Public Agenda...28 May 2015 9.30am Owner Attached Time 1) Welcome and Apologies JJ Verbal 0930 2)...

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Public Agenda

Trust Board of Directors Room 219, Second Floor, Trust Headquarters, North Manchester General Hospital

28 May 2015 9.30am

Owner Attached Time

1) Welcome and Apologies

JJ Verbal 0930

2) Declaration of Interests

JJ Verbal

3) a) b) c)

Procedural Business Minute of Meeting held on 26 March 2015 Matters Arising Action checklist

JJ JJ GB

Attached Attached

4)

Chairman’s Remarks

JJ Verbal 0935

5)

Chief Executive’s Report

GF To follow 0940

6) a) b) c)

Performance and Assurance Integrated Performance Report Strategic Risk Register CQC Registration Annual Review 2014/15

BS GB GB

Attached Attached Attached

0955 1030 1035

7) a) b) c) d)

Quality, Clinical and Patient Issues Clinical Governance Review Mortality Report Medical and Revalidation Appraisal Dr Kershaw’s Hospice

GH AS AS JW

To follow Attached Attached Attached

1040 1100 1105 1110

8) a)

Strategy and Partnerships Trust Programmes Update

SG

Attached

1115

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9) a)

Business and Commercial IM&T Strategy

BS

Attached

1120

10) a)

Regulatory No items

11) a) b) c) d) e) f)

Minutes of Board Sub-Committees Audit Committee – 7 April 2015 Trust Programmes Board – 24 March 2015 Trust Programmes Board – 21 April 2015 Quality and Performance Committee – 24 March 2015 Quality and Performance Committee – 28 April 2015 Quality and Performance Committee Highlight Report – 26 May 2015

RA SG SG SD SD SD

Attached Attached Attached Attached Attached Tabled

1140

12) Date of Next Meeting Thursday 25 June 2015, Room 219, Trust HQ at 9.30am

JJ 1150

13) Resolved That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

JJ

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Minute

Trust Board of Directors Willow Suite, Norton Grange Hotel, Manchester Road, Castleton, Rochdale

26 March 2015 9am

Owner Timescale

Present Mr J Jesky, Chairman Mr R Ahmad, Non-Executive Director Mrs W Cardiff, Non-Executive Director Mrs S Dixon, Non-Executive Director Dr G Fairfield , Chief Executive Mrs C Guereca, Non-Executive Director Mr J Lenney, Director of Workforce and OD Mrs C Mayer, Non-Executive Director Mr H Mullen, Director of Operations Mrs M Ollerenshaw, Non-Executive Director Mrs K Salmon-Jamieson, Acting Chief Nurse Dr A Sinniah, Acting Medical Director Mr B Steven, Deputy Chief Executive / Director of Finance

In Attendance Mr G Barclay, Assistant Chief Executive / Board Secretary Ms S Good, Director of Strategy and Commercial Dev’t Mr A Lynn, Head of Communication Mr J Wilkes, Director of Estates and Facilities

Public One member of staff and one staff side representative.

01/15 Welcome The Chairman welcomed everyone to the meeting.

02/15

Declarations of Interest The Chairman declared that he had joined the Board of Buxton Festival. Mr Barclay reported that Dr Sinniah had completed his declaration of interests form on joining the Board, and had no interests to declare. Dr Sinniah had confirmed that he subscribed to the Codes of Conduct and Accountability.

03/15 a)

Procedural Business Minute of the Trust Board of Directors Meeting dated 18 December 2014 The minute was submitted and approved.

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b)

Action Checklist The Board reviewed each item on the checklist, noted the updates and agreed to close a number of actions where appropriate. The Action Checklist was updated and noted.

04/15 Chairman’s Remarks The Chairman stated that:

Work on Devo Manc was progressing and he had attended a recent meeting for Trust Chairs where it had been agreed to re-instate such a meeting on a regular basis.

Along with Dr Fairfield he had met with the Chairman and Chief Executive of Central Manchester Foundation Trust.

He had attended a recognition event for MedEquip4Kids at the Children’s A&E unit at The Royal Oldham Hospital to thank them for their generous support both for providing equipment to that department and for their fundraising over a number of years.

05/15 Chief Executive’s Report Dr Fairfield spoke to her report which summarised key national, local and Trust issues and developments. In particular, she commented on:

Health Select Committee report on complaints and raising concerns;

Freedom to Speak Up;

Investigation report into Morecambe Bay Trust;

Savile Report;

The Chancellor’s recent budget statement;

Devo Manc. Dr Fairfield said that she had been co-opted onto the programme board jointly chaired by Simon Stephens and Sir Howard Bernstein;

Pride in Pennine – Chief Executive’s Challenge on health, wellbeing and sickness absence had generated 15,000 contributions from staff within two weeks;

Ebola;

Duty of Candour;

Safer Sharps EU Directive. Mrs Salmon Jamieson said that the Trust had been visited by the HSE on 18 March 2015 and would be issued with a notice of contravention which would take the form of a formal letter and a fee for intervention. The HSE were satisfied that the Trust had an improvement plan and therefore at this stage would not issue and improvement / enforcement notice or take any action to prosecute;

Changes in the Executive and Senior Team The report was noted.

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06/15 Integrated Performance Report Mr Steven spoke to the report and said that the Quality and Performance Committee had reviewed, in detail, many of the indicators presented in the report. Quality

HCAI – The Trust had exceeded the year end upper threshold for C-Difficile at the end of month 11 with 67 cases against a year end upper threshold of 62. There had been 5 MRSA cases reported year to date. Mrs Salmon Jamieson said that she was starting a new campaign “Don’t wait to isolate” as this was the key area where action was needed. A new risk assessment would also be introduced. Further work by the ward teams would also reinforce professional standards and the work required at ward level, in contrast to what appeared to be a current focus on the Infection Prevention and Control Team. Mrs Dixon supported this approach and commended the emphasis on work at ward level.

Pressure sores – Mrs Salmon-Jamieson said that a new risk assessment and been introduced and further action planning was underway.

Safe Nursing and Midwifery staffing levels – the Trust met the 80% fill rate standard in February (all wards met the standard).

It was agreed that the Mortality Report, currently presented separately on the agenda, should be integrated into the next iteration of the Integrated Performance Report.

Operational Performance

Referral to Treatment - all three RTT standards were achieved in February.

All of the national cancer standards were achieved for Q3 and for January. All local cancer targets had been achieved for Q3 and January with the exception of the 62 day GP referral reallocated standard.

4 hour urgent care standard – Mr Mullen said that North Manchester General Hospital would achieve the year end standard for the first time. This was a significant achievement and turn-around of previous performance. The CCG was particularly keen to celebrate this and held a view that the North Manchester health economy was performing better than ever before. The Chairman asked Mr Mullen to arrange for a letter of commendation to staff from the Board and for Board member visits to recognise this achievement. Mr Mullen said that The Royal Oldham Hospital continued to experience difficulties in achieving the standard and there were issues relating to admissions and delayed discharges. The adult social care budget in Oldham had reduced by 50% over recent years. There were

BS HM

May 2015

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c40 more patients classed as delayed discharges at The Royal Oldham Hospital compared to North Manchester General Hospital. Along with Dr Sinniah, he had met with the Chief Executive of Oldham Council to discuss this matter. Mr Mullen also acknowledged that there were further improvements that could be made within the Trust and he would look to the new medical leadership team of Divisional Medical Director and Clinical Directors, once fully in post, to take this forward with medical and other clinical staff.

