Balanced Score Card Report Review of January 2018 Data · Balanced Score Card Report Review of...
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Balanced Score Card Report Review of January 2018 Data
Transcript of Balanced Score Card Report Review of January 2018 Data · Balanced Score Card Report Review of...
Balanced Score Card Report Review of January 2018 Data
Balanced Scorecard
Patient Access
Quality
&
Safety
Human Resource
Management Finance
Patient and Service User
Patient Access – Emergency Department
6 Hr PET @8:00am – January 2018
4
2017/2018 30 Day Moving Average
5
AMAU Activity
0
20
40
60
80
100
120
140
160
180
200
Admitted Patients EmergencyDepartment
General Practitioner Planned RepeatAdmissions
OutpatientsDepartment
Other Referrals
184
104
140
64
13 5
AMAU Referrals January 2018
Non Admit PET January Comparison
0%
10%
20%
30%
40%
50%
60%
70%
80%
2014 2015 2016 2017 2018
62%
71% 73% 77% 74%
Annual Non Admit PET 2014 - 2017
>24 Hour PET
0
50
100
150
200
250
300
350
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18
320 316
264
328
85 98
68
89
136
86
137
95
266
PET >24hrs
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18
>75yrs Bed Wait >9hrs
0
50
100
150
200
250
Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18
218 199 200
215
129 120
57
108
143 126
170 149
248
>75yrs Bed Wait >9 hrs (2017)
Full Year Non Admit PET
0%
10%
20%
30%
40%
50%
60%
70%
80%
2014 2015 2016 2017
67% 71% 73%
79%
Targeted >14 Day Occupancy
0
20
40
60
80
100
120
140
160
180
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
01/09/2017 01/10/2017 01/11/2017 01/12/2017 01/01/2018 01/02/2018 01/03/2018
>14 Day Patients and >14 Day Occupancy
Bed Days Patients
January Review
607 patients on trolleys compared with 719 in January 2017
(17% reduction)
Decrease in Gen Medical Bed Stock
Infection Control Measures were challenging
2 strains of flu and Norovirus
Visiting restrictions difficult
Only one day of surge of orthopaedic trauma
Project Flow Improving Patient’s Hospital Experience
Project Flow 2018
PF 18 Objectives
Input Throughput Egress
PET across acute floor • non admit – 95% • overall – 70-75%
↓ >75 years conversion rate
100% PDD documentation SAFER implementation Red to Green concept
Bi-directional flow >14 days - >7days ↓ 14 day occupancy
PF18 Priorities
Implementation of SAFER bundle:
– Senior review before 11am for all patients
– All patients must have PDDs
– Flow from assessment units to wards early
– Early discharges before 11am
– Review patients with extended lengths of stay
Red2Green
Increase communication to all staff
PF18 Priorities contd...
Bidirectional flow with Mallow – protocol
Audit weekend discharge process
Enhance links with community services re: LTC, transitional
care, home care packages
Continue PDD audits
National Patient Experience Survey = enhance discharge information provided to patients
Patient Access - Outpatient Waiting Lists
Total Medical Patients to be seen by 15 Month Target (176) (14/02/2018)
Total Surgical Patients to be seen by 15 Month Target
(3361) (14/02/2018)
Patients Currently Waiting Longer Than 12 Months
(5081) (14/02/2018)
Ophthalmology Waiting List Validation 9253 patients - Summarised below
Ophthalmology Return Waiting list validation
Consultant G.O.Connor E.O. Connell S.Fenton A.Cullinane Z.Idrees Total
Letters sent out 2583 1540 1168 2052 1910 9253
Yes to Stay on w/l 2014 1153 872 1550 1445 7034
Pt request removal 155 89 72 157 96 569
RIP 31 29 12 30 34 136
No response to validation but attended TCI 39 42 33 25 33 172
Query for service 1 1
Return Post, Trying to contact patient 0 Also attending Diabetic Screening - ? Potential removals 74 72 46 102 108 402
Hospital Removed 15 9 11 14 15 64
Incorrect w/l entry 1 1 2
Removed through no response to validation 251 143 121 168 175 858
No response to date 26/02/2018, Still on w/l due to DNA,TCI 4 3 1 4 3 15
Total 2583 1540 1168 2052 1910 9253
Total removed through No response to validation 942
Total Re-instated after removal through No response 82
Patient Access - Inpatient Waiting List
Inpatient and Day Case Waiting List (23/02/2018)
Count of IDWait category
wl type ACTIVE PREADMIT SUSPENSION Grand Total
Adult 1266 250 29 1545
Child 116 27 1 144
GI Scope 110 165 8 283
Grand Total 1492 442 38 1972
Patients waiting > 15 months – 285 (17/01/2018)
Endoscopy Activity (Source: NQAIS)
AAU Emergency Elective Total
2015 125 589 2076 2790
2016 121 612 2345 3078
2017* (Jan-Nov
Inc.)
