions
Source
of
assura
nce
3
3
Gaps
in
assur
ance
C
C
Targe
t Risk
8
(L=2
X
S=4)
10
(L=2
x
S=5)
Lead Commentary
As a consequence of the reduced capital
programme allocation for 2013/14 from £42M
to £28M the ‘buy out’ of Phase V at CHH has
been postponed and will be reviewed in
2014/15. Additionally this has delayed the
commencement of the OFOS scheme. The
Trust Board received and approved a revised
capital programme for 2013/14 in October
2013.
The Risk Owner recommends no change to
the risk rating from the previous assessment
The Risk Owner confirms that the Financial
Plan for 2013/14 was delivered. However it did
require the support from surplus funds. This
was mainly due to the fact that both the CRES
and the income from activity were not
achieved as was planned.
A surplus of £5.9M was delivered
The Risk Owner therefore recommends that
the risk be reduced to (L=1 x s=5) = 5 low risk
for year end.
O – Delivery against our priorities & objectives
BAF
Lead
Principal Risk
Initial
Ref
Risk
Score no
controls
O1
Chief
Operating
Officer
That the Trust does
not have clarity on its
future service
provision due to the
changes in
commissioning and
development of
service specifications
based on population
service users
16
(L=4
X
S=4)
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
9
(L=3
x
S=3)
9
(L=3
x
S=3)
9
(L=3
x
S=3)
9
(L=3
x
S=3)
Overall
progress
with
actions
Source
of
assura
nce
3
Gaps
in
assur
ance
D
Targe
t Risk
6
(L=2
x
S=3)
Lead Commentary
The Clinical Services Strategy has been
approved at Trust Board (January 2013).
Specialties are developing their strategies in
line with the Clinical Services Strategy and
require sign off by EMB.
Derogation of Specialist Services for 2014/15
has been provided, this is based on the
population served at present not meeting that
as determined in the SCG contracts
The Trust confirmed its compliance levels or
derogation requirements against specifications
for levels 2, 3 and 4 to NHS England in March
2014. For the few services were we derogate
there are action plans in place.
The Risk Owner recommends no change to
the risk rating from the previous assessment
W – Capable, effective, valued & committee workforce
BAF
Lead
Principal Risk
Initial
Ref
Risk
Score –
no
controls
W1
W2
Chief of
Workforce &
OD
Chief of
Workforce &
OD
Failure to achieve the
required behavioural
changes amongst
staff in terms of
responsibility &
accountability to
deliver the Trust's
vision.
That mandatory
training targets are
not met.
12
(L=4
x
S=3)
16
(L=4
x
S=4)
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
12
(L=4
x
S=3)
12
(L=4
x
S=3)
12
(L=4
x
S=3)
12
(L=4
x
S=3
9
(L=3
x
S=3
9
(L=3
x
S=3)
9
(L=3
x
S=3
9
(L=3
x
S=3
Overall
progress
with
actions
Source
of
assura
nce
3
Gaps
in
assur
ance
Targe
t Risk
c
9
(L=3
x S=3
Lead Commentary
The PDR system is still embedding within the
Trust. Behavioural objectives for staff have
now been included.
The Middle Management Development
Programme, ‘Great Leaders’ began in October
2013 and this will strengthen the behavioural
culture at that level of the organisation
influencing the behaviours of other staff.
2
c
6
(L=2
x
S=3)
The Risk Owner recommends no change to
the risk rating from the previous assessment
The Trusts statutory mandatory training
performance remains at 79 % at the end of
March against the Trust target of 85%.
The Education & Development team is
developing alternative techniques and
methodologies in order to improve the access
to training courses. This includes the potential
for development days for departments The
team are also reviewing the content of the
mandatory training to reflect this to individual
job roles.
There is usually an increase in the training
demands over the summer as staff are able to
be released from their normal duties to attend
training. This surge did not occur in 2013 which
has the potential to impact negatively on the
year end projection, and this is being
monitored by the Training and Development
team.
A sustained achievement is required before
any consideration is given to downgrading the
risk and therefore the Risk Owner
recommends no change to the risk rating from
the previous assessment
W – Capable, effective, valued & committee workforce
BAF
Lead
Principal Risk
Initial
Ref
Risk
Score –
no
controls
W3
Chief of
Workforce &
OD
That staff will not
receive high quality
PDRs.
12
(L=4
x
S=3)
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
9
(L=3
x
S=3
9
(L=3
x
S=3
9
(L=3
x
S=3
9
(L=3
x
S=3
Overall
progress
with
actions
Source
of
assura
nce
4
Gaps
in
assur
ance
Targe
t Risk
c
6
(L=2
x
S=3)
For Q4 2013/14 the Appraisal performance
was at 69.9% which is below the Trust target of
85% and a decrease in performance as of the
outturn for Q3.
The Middle Management Programme is
expected to influence the high quality element
of Apraisals. The first cohort started in October
2013.
W4
Chief of
Workforce &
OD
That the workforce
strategy will not be
delivered across the
organisation.
20
(L=5
x
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
12
(L=3
x
S=4)
3
c
9
(L=3
x
S=3)
The Risk Owner recommends no change to
the risk rating from the previous assessment
The Director of Workforce & OD is to
amalgamate the Workforce and Leadership
Strategies into an overall Peoples Strategy.
This strategy will include all the work currently
underway e.g. Leadership Programme,
Pioneer Team etc.
Workforce Plans have been completed.
Nurse Staffing and patient acuity work by Chief
Nurse saw an investment of circa £1M being
made available for additional nursing posts.
The Trust apprentice programme received a
boost when one of the Trusts apprentices won
the “Apprentice of the Year” AWARD
The Risk Owner recommends no change to
the risk rating from the previous assessment
L – Strong, respected, impactful leadership
BAF
Lead
Principal Risk
Ref
L1
L2
Chief
Executive
Chief
Executive
Initial
Risk
Score –
no
controls
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
There is a risk that
the Trust Board is not
high performing with
the right composition
of substantive
director & NonExecutive Directors.
16
(L=4
x
S=4)
16
(L=4
x
S=4)
16
(L=4
x
S=4)
20
(L=5
x
S=4)
20
(L=5
x
S=4)
There is a risk that
there is a lack of
strong, respected,
impactful leadership.
20
(L=4
x
S=5)
Overall
progress
with
actions
Source
of
assura
nce
3
Gaps
in
assur
ance
C
Targe
t Risk
8
(L=2
x
S=4)
Lead Commentary
Chairman has announced his resignation From
the Trust. There are currently 18 vacant Chair
posts for Non-FT Trust nationally which
suggests recruitment may be difficult.
This risk was not formally reviewed in Q4 with
the Risk Owner
15
(L=3
x
S=5)
15
(L=3
x
S=5)
20
(L=4
x
S=5)
20
(L=4
x
S=5)
3
D
10
(L=2
x
S=5)
This risk is reflective of the Triumvirate and
Divisional management levels. All 4 Health
Groups are in ‘special measures’ and therefore
under regular scrutiny of the Executive
management team. Fortnightly meetings have
been established with the Health Groups
triumvirate in order that target actions for
recovery are established and progress is
monitored.
The Chief Executive Officer is also meeting
with Lead Clinicians and Managers from
Divisions on a monthly basis in order that they
are aware and understand the pressures faced
by the Trust and the expectations of them.
2 of the 4 HG’s are currently undertaking a
restructure and review of management
arrangements.
This risk was not formally reviewed in Q4 with
the Risk Owner
L – Strong, respected, impactful leadership
BAF
Lead
Principal Risk
Ref
L3
Chief
Executive
There is a risk that
the Trust does not
have strategies and
processes in place to
support and develop
our leaders at all
levels to work
together in an
efficient and effective
way to deliver well
governed, high
quality, high
performing services.
Initial
Risk
Score –
no
controls
Q1
2013/
14
Q2
2013/
14
Q3
2013/
14
Q4
2013/
14
15
(L=3
x
S=5)
15
(L=3
x
S=5)
15
(L=3
x
S=5)
15
(L=3
x
S=5)
15
(L=3
x
S=5)
Overall
progress
with
actions
Source
of
assura
nce
Gaps
in
assur
ance
3
D
Targe
t Risk
Lead Commentary
10
(L=2
x
S=5)
A middle management programme
commenced in October 2013. This will be
supported by a Coaching programme for the
middle managers once they have completed
the programme.
The Trust has implemented a revised induction
programme for new consultant appointments.
The CEO and CMO meet with junior doctors
on a regular basis to review progress and
clinical leadership
This risk was not formally reviewed in Q4 with
the Risk Owner
Appendix 2
Almost
Certain
Likely
Board Assurance Framework 2013/14 – Quarter 4 Position (including proposed changes)
5
Unlikely
Embedding
Visions & Values
W1
4
L
i
k
e
l
i Possible 3
h
o
o
d
High performing
Board
L1
Staff PDR’s
W3
Functional
relationships
P2
Risk
Management
C2
Clinical Service
Strategy
O1
TDA
Accountability
Framework
F4
CQC
Registration
F1
Patient
Experience
C4
2
Lorenzo
Deployment
F6
Patient
Safety
C1
Mandatory
Training
W2
Staff
Motivation
C3
National
Operating
Targets
F3
Capital
Programme
R1
Health
partnerships
P3
Quality
Governance
Framework
F2
Distributed
Leadership
L3
Cancer &
Tertiary
Services
P1
Workforce
Strategy
W4
BGAF
F5
CRES
R2
3
Moderate
4
Major
Severity
5
Catastrophic
Strong Senior
Leadership
L2
Appendix 3
BOARD ASSURANCE FRAMEWORK Q3 - 2103/14
Risk
Ref:
Accountable
Chief /
Director.
Link to
strategic
objectives
Principal Risk
Initial
Risk
Rating
(no
controls)
What could prevent
the Trust from
achieving its
objectives ?
F2
Director of
Governance
Foundation
Trust
Quality Governance
The Trust is not able
to demonstrate that it
complies with all
elements of Monitor's
Quality Governance
Framework. Failure
to achieve a score of
3.5 or less will
prevent the Trust
from progressing its
FT application
16
L-4
x
S-4
Mitigating Actions
2013/14 risk ratings
Target
risk
rating
What is being done
to manage the risk?
Where controls are
still needed or not
working effectively
What needs to be put
in place to mitigate
gaps in controls
Q1
Q2
Q3
Q4
The Trust Board
undertakes selfassessment against
the Framework
A score of 0 has not yet
been achieved in 7 of
the 10 domains at the
last self-assessment in
March 2014. Action is
required around risks to
quality, leadership,
quality focussed
culture, escalating
issues, engaging
stakeholders, quality
information and
effective use of quality
information
Regular selfassessment against the
framework will be
included in the board
development
programme for 2014/15
12
12
12
12
L- 3
X
S-4
L- 3
X
S-4
L- 3
X
S-4
L- 3
X
S-4
An independent
assessment has
been undertaken
(Deloitte) and
actions agreed by
the Board
Evidence files are
maintained which
demonstrate
improvements in
areas requiring
strengthening
Assurances
What evidence is there to
assure the Board that the
controls are working
effectively?
4
L-1
X
S-4
Deloitte's external report
(December 2012).
Trust Board selfassessments - July 2013,
March 2014
East Coast Consortium
Report –
Clinical Assurance
Statements (January 2013)
significant assurance
2
Progress
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
GOING CONCERN REVIEW
Trust Board
date
Director
24 April 2014
Reason for the
report
To review and support the Chief Financial Officer’s assessment of
whether the Trust is considered to be a going concern.
Type of report
Concept paper
Lee Bond – Chief
Financial Officer
Performance
2014 – 4 - 19
Reference
Number
Author
Di Roberts – Assistant
Director of Finance
Strategic
options
Information
Business
case
 Review
1
RECOMMENDATIONS
The Board is asked to review the detailed assessment and conclusions at appendix
one.
2
Key purpose
3
4
5
Decision
Approval
Discussion
Information
Assurance
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and
prioritised effectively
 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
CQC Regulation(s)
n/a
Assurance
Ref: n/a
Legal advice
Framework No
BOARD/BOARD COMMITTEE REVIEW
No
The Going Concern review was considered by the Audit Committee in February 2014
which recommended its adoption by the Board.
123
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
GOING CONCERN REVIEW
1.
PURPOSE
The purpose of this paper is to provide the basis for discussion and review
regarding the Trust’s status as a “going concern.”
2.
