Balanced Score Card Review of May 2015 Data

Balanced Scorecard

Patient and Service User

Finance

CUH Group Budget 2015

Budget 2015

Group Budget €283.6m (2014 €284.9m)

Group projected expenditure €283.3m (2014 €284.2m)

Group Projected Surplus €0.3m (2014 surplus 0.7m)

CUH Budget €264.1m (2014:€262.8m)

CUH projected actual €264.1m (2014 €265.2m)

CUH projected Deficit €20k (2014 €2.4m)

MGH Budget €17.3m (2014:€17.5m)

MGH Projected Actual €17.0m (2014 €16.8m)

MGH Projected Surplus €0.3m

Actual Outturn YTD - May 2015

• Group budget €116.95m (2014 €113.6m)

• Group actual expenditure €116.86m (2014 €118.7m)

• Group actual deficit €91k ( 2014 €5.1m)

• CUH Budget €109.8m (2014:€105.5m)

• CUH /SMOH actual expenditure €110.1m (€110.3m)

• CUH /SMOH actual deficit €247k (2014 €4.8m)

• Mallow Budget €7.1m (2014:€6.9m)

• Mallow actual expenditure €6.8m (2014 €7.3m)

• Mallow actual surplus €338k ( 2014 deficit €404k)

CUH Summary Budget v Actual Expenditure May 2015

Pay €k Non-Pay €k Income €k Total

CUH -271 -538 787 -22

SMOH -2 19 17

CUH-SMOH -271 -540 806 -5

Mallow 98 -143 199 154

Total -173 -683 1,005 149

CUH Actual Non-pay Expenditure €k YTD May 2015 v 2014

CUH Group –Surplus / (Deficit) percentage %

CUH AGENCY COSTS €k 2013– May 2015

CUH Agency Costs – April 2015

CUH Average Nursing & HCA Agency WTE’s per Week 2013-15

CUH Average Specials /Other Nursing & HCA Agency WTE’s per Week 2014-15

Patient Income 2013 – May 2015

Cost Containment

Consultant Private Insurance Claims O/s Consultant claims at 29th May 2015

Directorate Value €k

Prev Value €k Current

Diagnostics 17 19

Medicine 3,299 3,818

Surgery 2,148 2,293

Women and Children CUH 401 430

Total-CUH Primary 5,864 6,560

Women & Children CUMH 500 500

Total-CUH /CUMH Primary

6,364 7,060

Consultants at 16th June

No of claims Value €k

HARTY, JAMES 169 529,945

POWER, DEREK 240 331,388

CROSBIE, ORLA 20 280,233

ANDREWS, EMMET J. 76 245,273

TAYLOR, COLM 56 223,890

PLANT, WILLIAM 46 193,670

KAAR, GEORGE 18 169,432

GILMORE, JENNIFER 1 149,341

KEARNEY, PETER 56 136,655

O'MAHONY, DENIS 10 112,194

FLEMING, PAT 23 109,286

O'HALLORAN, D. J. 24 104,411

O'CONNOR, MICHAEL 15 102,430

KELLY, PETER 38 100,093

PLANT, BARRY 15 98,147

GUERIN, SHANE 19 96,869

HARTY, JAMES 169 529,945

O'LEARY, PAULA 28 95,219

TOTAL 3,168,791

Access

CUH Weekly INMO Trolley Report

Week ending 19th June 2015

Daily Trolley Numbers – May - June 2015 ( 21/06/2015)

ED – 6hr Target (April Dashboard)

R

ED – 9hr Target (April Dashboard)

R

ED >24hrs (April Dashboard)

R

ALOS for all Patients (April Dashboard)

G

Medical ALOS (April Dashboard)

A

Surgical ALOS (April Dashboard)

R

ALOS – Excluding LOS over 30 days (April Dashboard)

G

HIPE Coding (April Dashboard)

G

Day of Procedure Admission Rate for Surgical Inpatients (April Dashboard)

G

Delayed Discharges - 2015 January – June (9th June)

Inpatient – Day case Waiting Lists

Total Adult Waiting List (Active – 1310) May (1310) and June (1245)

0 100 200 300 400 500 600

Breast Surgery

Cardiology

Cardio Thoracic

Gastro

Gen Surgery

Gynaecology

Neurology

Neurosurgery

Orthopaedics

Plastic Surgery

Respiratory

Urology

Vascular

June

May

Prospective View – June 2015 (48 Active)

Cardio Thoracic – 1 suspended per patients Gen Surgery – I TCI, 4 Suspension per patients, I date to be arranged Gynaecology – presently being transferred to outside provider Urology – 2 Suspensions per patient Vascular - 6 to Outpatients per consultant

Prospective View – December 2015 (381)

