Balanced Score Card Report Review of September 2017 Data

Balanced Scorecard

Patient Access

Quality

&

Safety

Human Resource

Management Finance

Patient and Service User

Patient Access – Emergency Department

CUH 30 Day Moving Average 2017 v 2016

5

6 Hour PET & 8AM TrolleyGAR per 100 ED Attends

6

PET Monthly Comparison (Non Admitted)

PET Monthly Comparison (Admitted)

Patient Experience Time >24 Hours

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

320 316

264

328

85 98 68 89

136

PET >24 hours

>75 years >9 hour bed wait

0

50

100

150

200

250

218 199 200 215

129 120

57

108 143

>75yrs Bed Wait >9 hrs (2017)

>14 Day Target Reduction

Project Flow Improving Patient’s Hospital Experience

Project Flow 2017

>14 Day Review

• Weekly Meetings • 193 Patients >14 Days 27th April (9,778 BDs) • 137 Patients >14 days today (7,569 BDs)

– 15 patients >100 Days (3,438 BDs)

• Difficulties with Nursing Home Bed Capacity

• Difficulties with Home Care Provider Capacity

• Plan for increased Transition Care Beds – Clonakilty (16 beds)

Weekend Demand/Capacity

Non Invasive Cardiology

Winter Plan Submission

Report average inpatient waiting time for echo / stress

Potential diagnostics as outpatient

for discussion with Radiology

Communication of bi directional capacity

Bulk text message to Medical Staff

Whiteboard capture

Delegated discharge responsibility (for action)

Friday Specialty Handover (for action)

Resource Dependant Initiatives Transitional Care (50 Beds in

Community)

Acute Beds (Ward 2A)

Operational HUB

Flow Coordinators

Regularisation of extra unstaffed beds

24/7 AMAU Service

ITU & HDU Capacity

Diagnostics

o Point of Care (H1N1, Ketones, Pregnancy testing)

o CT Scanning

o 7 Day Echocardiograph

Bed Management & Acute Floor Information Systems

Ambulatory Care Facilities / Surgical & Cardiac Assessment

Health & Social Care (Rehabilitation)

15

Patient Access - Outpatient Waiting Lists

Total Medical Patients to be seen by 15 Month Target (September) (176) (23/10/2017)

86

27

22

15

8 4 3 2 2 2 2 1 1 1

0

10

20

30

40

50

60

70

80

90

100

Total Surgical Patients to be seen by 15 Month Target (3078) (23/10/2017)

545 527

405

357

293

167 150

121 115 99

77 75 53 48

26 11 3 3 3

0

100

200

300

400

500

600

Patients Currently Waiting Longer Than 12 Months

(5080) (23/10/2017)

2495

838

559

209 194 145 123 121 109 98

51 50 36 23 9 8 6 6 0

500

1000

1500

2000

2500

3000

Ophthalmology Waiting List Validation

Ophthalmology Return Waiting list validation

Consultant G.O.Connor E.O. Connell S.Fenton A.Cullinane Z.Idrees Total

Letters sent out 737 650 444 950 468 3249

Letters left to sent out 520 486 1006

Outcomes

Yes to Stay on w/l 528 230 312 678 319 2067

Request removal 25 14 12 37 11 99

RIP 4 4 8 6 22

Attended TCI 1 1 2

Query 8 2 6 7 4 27

Return Post 2 3 3 2 1 11

Diabetic Screening 16 8 14 24 17 79

No response to date 25/9/17 154 388 97 194 109 942

Patient Access - Inpatient Waiting List

Patients to be Treated by 19th October 2017

Specialty Number of Patients

Breast Surgery 0

Cardiology 0

Cardiothoracic 3

General Surgery 63

Neurology 0

Neurosurgery 0

Orthopaedics 0

Plastic Surgery 69

Respiratory Medicine 0

Urology 43

Vascular 10

Total 188

Urology Waiting List (43)