BACKGROUND
Going concern is a fundamental accounting concept that underlies the
preparation of financial statements of companies, charities and public bodies.
The going concern concept assumes that an organisation will continue to operate
into the foreseeable future. This translates into there being a high level of
confidence that the organisation will have the necessary liquid resources to meet
liabilities as they fall due, and is able to sustain its current business model,
strategy and operations and remain solvent in the face of predictable internally or
externally generated shocks. The term foreseeable future generally refers to a
period of 12 months from the date the statutory accounts are signed by the
Board.
Auditors are required to make an assessment of the Board’s conclusions on
going concern, and KPMG will consider this during their audit.
The Audit Committee undertook a preliminary assessment in February 2014 and
recommended adoption to the Trust Board. Because the accounts for a going
concern are prepared on a different basis than those for an organisation not
considered to be a going concern, it is important to confirm the position prior to
the year end.
Where the Board does become aware of material uncertainty related to particular
events or issues that cast significant doubt upon the Trust’s ability to continue as
a going concern, this should be disclosed in the accounts.
The detailed review is set out in appendix one.
3.
RECOMMENDATION
The Board is asked to review the detailed assessment and conclusions at
appendix one.
Lee Bond
Chief Financial Officer
April 2014
124
APPENDIX ONE
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
GOING CONCERN DETAILED REVIEW
LIQUIDITY AND PROFITABILITY
The Trust submitted a draft financial plan for 2014/15 to the Trust Development Agency
(TDA) in January 2014 and will be submitting a further 2 year plan to the TDA in March
2014. This will set out the financial plans of the Trust for the 2014/15 and 2015/16
financial years. The plan includes forecasts of income and expenditure that, in so far as
they are able, fit with the intentions of commissioners. The Trust currently has a medium
term integrated business and financial plan that covers a 5 year period that has been
approved by the Board. This will be revised and updated to reflect the latest 2 year plan
for the end of June.
The plans will be subject to review by the Trust Development Agency (TDA) and should
the Trust be recommended for progression with its application for Foundation Trust (FT)
status the plans will be reviewed by Monitor and independent accountants as part of the
FT approval process.
Our plan shows the Trust remains modestly profitable for its duration, but does highlight
potential liquidity risks should the Trust fail to meet the assumptions over activity levels,
profit margins and achievement of cost reduction. The introduction of the Better Care
Fund is likely to impact in 2015/16 and is not therefore within scope of this review. The
impact of this initiative has yet to be determined for the local health economy as a whole,
and whilst this represents a significant financial risk, the Trust is ensuring it is very much
involved in planning and is therefore sighted early on any potential impact. In respect of
contracting for services and the speed at which the Trust can reduce its cost base,
CCG’s have transitional funding available to support provider organisations.
The weak liquidity position continues to be both a concern and a challenge, though
remains manageable. If, during the period, the Trust is asked to pursue a formal FT
application it will request a cash injection as part of this process. The terms of such an
injection would need to be agreed.
WHAT ARE THE RISKS ASSOCIATED WITH THE ECONOMIC DOWN TURN?
The Trust is ultimately funded by the UK Government. The pressure on Government
spending is well documented, and has resulted in the expectation of no growth or real
terms negative growth in NHS funding.
A formal failure regime has recently been introduced within the NHS (both Foundation
and Non Foundation Trust sectors) However, even in extreme circumstances where
such a regime would be utilised there is a commitment to maintain continuity of services
and for creditor obligations to continue to be met. This has been observed recently in
South London and Mid Staffordshire.
In addition there is now a distress funding regime in existence which is designed to
support Trusts who do not trigger the failure regime. This again supports the view that
even in times of financial distress there is a commitment (backed by the Secretary of
State - see attached letter) to ensuring that services will continue to be provided.
125
ARE THERE ANY TRUST SPECIFIC RISKS ASSOCIATED WITH THE ECONOMIC
DOWN TURN?
Some services will be more impacted on as a consequence of the downturn than others.
As an Acute Trust our specific risks are likely to be around our commissioners’ ability to
control demand for services and our ability to flex the cost base in response to this. The
Trust has a good record of working successfully with its two main commissioners to
ensure that overall demand is delivered and funded whilst maintaining financial
sustainability in the local health economy.
Specialist Commissioning Group (SCG) specifications are potentially an issue for a
number of services, although the Trust currently has a small number of derogations in
place. Whilst the potential pace of change resulting in this area is not clear the SCG
have indicated that the derogations will continue through 2014/15 and as such this is not
viewed as a problem for the coming financial year.
DOES THE TRUST HAVE A STRATEGIC BUSINESS PLAN?
The Trust has a strategic business plan and the plan is aligned, in so far as it can be,
with the plans of its Commissioners. The plan takes account of the potential effects of an
economic downturn and changes within the local health economy and wider NHS so far
as they are known.
ARE THERE RISKS ASSOCIATED WITH FINANCING AND INVESTMENTS?
These risks are low with no exposure to floating interest rate agreements.
As part of the NHS the Trust is funded and in effect backed by the UK Government.
Banks and lenders are not currently relied upon to provide short term working capital
support or longer term borrowing to support expansion - both are funded by the
Treasury. Interest is charged at a market rate. The Trust does not make use of
investments associated with significant risks.
The Trust’s business and capital planning arrangements ensure that all types of cost and
risk are fully considered as part of the decision making process.
ARE THERE RISKS ASSOCIATED WITH BANK COVENANTS?
Apart from the use of a commercial bank for payment transactions, the Trust’s banking is
conducted primarily through the Government Banking Service. There are no restrictive
covenants in force and hence no risk associated with them so at this point in time there
are none in place.
ARE THERE RISKS ASSOCIATED WITH CASH CONTROL AND CASH SAFETY?
Cash is controlled through a weekly based cash flow forecast which covers at least one
year ahead. The Trust is only able to invest in the NLF and GBS account – both of
which are backed by HM Treasury. These risks are therefore currently low. The
Treasury management policy will ensure that risk and spread of risk is controlled once
the Trust achieves Foundation Trust status when a wider range of investment
opportunities will be available.
126
LIQUIDITY
The Trust’s liquidity is challenging but is not bad enough to present a significant risk to
the organisation’s ability to continue as a going concern. The Trust is still able to meet its
short term obligations within an acceptable timescale. Currently short term working
capital deficiencies can be funded through temporary borrowing if necessary. Failure to
meet the level of savings required and to deliver the income and expenditure plan in
2014/15 and subsequent years, and to ensure those savings are cash backed, would
have a serious effect on the Trust’s liquidity.
DO THE POST YEAR END RESULTS INDICATE ANY ISSUES?
The audit deadline is very shortly after the year end so there is limited time for any
events which may impact on going concern to become apparent. This is considered to
be a low area of risk.
WHAT ARE THE RISKS ASSOCIATED WITH CUSTOMERS?
Current risks with customers are around the commissioners exerting significant and
changing demand for our services, changes in funding flows (for example specialist
commissioning and the Better Care Fund) and the desire for a more primary care led
NHS with care being provided closer to home.
The Trust will need to ensure that it is paid appropriately for additional activity and
ensure that risks such as commissioner affordability are covered.
Lack of customers (patients) is not an issue in the short/medium term, however in the
future as more services are delivered within the primary and community sectors and
potentially within the private and voluntary sectors this issue may become more
important in terms of going concern considerations. Whilst the threat of competition
exists, opportunities also exist in tertiary markets and in local care. For example there
are opportunities to develop community care models with partners such as with CHCP or
on our own.
The new NHS system brings with it uncertainties about funds flows, particularly around
where funds flow from. This is unlikely to be sufficiently destabilising in 2014/15 to
change any view concerning going concern.
WHAT RISKS ARE THERE AROUND SUPPLIERS?
There are always risks related to suppliers within a recession. The Trust has little
exposure to single suppliers for its major supplies (drugs and clinical consumables).
Suppliers to the NHS tend to be large suppliers that supply the whole of the sector and
have a good customer base with which to ride out a recession. There is a small risk
within medical equipment where full systems are tied in with and only operate through
one supplier. This is considered to be a low risk in terms of our going concern
assessment.
WHAT ARE THE BUSINESS RISKS AROUND INVENTORY HOLDING?
127
The Trust’s inventory is high compared to some other similar NHS organisations but is
on a downward trajectory. Potential risks include losses arising from holding inventory
which became unusable for any reason, for example through damage, theft or
obsolescence.
However, inventory holdings do not present a material business risk, as hospitals are
effectively service organisations rather than manufacturing concerns, and stocks form a
relatively small proportion of the overall cost of services provided. Nevertheless a project
to reduce stock holding and hence the amount of cash tied up formed part of the KPI’s
for health groups during 2013/14 this will be strengthened for 2014/15 so that it is
deemed a key indicator of good performance.
WHAT ARE THE RISKS ASSOCIATED WITH PRICING AND MARGINS?
The Trust’s prices are, in the main, part of a tariff based system, so prices are fixed. The
main impact on margins is therefore cost. The use of Service Line Reporting will enable
us to be more flexible in the future in understanding its services and margins.
Notwithstanding this, the Trust’s medium term financial plan indicates that the Trust will
remain profitable at least into the medium term. The Trust does not see this as a high
area of risk at this stage.
ARE THERE ANY RISKS ASSOCIATED WITH EQUIPMENT REPLACEMENT?
The Trust is refining its medium term capital programme and recognises the need for
replacing medical equipment is substantial, and is in excess of available funding.
Around £5m will be spent on replacing medical equipment in 2013/14 through a
combination of purchase and leases with a further £13m for 2014/15. The 2014/15
allocation will have a small contingency for unexpected equipment failure. The process
for determining equipment replacement is service led and based on risk in the context of
continuation and quality of service. There has been no significant loss of service, and
hence income, due to equipment failure during the last 12 months.
The availability of central capital resource, whilst we are an NHS trust, is a risk however
indications remain positive for 2014/15 and the £13m is included within our capital plans
submitted to the TDA. This expenditure is reliant in part on loan finance and current
indications from the TDA are that they can meet this requirement. There are no plans to
supplement our equipment replacement programme with leasing arrangements.
The capital program for 2014/15 also includes an element for backlog maintenance to
the Trust building stock. Whilst the Trust recognises the requirement for investment in
certain aspects of its infrastructure this is not considered to be sufficient to cause any
major disruption to service in 2014/15.
IS THE TRUST ACTIVELY MARKETING ITS SERVICES – ARE THERE ANY RISKS
AROUND SPECIFIC SERVICES?
The Trust has not widely marketed its services to date but is starting to develop a more
commercial awareness around the feasibility of certain services and developing longer
term relationships and alliances with partner organisations such as NLaG and York.
Relationships will need to be developed more closely with GP’s and clinical
commissioning groups as new commissioning arrangements embed. The Better Care
Fund (BCF) represents a risk to the organisation in terms of destabilising the local health
economy if not managed well. The Trust will make sure it is represented at BCF
128
discussions and is required by the TDA to be an active partner in approving the plans for
the local health economy.
WHAT ARE THE RISKS AROUND PERFORMANCE AND QUALITY?
In terms of assessing the impact of these risks on the Trusts ability to remain a going
concern there is no significant risk in relation to performance issues. There is a potential
risk arising from quality and the power of the CQC to act where there are issues around
quality. There are currently no concerns to indicate that this is a substantial risk although
the recent CQC inspection may highlight areas for further improvement and investment.
There is a possibility that guidance on minimum staffing levels will be published in the
near future which may also cause a cost pressure. Shortages in the current labour
market mean that the Trust is unlikely to increase staffing very quickly in the short term.
ARE THE BOARD COMPETENT ENOUGH TO IMPLEMENT THEIR PLANS?
The Board are committed to financial viability a key priority. As part of the assessment
process for Foundation Trust status the Boards’ ability to deliver, based on current
arrangements and past performance, has been and will continue to be scrutinised in
detail. The Board have undergone further development and change during the last 12
months, and are led by a strong and focused Chief Executive. Independent assessments
of the Board’s capability have been positive and the Board is focused on both individual
and collective development. The Board will need to be strong and very focused to drive
through the changes needed, particularly to achieve the significant level of savings
required for the next 5 years.
There is an independent Board review by the TDA in March. The Board will look to
strengthen its competencies on the back of any recommendations for improvement
made by the TDA review.
WHAT IS THE IMPACT OF THE TRUSTS LONGER TERM STRATEGIC PLANS?