Finance

For the eleven months to February 2015 the Trust had delivered a deficit of £1.9m (before technical adjustments), an adverse variance of £0.8m. The Trust had received £9m of non-recurrent deficit funding from the TDA for 2014/15 which had allowed the forecast outturn position to be revised to break-even. Achieving this position would still require tight financial control and achievement of all planned CIPs to the end of the year. Income was above plan by £2.3m. Expenditure was above plan by £3.3m. Capital expenditure had been £11.13m against a plan of £16.9m. The cash position remained positive at £59m (£20.1m above plan). The continuity of service risk rating had increased to 4 with a year end forecast of 3.5.

Workforce

Sickness absence remained high at 6.05% in February (5.71 year to date).

Regulatory Assessments

The Monitor’s Risk rating remained three (amber) but Mr Steven cautioned that this might turn red due to the combination of some targets being missed for successive quarters.

The report was noted.

07/15 Staff Survey Report Mr Lenney spoke to the report which gave a brief outline of the results from the staff survey conducted in the autumn of 2014. Over 2,700 members of staff had taken part. Whilst the overall engagement score had again improved from 3.58 to 3.61 the results remained significantly below average in comparison to other NHS providers. Mr Lenney said that the Trust was beginning a journey to better engage with its workforce and to improve staff morale and staff satisfaction. The current Pride in Pennine – Chief Executive’s Challenge with its focus on health, well-being and engagement would be used as the launchpad for actions to address the issues raised. Dr Fairfield said that the Pride in Pennine Chief

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Executive’s Challenge had already generated significant interest and she was particularly pleased that staff side were keen to be involved in addressing the issues raised. Mrs Mayer said that she acknowledged that changing culture and attitudes would take time but she felt that the Trust still had significant work to do. Dr Fairfield said that the right team with the right ideas were now in place to implement a whole series of actions which would in turn see change take place. The Chairman said that the national staff survey appeared to give worse results than the Trust’s own internal intelligence gathering. Mr Lenney said that the national staff survey methodology was robust and allowed for comparisons to be made across the country. He said that while the survey highlighted areas for improvement, the Trust Board needed to remember that the Trust employed thousands of very committed staff who delivered high standards of care. Mrs Cardiff asked about examples of good practice. Mr Lenney said that there were some examples highlighted in the survey. He said it would be important to understand the needs and motivators for different staff teams and groups as they many need different approaches. Mrs Ollerenshaw asked whether managers debriefed their teams on the survey results for their areas. Mr Lenney said that action plans were developed at local level but more work was needed on this to ensure that they addressed specific departmental issues. Mrs Ollerenshaw asked whether the departmental scores were taken into account during managers’ PDRs. Mr Lenney said this should form part of the overall service performance review process as there would be many factors other than the actions of any individual which would impact on the score for a department. However, he was keen to introduce 360 degree appraisals. Mrs Cardiff suggested that the Trust should encourage staff views and feelings to be expressed at every 1-1 meeting in a way that allowed that collective intelligence to rise through the Trust. Mr Lenney said that he planned to devote time and energy to improving the PDR process in the first instance. Mrs Dixon asked whether there was enough resource allocated to address all of the issues identified in the survey. Mr Lenney said that the Executive Team were reviewing the financial plans for 2015/15. He said that while everyone recognised the need for investment in this area, there were other financial challenges which also had to be considered. Mrs Dixon asked whether mid year surveys were undertaken. Mr Lenney said that one third of the staff was surveyed through the Staff Friends and Family Test in three of the four quarters of the year and all staff received

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the national staff survey in the fourth quarter. Dr Fairfield said that the Trust had thousands of staff comments and views from the Pride in Pennine work and she would be cautious about carrying out any further surveys other than periodic pulse checks. She added that it was interesting to read through Pride in Pennine which issues really mattered to staff and could improve their daily working lives and in turn the care they were able to provide. The Trust had to act on these comments and views. The report was noted.

08/15 Strategic Risk Register / Board Assurance Framework Mr Barclay spoke to the revised Strategic Risk Register and Board Assurance Framework which had been previously considered at the Board risk workshop on 13 January 2015. Mr Barclay reminded the Board of the earlier work by the Board in the summer of 2014 to identify the significant risks and the development of the risk register and assurance framework, through the Quality and Performance Committee, since that time. He said that the revised format set out the controls, assurances and gaps much more clearly. The Board Assurance Framework was directly linked to the Trust’s corporate priorities. Mr Barclay said that most of the more recent work since January 2015 on revising the Strategic Risk Register and Board Assurance Framework had been led by the new Director of Clinical Governance who would also now review the risk management strategy and policy within the Trust. Board members said that the new Stratgeic Risk Register and Board Assurance Framework were very clear, comprehensive and logical. The Strategic Risk Register and Board Assurance Framework were approved and it was agreed that the Board should receive a monthly report on significant risks with the full Strategic Risk Register and Board Assurance Framework submitted on a quarterly basis.

GB

09/15 Mortality Report Dr Sinniah spoke to the report and stated that while the Trust’s HSMR had risen in November 2014, this was due to incomplete data submission and would be resolved for the December submission when he expected the previous positive trends to continue. Setting aside the incomplete data submission, Mrs Mayer asked Dr Sinniah whether he was satisfied with progress being made on the various actions set out for The Royal Oldham Hospital. Dr Sinniah said that he was content with progress at present and would expect implementation of

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actions to continue. Mrs Mayer asked about lowering the threshold for triggering individual concerns to below 95. Dr Sinniah said that he had discussed this with Dr Prudham and the Director of Clinical Governance and they had come to the conclusion that they did not feel that the threshold should be lowered to 85. They were of the view that there was appropriate monitoring of individual performance in place and that there could be valid reasons for individual dip in mortality. Monitoring of trends would be more important and he acknowledged that further work was required in this area. He said that the appointment of new Clinical Governance Managers at Divisional level would have a positive impact, along with standardising of reporting and the agendas for the morbidity and mortality meetings which was being led by the Director of Clinical Governance. Dr Fairfield commented on the significant work undertaken over the last year to refocus the Trust. She said that a key part of this had been to put clinical leadership at the centre of the Trust and once the final elements were in place at Directorate level work could be taken forward at a faster pace. Mrs Guereca and Mrs Ollersnshaw asked why Fairfield General Hospital had a higher acuity that the other hospitals. Dr Sinniah explained that Rochdale Infirmary managed lower acuity patients meaning that higher acuity patients formed a greater proportion of patients admitted to Fairfield General Hospital. The Chairman proposed that the report should be made available to Consultants across the Trust so that they were aware of the level of detail considered by the Board, although it was also acknowledged that it had been agreed earlier in the meeting that the mortality reports should be integrated within the Integrated Performance Report. The report was noted.