Plastic Surgery Waiting List

General Surgery Waiting List

Scope Waiting List

Quality & Safety

ALOS All Inpatients – August 2017 G

ALOS Medicine – August 2017

29

A

ALOS Surgery –August 2017

30

R

HIPE Coverage - Prior Month - % of cases entered into HIPE(A38)

G

Cancer KPI – Breast-Lung-Prostate January – September 2017

Chemotherapy Patients In/Out of Target - September

33

In Target, 36, 86%

Outside Target, 6, 14%

Reason for Treatment Delay - September

34

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

PersonalChoice

MedicalReasons

Capacity DataMissing

Other

Total 0 1 5 0 0

Radiotherapy Patients In/Out of Target - September

35

IN TARGET, 39, 52%

OUT OF TARGET, 36,

48% IN TARGET

OUT OF TARGET

Consultants Reasons for Out of Target - September

36

0 1 2 3 4 5 6 7 8 9

Dr Faisal Jamaluddin (Locum RO)

Dr. Aileen Flavin (RO)

Dr. Bolanle Ofi (Locum RO)

Dr. Carol McGibney (RO)

Dr. Frederik Vernimmen (RO)

Dr. Paul Kelly (RO)

1

1

2

3

2

3

1

2

3

6

5

1

3

3

Personal choice

Medical

Capacity

Data Missing

Other

Risk Management – September KPI data

Serious Reportable Events reported CUH -1

Medication Safety Incidents reported - 24

Complaints – 7 complaints raised in July with 42% closed within 30 day timeframe

New claims notified to hospital – 75

Risk Register

Risk Register updated in June– one new risk added

Quality and Safety Pressure Ulcer To Zero

Continue to roll out PUTZ initiative – ward 3B and ICU

SWARTZ Round

2nd round scheduled for 31st October

National Patient Satisfaction Survey

CUH – 55% response rate

Emerging theme is the Discharge Process

Workshop at Group level to review results of the survey

Staff Quality Survey Completed

Vision

Mission Statement

National Patient Survey Key areas for Improvement & Nationally

Discharge Planning

– Need for information on discharge

– Danger signs, what to look out for

– Written information, medication information

Care on the Ward

‾ Nutrition

‾ Worries and Fears

Examinations/diagnosis/Treatment

Need for information

Improved communication

Quality and Safety

Vision

Delivering Safe, Effective, Person-Centred care, Every time

Mission Statement

All CUH staff are committed to delivering the highest level of Quality Care achievable. We will work with you, our service users in enhancing services that are safe, clinically effective and delivered in a clean environment.

40

5 top priorities 20 additional priorities

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 - August 2017

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

Project group in place

Application for planning permission submitted

Tender Pack being prepared

Helipad

Meeting held with the IAA

Ground Level Helipad the agreed option

Finance

Finance Report – August 2017

CUH Actual outturn YTD 2017

PAY & NONPAY

Gross pay & non pay budget €268.2m (2016 :€256.4m)

Actual pay & non pay €277.8m (2016: €263.9m)

Actual Deficit €9.6m (-3.6%) (2016 :€7.5m/-2.9%)

Less Adjustments €5.4m

Increase in Bad debts provision €2.7m

PCRS Drugs €0.7m

LRA Restoration unfunded €1.7m

Living out allowance €334k

Adjusted Deficit €4.2m(-1.55%) (2016 :€3.5m/-1.4%)

CUH –Pay & Non pay Budget Surplus/(Deficit) %

CUH – Patient Income Budget Surplus/Deficit %

49

CUH AGENCY WTE 2014-7

Jul-14 Sep-14 Dec-14 Jan-15 Mar-15 Jun-15 Sep-15 Dec-15 Jun-16 Sep16 Oct 16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

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 0.95 0.9

Radiographer 0.09 0.05 0.06

Labs 12.04 13.40 11.0 12.19 1.0

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 9.3

Nursing 46.20 33.0 34.7 37.8 40.0 30.4 28.6 26.1 31.6 27.6 29.6 31.5 25.5 33.3 33.3 32.7 31.7 34.3 37.3 44.8 41.3 42.0