The Board have recognised that the Trust is not likely to remain a successful and
progressive trust beyond the next 3-5 years unless it responds proactively to the
changing external environment. Currently a number of potential strategies are being
considered and will be developed in more detail. The strategy adopted will inevitably in
the current environment have inherent risks. The aim is to make the organisation fit for
purpose and capable of withstanding the impact of future change in the longer term and
therefore at this stage is not considered to have a negative impact on the going concern
assessment.
129
CONCLUSION
There are concerns going forward relating to factors outside of the control of the
organisation such as the economic and political environment and the general instability
that accompanies public sector and political and social reform. Insofar as it can, the
Trust is positioning itself to be best placed to cope with these challenges and there are
no particular issues that cast doubt upon the Trust being a going concern.
For 2014/15 and the following 4 years the Trust has a significant challenge ahead in
terms of making the changes needed to deliver a substantial savings programme and
the necessary service transformation. Failure to deliver the programme will place more
pressure on working capital and the Trust’s liquidity position.
Despite major challenges there are no significant issues of concern that would lead me
to believe the Trust will not continue as a going concern within the foreseeable future. I
recommend that that the Board therefore prepares the 2013/14 financial accounts on
this basis.
Lee Bond
Chief Financial Officer
13 February 2014
130
South West House
Blackbrook
Park Avenue
Taunton
Somerset
TA1 2PX
Tel: 01823 361338
[email protected]
29 May 2013
Director of Finance
Dear
Temporary Public Dividend Capital
Thank you for your recent correspondence. I can confirm that it is reasonable for the
Directors of Barnet and Chase Farm Hospitals NHS Trust to assume that the NHS Trust
Development Authority will make sufficient cash financing available to the NHS Trust
over the next twelve month period such that the NHS Trust is able to meet its current
liabilities.
On this basis I fully support your view that the NHS Trust Accounts are prepared on a
Going Concern basis.
Yours sincerely
Elizabeth O’Mahony
Deputy Director of Finance
131
132
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
STAFF SURVEY
Trust Board
date
Director
24 April 2014
Reason for
the report
The purpose of this paper is to outline for the Trust Board the key outcomes of
the Trust’s staff survey responses to the 2013 annual national survey.
Type of
report
Concept paper
Jayne Adamson – Chief of
Workforce and OD
Reference
Number
Author
Strategic
options
Information
Performance
2014 – 4 - 19
Myles Howell – Director of
Communications and Enagement
Business
case
 Review

1
RECOMMENDATIONS
The Trust Board is asked to note the findings of the Staff Survey and endorse the Staff
Survey 2013 Action Plan.
2
Key purpose
Decision
Information
3
Approval

Assurance

Discussion
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and prioritised
effectively



4
5
Delivery against our priorities and objectives
Capable, effective, valued and committed workforce
Strong respected impactful leadership
LINKED TO
Outcome 13: Staffing
CQC Regulation(s)
Assurance
Ref:
Framework
BOARD/BOARD COMMITTEE REVIEW
Legal advice


No
This report has not been considered at any other Board committee.
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
2013 National Staff Survey Results
1.
Purpose
The purpose of this paper is to outline for the Trust Board the key outcomes of the
Trust’s staff survey responses to the 2013 annual national survey.
The Board is also requested endorse the actions that the Trust is taking in order to
address those areas where improvement has been identified as being required.
2.
Background
The Trust undertook the NHS National Staff Survey 2013 between October and
December for a sample of its staff. In the 2013 reports there are 28 key findings
(scores) and a measure of staff engagement, the same as in 2012.
The sample response rate for the Trust was 52% in 2013, which is average when
compared against other Acute Trusts. This is an improvement on 35% in 2012 .
A summary overview of the profile of respondents is shown in the table below:
Occupational profile
% of Survey
Respondents
Allied Health Professionals
Medical
Nursing and midwifery (registered)
Nursing or health care assistants
Non-clinical
General management
2
20%
11%
29%
10%
28%
2%
2013 Staff Survey Outcomes
Answers to each of the survey questions are clustered into Key Findings. There are
a total of 28 Key Findings in the 2013 survey. These can be summarised as follows:





3 issues in the best 20% of trusts
0 issues better than average
4 issues at the average
8 issues worse than average
13 issues in the worst 20%


5 issues have improved since 2012
0 issues have deteriorated since 2012
The five areas where the Trust improved significantly reflect areas of focus in 2013 –
including the development of a new appraisal system - and are as follows:
1. KF7 - Percentage appraised in the last 12 months – (85%)
2. KF 8 - Percentage of staff having well structured appraisals in the last 12
months – (33%)
3. KF 9 - Support from immediate managers – (3.59)
4. KF 15 - Fairness and effectiveness of incident reporting procedures – (3.46)
5. KF 24 – Staff recommendation of the Trust a place to work – (3.41)
Overall staff engagement score is 3.56 which is an improvement on the 2012 score
of 3.46. However, this is still below the national average of 3.73.
There are three sub-dimensions to staff engagement:
–
–
–
4.
KF22: Staff ability to contribute towards improvement at work – Trust score
61%
KF24: Staff recommendation of the Trust as a place to work or receive
treatment – Trust score 3.41
KF25: Staff motivation at work – Trust score 3.72
Shifts, trends and themes
Each Directorate and Health Group has a different story to tell with their scores
highlighting clear areas of focus for the next 12 months.
The survey’s engagement score is made up from three key findings and the
questions which contribute to those key findings. Overall the Trust is below the
national average or around the national average for these scores, however in most
areas the scores are improving and in some cases significantly. In two areas though
– Family and Women’s Health and Infrastructure and Development - we are seeing a
downward shift.
KF31. Staff ability to contribute towards improvements at work
7a.There are frequent opportunities for me to show initiative in my role (national
average 69%)
The Trust improved across each Health Group and Directorate, however
Infrastructure and Development was significantly below the national average with
a score of 53%. Family and Women’s Surgery and Medicine had scores of 63%,
63% and 64% respectively. Corporate scored well above the national average at
80%.
7b. I am involved in deciding on changes introduced that affect my work area
(national average 52%)
Improvements in all Health Groups and Directorates but a significant
deterioration in Family and Women’s Health (61%-47%). Infrastructure and
Development improved slightly but is the lowest scoring area in the Trust and
well below the national average of 74% with a score of 60%.
7d. I am able to make improvements happen in my area of work (national
Average 55%)
Significant improvement in Clinical Support Services (49%-60%) but a
deterioration elsewhere especially in Infrastructure and Development (45%-37%)
(NB: If we remove the scores for Infrastructure and Development and Family and
Women’s Health the Trust scores above average for 7a and 7b and the same as the
national average for 7d.)
KF34. Staff recommendation of the trust as a place to work or receive treatment
12a. The care of patients/service users is my Trust’s top priority(national average
69%
Improvements in most areas and especially Corporate (59%-75%) and CSS
(51%-65%) but a significant deterioration in Infrastructure and Development
(62%-53%)
12c. I would recommend my organisation as a place to work (national average
61%)
Globally an improvement (one of our five significant improvements overall) but
significant downward shifts in Family and Women’s (48%-34%) and
Infrastructure and Development (71%-50%)
12d. If a friend or relative needed treatment I would be happy with the standard
of care provided by this Trust (national average 69%)
Improvements across the Trust especially in Corporate (56%-75%) however
significant deterioration in Family and Women’s (57%-45%) and, particularly,
Infrastructure and Development (78%-47%)
(NB: Family and Women’s Health registered the lowest scores for both 12c and 12d.
Corporate staff registered the highest scores for 12a and 12d.)
KF35. Staff motivation at work
5a. I look forward to going to work (national average 85%)
There are no noticeable shifts across the Trust for this score, but, notably the
highest scoring Health Group is Family and Women’s Health.
5b. I am enthusiastic about my job (national average 93%)
Generally the Trust is close to the national average for this score at 92%
however Family and Women’s has deteriorated to below the national average
(98%-91%)
5c. Time passes quickly when I am working (national average 94%)
The Trust scores the same as other Trusts for this score. However there has
been a big improvement in Corporate (92%-100%) and a deterioration in Family
and Women’s Health (100%-92%)
(NB: Corporate scored higher than all of the rest of the Health Groups and
Directorates on all three questions for KF35.)
In terms of their individual performance when compared with both the national and
Trust averages the scores for the Health Groups and Directorates are:
Finance
Corporate
CSS
F&WH
Inf&Dev
Medicine
Surgery
No. of questions
where scores are
equal to or better
than national and
Trust average
56
53
47
30
26
20
19
Better than Trust
average but below the
national average
Below Trust and national
average
5
8
22
10
11
8
11
24
24
16
44
48
57
55
But this alone masks where different areas have made improvements or seen a
deterioration. The survey itself is divided into five sections:
1.
2.
3.
4.
5.
Your Personal Development (training and development, appraisals)
Your Job (team-working, motivation, freedom to act, ability to influence decisionmaking)
Your Manager (support, inclusion, feedback, communication)
Your Organisation (recommending as a place to work/receive care)
Health and Wellbeing at work (stress, bullying, reporting incidents)
On the whole scores are showing more improvement than deterioration in most of the
five domains. However in some areas the level of deterioration is greater or equal to
the improvement, as follows:
Medicine
Your Job
Infrastructure
Your Job
Your Managers
Your Organisation
Health And Wellbeing
Family And Women's
Your Job
Clinical Support Services
Your Personal Development
Improved
12
Improved
10
1
3
9
Improved
13
Improved
7
Deteriorated
15
Deteriorated
17
9
3
12
Deteriorated
15
Deteriorated
9
(NB: Corporate and Surgery showed greater levels of improvement than deterioration
for all five domains. The Corporate improvement, in particular, was stark.)
4.
Key Issues and next steps
The Trust remains in the lowest 20% of Trust for 12 of the 28 key findings:
1.
KF 2 - Percentage agreeing that their role makes a
difference to patients – (87%)
2.
KF 3 - Work pressure felt by staff – (3.17)
3.
KF 6 - Percentage receiving job-relevant training, learning or
development in the last 12 months – (78%)
4.
KF 8 - Percentage of staff having well-structured appraisals in the
last 12 months – (33%)
5.
KF 11 - Percentage suffering work-related stress in the last 12
months – (40%)
6.
KF 14 - Percentage reporting errors, near misses or incidents
witnessed in the last month – (85%)
7.
KF 16 - Percentage experiencing physical violence from
patients, relatives or the public in the last 12 months – (18%)
8.
KF 20 - Percentage feeling pressure in the last 3 months to
attend work when feeling unwell – (33%)
9.
KF 22 - Percentage able to contribute towards improvements at
work – (61%)
10.
KF 23 – Staff job satisfaction – (3.50)
11.
KF 24 – Staff recommendation of the Trust a place to work – (3.41)
12. KF 25 - Staff motivation at work – (3.72)
Understanding this, and the areas for each Health Group where deteriorating scores
are high, we have been able to focus our attention on specific aspects for
improvement. This year, therefore, for the first time, we have identified key areas for
actions with each of the Health Groups and Directorates as well as support services,
including Governance and Education and Development. Each area has agreed a set
of actions to address issues which are most affecting their performance in the survey.
These will be reported through the Performance and Finance Committee.
At a Trust-wide level the OD programme will continue to address some of the issues
the Trust faces in terms of its leadership capability and staff engagement. The OD
team will also undertake a specific piece of work to establish where we have
particular issues of stress and bullying and identify actions to address these.
The Trust will also work to understand from staff why there is a large discrepancy
between the results of the Friends and Family Test for patients (where 4.7 out of 5 –
94% - of patients would recommend our hospitals as places to receive treatment)
and the score that our staff report, which is closer to 50%. A programme of focus
groups being run by the Communications and Engagement team will run between
March-November and the summer engagement events planned for staff will focus on
this issue.
6.
Recommendations
The Trust Board is asked to note the findings of the Staff Survey
and endorse the Staff Survey 2013 Action Plan.