AS

10/15 Review of how the Trust Applies the Mental Health Act Mrs Salmon-Jamieson spoke to the report of an external review on how the Trust applied the Mental Health Act. The report had been received by the Senior Management Team and the SMT had accepted the recommendations which would need to be followed through to ensure that the Trust fully complied with the requirements under the Act. The Chief Nurse would be the Executive lead, with implementation being taken forward by the Director of Clinical Governance. Dr Fairfield asked that Mrs Good, who remained a registered Mental Health Nurse, be involved in supporting the implementation of the recommendations.

KSJ / SG

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The Chairman asked that arrangements be made for reports to be brought to the Board on implementing the recommendations and on compliance with the Act. The report was noted.

KSJ

11/15 Review of Complaints Handling within the Trust Mrs Salmon- Jamieson spoke to her paper which described a benchmarking exercise undertaken against the PHSO report on expectations for raising concerns and complaints which had been published in November 2014. She said that while it was acknowledged there had been improvements in the quality of Trust complaint responses and a reduction in the number of dissatisfied complainants, this had been at the expense of a significant deterioration in the speed of complaint response. Further work was needed to ensure that each complainant was provided with a person centred experience that ultimately offered a comprehensive, assurance based and timely response. Mrs Dixon welcomed the review and the emphasis on face to face contact at the start of any complaint process. Mrs Guereca said that the review was comprehensive and supported the emphasis on early resolution. She asked whether the reasons for delays in providing responses were explained to complainants. Mrs Salmon-Jamieson said that this was the case and added that there was now an increasing emphasis on meeting with complainants. Mrs Cardiff said that in view of the forthcoming new arrangements for visits to wards and departments it would be helpful for Non-Executive Directors to have some training and advice on how to handle any issues raised by patients. Dr Fairfield said that this paper was an example of another area within the Trust which had been subject to a comprehensive review. Since taking up post she had received all complaints responses for personal review and acknowledged that some of the delays in providing final responses had arisen because she had sent draft responses back for further investigation or more information and had also insisted that local clinical managers in Divisions and Directorates review investigation reports and draft responses, all of which had added to the length of time taken. With the finalising of the new management arrangements, the implementation of the other recommendations described in the paper and an increase in the capacity and profile of the PALS service, she expected response times to reduce. The report was noted.

KSJ

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12/15 Trust Programmes Update Mrs Good reported as follows:

Six of the eight programme manager posts in the PMO had been filled and she expected all to be in place by June;

Transformation Delivery Managers, to be embedded in the Divisions, had been recruited;

Clinical Service Transformation - the see one, do one, teach one process was underway;

CIP – on target to achieve 2014/15 objectives. £20m of CIP for 2015/16 had been identified. The external consultancy support provided for 2014/15 was being evaluated and consideration was being given a engaging further support in 2015/16, directly linked to the Clinical Transformation Strategy, while also supporting further development of internal capability and capacity;

Workforce and Leadership – the programme would be re-launched;

Foundation Trust – there was a need to focus on FT member engagement. Feedback on the draft IBP submitted in December was due in the next week with the next iteration of the IBP due in September 2015. A Board to Board session with the TDA was anticipated in June 2015.

Mrs Ollerenshaw stated that the Trust had previously established a Service Delivery Unit, essentially a PMO, several years ago, supported by external consultants and with the intention to transfer skills to Trust staff. She said that this had had some initial success but had then faltered. She asked what would be different this time to ensure that the same good intentions were delivered. Mrs Good said that filling the PMO posts would free up capacity and the Transformation Programme Managers would be embedded in the Divisions. Mrs Guereca commented on the stakeholder engagement event held the previous evening as part of the Clinical Service Transformation. She described this as a fantastic event attended by c70 senior clinical leaders from the Trust, CCGs, local authorities, TDA, NWAS and neighbouring Trusts. She said that it had been good to see clinicians presenting and leading the engagement with partners.

13/15 Social Services Integration in North Manchester Mr Mullen spoke to his report which set out the latest position on the “Early Adopter” health and social care integration programme within North Manchester. The papers et out the service model for phase 1 of the proposed integration and highlighted key enablers and risks alongside the joint Trust / Manchester City Council governance arrangements for the programme.

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Management arrangements for 120 staff would transfer from the City Council to the Trust on 1 April 2015. The budget would remain with the City Council in the first instance. The report was noted.

14/15 Data Quality Assurance Framework Mr Steven summarised the main elements of the report which was a key document in allowing the Board to sign off the Quality Accounts in due course. The report was noted.

15/15 Minutes of Board Sub-Committees The minute of meeting of the Audit Committee dated 10 February 2015 was submitted and noted. The minute of meeting of the Trust Programme Board dated 27 January 2015 was submitted and noted. The minute of meeting of the Trust Programme Board dated 17 February 2015 was submitted and noted. The minute of meeting of the Quality and Performance Committee dated 12 December 2014 was submitted and noted. The minute of meeting of the Quality and Performance Committee dated 20 January 2015 was submitted and noted. The minute of meeting of the Quality and Performance Committee dated 24 February 2015 was submitted and noted. Mrs Dixon tabled and spoke to the Highlight Report from the meeting of the Quality and Performance Committee held on 24 March 2015 and commented specifically on the SUI review, the Health and Safety Report, Quality Priorities and the improvement in RTT performance. Dr Fairfield said that she found the Highlight Report very helpful. She added that along with Mr Barclay she would be reviewing reporting arrangements across the entire committee structure.

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16/15 Papers for Information and Acceptance Medical and Dental Undergraduate and Post Graduate Update – noted. Freedom of Information Annual Report 2014 – noted. Eliminating Mixed Sex Accommodation – Declaration of Compliance – the Board approved the declaration. Equality Reports – Patient Equality Report and Staff Equality Report – approved. Board Agenda Planner – Mr Barclay said that he had prepared the planner and would reviewed it with Dr Fairfield as part of the review of sub-committee reports referred to earlier in the meeting and would then discussed the planner with the Chairman.

GB

17/15 Date of Next Meeting Thursday 28 May 2015

18/15 Resolved That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

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Title of Report

The Integrated Performance Report

Executive Summary

The report provides information about the Trust’s key performance areas

Actions requested

The Quality & Performance Committee and the Board are asked to:- 1. Review the information submitted 2. Note that development of the Integrated Performance Report is

continuing, with the following changes: – (1) Compliance dates have been added; (2) Quality Section: a new Harm Free care KPI, a new FFT KPI; 2 KPIs for cancer quality; (3) Workforce Section: Mandatory training KPI updated; Vacancy KPI added – (4) Work is also underway to incorporate an expanded suite of mortality KPIs.

Corporate Objectives supported by this paper: Links to corporate objectives are specified in the report’s scorecard

Risks: The risks identified in this report are picked up in the relevant risk register.

Public and/or patient involvement: Key performance indicators within this report are derived from the expectations of patients and the public.

Resource implications: Failure to achieve the performance indicators could result in loss of income.