102 606 2266 2974
25
Quality & Safety
Clostridium Difficile
27
G
S. Aureus bloodstream infection
28
G
NEWS Full Implementation
29
G
ALOS All Inpatients – November 2017 R
ALOS Excluding LOS over 30 Days
31
R
ALOS Medicine – November 2017
R
ALOS Surgery – November 2017
33
R
HIPE Coverage – November - % of cases entered into HIPE(A38) G
% of people waiting less than 13 weeks (≤13 weeks) for a routine colonoscopy
35
G
Routine Colonoscopy – December 2017
36
R
% day case rate for Elective Laparoscopic Cholecystectomy – December 2018 (mean Jan – Nov)
37
Cancer KPI – Breast-Lung-Prostate October 2017 – January 2018
Rapid Access Clinic Review
Symptomatic Breast Service Review the current pathway for this patient group – to be
progressed by the NCCP
Test messaging service to send outpatient appointment reminders to patients to be discussed with ICT
The requirement for an additional Consultant for the Breast Reconstruction service
Audit of the input from the GP sessions to be completed
Prostate Service Requirement for additional Registrar to facilitate return patient
clinics
Additional access for MRI Scans, Bone Scans and CT Staging Scans.
Access to Robotics which would provide many benefits in relation to patient treatment options
Rapid Access Clinic Review
Thoracic Lung Service The SSWHG have funded an additional 5 CT slots for RALC to allow all patient to have their CT prior to first clinic visit CNS and consultant conduct a virtual nodule clinic and patients are either issued a clinic appointment or discharged over the phone by the CNS From February 2018 the RALC will change from Monday to Friday to allow for increased capacity Work has taken place to streamline the Cardio Thoracic MDM and it is anticipated that the MDM component of MOCIS will help further by allowing the meeting to be recorded electronically The ANP post funded by the NCCP is currently being progressed
Radiotherapy Patients In/Out of Target - January 2018
IN TARGET, 30, 33% OUT OF TARGET,
60, 67%
Consultants In/Out of Target January 2018
0
5
10
15
20
25
Dr FaisalJamaluddin(Locum RO)
Dr. Aileen Flavin(RO)
Dr. Bolanle Ofi(Locum RO)
Dr. CarolMcGibney (RO)
Dr. FrederikVernimmen (RO)
Dr. Paul Kelly (RO)
Total 16 22 17 16 5 14
InTarget 7 8 2 3 1 9
Out of Target 9 14 15 13 4 5
Reasons for Out of Target – January 2018
43
0
5
10
15
20
25
30
Personal choice Medical Capacity Data Missing Other
Total 2 14 26 16 2
Chemotherapy Patients In/Out of Target – January 2017
44
In Target, 39, 91%
Outside Target, 4, 9%
Consultants In/Out of Target January 2018
45
0
2
4
6
8
10
12
Dr DeirdreO'Mahony
Dr DearbhaileCollins
Dr DerekPower
Dr DervilleO'Shea
Dr OonaghGilligan
Dr RichardBambury
Prof SeamusO'Reilly
TOTAL 9 5 5 2 4 7 11
InTarget 7 5 5 2 3 6 11
Out of Target 2 0 0 0 1 1 0
Reasons for Out of Target – January 2018
46
0
0.5
1
1.5
2
2.5
3
Personal Medicial Capacity DataMissing
Other
Total 1 3 0 0 0
Risk Management – January KPI data Serious Reportable Events reported CUH – 4 communicated in January which
occurred in previous months (1 in July, 1 in August, 1 in November, 1 in December)
• 5 SRE’s occurred in January (currently being submitted)
Medication Safety Incidents reported - 20
Complaints – 10 complaints raised in July with 10% closed within 30 day timeframe
New claims notified to hospital – 78
Risk Register
Risk Register no new risks added
CPE Screening
Current CUH CPE Screening protocol:
All patients on admission to ICU/CITU and NICU and weekly thereafter
All patients on admission to the haematology unit 2D and weekly thereafter
All patients epidemiologically linked to a CPE carrier
all patients admitted from another hospital with a current CPE problem.