1
1
Staff Survey Action Plan
Key:
D - Delivered
O - On track to deliver to timescale
OA - Off track but additional actions in place that give assurance
Off - Off track with additional actions in place but no assurance
S - Off track with no additional actions in place
NHS Staff Survey 2013
REF
LEAD
ISSUE
ACTION
RESPONSIBLE
PERSON
REPORTING
COMMITTEE
OUTPUT
OUTCOME
START
DATE
1
Chief of
Workforce and
OD
STRESS AND BULLYING
Establish a task and finish group to run a
diagnostic in conjunction with an independent
provider
OD Manager
PAF
Diagnostic undertaken and
actions identified
Scores exceed
national average
May-14
May-15
Run three sets of 100 focus group sessions to
ask staff what is important to them and
establish quick wins/big wins
Director of
Communications and
Engagement
PAF
300 focus groups delivered
and quick wins acted upon
Scores exceed
national average
Apr-14
Jan-15
Promote FFT, good practice, CQC score, staff
inspirational stories to all staff
Head of
Communications
PAF
Trust-wide communications
plan to promote GREAT
CARE
Scores exceed
national average
Apr-14
Dec-14
Summer Big Tent events
Director of
Communications and
Engagement
PAF
Run four days of
engagement events to listen
to staff ideas, promote
positive stories and deliver
on Big Wins
Scores exceed
national average
Jul-14
Jul-14
Steer thirty more Pioneer teams through the
programme
Director of
Communications and
Engagement
PAF
Thirty more sets of results
from Pioneers, ABT training
and FFTs
Feb-14
Mar-15
Feedback on Big Wins from 2013
Head of
Communications
PAF
Trust wide communications
programme
May-14
Jun-14
220 managers to complete
the Ggreat Leaders
programme
Feb-14
Mar-15
Mar-14
Apr-14
2
3
Chief of
Workforce and
OD
Chief of
Workforce and
OD
RECOMMEND HOSPITAL AS
PLACE TO RECEIVE
TREATMENT/OVERALL
ENGAGEMENT - below
national average
OVERALL ENGAGEMENT below national average
Contribute towards
engagement score
exceeding national
average
Contribute towards
engagement score
exceeding national
average
Scores in the Your
Manager section to
exceed national
average
COMPLETION DATE RAG STATUS
4
Chief of
Workforce and
OD
YOUR MANAGERS - below
national average in most areas
Reach 220 managers with the Great Leaders
programme
OD Manager
PAF
5
Chief of
Workforce and
OD
STRENGTHEN MANAGEMENT
ACCOUNTABILITY FOR
STAFF SURVEY
Identify QPR measures for HGs and
Directorates
Director of
Communications and
Engagement
PAF
Head of E&D
PAF
Focusing on people
rebranded as Patient
Experience training
Staff able to to
recognise this more
easily in staff Survey
Mar-14
Apr-14
PAF
Trust-wide Patient
Experience training
package launched
Staff in all
wards/depts able to
access patient
Experience training to
suit their needs
Mar-14
Sep-14
Re-brand current training package as an
interim measure
6
Director of
Workforce
YOUR PERSONAL
DEVELOPMENT - Review of
patient/service user training
Review programme content and accessibility
for different staff groups
Head of E&D
Identify areas of weakness
Observable
for each HG and Directorate
improvement against
and agree appropriate
all perfromance
performance measures for
measures
QPRs
2
2
7
LEAD
8
Director of
Workforce
9
Director of
Workforce
ISSUE
ACTION
Programmes content based on staff group
YOUR PERSONAL
need, i.e. clinical high tension areas needing
DEVELOPMENT - My training
different content compared to patient admin
helped me to do my job better
teams. Delivery of an elearning option.
YOUR PERSONAL
DEVELOPMENT - making
training easier to access
PAF
OUTCOME
START
DATE
COMPLETION DATE RAG STATUS
Staff are
Flexible options for acces of appropriately trained
conflict resolution training
acoording to area of
need.
Mar-14
Sep-14
Staff and managers
will see what they
have completed but
also importantly what
they need to do.
Mar-14
Apr-14
Head of E&D
PAF
Delivery of a "one stop shop" for all education
and appraisal needs. Develop learning
management system further which displays
appraisal, training opprtunities with easy
booking, e-learning and real time training data
all in one place.
Head of E&D
PAF
Ease of access whenver
needed
clarity for staff and
managers
Mar-14
Apr-14
Head of E&D
PAF
Relevant staff have access
to training
Satff understand
responsibilities for
equality and diversity
May-14
Jul-14
Director of
Infrastructure and
Development
PAF
80% staff know who
I&D Senior Manager boards
the senior managers
erected in all key areas
are
Mar-14
Jun-14
Director of
Infrastructure and
Development
PAF
Improve the number of I&D
85% of I&D staff have
staff having annual
an appraisal
appraisals
Feb-14
Feb-15
Director of
Infrastructure and
Development
PAF
All senior management
team attends the course
10% improvement on
and agrees objectives
Q.10a, Q10d
linked to staff survey results
Feb-14
Sep-14
Director of
Infrastructure and
Development
PAF
I&D to score in the
Three year strategy created top 20% of Trusts for
with milestones identified
YOUR MANAGER
section of the survey
Mar-14
Sep-14
HR Business partner
PAF
Mar-14
Mar-15
HR Business partner
PAF
Feb-14
Mar-15
HR Business partner
PAF
Ask staff what is getting in
the way of providing
GREAT CARE - deliver on
quick wins and big wins
2014 score is above
average
Apr-14
Mar-15
HR Business partner
PAF
Ask staff what is getting in
the way of providing
GREAT CARE - deliver on
quick wins and big wins
2014 score is above
average
Apr-14
Mar-15
YOUR PERSONAL
DEVELOPMENT - Have you
had any Equality & Diversity
Training in the last 12 months
Existing package will be revised and promoted
to staff who this is appropriate for
11
Chief of
Infranstructure
and Development
YOUR MANAGER - increase
visibility of senior managers
Create senior manager photo boards
12
Chief of
YOUR MANAGER Identify areas where appraisal rates are low
Infrastructure and communication between senior
and ensure managers are delivering appraisals
Development
managers and staff is effective
13
Chief of
Infrastructure and
Development
14
Chief of
Infrastructure and
Development
15
F&WH Medical
Director
YOUR MANAGER - ask for my
opinion before making
Ensure senior management team attends the
decisions, encourages us to Great Leaders course
work as a team
Develop a 3-year strategy for OD and staff
engagement intervention within the directorate
YOUR MANAGERS - acts on Align Great Leaders' commitments to manager
feedback, asks for my opinion engagement
Run five focus group sessions with staff in
maternity and breast care
16
Head of E&D
OUTPUT
Instant real time accees to
reports
Director of
Workforce
F&WH Medical
Director
REPORTING
COMMITTEE
Further development of learning management
system which will display individual training
records. Managers will have acces to their
team training reports. (real time data)
10
YOUR MANAGER
RESPONSIBLE
PERSON
Hold Big Conversation session with
YOUR ORGANISATION recommendation of Trust as Ophthamology
place to work/receive treatment
Hold Big Conversation session with Paediatrics
Score for listens to
All F&WH Great Leaders
my opinion and accts
attendees have
on feedback are
commitments which address
above national
staff engagement issues
average
Five sessions to ask staff
what would need to happen 2014 score is above
for them to recommend the
average
Trust
3
3
REF
17
LEAD
ISSUE
Director of
Governance and
Corporate affairs
MY ORGANISATION Encourages us to report
incidents (lower than national
average)
RESPONSIBLE
PERSON
REPORTING
COMMITTEE
OUTPUT
OUTCOME
START
DATE
Redesign incident reporting form
Head of risk resilience
and safety
PAF
launch new online form
2014 score is in top
20%
Mar-14
Jun-14
Global comms campaign around the
importance of reporting incidents
Head of risk resilience
and safety
PAF
All corporate
communications employed
for a six month period
2014 score is in top
20%
Apr-14
Oct-14
ACTION
COMPLETION DATE RAG STATUS
4
4
e it will come back on track
it will come back on track
June 2014 Update
5
5
June 2014 Update
6
6
June 2014 Update
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
TRUST BOARD MEETING
HELD ON 27TH MARCH 2014
IN THE BOARD ROOM, HULL ROYAL INFIRMARY
PRESENT
IN ATTENDANCE
1
Dr K Hopkins (Chair) Non Executive Director
Mr P Morley
Chief Executive Officer
Mr A Snowden
Non Executive Director
Miss A Pye
Chief Nurse
Mr J Hattam
Non Executive Director
Ms M Olsen
Chief Operating Officer
Prof. I Philp
Chief Medical Officer
Mrs U Vickerton
Non Executive Director
Dr D Ross
Non Executive Director
Mrs J Adamson
Chief of Workforce & OD
Ms J Myers
Director of Planning & Delivery
Ms L Thomas
Director of Governance
Mr D Taylor
Interim Chief of Infrastructure and Development
Mr M Greensill
Deputy Director of Finance
Mrs R Thompson
Assistant Trust Secretary (Minutes)
ACTION
APOLOGIES FOR ABSENCE
Apologies were received from Mr R Deri, Chairman, Prof. J Hay, Associate Non
Executive Director, Mr L Bond, Chief Financial Officer and Mrs P Lewin, Chief of
Infrastructure and Development.
1.1 - DECLARATION OF INTERESTS
Miss Pye advised that she was now a visiting lecturer at Hull University and the
Board congratulated her on this appointment.
1.2 - CONFLICTS OF INTEREST ARISING FROM THIS AGENDA
There were no conflicts of interest arising from the agenda.
2
MINUTES FROM THE MEETING HELD:
30 January 2014
The following changes were requested
 Item 11 – Mrs Olsen advised that the recovery plan in place was to reduce
the backlog of RTT incompletes rather than clear it.
 Item 17 – Miss Pye asked that the minutes be amended to make it explicit
that the 10 expectations for Boards regarding Nursing and Midwifery staffing
levels were clearly set out in her paper and acknowledged by the Board.
Following these changes the minutes were approved as an accurate record.
Mr Hattam asked whether any changes had been made to Chief portfolios as the
Remuneration Committee which had been due to meet in January 2014 was
cancelled. This Committee was due to give consideration to Mr Morley’s proposals
presented at the Board meeting on 30 January 2014. Mr Morley advised that
although some changes had been made, no salary adjustments had been
implemented.
27 February 2014
The following changes were requested
3

Item 4 – The spelling of Sir Ian Carruthers to be corrected
-
Paragraph 4 should read, “Dr Hopkins questioned the categorisation
of falls resulting in fracture neck of femur not being recorded as
severe harm.”
Subject to the above changes the minutes were approved as an accurate record of
the meeting.
3
ACTION TRACKER
External review of Midwifery Staffing – To be received at the April Board meeting
Risk Strategy – Ms Thomas advised that this would be brought to the Board at the
end of July as the Quality & Safety Strategy (to be completed in June) would inform
its review.
CRES Clinical Sign Off – This item was to be received at the April Board.
Emergency Care Model – This item was included in the Trust’s Forward Plan.
Meeting of Sub Committee Chairs – It was agreed that this would be an agenda
item at the next Non Executive Director meeting to discuss overlap of work streams
of the Board committees.
Resolved:
The Board agreed to remove the completed actions marked green.
4
CHAIRMAN BRIEFING
Dr Hopkins updated the Board regarding the resignation of Professor John Hay
(Associate Non Executive Director) from the University and the discussions ongoing
with Hull University for his replacement. Dr Hopkins advised that Professor Hay had
been offered to remain as an Associate Non Executive Director.
5
CHIEF EXECUTIVE BRIEFING
Mr Morley reported that all the commissioner contracts had been signed except the
Specialist Commissioning Group which was not finalised due to lack of clarity
regarding specialist commissioner budgets. A letter from the TDA had been
received that requested 30, 60, 90 day action plans to be supplied for failing access
targets such as referral to treatment times. Mr Morley advised that other Trusts had
also faced similar challenges due to increased referrals. The Trust was still waiting
for the Chief Inspector of Hospitals Report that had been expected on 24.03.14. The
Care Quality Commission had been contacted to find out when it would be available.
There was a discussion around the local television report on the Trust regarding
ambulance turnaround times at A&E. Mr Snowden asked for reassurance as he had
seen the report and Mr Morley assured him that the Trust did not hold patients in
ambulances. Miss Pye assured the Board that there were escalation processes in
place to capture any problems arising in A&E and it was agreed that a report
detailing ambulance turnaround issues would be received at the Performance &
Finance Committee. There will be a national fine introduced next year for holding
ambulances at A&E.
Mr Morley advised that NHS England has requested Trusts to review their
arrangements for the disposal of foetuses in particular the use of incineration and
also patients being moved between wards in hospital between 11pm and 6am.
Mr Morley assured the Board that the Trust does not incinerate foetuses and that
they are disposed of in a sensitive way with full involvement of the families.