Communication: Through management structures

Have all implications been considered? YES NO N/A

Assurance X

Contract X

Equality and Diversity X

Financial / Efficiency X

HR X

Information Governance Assurance X

IM&T X

Local Delivery Plan / Trust Objectives X

National policy / legislation X

Sustainability X

Name Brian Steven

Job Title Deputy Chief Executive and Director of Finance & IM&T

Date May 2015

Email [email protected]

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len

gth

of

stay

CIP

Ach

ieve

me

nt

- ve

rsu

s P

lan

The

atre

pro

du

ctiv

ity

Cas

h B

alan

ce v

s P

lan

Gre

en

s10

MR

SAG

ree

ns

4S&

A

Re

ds

3H

and

ove

r o

f ca

re c

om

m (

OP

<10d

y)R

ed

s4

Ban

k &

Age

ncy

sp

en

d,

Re

adm

issi

on

sFF

T -

pla

ce t

o w

ork

PD

Rs

Gre

en

s10

A&

E 4

ho

urs

Gre

en

s1

Re

ds

4C

ance

r 62

day

scr

ee

nin

g n

atio

nal

Re

ds

3

Can

cer

62 d

ay G

P r

eal

loca

ted

loca

l

6 w

ee

k d

iagn

ost

ic t

est

s

Pe

rfo

rman

ceP

erf

orm

ance

PerformanceBusiness Capability Quality

Regulatory

AssessmentsWorkforceFinance

TDA

- O

vers

igh

t &

Esc

alat

ion

Stat

us

Leve

l 3 (

Inte

rve

nti

on

) d

ue

to F

inan

ce S

core

an

d 4

Qu

alit

y

ind

icat

ors

Mo

nit

or'

s R

isk

Ass

ess

me

nt

Fram

ew

ork

- 2

Acc

ess

& O

utc

om

e

me

tric

s o

ver

a ti

me

& C

oSS

R <

3

Tre

nd

s K

ey

Be

tte

r th

an la

st p

eri

od

Sam

e a

s la

st p

eri

od

Wo

rse

th

an la

st p

eri

od

Page 18 of 196

(2)

EX

EC

UT

IVE

SU

MM

AR

Y

Bu

sin

ess C

ap

ab

ilit

y

SLR

Q3 K

PI

perf

orm

ance t

ells

a s

imila

r sto

ry a

s r

eport

ed f

or

Q2 w

ith 3

specia

ltie

s (

11%

) not m

akin

g a

contr

ibution t

o o

verh

eads a

nd a

fu

rther

16 (

57%

) not m

akin

g a

surp

lus. W

ork

is u

nderw

ay t

o m

ake b

etter

use o

f S

LR

to c

ontr

ibute

to im

pro

ved p

erf

orm

ance a

nd

org

anis

ational susta

inabili

ty.

This

initia

tive w

ill e

nable

the D

ivis

ions t

o a

ccess im

pro

ved a

nd inte

ractive S

LR

info

rmation s

yste

ms, backed u

p

by a

user

train

ing

packag

e. W

e h

ave a

lso e

xte

nded t

he p

rogra

mm

e o

f deep d

ives t

o incorp

ora

te a

furt

her

8 s

pecia

ltie

s (

wo

rk w

ill s

tart

in

June).

We a

re a

lso u

ndert

akin

g s

om

e w

ork

to m

odel th

e p

ossib

le S

LR

positio

n b

y 1

9/2

0 (

post tr

ansfo

rmation).

Additio

nal

activity h

as b

een c

om

mis

sio

ned f

rom

the T

rust

as p

art

of

the 1

5/1

6 c

ontr

act

for

a s

ele

ction o

f surg

ical

specia

ltie

s t

o s

upport

im

pro

ved a

ccess p

erf

orm

ance.

Pro

vis

ional in

form

ation,

based o

n F

FC

E’s

, in

dic

ate

s t

hat

activity d

eliv

ere

d is b

elo

w t

he levels

pla

nned t

o b

e

achie

ved f

or

Apr-

15.

‘Off

icia

l’ in

form

ation s

how

ing

perf

orm

ance a

gain

st

activity t

arg

ets

, based o

n s

pells

, w

ill b

e a

va

ilable

next

month

. D

eliv

ery

of

activity m

ay influence t

he c

hoic

e o

f pro

vid

ers

made b

y c

om

mis

sio

ners

and t

here

fore

the f

utu

re s

usta

inabili

ty o

f serv

ices.

A n

ew

theatr

e p

roductivity indic

ato

r has b

een a

dded t

o t

he r

eport

follo

win

g c

om

ple

tion o

f th

e n

ew

theatr

e d

ashboard

on 1

9th M

ay.

The

dashboard

will

be u

sed to s

upport

work

to im

pro

ve p

roductivity,

with t

his

and o

ther

KP

Is b

ein

g u

sed t

o info

rm the p

ote

ntial scale

of

impro

vem

ent availa

ble

to t

he T

rust

in t

he L

TF

M m

ovin

g f

orw

ard

.

Work

is o

ng

oin

g to r

evie

w a

nd r

efine, at a m

ore

deta

iled

and o

pera

tional le

vel, t

he k

ey s

erv

ice c

hang

e a

ssum

ptions that

underp

in t

he

various p

ossib

le o

utc

om

es o

f th

e T

rust’s T

ransfo

rmation o

ptions.

Qu

ality

HC

AI

– C

-Diff

was b

ett

er

than t

raje

cto

ry w

ith t

he f

ew

est

num

ber

of

cases r

eport

ed in a

ny A

pri

l. T

here

was 1

MR

SA

in

April, w

hic

h is b

ein

g

investig

ate

d.

SU

Is –

follo

win

g t

he T

rust

com

mis

sio

ned M

ate

rnity R

evie

w a

num

ber

of

incid

ents

were

retr

ospectively

report

ed i

n A

pril. T

og

eth

er

with

C

CG

s the s

tatu

s o

f each incid

ent

is b

ein

g r

evie

wed in M

ay.

The S

afe

ty T

herm

om

ete

r H

arm

Fre

e C

are

KP

I has b

een a

dded t

o t

his

month

’s r

eport

– A

local

targ

et

is b

ein

g d

evelo

ped

for

inclu

sio

n i

n

next

month

’s r

eport

.

A n

ew

FF

T K

PI

has b

een a

dded to this

month

’s r

eport

to r

eflect th

e c

hanges t

o t

he n

ational m

easure

ment

syste

m d

uri

ng

2014-1

5.

Handover

of

care

com

munic

ation –

Inpatient

com

plia

nce s

ignific

antly i

mpro

ved a

nd t

he 9

5%

targ

et

was a

chie

ved f

or

the f

irst

tim

e e

ver

in

Marc

h.

Outp

atient

lett

ers

com

plia

nce h

as a

lso im

pro

ved

over

the y

ear,

but

levelle

d o

ff b

elo

w 9

5%

- W

ith t

he s

upport

of

the P

MO

, additio

nal

actions a

re b

ein

g im

ple

mente

d to a

ddre

ss t

he issues identified

during 1

5-1

6.

2

ne

w

inte

rnal

cancer

qualit

y

KP

Is

have

been

added

to

the

report

to

support

im

pro

vem

ent

of

com

munic

ation

of

clin

ical

path

wa

y

manag

em

ent

info

rmation f

or

patients

on a

cancer

path

way.

Mort

alit

y –

HS

MR

rem

ain

s r

ela

tively

good.-

SH

MI re

main

s a

bove 1

.00 a

nd w

ithin

the e

xpecte

d r

ang

e

Op

era

tio

nal

Perf

orm

an

ce

All

3 n

ational

RT

T s

tandard

s w

ere

achie

ved f

or

the s

eventh

consecutive m

onth

. T

he d

iagnostic 6

week s

tandard

was m

issed i

n A

pril.