HCA 34.80 16.2 22.7 23.2 24.4 29.8 30.8 38.2 38.4 52.1 56.9 32.1 17.7 26.1 25.3 34.5 34.5 33.9 36.6 41.6 35.7 39.4

House-Keeping 10.40 0.16

Physics 4.30 2.6 1.6 1.09 0.92 0.75 0.66 0.46 0.83 0.83 0.83 0.83 0.83 0.83 0.83 0.23

Catering 3.00 8.5 2.0 2.7 1.8 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

Medical 11.00 5.27 4.77 4.4 6.35 5.86 7.97 15.73

Consult 0.25 0 0.38 1.62 0.6 0.34 2.9 3.94 0

NCHD 2.47 6.7 2.99 2.84 1.87 1.82 2.83 2.94 2.15 2.34 1.54 0.8 1.18 3.04

164.5 99.7 91.1 98.26 84.7 74.6 71.9 81.4 76.75 88.23 91.70 69.89 46.9 63.05 63.26 71.37 69.95 71.88 76.4 91.1 83.12 85.44

CUH AGENCY COSTS €k 2015 - 2017

Acute Nursing Agency WTE 2015 to 2017

Acute HCA Agency WTE 2015 to 2017

51

CUH Average Nursing & HCA Agency WTE’s per Week 2015-17

CUH Average Specials /Other Nursing & HCA Agency WTE’s per Week 2016-17

53

CUH Nonpay-Budget v Actual YTD September 2017Budget Actual Variance Actual YTD 2016 Diff 2017-16

Medicines 24,434 25,731 -(1,298) 23,448 -(2,283)

Medical & Surgical 22,174 23,023 -(849) 21,698 -(1,325)

Blood 3,705 4,273 -(568) 3,824 -(449)

Medical Gases 313 338 -(25) 319 -(19)

Medical equipment 3,358 3,703 -(345) 3,513 -(190)

Radiology 4,123 4,497 -(374) 4,008 -(489)

Provisions 1,538 1,600 -(62) 1,493 -(107)

Catering 369 336 33 384 48

Cleaning/Waste 2,847 3,182 -(335) 2,894 -(287)

Laundry 1,370 1,380 -(9) 1,382 2

Energy 2,305 2,353 -(48) 2,400 46

Bedding/ clothing 308 358 -(50) 324 -(33)

Furniture 137 191 -(54) 204 13

Pathology 7,835 7,873 -(38) 8,677 804

Maintenance /Grounds 547 673 -(126) 614 -(59)

Transport /staff travel 1,414 1,436 -(22) 1,517 81

Office expenses 1,473 1,666 -(193) 1,465 -(201)

Telecommunications 350 371 -(20) 354 -(17)

Computer 888 809 78 905 96

Administrative expenses 5,568 8,722 -(3,154) 5,617 -(3,105)

Staff recruitment/training 557 526 31 540 14

Miscellaneous 1,218 944 273 1,290 345

TOTAL NON-PAY 86,830 93,986 -(7,156) 86,871 -(7,115) Less Bad debts -938 -3,455 2,517 -3,511 -(56)

NON-PAY excl Bad Debts 85,892 90,531 -(4,639) 83,359 -(7,172)

CUH Actual Non-pay expenditure €k August

2017 v 2016

CUH Bed Occupancy 2017 v 2016

147 145

139

151

128 130

120 123

125

117 120

108

115 113

111 114

110 111 107

117 119

100

110

120

130

140

150

160

jan feb mar apr may jun jul aug sep oct nov dec

CUH Bed Occupancy 2017 v 2016

2016

2017

Patient Income 2015 –2017

C U H Ot her Income Y TD Sept ember 2 0 17

  Income B udget €k A ct ual €k V ariance €k

R ent al income 3 3 5 72 2 3 8 7

B equest s/ D onat ions 117 13 9 2 2

R esearch grant s 2 2 8 16 3 - ( 6 5)