4
AP
LT
IP
JM
LT
Mr Morley spoke about NHS Hull and their strategic plans for Hull 20/20. He asked
for Board for approval to work in conjunction with other stakeholders to progress this
work. It was also noted that the Local Authority were required to present their plans
to the Trust regarding changes associated with the introduction of the Better Care
Fund.
Mr Morley also asked for the Board’s approval to join the Quest for Quality Group as
they had approached the Trust because of the Nursing and Medical work both Miss
Pye and Prof. Philp were leading on. He advised that the Group works with Trusts
benchmarking and analysing good practice. The membership would cost £30k for
two years.
Resolved:
The Board received Mr Morley’s briefing and agreed the following actions:
 A report to be received at the Performance & Finance Committee detailing
issues relating to ambulance turnaround times.
 A briefing paper to be received at the next Board meeting regarding the
disposal of fetal remains and transfers of patients between wards out of
hours
 The Board approved the Trust’s involvement in NHS Hull’s strategic plans.
 Diary dates would be agreed for inviting stakeholders to present plans
relating to the Better Care Fund.
 The Board approved the Trust joining the Quest for Quality Group.
6
MO
IP
RT
2 YEAR OPERATING PLAN
Ms Myers presented the paper which highlighted the work that had been undertaken
to develop the Trust’s two year Operating Plan 2014/15 – 2015/16 in accordance
with the Trust Development Authority planning guidance.
The plan included a narrative on the next two years including the impact of strategic
commissioning intentions and service changes, the approach to be taken to improve
quality and safety, service capacity and developments, delivery of operational
performance standards, workforce plans and the financial and investment strategy.
The plan also outlined the Trust’s activity plans, C Difficile and A&E trajectories as
well as the financial plan for 2014/15.
There was a discussion around workforce numbers increasing when the Trust had
forecasted a reduction in the headcount in 2013/14. Mr Hattam advised that this was
being reviewed in more detail at the Performance & Finance Committee in April
2014.
Mr Greensill updated the Board regarding the Financial plans and advised that the
Trust was planning for a surplus of £2.9m (0.6%) and planned to delivery efficiency
savings of 4% (£21.3m). The Continuity of Service Risk Rating had been forecasted
at 3 for the two year plan, with a servicing capacity ratio of 3 and a liquidity ratio of 2.
Mr Greensill also informed the Board that the Trust would need cash funding and
loans for business cases of up to £25m from the Trust Development Authority.
Dr Hopkins asked if the Finance team were confident these repayments could be
met and Mr Greensill assured him that the Trust was borrowing within its limits and
the loans are included in the 2 and 5 year financial plans. Mr Morley stated that the
Trust had a good credit history and that it owned land that could be used as
collateral.
5
Mr Greensill highlighted a number of financial risks to the plan which were the
Trust’s liquidity position, the CRES programme and funding of the Capital
Programme.
Resolved:
The Board approved the two year plan and thanked Mr Bond and his team for the
work undertaken to achieve the end of year surplus at March 2014.
7
CORPORATE PERFORMANCE REPORT
Miss Pye presented the report and highlighted that the mortality indicators were on
track, C-Section rates year to date were above peer, the reporting of incidents was
improving and Fractured Neck of Femurs following falls were now being reported.
Miss Pye advised that the Nurse Directors would present falls information for each
of the Health Groups at the April Board meeting.
AP
Fluid balance and observations remain below target and was being monitored at the
Quality Effectiveness and Safety Committee. Miss Pye was working closely with the
staff to review the fluid balance audits and how the figures were reported.
Predictions relating to cardiac arrest calls was not on target and CDifficile would not
meet the threshold set for the year. However action was in place to improve
performance in both areas.
Mr Greensill gave and overview of financial performance and Mr Clarke was
thanked for the development of the CRES reports and the way that the Finance
team worked closely with Health Groups to achieve the savings.
Mr Morley stated that it had been a difficult year for the Trust due to A&E being busy
all year, a greater number of referrals, and issues with the cancer pathways, but
clinical outcomes had been good and the Trust’s finances had been well managed.
Resolved:
The Board received the Corporate Performance Report.
8
ACCESS TARGET ACTION PLANS
8.1 – CANCER
Ms Myers presented the paper to the Board which gave an update regarding the
challenges that the Trust was experiencing in delivering the cancer waiting time
standards during quarters 3 and 4.
Ms Myers advised of the actions taken to date. These included weekly patient
tracking list meetings with the Trust Lead Cancer Manager and Divisional General
managers, weekly escalation to Operations Directors of any risks, introduction of 2
internal stretch targets (90% see by day 7 and 90% 62 day referral to treatment for
patients referred by their GP to HEY), revised breach root cause analysis and
establishment of a monthly Access Improvement Meeting.
The 2 week wait standards were failing in quarter 4 and the following actions had
been put into place: staff to inform patients of the urgency of the appointment, the
Clinical Commissioning Groups had reminded GPs to refer urgently within the 2
weeks, the Department of Health 2 week wait demand and capacity tool had been
utilised for all teams and all multi disciplinary teams have been asked for their plans
to achieve see by day 7 for 50% of all patients by end of March 2014.
6
The Trust had failed the 62 day standard in quarter 3 and was at risk of failing it in
quarter 4 with the key cause of the deterioration remaining in the Urology multi
disciplinary teams performance. Dr Hopkins expressed concern at the reoccurring
problems in Urology and asked if the capacity was in place to meet demand. Mr
Morley advised that the pathway was continually changing with an increase in
referrals from York. Ms Myers assured Dr Hopkins that the pathways were being
reviewed with Clinical Commissioning Groups and GPs with enhanced patient
tracking and escalation processes to help better manage the capacity.
Ms Myers added that the remedial actions already delivered had recovered
performance in March 2014 in all areas except the 62 day standards. Further
actions were identified which would ensure delivery of all cancer waiting time
standards in quarter 1.
Mr Hattam welcomed the paper and the assurance it gave to the Board and asked
that the detailed action plan with timings be received at the Performance & Finance
Committee for monitoring.
8.2 – A&E
Ms Myers gave the presentation to the Board and highlighted the recovery plan in
place to improve A&E 4 hour standard performance. She advised that additional
consultants had been appointed as well as Band 7 co-ordinators in Emergency
Department on a 24 hour 7 days a week basis, a pilot of the Rapid Assessment and
Treatment (RAT) model had been implemented and a 2nd consultant had been
added on the busiest shifts. There had been early wins from the Discharge Hub
through partnership working and temporary additional capacity had been added to
Emergency Department .
Ms Myers advised that 30, 60 and 90 day action plans had been put into place. The
30 day plan looked at maintaining elements of the winter planning, further gains
from the RAT model, establishing the Emergency Department improvement project
and developing a plan for a sustainable operational flow management system.
The 60 day plan looked at reviewing the impact of 30 day actions, implementing
early wins from the Emergency Department ‘Crowding’ improvement project,
improving morning discharges and completing the Project Plan for acute medicine
transformation.
Within the 90 day plan the Trust would review the impact of the 30 day actions,
finalise new models of care for frailty and acute ambulatory patients, finalise
configuration and medical models for centralisation of acute medical beds, agree
key elements of the 2014/15 Winter Plan and implement new operational flow
models.
Dr Hopkins expressed concern regarding the lack of resource within the Emergency
Department and Miss Pye advised that the 2nd consultant assisted in managing the
volume of patients visiting the department. Mr Morley added that the Medicine
Health Group Operations Director was working closely with the local health partners
to try to resolve activity levels.
8.3 – REFERRAL TO TREATMENT TIMES
Ms Myers updated the Board regarding the incompletes target of 92%.
She advised that a plan was developed in October 2013 to reduce the backlog to
2600 whilst maintaining Trust level delivery of complete targets. However this had
not been achieved.
7
Ms Myers highlighted the causes for the failures which included delays and
difficulties in increasing capacity to meet planned demand, recruitment difficulties,
under-developed understanding of demand and capacity at specialty level and the
failure to manage closely the patients who had been waiting longer than 18 weeks.
Mrs Vickerton questioned whether inappropriate GP referrals were monitored.
The Trust had taken the following actions to address the issues. Local rules had
been removed, the internal audit programme had commenced, post audit training
was being delivered, greater financial incentives for specialty performance in the
contracts were being introduced and further roll out of Choose and Book would take
place. There would be wider publication of patient ‘rights’ and the Intensive Support
Team (IST) audit was underway. Ms Myers advised that the recovery plan would be
received at the Executive Management Board on 16.04.14 and at the Trust Board
on 24.04.14.
Dr Ross highlighted that cancer and RTT targets had been continuously met in the
previous year and asked what had changed? Ms Olsen indicated there had been
unexpected increases in referrals in some specialities.
Mr Hattam asked for a bridge analysis to be included in the April Board paper
together with the IST report.
JM
There was a discussion around clearing the backlog by planned failure of the
targets. This would need to be managed carefully and assurance would need to be
received that performance would subsequently improve and be sustained. There
was discussion regarding patients who had been on the waiting list after 18 weeks
and whether this posed a clinical risk to the individual. Prof. Philp also suggested
that ownership of the backlogs should be at specialty level with the clinical leads
understanding and assessing the risks.
Resolved:
The Board agreed the following:
 Approved the recovery plan and performance trajectory for the cancer
targets and that the action plan should be monitored through the
Performance & Finance Committee.
 Endorsed the action plan for A&E and agreed that the Performance &
Finance Committee should monitor its progress.
 Agreed to receive the referral to treatment times recovery plan at the April
Board meeting.
 To review long waiting patient to ensure that the Trust was not placing
patients at risk.
9
JM
JM
MO
TDA MONTHLY SELF CERTIFICATION
Ms Thomas presented the paper and highlighted Board Statements 5,10,12 and 13
for discussion. Statement 5 related to the NTDA Accountability Framework and the
Trust’s compliance with it. The Board agreed that this should remain as compliant.
Mr Hattam asked if Statement 10 should be reconsidered due to the end of the
financial year, but the Board agreed to leave it as a risk. It was agreed that
Statement 12 should now be declared as a risk due to the uncertainty of the plans
for the recruitment of a Chairman and the vacant Non Executive Director post.
Statement 13 should stay as compliant until the TDA Review of the Board report had
been received.
No issues were raised in relation to compliance with the License conditions.
8
Resolved:
The Board agreed that Statement 10 and 12 should be declared as risks with a
narrative included in the monthly return to the TDA. All other Statements to be left
at compliant.
10
STAFF SURVEY
Mrs Adamson reported that 840 staff surveys had been sent out and 427 members
of staff took part giving a 52% return. Where questions had remained the same the
Trust had improved in 5 areas and no areas had deteriorated. In the areas were the
Trust had scored in the bottom 20% nationally action plans were being put into
place.
There was discussion around bullying and harassment and whistleblowing cases.
Mrs Adamson advised that she would bring the action plan relating to the staff
survey to the next meeting. The staff element of the Friends and Family was being
rolled out from 1 April 2014 and this would replace the pulse checks.
Resolved:
The Board noted the overview and agreed to receive a more detailed report
including a trend analysis back to 2011 at the next Board meeting in April.
11
JA
UNADOPTED COMMITTEE MINUTES
11.1 – PERFORMANCE & FINANCE
Mr Hattam presented the minutes from the meeting held on 27 February 2014 and
advised that the meeting to be held today had been cancelled due to quoracy not
being met. Performance issues had already been discussed under item 7 in the
Corporate Performance Report.
11.2 – PERFORMANCE & FINANCE TOR
Mr Hattam advised that further amendments needed to be made to the quorum of
the meeting before they could be signed off. This would be discussed at the April
meeting of the Performance & Finance Committee.
JH
11.3 – QUALITY EFFECTIVENESS AND SAFETY
Mr Snowden presented the minutes and advised that the People Strategy workshop
would be held at a Board Development day.
11.4 – GOVERNANCE & ASSURANCE
Mr Snowden advised that the meeting that was due to be held on 20 March 2014
had been cancelled due to quoracy not being met. He welcomed the decision to
discuss overlapping work streams of the committees at the next Non Executive
Director meeting.
12
ANY OTHER BUSINESS
Miss Pye advised the Board that the Nursing Conference was being held on 25th
April 2014 and that all were welcome to attend. She also advised that a paper had
been published in the Nursing Times relating to the Cayder Boards giving examples
of good practice within the Trust.
13
DATE AND TIME OF NEXT MEETING
24 April 2014, 11am, The Boardroom, HRI
…………………………………………………………………………..