Contr

ibuto

ry f

acto

rs inclu

ded r

ecent

cancer

aw

are

ness c

am

paig

n r

ela

ted d

em

and incre

ase f

or

scopes a

nd c

apacity c

onstr

ain

ts –

Clin

ically

urg

ent patients

are

bein

g p

rioritised a

nd a

pla

n h

as b

een s

ubm

itte

d to S

MT

.

Item

6a

Page 19 of 196

7 o

f th

e 9

cancer

targ

ets

were

met

in Q

4.

The T

rust

did

not

meet

1 o

f th

e 7

national

targ

ets

monitore

d b

y t

he T

DA

(th

e 6

2 d

ay t

arg

et

for

scre

enin

g r

efe

rrals

). T

he l

ocally

monitore

d 6

2 d

ay G

P r

efe

rral

reallo

cate

d s

tandard

did

not

achie

ve

for

Jan

-15.

The p

lan a

gre

ed w

ith

com

mis

sio

ners

and d

iscussed w

ith t

he T

DA

is b

ein

g im

ple

mente

d.

The a

gre

ed im

pro

vem

ent

traje

cto

ry f

or

the 6

2 d

ay c

ancer

sta

nda

rds w

as

met fo

r re

ferr

als

receiv

ed fro

m 1

st D

ecem

ber

for

Jan

-15, F

eb-1

5,

and M

ar-

15. T

he I

ST

report

will

be s

ubm

itte

d t

o S

MT

in J

une.

The 4

hour

sta

ndard

wa

s a

chie

ved f

or

Q1 a

nd Q

2.

Whils

t perf

orm

ance h

as i

mpro

ved i

t has r

em

ain

ed b

elo

w t

arg

et

for

the l

ast

7 m

onth

s

Pre

ssure

s r

em

ain

hig

h d

ue t

o h

igh a

cuity,

and b

ed p

ressure

s r

esultin

g f

rom

dela

ys in t

he d

ischarg

e p

rocess.

The T

rust

has a

gre

ed a

pla

n

with t

he T

DA

to i

mple

ment

“The P

erf

ect

Week,”

anticip

ating

that

this

will

hig

hlig

ht

the n

eed t

o e

nsure

com

plia

nce w

ith t

he b

est

pra

ctice

sta

ndard

s o

f w

hic

h t

he T

rust is

already a

ware

. U

pdate

s o

n t

he o

utc

om

es o

f T

he P

erf

ect W

eek w

ill b

e r

eport

ed a

nd incorp

ora

ted in

to p

lans.

F

inan

ce

The f

inal 2015/1

6 A

nnual F

inancia

l P

lan w

as s

ubm

itte

d t

o t

he N

HS

Tru

st

Develo

pm

ent

Auth

ority

on 1

4th M

ay 2

015 f

ore

casting a

year

end

deficit o

f (£

25.8

m),

com

pare

d t

o t

he b

reakeven p

ositio

n r

eport

ed a

t th

e e

nd o

f 2014

-15.

The i

mpro

vem

ent

from

the (

£29.9

m)

deficit p

lan

subm

itte

d o

n 7

th A

pril 2015 w

as a

ppro

ved b

y t

he B

oard

of

Directo

rs a

t th

e 3

0th A

pril C

onfirm

and C

halle

ng

e m

eeting

.

At

Month

1 t

here

wa

s a

n a

dvers

e p

erf

orm

ance o

f £0.5

m a

gain

st

pla

n b

efo

re i

mpairm

ents

and t

echnic

al

adju

stm

ents

. T

he d

eliv

ery

of

the

financia

l pla

n is c

onting

ent

on:

[1]

Deliv

ery

of

PbR

Incom

e;

[2]

Deliv

ery

of

CIP

- £

0.5

m a

dvers

e v

ers

us p

lan a

t M

1 a

nd

is b

ack-loaded t

o t

he

second h

alf o

f th

e y

ear;

[3]

Deliv

ery

of

CQ

UIN

s a

nd c

ontr

act K

PIs

.

The y

ear

to d

ate

Continuity o

f S

erv

ice R

isk R

ating

(C

oS

RR

) re

duced t

o 2

.0,

and t

he f

ore

cast

year

end C

oS

RR

is 1

.0 –

belo

w t

he a

spirant

FT

targ

et of

3.0

W

ork

forc

e

A n

um

ber

of

inte

r-re

late

d W

ork

forc

e K

PIs

have m

issed t

arg

ets

for

som

e t

ime (

S&

A,

Bank a

nd A

gency s

pend,

Sta

ff F

FT

, and P

DR

s).

A

diffe

rent

appro

ach is b

ein

g t

aken in o

rder

to e

nsure

qualit

y o

f care

, perf

orm

ance a

nd f

inancia

l obje

ctives a

re s

usta

inably

met.

The ‘P

ride in

Pennin

e’

CE

O c

halle

ng

e e

vent

on “

Health a

nd A

ttendance”

will

seek s

olu

tions t

hro

ug

h w

ide s

taff

eng

ag

em

ent,

whic

h w

ill r

esult i

n a

pla

n

bein

g d

raft

ed a

t th

e e

nd M

ay,

follo

win

g t

he o

nlin

e w

ork

undert

aken (

Marc

h /

April) a

nd t

he larg

e g

roup m

eeting o

n 2

2nd M

ay.

Recru

itm

ent

initia

tives a

re a

lso u

nderw

ay t

o f

ill v

acancie

s.

Reg

ula

tory

Assessm

en

ts

The C

QC

assessm

ent

of

pote

ntial

risks d

escribed i

n t

he I

nte

llig

ent

Monitoring

Report

show

s t

he r

ating

rem

ain

s a

t band 6

(th

e l

ow

est

risk

cate

gory

) – 1

new

Ele

vate

d R

isk w

as a

dded

; 1 r

isk w

as r

em

oved; and 1

ris

k w

as r

educed fro

m E

levate

d to R

isk in t

he M

ay-1

5 r

eport

.

Both

th

e T

DA

O

vers

ight

and E

scala

tion S

core

and th

e shadow

m

onitoring

ag

ain

st

Monitor’s R

isk A

ssessm

ent

Fra

mew

ork

show

th

at

impro

vem

ent

is n

eeded in o

rder

to p

rogre

ss t

ow

ard

s F

T s

tatu

s.

The T

DA

report

ed a

susta

ined r

ating

of

3,

hig

hlig

hting

the f

ollo

win

g i

tem

s:

financia

l perf

orm

ance,

the M

ate

rnity S

erv

ices R

evie

w c

om

mis

sio

ned b

y the T

rust;

and p

erf

orm

ance a

gain

st:

A&

E, C

-Difficile

, and the S

afe

ty

Therm

om

ete

r ta

rget. M

onitor’s s

hadow

assessm

ent

als

o h

ighlig

hts

failu

re t

o a

chie

ve 2

Access &

Outc

om

es a

reas.

Page 20 of 196

(3)

Inte

gra

ted

Sc

ore

ca

rd

Pri

ori

tyLe

adIn

dic

ato

r n

ame

Fre

qTa

rge

t14

-15

Cu

rre

nt

Pe

rf

Dat

a u

p

toTr

en

d

YTD

15-

16

15-1

6

Fore

cast

2H

MO

utp

atie

nt

1st

vs p

lan

M>=

0%6.