C arpark 1,73 1 2 ,2 13 4 8 2

D rug rebat es / PC R S 7,8 2 1 7,8 9 5 74

M isc 116 10 5 - ( 11)

10 ,3 4 8 11,2 3 7 8 8 9

C U H R ecoupment s and R ef unds Y TD Sept ember 2 0 17

  Income B udget €k A ct ual €k V ariance €k

R ecoupment s Pay 6 8 7 79 2 10 5

R ef unds- Pay 13 0 10 6 - ( 2 4 )

R ef unds- Ot her 18 1 8 8 - ( 9 3 )

U nclassif ied 153 14 2 - ( 11)

1,151 1,12 7 - ( 2 4 )

CUH Debtor Days Consultant Claims September 2017

59

Cost Containment Initiatives update at 30/9/17

TARGET JAN/F

EB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC ACTUAL

Unrostered overtime-DIT 250 50 50 50 50 50

2

Reduction in Medical agency

300 30 30 30 30 30 30 30 30 30 30

236 99 53 -43 -45 117 -24 -4 82

3

Drug savings

0

4

Procurement (NDC) one-off & recurring

600 60 120 120 120 180

5

Reduce Waste costs

30 5 5 5 5 5 5

-105 -39 -26 -40

6

Reduce Energy costs

30 5 5 5 5 5 5

8 7 7 -6

7

Reduce Bad debts

0

8

Blood science savings

1,000 100 100 100 100 100 100 100 100 100 100

905 74 70 165 162 40 100 152 142

9

Additional cafe income

330 140 110 10 10 10 10 10 10 10 10

229 4 9 38 0 170 20 7 -18

10

Recode Clinical trials expenditure 100 100

100 100

11

Recode Donated funds expend 200 200

12 Replace pressure relieving mattresses 0

75 75

13 Additional non patient income 0

482 482

TOTAL-Target 2,840 270 240 140 240 150 260 320 320 320 580

TOTAL- Actual 1,930 177 132 160 117 327 164 136 717

MGH - Finance Report – September 2017

Mallow YTD September 2017 outturn

Gross pay & non pay budget €15.16m (2016:€13.4m)

Actual pay & non pay €15.54m (2016:€13.5m)

Actual deficit €389k (-3%)

Less Adjustments €324k

increase in Bad debts provision €223k

LRA Restoration unfunded €85k

living out allowance €16k

Adjusted deficit €65k (-0.4%) (2016:€87k/-0.7%)

Mallow Income outturn

Income budget €2.67m (2016:€2.57m)

Actual Income €2.74m(2016:€2.42m)

Actual surplus €66k (3%) (2016:Deficit €150k/-6%)

BGH - Finance Report – September 2017

Bantry YTD September 2017 outturn

Gross pay & non pay budget €15.57m

Actual pay & non pay €16.11m

Actual deficit €535k (-3.4%)

– Less Adjustments €355k

– Increase in Bad debts provision €92k

– St. Josephs ward €168k

– LRA Restoration unfunded €78k

– Living out allowance €14k

– Waiting list initiative €2k

Adjusted deficit €180k (-1.16%)

Bantry Income outturn

Income budget €2.7m

Actual Income €2.7m

Actual surplus €6k (0.2%)

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

Project group in place

Application for planning permission submitted

Tender Pack being prepared

Helipad

Meeting held with the IAA

Ground Level Helipad the agreed option

Key Issues

Structured Overtime

Pay controls clearly working

Need for change in accounting for PCRS funded drugs

Bad Debts

PF17 working well

Challenge with complex discharges

Ophthalmology service risk

CAMHS

Pharmacy Review

Quality Strategy

National Quality Survey

Unscheduled Care Process

Day Surgery Unit

INMO relations working well

Implementation of change programme in Catering/Housekeeping

Sick Leave Focus

HR recruitment workload

Grading of staff must be addressed

Finance Patient Access

Quality & Safety

Patient and Service User

Human Resource