All international transfers/admissions (inc NI)
As directed by the Infection Prevention and Control Team
Falls Prevention
Trial of Falls Prevention non-slip socks on Ward 1A will finish at the end of January
Trial to be done on Medical Short Stay Ward
Ward 4C have been using the safety cross for 1 year and have seen a 15% reduction in falls.
Falls Prevention group currently appraising different falls risk assessments and will be updating the CUH falls policy.
Rate of Falls per 1,000 Bed Days
50
Spread Across the CUH Campus
52
Rate of Pressure Ulcers reported per 1,000 bed days Jan – Dec 2017
53
Human Resource Management
CUH Sick Leave 2016 v 2017- CHANGE
4.65 4.59
4.53
3.913.39
4.27
3.78
3.773.94
4.04
4.08 4.984.77
3.84 3.924.22 4.17 3.9
3.65 3.98
0
2
4
6
Jan Feb Mar April May June July August Sept Oct Nov Dec
%
CUH – Total % Sick Leave 2016 v 2017
2016% 2017% % Target
40.7635.76
38.81
32.49
41.8
43.96 44.55 34.5537.35
31.14
28.89 44.1540.05
0
10
20
30
40
50
Au
g-1
6
Sep
-16
Oct-1
6
No
v-16
De
c-16
Jan
-17
Feb
-17
Ma
r-17
Ap
r-17
Ma
y-17
Jun
-17
Jul-1
7
Au
g-1
7WTE’s
CUH Long Term Sick Leave – WTE’s
EWTD Compliance –January - December 2017
Finance
Finance Report –January 2018
CUH /CUMH Actual outturn FY 2017
PAY & NONPAY
Gross pay & non pay budget €363.1m (2016 :€352.9m)
Actual pay & non pay €371.3m (2016: €355m)
Actual Deficit €8.2m (-2.3%)
o Less Adjustments €3.8m
o Bad debts provision €3.19m
o PCRS Drugs €626k
Adjusted Deficit €4.4m (-1.2%) ((2016 :€2.1m/-0.6%)
Income
Income budget €77.7m (2016 :€80.5m)
Actual Income €76.0m (2016 :€79.9m)
Actual Deficit €1.7m (-2.2%) (2016 :€0.6m/-0.7%)
58
Finance Report- January 2018
59
Finance Report -January 2018
60
Actual outturn Jan 2018
PAY & NONPAY (pre CUMH transfer) Gross pay & non pay budget €31.5m (2016 :€28.8m)
Actual pay & non pay €33.1m (2016: €29.1m)
Actual Deficit €1.6m (-4.9%) (2016 :€330k/-1.1%)
PAY & NONPAY (excl CUMH ) Gross pay & non pay budget €28.1m
Actual pay & non pay €29.7m
Actual Deficit €1.6m (-5.6%) - Less adjustments
Bad debts provision €0.9m
- PCRS €45k
Adjusted Deficit €0.6m (-2.2%)
DIRECT PAY & NONPAY –CUMH Gross Direct pay & non pay budget €3.44m
Actual direct pay & non pay €3.43m
Actual Surplus €13k (0.4%)
CUH –Pay & Non pay Budget Surplus/(Deficit) %
62
CUH AGENCY WTE 2014-8
Jul-14 Sep-14 Dec-14 Jan-15 Jun-15 Sep-15 Dec-15 Jun-16 Sep16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18
Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual
Radiotherapist 9.40 4.00 4.87 2.78 0.9
Radiographer 0.09 0.05 0.06
Labs 12.04 13.40 11.0 12.19
Cardiac Techs 3.80 3.80 1.0
Physio 1.60 1.50
Pharmacy 2.00 1.00
Admin 23.40 9.08 9.36 14.1
Nursing 46.20 33.0 34.7 37.8 30.4 28.6 26.1 31.6 27.6 25.5 33.3 33.3 32.7 31.7 34.3 37.3 44.8 41.3 42.0 41.3 35.4 42.3 48.4
HCA 34.80 16.2 22.7 23.2 29.8 30.8 38.2 38.4 52.1 17.7 26.1 25.3 34.5 34.5 33.9 36.6 41.6 35.7 39.4 40.8 39.2 47.4 54.7
House-Keeping 10.40 0.16
Physics 4.30 2.6 1.6 1.09 0.75 0.66 0.46 0.83 0.83 0.83 0.83 0.83 0.23
Catering 3.00 8.5 2.0 2.7 6.9 3.9 0.9 1.2
Social Work 1.00 0.5
Occ Therapy 1.00 0.37
Dietician 0.50 0.3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Medical 11.00 5.27 4.77 4.4 5.86 7.97 15.73
Consult 0.25 0 0.6 0.34 2.9 3.94 0 1 0 0 0