1%6.

1%A

pr-

Mar

n/a

G

2H

MO

utp

atie

nt

Re

vie

w v

s p

lan

M>=

0%2.

8%2.

8%A

pr-

Mar

n/a

G

2H

MEl

ect

ive

inp

atie

nt

vs p

lan

M>=

0%-8

.5%

-8.5

%A

pr-

Mar

n/a

G

2H

MD

ay C

ase

vs

pla

nM

>=0%

-1.2

%-1

.2%

Ap

r-M

arn

/aG

2H

MN

on

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ctiv

e v

s p

lan

M>=

0%6.

1%6.

1%A

pr-

Mar

n/a

G

2H

MA

&E

atte

nd

s vs

pla

nM

>=0%

6.2%

6.2%

Ap

r-M

arn

/aG

2H

MG

P r

efe

rral

s gr

ow

th v

s la

st y

ear

M>=

0%7.

3%14

.2%

Mar

-15

n/a

G

2, 4

HM

Ord

er

bo

ok

(siz

e o

f w

aiti

ng

list

s)Q

n/a

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r-15

n/a

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BS

No

. of

spec

ialt

ies

ma

kin

g a

+ve

con

trib

uti

on

Q28

n/a

25A

pr

-Se

pn

/a

2, 4

BS

Va

lue

(£m

) o

f sp

ecia

ltie

s m

aki

ng

a

con

trib

uti

on

Qtb

cn

/a38

.0A

pr

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pn

/a

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BS

No

. of

spec

ialt

ies

ma

kin

g a

su

rplu

sQ

28n

/a9

Ap

r -S

ep

n/a

2, 4

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Va

lue

(£m

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pec

ialt

ies

ma

kin

g a

surp

lus

Qtb

cn

/a15

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pr

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pn

/a

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HM

LoS

- El

ect

ive

Inp

atie

nt

(day

s)Q

2.76

2.66

2.52

Jan

-Mar

n/a

G

2, 4

HM

Los

- Non

-Ele

ctiv

e In

pati

ent

(day

s)Q

3.36

3.46

3.65

Jan

-Mar

n/a

tbc

2, 4

HM

The

atre

pro

du

ctiv

ity

Q>=

85%

82.3

%81

.2%

Jan

-Mar

n/a

tbc

2, 4

HM

Ou

tpa

tien

t p

rod

uct

ivit

yQ

tbc

1, 6

, 10

AS

SHM

I (ro

llin

g ye

ar t

o d

ate

)Q

Exp

ect

ed

1.04

1.05

Sep

-14

n/a

G

1, 6

, 10

AS

HSM

RM

<=10

083

.05

74.1

9D

ec-

14n

/aG

1, 6

, 10

GH

C-D

iff

M<=

5572

1A

pr-

151

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1, 6

, 10

GH

MR

SAM

06

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pr-

151

tbc

1, 6

, 10

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Cle

anin

g sc

ore

sM

>=88

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94.7

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Ap

r-15

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%G

1, 6

GH

% H

arm

Fre

e C

are

- A

ll h

arm

sM

tbc

94.5

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Ap

r-15

94.0

%

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GH

Ne

ver

Eve

nts

M0

10

Ap

r-15

0G

1G

HSe

rio

us

Un

tow

ard

Inci

de

nts

Mtb

c76

27A

pr-

15

1G

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atio

nal

Saf

e S

taff

ing

RA

G R

atin

gM

>=B

lue

n/a

Blu

eFe

b-1

5N

ew

n/a

G

1G

HSa

fe S

taff

ing

leve

ls -

ove

rall

fil

l ra

teM

>=80

%97

.5%

97.6

%A

pr-

1597

.6%

G

1G

HN

um

ber

of

wa

rds

bel

ow

80

% f

ill

rate

Mn

/a6

0A

pr-

150

1A

SH

and

ove

r o

f ca

re c

om

m (

IP<2

4hr)

M>=

95%

92.7

%95

.1%

Mar

-15

n/a

G

1A

SH

and

ove

r o

f ca

re c

om

m (

OP

<10d

y)M

>=95

%84

.9%

80.3

%M

ar-1

5n

/aM

ar-1

6

1H

MIn

com

plet

e ca

ncer

pat

hway

lett

ers

M0

4913

Ap

r-15

n/a

1H

MO

pe

n c

ance

r p

ath

way

ste

p d

ow

ns

M0

7483

Ap

r-15

n/a

1, 2

, 4H

MR

ead

mis

sio

ns

rate

(28

day

)Q

<=10

011

111

1Ju

l-Se

p11

1tb

c

1,6

HM

Mix

ed

Se

x A

cco

mm

od

atio

nM

00

0A

pr-

150

G

1, 5

GH

FTT

- P

atie

nt

fee

db

ack

targ

ets

me

tM

12N

ew

12M

ar-1

5N

ew

n/a

G

Business Capability Quality

Pe

rfo

rman

ce R

AG

Tre

nd

s

Targ

et

ach

ieve

dB

ett

er

than

last

pe

rio

d

Targ

et

un

de

rach

ieve

dSa

me

as

last

pe

rio

d

Wo

rse

th

an la

st p

eri

od

Pri

ori

tyLe

adIn

dic

ato

r n

ame

Fre

qTa

rge

t14

-15

Cu

rre

nt

Pe

rf

Dat

a u

p

toTr

en

d

YTD

15-

16

15-1

6

Fore

cast

6, 1

0H

MR

TT s

tan

dar

ds

ach

ieve

dM

43

3M

ar-1

53

Oct

-15

6, 1

0H

MC

ance

r st

and

ard

s ac

hie

ved

M9

87

Mar

-15

8Ju

l-15

6, 1

0H

M4

ho

ur

Urg

en

t C

are

Sta

nd

ard

M>=

95%

93.6

%91

.5%

Ap

r-15

91.5

%O

ct-1

5

2, 4

, 10

BS

Co

SRR

vs

TDA

Pla

nM

>=2

4.0

2.0

Ap

r-15

2.0

tbc

2, 4

, 10

BS

Surp

lus

/ D

efi

cit

vs P

lan

(£m

)M

>=0

1.9

-0.5

Ap

r-15

-0.5

tbc

2, 4

, 10

BS

Inco

me

vs

Pla

n (

£m)

M>=

04.

4-0

.8A

pr-

15-0

.8tb

c

2, 4

, 10

BS

Exp

en

dit

ure

Vs

Pla

n (

£m)

M>=

0-4

.80.

2A

pr-

150.

2G

2, 4

, 10

HM

CIP

Ach

ieve

me

nt

- ve

rsu

s P

lan

M>=

34.1

-12.

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.5A

pr-

15-0

.5tb

c

2, 4

, 10

BS

Cas

h B

alan

ce v

s P

lan

(£m

)M

>=0

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-6.7

Ap

r-15

-6.7

tbc

2, 4

, 10

BS

Capi

tal R

esou

rce

Lim

it v

s Pl

an (£

m)

M>=

03.

92.

0M

ar-1

52.

0G

4, 8

JLB

ank

& A

gen

cy S

pe

nd

M<=

8%11

.0%

11.3

%A

pr-

1511

.3%

tbc

4, 8

JLS&

AM

<=4.