Chairman
9
10
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
PEOPLE STRATEGY
24 April 2014
2014 – 4 - 21
Trust Board
date
Director
Reference
Number
Jayne Adamson – Chief of Author
Workforce and OD
Reason for
the report
The purpose of this report is to seek the Board’s approval of the Trust’s
new People Strategy 2014/16.
Type of
report
Concept paper
Performance
1
Strategic
options
Information
Chief of Workforce
and OD
Business
case
 Review

RECOMMENDATIONS
The Board is requested to approve the People Strategy 2014-16.
2
3
4
5
Key purpose
Decision
Approval
Information
Assurance

Discussion
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and
prioritised effectively
 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
Outcome 13 - Staffing
CQC
Regulation(s)
Assurance
Ref:
Legal advice
Framework No
BOARD/BOARD COMMITTEE REVIEW


No
This report has also been considered by the Quality Effectiveness & Safety
Committee 17.04.14 and the Performance & Finance Committee 24.04.14.
135
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
24TH APRIL, 2014
PEOPLE STRATEGY 2014 – 2016
Purpose
1. The purpose of this report is to seek the Board’s approval of the Trust’s new
People Strategy 2014/16.
Background
2. The Trust has had a Workforce Strategy and separate Leadership Strategy
covering the period 2010 to 2013. These Strategies have delivered much, but
the organisation requires a further integrated strategy to continue the
management and development of our workforce to meet our organisational
goals.
3. The Workforce and Organisational Development Directorate with HR
Business Partners and HR staff have developed this strategy with Health
Group Triumvirates.
The Workforce Transformation Committee have
contributed to and endorsed the strategy and recommend it for approval.
Current position
4. The People Strategy 2014/16 sets out the vision for our workforce. It outlines
how Hull and East Yorkshire Hospitals NHS Trust working with partners plans
to manage and develop the workforce in order to deliver the Trust’s vision,
values and priorities as set out in our five year Integrated Business Plan.
5. The strategy sets out the challenges facing HEY over the next 3 years, the
impacts upon our workforce and how we intend to respond in the short and
longer term.
6. As a result of the worst economic recession for decades and the very high
level of national debt, the NHS has faced unprecedented spending cuts which
will continue for the lifespan of this strategy and therefore a key focus of the
strategy is on service reform, repositioning the organisation and managing the
transition. The Trust will require managers to operate as transformational
leaders and require a workforce that is flexible, skilled and productive.
7. Our organisation will continue to be focussed on quality and safety and
improving the patient experience, but it will be leaner, intent on reducing
costs, whilst at the same time sustaining high performance. The shape of the
organisation will change, as we and partners seek to improve services and
modernise care pathways and deliver more services within local communities,
building upon the successes of the past.
8. The Strategy proposes 6 strategic workforce themes, underneath each a
number of actions will be developed and implemented over the lifetime of the
strategy. The 6 themes are:a. Leadership capacity and capability
b. High performance and culture of excellence
c. Employee engagement and recognition
d. Workforce learning and development
e. Diverse and healthy organisation
f. Modern, fair and affordable employment package
Recommendation
9. The Board is requested to approve the People Strategy 2014-16.
Jayne Adamson
Chief of Workforce and OD
136
People Strategy
2014-2016
Contents
1.
FOREWORD
2.
INTRODUCTION
2.1
2.2
2.3
2.4
The need for change
Success through people
Key influences
Workforce profile
3.
ACHIEVEMENTS 2010 - 2013
4.
CONTEXT FOR THE PEOPLE STRATEGY
4.1
4.2
Integrated Business Plan 2013/14 to 2017/18
Medium Term Financial Plan
5.
VISION AND VALUES
6.
THEMES
6.1
6.2
6.3
6.4
6.5
6.6
Leadership capacity and capability
High performance and culture of excellence
Employee engagement and recognition
Workforce learning and development
Diverse and healthy organisation
Modern, fair and affordable employment package
7.
GOVERNANCE
7.1
Governance Structure
1. Foreword
Hull and East Yorkshire Hospitals NHS Trust is an ambitious and progressive Trust that strives to
improve the quality of care for its patients, as well as wider health and wellbeing of residents within Hull
and East Riding. The Trust’s vision and key priorities will be delivered through the Integrated Business
Plan 2013/14 - 17/18, supported by our Medium Term Financial Plan and through our five core values
and ‘I will’ statements. We rely on staff to deliver these priorities and to display the core values in the
way we work.
Our workforce is recognised as our greatest
asset and, through our people, developing
‘Great Staff’, we will deliver ‘Great Care’ that will
give us a ‘Great Future’. (And we will achieve
this at the same time as offering outstanding
value for money).
It is only through our people’s skill, creativity
and commitment will we achieve our ambition
to make Hull and East Yorkshire Hospitals NHS
Trust one of the safest hospitals in England by
2017. At the same time creating an organisation that will be recognised as an ‘employer of choice’ where
our employees feel engaged, valued and empowered and are proud to work for the Trust, passionate
about what they do, and to feel that it’s more than just a job.
As one of the largest employers in the area, we understand the important role we play in providing
opportunities for improving skills and employment for local people and we have reflected this in our
strategy.
Over the next three years, the Trust will continue to face the unprecedented challenge of providing
services within a landscape of significant public sector spending cuts. The ability to sustain an effective
relationship with our staff will be crucial to our success. We need motivated, well-led staff who will deliver
high performance and excel at work. Difficult decisions lie ahead and this People Strategy sets out how
we will reshape the Trust in partnership with our workforce.
This document sets out a strategy of transformation through people and the priorities on which we will
focus our efforts over the next 3 years. Through its delivery, we will ensure the Trust achieves its safety,
quality, social and environmental goals and remains a leading employer within the sector.
Chief Executive
Chairman of the Trust
2. Introduction
The People Strategy sets out our vision for our workforce. It outlines how Hull and East Yorkshire
Hospitals NHS Trust working with partners plans to manage and develop the workforce in order to
deliver our vision, values and priorities, as set out in the Integrated Business Plan.
This Strategy sets out the challenges facing Hull and East Yorkshire Hospitals over the next three
years, the impacts upon our workforce and how we intend to respond in the short and longer term.
2.1 The need for change
As a result of the worst economic recession for decades and the very high level of national debt, the
NHS is struggling to come to terms with unprecedented spending cuts and therefore a key focus of
the Strategy is on service transformation and reform, repositioning the organisation and managing
that transition. The shape of the organisation will undoubtedly change, as we and partners seek to
improve patient experience and care pathways and deliver more services within local communities,
building upon the successes of the past.
NHS reforms have also sought to provide greater transparency and clearer accountability, with less
bureaucracy and improved joint working with General Practitioners through new Clinical
Commissioning Groups. The Coalition Government has also increased competition in health care,
and placed a greater emphasis on innovation, efficiency and productivity to provide services with
less money. Whilst the changes are still settling
down, the Government reforms maintain ‘quality’
as the organising principle of the NHS, with a
focus on improving outcomes rather than
processes.
The context of health care and support is also
changing, with people living longer, many with
multiple and complex needs, and with higher
expectations of what health, care and support can
and should deliver. In response to the
Department of Health’s Compassion in Practice –
Nursing, Midwifery and Care Staff, the Trust has
set out a shared purpose for nurses, midwives
and care staff to deliver high quality,
compassionate care and to achieve excellent health and well-being outcomes. The document sets
out the six fundamental values of care, compassion, competence, communication, courage and
commitment (the 6Cs). Our organisation is committed to upholding these values.
The Trust will continue to be focused on quality and meeting patient needs, but it will inevitably be
leaner, intent on getting things right first time and sustaining high performance. As a result of service
reform and downsizing, the Trust will work differently with partners to deliver health care services for
the population of Hull and East Riding.
To achieve more with less resources, our workforce needs to be skilled and productive. We will therefore
continue to maximise our employees’ performance and continue to develop new ways of working. Our
current leadership styles will also need to change to inspire, engage and empower a more flexible
workforce.
Over the next three years, the Trust will need to integrate services around patient needs, and offer
greater choice and personalised care that reflects an individual’s health and care needs. Patient focus
will inform all that we do in our
community leadership and governance roles and as
service providers and service enablers. These roles will
require managers and staff to work differently in the future
and the People Strategy will ensure that we are able to
meet these demands.
2.2 Success through people
The People Strategy has been developed around
6 strategic workforce themes to focus our
priorities, and inform where activity is best concentrated
and to generate annual delivery plans.
The themes are:●
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Leadership capacity and capability
High performance and culture of excellence
Employee engagement and recognition
Workforce learning and development
Diverse and healthy organisation
Modern, fair and affordable employment package
Success for the Trust in the end will depend less on our
structures, systems and processes, but more on the way
that our employees work effectively within them. What we
offer our employees as part of our written and
‘psychological’ contract and how we communicate and engage employees will set the tone and culture
for our organisation. It will enable the Trust to overcome the challenges we face together and provide
safe and quality outcomes for patients.
Our core values remain and we will build on the people management successes of the past. This People
Strategy also takes account of expected changes in the environment and the future aspirations of the
Trust.
2.3 Key influences
The People Strategy actions take account of other internal strategies and plans. Internally, these are the
Quality and Safety Strategy, Sustainable Healthcare Plan, Equality, and the Diversity and
Human Rights Plan, and NHS Staff Survey results. External drivers are the NHS Employers
Workforce Strategy, the Francis and subsequent reports (Berwick, Keogh and Cavendish), the NHS
Leadership Academy Leadership Strategy and model and feedback from our
Friends and Family Test (I want Great Care) and CQC service inspections.
The Strategy focuses on the priorities that will deliver high performance. It
also complements and informs a number of other workforce strategy
documents, that have been developed by Humber NHS
Foundation Trust, Hull City Council and East Riding of Yorkshire Council.
2.4 Workforce Profile
The Trust employs 8153 people.
10% of our people are from black and ethnic minority (BME) communities. Hull and East Riding’s BME
population is 3%.
We employ 1% people who are disabled and currently 30% of the workforce has declared whether they
are disabled or not.
The gender breakdown of our employees is 22% men and 78% women. Within our region the gender
population is 49% are male and 51% are female.
1% of our employees declare their sexual orientation as lesbian, gay or bisexual, however only 48% of
the workforce has declared their sexual orientation.
16% of employees have declared their religion to be other than Christian, although only 55% of our
employees have declared a religion.
3. Achievements 2010-2013
The aim of the Leadership Strategy
and Workforce Strategy 2010 – 2013
was to develop a world class
workforce. The Trust believes it has
delivered many benefits, but
importantly has developed a solid
platform on which we can build to
achieve a truly modern and diverse
workforce which is well led, skilled
and motivated to take on new and
emerging roles as we continue to push back boundaries and work in
partnership with Hull and East Riding partners.
The Trust is rated as ‘XXX’ by the Care Quality Commission (CQC) (March, 2014). It has also
received further validation of our performance through recognition from the Friends and Family Test in
which 7000 patients rated the Trust as 4.7 out of 5 (December 2013) which makes HEY the best Trust
in Yorkshire and Humber and in the top 5 nationally. Internally, the staff survey 2013 confirmed that
48% of the workforce would recommend the Trust as a place to work.
In addition, the Trust is transforming its approach to people management through the creation of HR
Business Partners in Health Groups and the development of the HR service. It has also redefined the
role of the manager to take on the full people management responsibilities.
The leadership and Workforce Strategies 2010 – 2013 delivered many
successes. These include:
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Delivery of a reward and recognition scheme – Golden Hearts (man ager to staff)/Moments of
Magic (colleague to colleague)
Staff engagement programme – Big Conversations held with over 2000 staff. Big wins identi
fied and delivered
Launched the Pioneer Teams initiative which improved the patient experience and delivered
quality patient outcomes
Improved communications with the Link Listeners initiative – recognised by CQC as good
practice
Developed an OD strategy and commenced delivery which resulted in an HPMA award for sup
porting transformation through strong impactful leadership
Delivered the car parking collective agreement so all staff pay for parking and on-call collective
agreement harmonising on-call payments for Agenda for Change staff
Staff receiving an appraisal has risen year on year from 62.7% in 2010 to 84.8% in 2013
Developed and delivered the Trust Discretionary Reward Scheme which promotes appraisal,
mandatory and statutory training and attendance - links with patient safety and valuing staff
Launched Apprenticeship Programme to address high youth unemployment within Hull and
support long term recruitment needs of the Trust
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ACAS – Investigating Officer Training provided managers with the skills and knowledge to effec
tively manage employee relations cases with a marked reduction in the length of internal investi
gations/grievances.