NCHD 2.47 6.7 1.87 1.82 2.83 2.94 2.15 2.34 1.54 0.8 1.18 3.04 1.51 2.85 2.98 2.09
164.5 99.7 91.1 98.26 74.6 71.9 81.4 76.75 88.23 46.9 63.05 63.26 71.37 69.95 71.88 76.4 91.1 83.12 85.44 85.61 78.45 93.68 106.19
CUH AGENCY COSTS €k 2016 - 2018
Acute Nursing Agency WTE 2016 to 2018
Acute HCA Agency WTE 2016 to 2018
64
CUH Average Nursing & HCA Agency WTE’s per Week 2016 - 2018
CUH Average Specials /Other Nursing & HCA Agency WTE’s per Week 2016- 2018
66
CUH Nonpay-Budget v Actual Jan 2018
NON-PAY Budget Actual Variance CUM H Ac t CUH/ CUM H Ac t 2017 Act
Medicines 2,688 2,722 -(34) 6 2,727 2,494
Medical & Surgical 2,323 2,420 -(98) 238 2,658 2,474
Blood 423 445 -(22) 1 446 411
Medical Gases 36 38 -(3) 0 38 41
Medical equipment 322 472 -(150) 45 517 421
Radiology 468 545 -(76) 0 545 461
Provisions 166 179 -(13) 10 189 174
Catering 40 39 1 2 42 35
Cleaning/Waste 228 244 -(16) 118 362 336
Laundry 155 155 -(0) 0 155 152
Energy 262 257 4 0 257 269
Bedding/ clothing 31 46 -(16) 8 54 33
Furniture 14 21 -(7) 3 24 8
Pathology 854 902 -(48) 6 908 919
Maintenance /Grounds 61 68 -(7) 3 71 67
Transport /staff travel 156 176 -(20) 10 186 154
Office expenses 163 186 -(23) 19 205 207
Telecommunications 39 40 -(1) 1 41 37
Computer 98 93 5 3 96 68
Administrative expenses 506 1,491 -(985) 87 1,578 634
Staff recruitment/training 59 96 -(37) -24 72 60
Miscellaneous 131 185 -(53) 26 211 133
TOTAL NON-PAY 9,220 10,820 -(1,600) 561 11,382 9,588 Less Bad debts -100 -991 891 -991 -90
NON-PAY excl Bad Debts 9,121 9,830 -(709) 561 10,391 9,498
CUH /CUMH Actual Non-pay expenditure €k Jan 2018 v 2017
Patient Income 2016 –2018
CUH – Patient Income Budget Surplus/Deficit %
69
C U H Ot her Income Jan 2 0 18
Income B udget €k A ct ual €k V ariance €k
R ent al income & Licence f ees 4 7 6 6 19
B equest s/ D onat ions 13 - ( 13 )
R esearch grant s 2 6 3 3 7
C arpark 19 7 2 3 1 3 4
D rug rebat es / PC R S 8 0 2 8 50 4 8
Insurance claims / M isc 4 - ( 4 )
1,0 8 9 1,18 0 9 1
C U H R ecoupment s and R ef unds Jan 2 0 18
Income B udget €k A ct ual €k V ariance €k
R ecoupment s Pay 78 78 - ( 0 )
R ef unds- Pay 15 - ( 15)
R ef unds- Ot her 2 1 1 - ( 19 )
Post age rebat e 4 7 4 7
U nclassif ied 17 15 - ( 2 )
13 1 14 1 11
CUH Debtor Days Consultant Claims 2016-2018
MGH - Finance Report – January 2018
Finance Report – January 2018
73
BGH - Finance Report – January 2018
BGH - Finance Report – January 2018
75
Capital Projects Project Status
Paediatric Unit Phase 1 - build programme completed
Phase 2 – funding received – proceed to Design Stage
Radiation Oncology Unit
Builder commenced on site on Monday 20th February
Education and Training Centre Draft Statement of Need completed and discussion
ongoing with UCC
Meeting held with UCC
Blood Sciences Project
Design Team appointed
Infrastructural works are near completion
Oncology Service
Expansion of Day Unit – plan signed off – submitted
for Philanthropic funding (ACT)
Refurbishment of Ward 2D – capital funding in place
Medical Oncology Centre – developing Statement of
Need
Ophthalmology Transfer – Phase 2
• OPD & Day Care – Tender documents ready to issue
in January ‘18
• Theatre Accommodation tender documents being
prepared for early ’18
Helipad
Meeting held with the IAA
Ground Level Helipad the agreed option