0

20

40

60

80

100

120

140

160

180

15 8

43

170

2 3 1

15

3

21

74 June

Scopes Urgent - April 2015 G

Scopes Routine – April 2015 G

Outpatient Waiting Lists

Medical Patients to be seen by the 30th of June 2015

Surgical Patients to be seen by the 30th of June 2015

Women and Children Patients to be seen by the 30th

of June 2015

OPD Potential Breach Report Count of ID

Specialty

18Mth by

June 30th 17.6.15

Expected

Total as of

22.6.15 for

June 30th

deadline

Comments /Update 22.6.15

Current RAG

Status

Expected RAG

Status

Diabetes Mellitus Yes 287 287 • Regular Clinics fully booked to 30th June

• Discussed Registrar post & GP Clinics with

Michael Murphy - No further update

• Dr. Sean Manning sees additional patients when his schedule allows

Endocrinology Yes 159 ?150 • Regular Clinics fully booked to 30th June

• Discussed Registrar post & GP Clinics with

Michael Murphy today - No further update

• 9 to be removed pending confirmation of their attendance privately

General Surgery Yes 42 0 • 3 returned for capacity in Mr. McCourt's Clinic

• 39 Purchased Care

Gynaecology Yes 1057 1057 • Discussed again with Miriam - there was agreement

to put on additional clinics however the service has now requested

this be used for urgent patients

• Dr. Babiker left end of May

• Routine patients that were booked with agreement have since been

cancelled by the service - so numbers may actually increase

Neurosurgery Yes 45 0 • Out of Hours Clinics held

• Physiotherapists commenced clinics

• Registrar to do Saturday Clinics - - last one on 27th June

• Entire list will be cleared

Ophthalmology Yes 81 0 • SLA agreed for purchased care with Dr. Mr. Traynor

• Referrals transferred and all patients notified by letter

Plastic Surgery Yes 138 0 • Met with consultants who agreed to request their teams to see

suitable patients on a See & Treat Basis - 30 deemed suitable -

Additional funding required for Theatre time (CUH) to treat these

patients.

• 59 + 6 agreed under Purchased Care - Additional funding required for

Theatre time in SIVUH to treat these patients

• 41 previously seen in Mater Private to receive required treatment under

purchased care

• 2 Patients suspended per validation as unavailable to attend on 30th

June

Rheumatology Yes 0 0 • Clerical Error - Patient cancelled appointment for 1.5.15

Urology Yes 41 0 • 39 Referrals transferred to Mallow General Hospital

• 1 Suspended to later date per patient request

• 1 to go to Purchased Care

Vascular Surgery Yes 62 0 • SLA for purchased care agreed with consultant

• Clinics commencing 25th June

Grand Total 1912 1606

Quality

Emergency Hip Fracture Surgery – April R

Emergency Re-admission - Medical

R

Emergency Readmission - Surgical

R

Cancer KPI – Breast-Lung-Prostate -Jan – May

Radiotherapy -New Treatments - May

CUH Patients undergoing Radical Radiotherapy commenced treatment within 15 working days of being deemed ready to treat

Treatment Delay

New Patients Treated Within Target January 2014 - May 2015

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15

Outside Target 11% 12% 9% 12% 10% 9% 14% 5% 7% 11% 19% 14% 21% 16% 18% 18% 20%

In Target 89% 88% 91% 88% 90% 91% 86% 95% 93% 89% 81% 86% 79% 84% 82% 82% 80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Complaints Management - Action Plan

CUH Hygiene Quality Improvement Team A

CUH Hygiene Quality Improvement Plan

B

Jul-05 C

D

2015

Quarter

Recommendation Action Required Measurement/Evidence of Implementation Responsible Person for Action Due Day for full Implementation 2 Standard 3 & 6 Improve Governance, improve reporting systems

1. Under the leadership of the CEO, continue a focussed team driving improvements in the area of hand hygiene and cleanliness of environment and facilities.

Minutes of CEO led team meetings Chief Executive Officer 30th June 2015 A

2. IPCC to develop portfolio of qualitative and quantative measures of compliance, reporting and frequency of reporting to timely identify & address poor compliance and/or incidents.

Portfolio to be presented to CEO Chair IPC Committee 30th June 2015 B

3. Revise the outbreak management policy to ensure significant outbreaks are notified, reviewed to identify possible areas of poor compliance and /or incidents, escalated and managed appropriately.

Update policy with defined escalation & communication criteria Chair IPC Committee 30th June 2015 A

4. Revise bedside alerts for effective communicational and identification of patients requiring isolation precautions (particularly in six bedded / recovery).

Update IPC Policy with revised bedside alerts IPC Team 30th June 2015 A

5. Reporting structure for IPCN Team, IPC Committee, Hygiene walkabout team, CEO Team, SMT Lead for hand hygiene in addressing audit report, outbreaks and incidents requires definition.