Developed and implemented a new Target Operating Model for the Trust creating 4 Healths
Groups which are clinically led by a Medical Director supported by a Triumvirate
Reviewed and restructured the HR service to ensure it was strategically led, and solution fo
cussed
Reduced sickness absence since 2010 and achieved attendance rate of 96% as at 31st Decem
ber, 2013
Revised and improved key employment policies, including Managing Attendance, Capability,
Organisational Change 5 step model (The Hey Way)
Defined the skills, behaviours and expectations of managers – The HEY Manager
Annual Staff Survey and Pulse Checks conducted and action plans implemented to make
improvements requested by staff
Implemented wellbeing initiatives to promote healthy lifestyles and physical wellbeing such as
Global Health Challenge
Occupational Health service achieved and were accredited by SEQOHS (Safe Effective Quality
Occupational Health Service). Feedback received from managers and staff stated that 97% rated
the service as good or excellent.
80.6% of staff received a flu jab in 2012. This rose to 82.6% in 2013. The Trust have performed
3rd in the country.
Reviewed and improved the PDR
process and paperwork ‘My Appraisal’ for managers and staff which resulted in 84.8% of staff
receiving an appraisal in 2013/14
Reviewed and enhanced the number of e-learning programmes available to staff ensuring more
time is devoted to the patients
Expanded the learning platform to give staff greater access to information and learning
opportunities and improved the quality of programmes across the Trust following Francis, Berwick
and Keogh.
In-house Change Agents training programme has achieved a cohort of individuals skilled in
coaching - working across the Trust on various programmes of change in addition to their day job
New roles and ways of working implemented – for example Junior Sister nursing role, clinical
leadership model across all Theatres, host of Operational Delivery Networks for the region.
Establishing and delivering a number
of community-based services including
PhysioHull, Cardiac Rehab, PARCs,
Pharmacy Out reach service for
intermediate care, Ultrasound.
4. Context for the People Strategy
4.1 Integrated Business Plan 2013/14 – 2017/18
The People Strategy 2014 – 2016 has been developed to support delivery of the Trusts Integrated
Business Plan (which brings together the key priorities for the Trust in one place to show how we are
working to deliver Great Staff, Great Care and to secure a Great Future).
The outcomes in the plan reflect:
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The NHS reforms and wider national public service improvement agenda from central government
Hull and East Riding’s changing social, economic and environmental context
What the public and our patients say needs improving
HEY’s ambition to building successful partnerships and their shared priority outcomes and,
The need for public services to work together effectively and provide outstanding value for money
It is the Trust’s ambition to achieve Foundation Trust
status and be in the top quartile for performance
across a range of measures, including quality, safety,
patient and staff experience, and financial
performance when measured against other Foundation
Trusts nationally. It is also the Trust’s ambition to be
the leading provider of acute health care services in
North and East Yorkshire and the northern part of
Lincolnshire, to be a leader in its chosen markets,
locally and regionally, working in strong partnerships
with key stakeholders, including commissioners, other
healthcare providers, local authorities, the voluntary
sector and patient/public groups.
It is the Trust’s intention to meet the needs of our population, our partners and our people by:
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Delivering excellent quality outcomes
Working in partnerships that add value and in ways that use public money wisely
Having buildings that are fit for purpose, and
By providing assurance to our regulators and commissioners that all necessary standards are
being met.
It is recognised that, for the Trust to deliver better outcomes for patients, the whole organisation and
its partners must work together effectively on ‘Whole System Change’. It is critical that the People
Strategy reflects the fact that, as community leaders, we will need to work collaboratively to develop
and lead partnevrship working and respond to the opportunities and demands on both us and our
partners locally, nationally and regionally.
The Trust is already providing services in partnership with Humber NHS Foundation Trust and York Hospitals NHS Foundation Trust and working with Northern Lincolnshire and Goole Hospitals NHS Foundation Trust regarding new service delivery models.
This will impact upon on our workforce, with people managed within new arrangements. Workforce
planning and development will be key, to better anticipate where new or additional jobs will be required
and where jobs may no longer be needed.
4.2 The Medium Term Financial Strategy
The economic downturn fundamentally changed the assumption of income growth across the NHS and
resulted in a requirement to realise £20 billion in efficiency savings across the NHS to 2015. With a
potential continuing funding gap, estimated at £30 billion by 2021, the NHS is
under sustained pressure to continue to realise
efficiency savings to meet the costs of demographic growth and technological change.
The Quality, Innovation, Productivity and
Prevention (QIPP) programme launched in
2010 aimed to reduce hospital demand and
promote the better use of community services.
This was to be achieved by reducing length
of stay, increasing day case rates, managing
emergency admissions and through greater
efficiency in the management of outpatient
attendances.
The Government’s Spending Review 2013
highlighted the fact that the QIPP programme is
on course to deliver these savings, but stressed that the NHS will need to continue to increase
productivity and make substantial efficiency savings to be able to deal with rising demand and cost
pressures. Working with local areas, NHS England has been tasked with leading further work, which is
expected to focus on areas such as better procurement, making savings through improved use of
technology, and reducing pressures on Emergency Departments by providing good alternatives and
more support to older people and people with multiple long term conditions.
The Trust’s Cash Releasing Efficiency Savings (CRES) programme is aimed at achieving recurring
savings of £100m over the next 5 years and is based on the transformation of services and the
workforce to improve quality and productivity and reduce costs. Efficiency savings on this scale require
the Trust to review all areas of expenditure. The Trust needs to strengthen its underlying financial
position to support its Foundation Trust application and the focus is on securing a sustainable level of
surplus, delivering a major efficiency savings plan, delivering an ambitious capital programme, improving
the Trust’s cash position and therefore achieving a minimum financial risk rating of 3 over the medium
term.
The Trust’s programme of planned savings will have each Health Group deliver between 4-5% of their
forecast expenditure for the 2014/15 financial year. To ensure as much
funding as possible is available for patient care, the Trust has set a more
challenging savings target for the Corporate (back office) departments of
7.5%.
To deliver the overall Trust financial plan and ensure its affordability,
whilst also planning to deliver an in-year surplus during 2014/15 of
£2.9m, the Trust will need to deliver efficiency savings of £21.3m.
The Trust is preparing to deliver efficiency savings of £24m in 2015/16.
Key delivery areas are:
● Transforming clinical pathways to drive improved clinical quality, outcomes and patient experience,
enabling effective rationalisation of the Trust estate and its supporting services;
● Reducing the total bed base through pathway transformation, length of stay improvement, increasing
ambulatory care services and re-alignment of services across sites and across the health
community;
● Maximise the efficiency and effectiveness of theatres, outpatient services and clinical support
services;
● Reducing total workforce costs through workforce transformation, role design, improved productivity,
minimising variable pay spend and reduced headcount;
● Reducing the cost of goods and services and delivering better value for money;
● Improving and automating back office processes, reducing the cost of these services;
● Use of technology as an enabler to increasing clinical productivity, enhancing clinical quality,
improving operational effectiveness, reducing administrative overheads and supporting workforce
transformation.
● Expand services to operate over 7 days to ensure the quality and safety of patients remains
consistently high 7 days per week.
● Reducing the total bed base through pathway
transformation, length of stay improvement,
increasing ambulatory care services and
re-alignment of services across sites and across
the health community;
● Maximise the efficiency and effectiveness of
theatres, outpatient services and clinical support
services;
● Reducing total workforce costs through workforce
transformation, role design, improved
productivity, minimising variable pay spend and
reduced headcount;
● Reducing the cost of goods and services and delivering better
value for money;
● Improving and automating back office processes, reducing the cost of these services;
● Use of technology as an enabler to increasing clinical productivity, enhancing clinical quality,
improving operational effectiveness, reducing administrative overheads and supporting workforce
transformation.
● Expand services to operate over 7 days to ensure the quality and safety of patients remains
consistently high 7 days per week.
In addition the value of the Capital programme for 2014/15 will be c.£42m and for 2015/16 it is expected
to be £48. The Capital programme includes a number of significant schemes including the
reconfiguration of the Emergency Department, Tower Block encasement, reconfiguration of the main
entrance to Hull Royal Infirmary, transformation schemes such as Operating for Organisational Success
(OFOS) and new clinical equipment.
5. Vision and values
Our Vision
Although we do absolutely believe that the organising principle is to build services around the patient and
their needs, as an organisation we need to ensure that our greatest asset is skilled, motivated and
properly prepared to deliver the best possible care. Therefore our vision is:-
As an organisation we will develop, support and equip our staff to enable them to deliver the highest quality care possible. We will provide the best facilities and environment we can to give a positive experience of
delivering services. We will engage, include and communicate as often as possible and listen to the ideas,
suggestions and views to improve patient care.
We want all staff to be proud of the healthcare we
provide and for them to recommend our hospitals
as places to receive care and treatment as well as
places to work.
If we can create this environment our staff will be
Great Staff and the care they deliver will be Great
Care. It is that which will ensure our Future is also
Great.
Our Mission
Listen:
To understand to empathise
To value feedback and challenge
To gain insight and clarity
To seek out ideas, innovation and
creative thoughts
● To be humble when we make mistakes
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Learn:
● To ensure we make better choices
● To capture what we did well and spread good
practice
● To not repeat mistakes and to prevent harm
happening
● To ensure lessons learned are always impactful
and enacted
● About what makes us
stronger, better and more
effective
LEAD
● We will be at the forefront of superb healthcare in England
● Delivering services in new and innovative ways, with models of care that put patients at the heart
of the pathway
● We will be a Teaching Trust that carries out research in selected areas and implements research
in all areas
● We will work with other partners to improve the health of our population and educate people to
better care for their own health and well being
● We will be an employer that is in the top twenty percent of employee and patient satisfaction for
hospitals; with an aim to be in the top ten percent by 2017
Our Values
These summarise what we value in each other as Trust employees. They are about how we work
rather than what we do. They are about the way managers work with their staff, the way staff work
with their managers, the way we all work with each other across every role, every team, every ward
and every department. They reflect both those
elements which have contributed to the significant
achievements of all parts of the Trust in attaining its
‘Outcome from CQC’ status, and those things which
need to be worked on for the future to both maintain
and improve our performance during change.
The values do not cover everything that we value
in each other and our staff. For example, we expect each other to be honest and hardworking, and
we require an active commitment to equality and
diversity. The fact that these qualities do not appear
in the values does not mean they are not important but the organisational values are designed to
emphasise the other qualities of how we work together which improve both working lives and service
delivery.
1. INTENTIONALITY
We want to ensure everything we do is purposeful and planned
That we have thought through issues and problems and created solutions that add value
We want to shape the future and be proactive in our strategies
We want to be creative and not be afraid to take opportunities to create the best future for the organisation
We will be responsive and adaptive to the world around us in a measured, controlled and calm manner
2. IDENTITY
We want to be an employer for whom people are proud to work
We
want a name and a reputation that gives confidence and assurance
We want to give services to our population that are second to none
3. INCLUSION
We value our talent
We are proud of our differences and want to
make the most of them
We believe each person has something of
value to add
We are stronger working together
We need strong partners to challenge and
support us so we can be stronger together
4. INSPIRATION
We will do all in our power to help and care for
you and to be there when you most need us
We want staff to be uplifted, enthused and
inspired by the lives that they change, at the
compassion they show and the difference they make
We want our partners to feel proud to stand alongside us and be a part of the changes we bring about
5. IT’S ALL ABOUT YOU
Every person matters, every person can make a positive contribution and every voice deserves to be
6. Themes
6.1 Leadership capacity and capability
The Trust is fully committed to ensuring that leadership skills and capacity are developed and enhanced
at all levels in the organisation. The Trust needs confident and competent managers who are clear about
their management accountabilities for people, finance, service delivery and patients. By 2017, we want
all our managers to operate effectively as leaders of transformational change, be able to inspire, motivate
and empower individuals and create an environment for people to do well.