0%5.

67%

5.65

%A

pr-

155.

65%

tbc

4, 8

JLTu

rno

ver

Rat

eM

>=8

% &

<=1

1%

9.72

%9.

94%

May

-Ap

rn

/aG

6JL

FFT

- re

com

me

nd

tre

atm

en

tQ

>=67

%65

%71

%Ja

n-M

arn

/aG

7, 8

JLFF

T -

reco

mm

en

d a

s p

lace

to

wo

rkQ

>=61

%56

%59

%Ja

n-M

arn

/atb

c

1, 7

, 8JL

Man

dat

ory

tra

inig

- A

ll s

taff

M>=

85%

89%

88%

Ap

r-15

n/a

7, 8

JLP

DR

co

mp

leti

on

Q>=

90%

68%

68%

Ap

r-M

arn

/atb

c

2 ,4

, 6, 8

JLV

acan

cy R

ate

Mtb

c9.

29%

9.94

%A

pr-

15n

/a

1, 1

0C

QC

IMR

Ris

k B

and

ing

Q>=

56

6M

ay-1

5n

/aG

10

TDA

Esc

alat

ion

& O

vers

igh

tM

53

3M

ar-1

5n

/atb

c

10

Mo

nit

or

Co

SSR

M>=

34

2A

pr-

15n

/atb

c

10

Mo

nit

or

Acc

ess

& O

utc

om

es

M<4

& n

o

esc

alat

ion

33

Mar

-15

n/a

tbc

Workforce RegulatorPerformance FinanceK

ey

Ye

ar e

nd

fo

reca

st

GO

n t

rack

to

de

live

r

AIm

pro

vem

en

t re

qu

ire

d (

com

pli

ance

dat

e)

RN

ot

ach

ievi

ng

& o

ff t

raje

cto

ry, o

r fa

ile

d f

or

the

ye

ar

Item

6a

Page 21 of 196

(4

.1)

Fo

cu

s o

n B

us

ine

ss

Ca

pa

bilit

y

Business Capability

Q3

SLR

per

form

ance

is t

he

sam

e as

Q2

wit

h 3

sp

ecia

ltie

s 11

% n

ot

mak

ing

a co

ntr

ibu

tio

n a

nd

a f

urt

her

16

(5

7% n

ot

mak

ing

a su

rplu

s)

The

SLR

das

hb

oar

d is

bei

ng

red

esig

ned

by

the

BI t

eam

to

be

mo

re u

ser

frie

nd

ly-

tech

nic

al t

esti

ng

wit

h F

inan

ce t

o b

e co

mp

lete

d e

nd

of

May

, pri

or

to t

he

use

r te

stin

g p

has

e. A

tra

inin

g p

acka

ge f

or

SLR

will

be

del

iver

ed b

y th

e e

nd

of

Jun

e.

In a

dd

itio

n t

o t

he

Dee

p D

ives

in 3

pri

ori

ty s

pec

ialt

ies,

8 D

eep

Div

e (l

igh

ts)

hav

e b

een

init

iate

d.

The

15-1

6 a

ctiv

ity

pla

n w

ill b

e tr

ansl

ated

into

th

e o

per

atio

nal

das

hb

oar

d (

AM

R)

du

rin

g M

ay in

ord

er t

o s

up

po

rt p

erfo

rman

ce m

anag

emen

t

The

4 lo

cal C

CG

s h

ave

com

mis

sio

ned

act

ivit

y in

sel

ecte

d s

urg

ical

sp

ecia

ltie

s in

ord

er t

o d

eliv

er im

pro

ved

acc

ess

per

form

ance

at

CC

G le

vel a

nd

to

ac

com

mo

dat

e t

he

actu

al g

row

th in

can

cer

dem

and

up

to

M8

of

14

-15

. Th

e sp

ecia

lty

nee

din

g to

del

iver

th

e la

rges

t ac

tivi

ty in

crea

se is

G

astr

oen

tero

logy

(D

ay C

ases

). A

pla

n h

as b

een

su

bm

itte

d t

o m

itig

ate

the

cap

acit

y lim

itin

g m

edic

al w

ork

forc

e va

can

cies

.

Pro

visi

on

al F

FCE

dat

a sh

ow

s A

pri

l-1

5 a

ctiv

ity

is lo

wer

th

an A

pri

l 14

fo

r al

l PO

Ds.

Gas

tro

ente

rolo

gy h

as s

een

th

e b

igge

st r

edu

ctio

n in

bo

th D

ay C

ase

and

Inp

atie

nt

acti

vity

rel

ativ

e to

Ap

ril 2

01

4;

-159

FFC

E (-

31

%)

and

-4

6 F

FCE

(-1

2%)

resp

ecti

vely

– m

edic

al w

ork

forc

e ca

pac

ity

is t

he

con

stra

int.

In

pat

ien

t b

ed c

apac

ity

is a

lso

a c

on

stra

int

in s

om

e su

rgic

al s

pec

ialt

ies

du

e to

N-E

l pre

ssu

res.

A n

ew t

hea

tre

uti

lisat

ion

KP

I has

bee

n a

dd

ed t

o t

he

rep

ort

. Bas

elin

e in

form

atio

n f

or

14

-15

sho

ws

that

per

form

ance

is b

elo

w t

he

inte

rnal

85

%

targ

et. T

he

new

das

hb

oar

d w

ill s

up

po

rt im

pro

vem

ent

wo

rk.

Thea

tre

staf

f en

gage

men

t ev

ents

fo

r ar

e p

lan

ned

at

eac

h s

ite

du

rin

g Ju

ne.

Sup

po

rtin

g in

form

atio

n

The

Bet

ter

Car

e B

ett

er

Val

ue

aver

age

len

gth

of

stay

b

ench

mar

kin

g in

dic

ato

r an

d D

r Fo

ste

r b

oth

sh

ow

th

at

the

Tru

st h

as a

rel

ativ

ely

goo

d le

ngt

h o

f st

ay.

The

tab

le b

elo

w s

ho

ws

IP a

ctiv

ity

tren

ds

(FFC

Es)

R

isks

Del

iver

y o

f ac

tivi

ty m

ay in

flu

ence

ch

oic

e o

f p

rovi

der

by

com

mis

sio

ner

s.

ALo

S an

d t

hea

tre

pro

du

ctiv

ity

per

form

ance

s n

eed

to

in

form

th

e le

vel o

f sa

vin

gs t

hat

can

be

assu

med

in t

he

LTFM

mo

vin

g fo

rwar

d.

Ind

icat

or

nam

eFr

eq

Targ

et

14-1

5C

urr

en

t

Pe

rf

Dat

a u

p

toTr

en

d

YTD

15-

16

15-1

6

Fore

cast

Ou

tpat

ien

t 1s

t vs

pla

nM

>=0%

6.1%

n/a

Ap

r-15

n/a

n/a

Ou

tpat

ien

t R

evi

ew

vs

pla

nM

>=0%

2.8%

n/a

Ap

r-15

n/a

n/a

Ele

ctiv

e in

pat

ien

t vs

pla

nM

>=0%

-8.5

%n

/aA

pr-

15n

/an

/a

Day

Cas

e v

s p

lan

M>=

0%-1

.2%

n/a

Ap

r-15

n/a

n/a

No

n-E

lect

ive

vs

pla

nM

>=0%

6.1%

n/a

Ap

r-15

n/a

n/a

A&

E at

ten

ds

vs p

lan

M>=

0%6.