Organisational flow chart for reflecting reporting structure IPC Team 30th June 2015 B

6. Plan for every ward to improve hand hygiene and cleanliness to be developed by CNM / CNMs under the leadership of the DON / DOM and monthly progress against the plan to be reported to CEO Led team.

Individual documented Ward Plan with monthly progress reports Chair IPC Committee 30th June 2015 A

7. Assess progress against planned timelines for implementation of QIPs.

Formal periodic reports on achievement of QIPs to CEO Director of Nursing & Director of Midwifery & CNM/CMMs

30th June 2015 A

8. Business Case to progress a Senior Nursing Leadership post dedicated to Infection Control across the hospital group

Business Case to progress a Senior Nursing Leadership post dedicated to Infection Control across the hospital group

Chief Executive Officer 30th June 2015 B

Standard 3 The physical environment, facilities and resources are developed and managed to minimise the risk of service users, staff and visitors acquiring a Healthcare Associated Infection.

Ward Managers 1. Implement across all ward/department accountability and responsibility for ensuring patient equipment is clean through the individual identification of staff to check compliance on cleaning with identified types of equipment. 2. Immediate notification to Ward Manager where there is visual contamination of equipment sent for repair.

Daily allocation checklists records in all wards/departments 1. Director or Nursing & Director of Midwifery. 2. Biomedical Engineering Manager

30th June 2015 B

Bio Medical Engineering Planned preventative programme introduced

Formal documented Programme

Biomedical Engineering Manager

A

National Standards for Safer Better Healthcare

Theme Status

Theme 1 - Peron Centred Care & Support

Self Assessment Completed

Theme 2 – Effective Care & Support

Self Assessment Completed

Theme 3 – Safe Care & Support

Self Assessment Completed

Theme 4 – Better Health & Wellbeing

Self Assessment Completed

Theme 5 – Leadership, Governance &

Management

Self Assessment Completed

Theme 6 – Standards for Workforce

Self Assessment Completed

Theme 7 – Use of Resources

Self Assessment Completed

Theme 8 – Use of Information

Self Assessment Completed

Clinical Adverse Event Report 2014

Count of Incident Type Incident Near Miss

Slips/Trips/Falls 679 18

Treatment Incident 108 24

Medication Incident 95 15

Equipment/Devise Incident 49 40

Absconsion 39 0

Peri-operative/Perif -procedure Incident 28 7

Indentification/Records/Documentation Incident 28 29

Discharge Incident 15 0

Infection Control Incident 13 1

Unplanned Events 7 0

Blood Transfusion Incident 6 3

Other 6 3

Diagnosis Incident 4 1

Unexplained Injury/Unknown Cause 4 0

Consent/confidentiality Incidents 3 1

Radiation Harm 1 0

Self-Harm 1 0

Total 1086 142

Clinical Adverse Event Report 2014

• 406,631 episodes of patient care activity in CUH in 2014

• 1228 clinical adverse events reported ( 0.3% clinical adverse rate – national average 2.9%)

• Patient Safety Culture Survey of staff highlighted that 53% of staff surveyed CUH staff believe clinical incidents or near miss incidents are reported

• Data quality is key in the analysis of clinical adverse events

Recommendations

Area for Improvement Recommendation

Data Quality

(a) Incomplete incident report received to be

returned to the line manager to ensure that all data is complete

(b) (b) the progression of an electronic reporting system to allow for prompt reporting

Adverse Incidents

Trending of adverse outcomes to be undertaken

HIQA Report - Portlaoise

• An overview of the report was presented to the Executive Quality and Safety Committee in May with a focus on the recommendations on governance.

• A large volume of the report is in relation to governance structures and the report was critical of the governance structures in place in Portlaoise hospital.

• HIQA have identified in all their recent reports that the sustainable delivery of safe, effective and reliable person-centred care depends on service providers having competent capacity and capability in areas of leadership, governance & management.

• There were 47 non compliances with National Standards at hospital level, 28 at HSE level and 9 at a governance level.

Human Resource

Sick Leave – April 2015

4.01

3.793.74

3.16

4.58 4.444.16 4.09

3.683.37 3.7

3.74 3.89 3.8

3.86

4.22

00.5

11.5

22.5

33.5

44.5

5

Jan

Feb

Mar

Ap

ril

May

Ju

ne

Ju

ly

Au

g

Sep

t

Oct

No

v

Dec

%

Month

CUH - Total % Sick Leave 2014 v 2015

% 2015 Sick Leave % 2014 Sick Leave % Target

EWTD Compliance (April Dashboard)

G

Challenges

• Recruitment of Nursing staff

• Management of Unscheduled Care

Implementation of Change Programme Initiatives

• Scheduled Care

Implementation of plan to meet waiting list targets –Hospital

Group approach to maximise capacity

• Budget Control and Cost Containment measures

• Mental Health Service