To deliver this we will:
Embed our leadership programmes (Achieve Breakthrough) for our top 100 managers
Deliver our Great Leaders middle management programme for current and future leaders
Develop a Medical Leadership programme for current and future clinical leaders
Develop ‘Leadership in Partnership’ across the region, supporting the development of leaders and
managers in taking forward transformational change across organisational boundaries
● Enhance our management development programmes and review our approach to Action Learning
Sets / Group learning
● Review the NHS Leadership Academy’s Leadership Strategy and Model against our current
leadership expectations, competency framework and behaviours and
revise our approach
● Continue to empower teams and improve organisational culture through
Pioneer Teams – Make It Happen approach
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● Procure/build a mechanism for team development activities (i.e, Insights) to address both specific
situations and elicit that ‘extra mile’
● Continue to support the NHS Graduate Management Training Scheme, and build relationships with
local Higher Education Institutes to grow our own operational leaders of the future
● Develop and implement a strategy to support current and future leaders through coaching or
mentorship, both internal and across the region
6.2 High Performance and Culture of Excellence
The Trust will continue its commitment to motivating staff to do their best and deal with
underperformance as it arises. The Trust will create an employment framework within which to recruit,
manage, organise and develop its people which will foster an innovative culture that is underpinned by
a strong approach to performance management and accommodates risk management. Empowered to
make a difference, our people will be ambitious about what they can achieve for our patients and
community, be passionate about delivering quality patient outcomes and proud to work for Hull and
East Yorkshire Hospitals NHS Trust.
To deliver this we will:
● Ensure all managers have the skills and
knowledge to manage change effectively
through a tailored development programme
● Create an environment where performance
management can be used as a catalyst to
increase individual and organisational
performance
● Define our organisational culture which
reinforces our values and how HEY does
business; a culture within which both
managers and employees are clear about
their priorities and are held to account and recognised as appropriate
● Develop a model of Service Improvement utilising the skills and capabilities of our people
● Continue to review the People Management approach within the Trust to support and enable the
HEY manager being an effective manager
● Strengthen our Performance Management framework through robust integrated service, workforce
and financial planning
● Increase capacity to support patient care through the timely and appropriate management of
attendance and capability
● Develop our ‘Employee Deal’ the agreement between the organisation and its staff to become /
remain a high performing Trust (psychological contract)
● Embed our Workforce Planning model across the Trust and work with partners to understand and
develop the region’s future workforce requirements
● Review the Workforce and Organisational Development KPI’s and set and report on annual
workforce targets for the Trust
● Develop and implement manager and employee self service to improve business processes, to be
more efficient and to provide managers with robust and timely workforce data to support the
management and performance of their staff
●
Develop and maintain an innovative employment framework that
enables managers to deal with employment issues in a timely manner whilst
sustaining high performance
● Continually review management and organisational structures. Develop a target operating model
for the future underpinned by agreed design principles that improves flexibility and speed of decision
making whilst ensuring strong governance
● Focus on rightsizing, repositioning the organisation and managing transition
● Develop and lead a strong HR community locally and regionally; share good practice and collaborate on key workforce initiatives to consistently raise workforce standards across the public sector.
6.3 Employee engagement and recognition
Engagement of the workforce and gaining the commitment of employees is a key strand of this Strategy
as the Trust wants to build upon the recognition and engagement activities that are already in place. We
want our people to work in an environment of trust and openess, where employees feel well informed
and listened to and where they feel valued and empowered to do the best job they can. We want our
employees to be proud to work for the Trust and ensure their contribution is recognised and celebrated.
Maintaining engagement through these difficult and uncertain times is the key challenge this People
Strategy seeks to address.
To deliver this we will:
● Promote the Hey It’s In Our Hands
Organisational Development brand,
in association with the Employment
brand and agreed key messages – a
golden thread of communications
through everything we do,
emphasising a fundamental shift in
the way we work
● Review and develop engagement
initiatives and systems to
communicate more effectively with
staff working
closest to the patient, including team
brief and the Link Listeners
programme
● Carry out the annual staff survey and more regular ‘pulse check surveys’ to understand the views of
our people and to re-affirm to staff that we listen to their ideas and act upon them through the
delivery of a post-survey action plan
● Manage change effectively by engaging, consulting and supporting employees appropriately and at
the right time
● Continuously promote the positive work the Trust does through a structured PR programme and
internal campaigns and enhance the Trust’s reputation in the local community and with
commissioners
● Deliver a structured programme of events through corporate communications and Lottery-funded
engagement events and promotional activities.
● Review and develop the Trust reward and recognition schemes, including Moments of Magic,
Golden Hearts and Nursing Hearts schemes
● Improve access to and systems of electronic communications, including social collaboration
mechanisms and mobile information
● Maintain professional relationships with Trade Unions and provide
appropriate forums and mechanisms for informal and formal consultation
6.4 Workforce learning and development
The Trust is committed to supporting the development of the workforce and its managers, enabling both
to have the right skills to deliver high quality services.
We want our people to be flexible to embrace change,
to look outside for new ideas and to find creative ways
to solve problems and improve services. We want to be
known as a national leader for innovation, and a Trust
that looks for potential in its people and develops every
member of staff to be their best, where everyone works
together to improve services.
To deliver this we will:
● Create an “ideas space”, where staff will be
encouraged to show innovation and think creatively
about the services they provide
● Develop a new Education and Development
Strategy and Plan for the next three years
● Review Medical and Non-Medical education and
training to improve and strengthen learning for all
● Ensure all staff receive a quality appraisal via our
new on-line My
TheAppraisal
NHS landscapapproach
e is changing beyond recogniti
on.
We need
transform
● Develop the Workforce
and
Organisational
ers. Are you ready?
HEY GREAT LEADERS LAUNCH
ES AUT
Development intranet
site as a source
of UMN 2013
information on learning and development
opportunities
● Develop a Coaching strategy within HEY to
underpin and support development and build upon
the Change Agent initiative within Health Groups
● Provide more opportunities for secondment and shadowing
● Provide education, learning and development opportunities and resources that are influenced and
shaped by business and service requirements. Delivery will be underpinned by technology to
improve the quality of learning.
6.5 Diverse and healthy organisation
We want to create a work environment that encourages every member of staff, whatever their role or
background, to succeed. We want to be known as an organisation where our people work hard to
make a difference for their patients, but where they also have fun, a good work/ life balance, and a safe,
healthy environment free from discrimination
To do deliver this we will:
● Review our approach to managing attendance including the role of HR, Occupational Health and line
manager
● Ensure staff have access to a quality Occupational Health service that is
SEQOHS (Safe Effective Quality Occupational Health Service) accredited
● Bring all Health and Wellbeing programmes into one, easily accessible
intranet site
● Review the effectiveness of the staff health and wellbeing
programmes, seeking the views of staff and ensure its driven by staff
● Embed Equality and Diversity into all decision making processes in a meaningful way and adapt
tools (including Equality Impact Assessments) to ensure they are more effective and user friendly
● Design a sustainable and effective apprenticeship programme across the Trust
● Promote equal opportunity and a balanced
workforce that understands and reflects the
community of Hull and East Riding
● Promote careers in the NHS in non-typical
groups where traditionally the opportunities do
not exist
● Create and enhance strategic partnerships in
health and external organisations in promoting
diversity and health and wellbeing
● Develop and deliver the Equality and Diversity
work programme. Review Equality and
Diversity training and build this into all Trust
training programmes
● To raise awareness and sensitivities with both
colleagues and service users in respect of Equality, Diversity, Health and Wellbeing
● Address health inequalities within the workforce to raise awareness and promote campaigns
● Review the Trusts current approach and framework to ensure the organisation has a flexible and
mobile workforce to deliver great care
● Establish two Steering Groups to lead and manage the Health and Wellbeing agenda and the
Equality and Diversity agenda
6.6 Modern, fair and affordable employment package
We want a modern, fair and affordable employment package that helps us recruit, retain and reward our
people at all levels within the Trust and at the same time demonstrates value for money to the public.
We want to be known as an organisation that offers a competitive employment package that reflects the
market of the community we serve.
To deliver this we will:
●
●
●
●
Review our terms and conditions, particularly business travel and additional allowances
Develop a ‘Total Reward’ approach to place a value on our employment package (1)
Explore the use and benefits of individual employment packages
Review our staff benefit scheme to ensure it is fit for purpose
1 Total Reward is a development that will detail all of the benefits staff receive from the Trust. These benefits will
be costed to illustrate the true value of the employment package.
7. Governance
The People Strategy cannot be delivered by Workforce and Organisational Development alone. The
People Strategy is the Trust’s People Strategy and Executive Directors, Non Executive Directors,
Directors, managers and employees must accept responsibility to deliver the agreed set of priorities to
develop and sustain a world class workforce.
Elements of the Strategy that are critical to service areas will feature in Health Group and Corporate
Directorates Forward Plans describing the specific actions to be taken. This approach will complement
the performance management framework where Health Group managers deliver corporate and service
priorities.
7.1 Governance Structure
-
The People Strategy and work plan is managed by the Workforce Transformation Committee. The
Committee is chaired by the Director of Workforce and each Health Group has a Triumvirate
representative on it. The Committee will meet monthly. The Committee will have lead responsibility
and be accountable for ensuring the Strategy and work programme is implemented, embedded and
delivered across the Trust to realise the full benefits.
-
Health Group representatives on the Committee will promote and lead the workforce agenda for their
area, supported by their HR Business Partner. Health Groups will require managers to implement the
People Strategy and to deliver their Health Group specific workforce agenda and to feed ideas and
comments to the Committee.
-
All workforce matters will be dealt with at this one Committee meeting and all delegates will become
‘People Champions’.
-
People Strategy progress reports will be presented to the Executive Management Board and
Performance and Finance Committee on a quarterly basis. In addition LNC and JNCC will be
informed of progress.
-
The Health and Wellbeing Steering Group and Equality and Diversity Steering Group will both report
to the Workforce Transformation Committee on a bi-monthly basis and whilst they do not form part of
the formal governance arrangements, they are an integral part of the People Strategy to inform and
shape the workforce agenda.
Governance
Structure
Intergrated
Business Plan
Executive
Management
Board
People
Strategy
Health Group/
Directorates
Performance and
Finance
Committee
Workforce Transformation Committee
Dependencies
Equality Act and duties, Performance Management, Culture & Values
Corporate Directorates
Clinical Support Health Group
Family and Womens Health Group
Medicine Health group
● Leadership capacity
and capability
● High performance
and culture of
excellence
● Employee
engagement and
recognition
● Workforce learning
and development
● Diverse and healthy
organisation
● Modern, fair and
affordable
employment
package
Surgery Health Group
People Strategy
2014 -2016
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
STANDING ORDERS
Trust Board date
24 April 2014
Director
Phil Morley
(Chief Executive Officer)
Reason for the
report
To approve those matters that are reserved to the Trust Board in accordance
with the Trust’s Standing Orders and Standing Financial Instructions.
Type of report
Concept paper
Reference
Number
Author
2014 – 4 – 21
Liz Thomas
(Director of
Governance)
Strategic
options
Information
Performance
Business
case
Review
1
RECOMMENDATIONS
The Trust Board is requested to authorise the use of the Trust’s Seal.
2
Key purpose
3
4
5
Decision
Approval
Information
Assurance


Discussion
Delegation
STRATEGIC OBJECTIVES
 Safe, high quality effective care
 Strong, high performing FT
 Creating and sustaining purposeful partnerships
 Efficient economic use of resources – targeted and prioritised
 Delivery against our priorities and objectives
 Capable, effective, valued and committed workforce
 Strong respected impactful leadership
LINKED TO
N/A
CQC Regulation(s)

No
Assurance Framework
Ref:
Legal advice
No
N/A
BOARD/BOARD COMMITTEE REVIEW
Changes to Standing Orders and Standing Financial Instructions are reserved to the Board
and have not been presented to another Committee
143
HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
STANDING ORDERS
1
PURPOSE OF THE REPORT
To approve those matters that are reserved to the Trust Board in accordance with the Trust’s
Standing Orders and Standing Financial Instructions.
2
APPROVAL OF SIGNING AND SEALING OF DOCUMENTS
The Trust Board is requested to authorise the use of the Trust seal as follows:
SEAL
DESCRIPTION OF DOCUMENTS SEALED
2014/05 Hull and East Yorkshire Hospitals NHS Trust and Mr Alvin Riley
(The Pyjama Shop) - deed of surrender
2014/06 Hull and East Yorkshire Hospitals NHS Trust and Quickline
Communications – Lease relating to premises know as part of the
water Tower at HRI, Anlaby Road, Hull
2014/07 Hull and East Yorkshire Hospitals NHS Trust and Ms Davison,
Transfer document relating to the land to the rear of Pasture
Terrace, Beverley
3
DATE
31.03.14
31.03.14
08.04.14
RECOMMENDATIONS
The Trust Board is requested to authorise the use of the Trust’s Seal.
Phil Morley
Chief Executive
April 2014
144