2%n

/aA

pr-

15n

/an

/a

GP

re

ferr

als

gro

wth

vs

last

ye

arM

>=0%

7.3%

14.2

%M

ar-1

5n

/aG

Ord

er

bo

ok

(siz

e o

f w

aiti

ng

list

s)Q

n/a

33,2

4434

,328

Ap

r-15

n/a

No

. of

spec

ialt

ies

ma

kin

g a

+ve

con

trib

uti

on

Q28

n/a

25A

pr

-Se

pn

/a

Va

lue

(£m

) o

f sp

ecia

ltie

s m

aki

ng

a

con

trib

uti

on

Qtb

cn

/a38

.0A

pr

-Se

pn

/a

No

. of

spec

ialt

ies

ma

kin

g a

su

rplu

sQ

28n

/a9

Ap

r -S

ep

n/a

Va

lue

(£m

) -s

pec

ialt

ies

ma

kin

g a

surp

lus

Qtb

cn

/a15

.6A

pr

-Se

pn

/a

LoS

- El

ect

ive

Inp

atie

nt

(day

s)Q

2.76

2.66

2.52

Jan

-Mar

n/a

G

Los

- Non

-Ele

ctiv

e In

pati

ent

(day

s)Q

3.36

3.46

3.65

Jan

-Mar

n/a

tbc

The

atre

pro

du

ctiv

ity

Q>=

85%

82.3

%81

.2%

Jan

-Mar

n/a

tbc

Ou

tpa

tien

t p

rod

uct

ivit

yQ

tbc

12-1

313

-14

14-1

52

year

var

1 ye

ar v

ar

Tru

st35

,337

32,8

1731

,572

-3,7

65-1

,245

Surg

ery

14,1

9413

,206

13,2

73-9

2167

Me

dic

ine

995

948

692

-303

-256

W&

C2,

179

1,93

61,

529

-650

-407

Dia

g17

,969

16,7

2716

,078

-1,8

91-6

49

IP A

ctiv

ity

Tre

nd

(FF

CEs

- s

ou

rce

MR

)

Page 22 of 196

(4

.2)

Fo

cu

s o

n Q

ua

lity

Quality

C-D

iff

was

bet

ter

than

tra

ject

ory

fo

r th

e m

on

th w

ith

th

e fe

we

st c

ases

re

po

rted

in a

ny

Ap

ril -

Th

ere

was

1 M

RSA

.

SUIs

– t

he

nu

mb

er r

epo

rted

sig

nif

ican

tly

incr

ease

d in

Ap

ril a

s a

resu

lt o

f re

tro

spec

tive

inci

den

ts a

risi

ng

fro

m t

he

Tru

st c

om

mis

sio

ned

Mat

ern

ity

Rev

iew

– A

mee

tin

g w

ith

CC

Gs

is t

akin

g p

lace

in M

ay t

o a

gree

th

e st

atu

s o

f e

ach

inci

den

t.

Har

m F

ree

Car

e -

A K

PI h

as b

een

ad

ded

to

th

is m

on

th’s

re

po

rt. T

he

TDA

has

his

tori

cally

ap

plie

d a

bla

nke

t ta

rget

of

95

% a

nd

hig

hlig

hte

d n

on

-co

mp

lian

ce w

ith

th

is t

arge

t in

th

eir

mo

nth

ly O

vers

igh

t &

Esca

lati

on

rep

ort

. A lo

cal t

arge

t w

ill b

e ag

ree

d (

the

TDA

is r

evie

win

g th

e 1

5-1

6 t

arge

t).

The

Har

m F

ree

care

KP

Is a

re a

mo

ngs

t th

e su

ite

of

nu

rsin

g m

etri

cs t

hat

are

bei

ng

dep

loye

d t

o im

pro

ve w

ard

leve

l qu

alit

y o

f ca

re p

erfo

rman

ce a

nd

re

po

rted

to

th

e N

urs

ing

& M

idw

ifer

y P

erfo

rman

ce m

eeti

ng.

Han

do

ver

of

care

co

mm

un

icat

ion

– S

ign

ific

ant

imp

rove

men

t in

14

-15

res

ult

ed in

th

e Tr

ust

ach

ievi

ng

com

plia

nce

wit

h t

he

inp

atie

nt

stan

dar

d f

or

the

firs

t ti

me.

Su

pp

ort

ed

by

the

PM

O, w

ork

is o

ngo

ing

to s

ust

ain

ach

ieve

men

t o

f th

e in

pat

ien

t st

and

ard

an

d im

pro

ve o

utp

atie

nt

per

form

ance

.

2 in

tern

al c

ance

r q

ual

ity

KP

Is h

ave

bee

n a

dd

ed t

o t

he

rep

ort

as

area

s fo

r im

pro

vem

ent

– B

oth

are

ab

ou

t h

ow

wel

l can

cer

pat

hw

ay in

form

atio

n is

co

mm

un

icat

ed

by

clin

icia

ns.

Th

e lo

nge

st w

ait

for

an in

com

ple

te c

ance

r le

tte

r w

as 1

6 w

eeks

– A

ll w

aits

are

su

bje

ct t

o a

n e

scal

atio

n p

roce

ss.

The

FFT

KP

I has

bee

n r

evis

ed t

o s

ho

w w

het

her

th

e Tr

ust

is a

n o

utl

ier

for

any

of

the

12 s

core

s u

sin

g th

e TD

A m

eth

od

olo

gy.

Sup

po

rtin

g in

form

atio

n:-

The

Safe

ty T

her

mo

met

er

Har

m F

ree

Car

e –

The

Tru

st is

bet

ter

than

ave

rage

co

mp

ared

to

ac

ute

pro

vid

ers.

The

12

FFT

ind

icat

ors

incl

ud

e 2

qu

esti

on

s (%

lik

ely

to

rec

om

men

d a

nd

% li

kely

to

no

t re

com

men

d)

for

the

follo

win

g se

rvic

es –

(1

) A

&E

(2)

Inp

atie

nt

(3)

Mat

ern

ity

– B

irth

, (4

) M

ater

nit

y A

nte

nat

al (

5)

Mat

ern

ity

– P

ost

nat

al

War

d, (

6)

Mat

ern

ity

– P

ost

nat

al c

om

mu

nit

y –

Tru

st p

erfo

rman

ce f

or

all F

FT K

PIs

is w

ith

in 2

st

and

ard

dev

iati

on

s o

f th

e p

rovi

der

ave

rage

(1

4-1

5 T

DA

met

ho

do

logy

).

The

R /

G r

atin

g fo

r SH

MI h

as b

een

ch

ange

d

to s

ho

w r

ed

if it

is o

uts

ide

of

the

exp

ecte

d

ran

ge

The

follo

win

g in

dic

ato

rs a

re u

nd

er d

evel

op

men

t:

Co

mp

lain

ts

A m

ort

alit

y su

b-s

ecti

on

is b

ein

g d

evel

op

ed

Ind

icat

or

nam

eFr

eq

Targ

et

14-1

5C

urr

en

t

Pe

rf

Dat

a u

p

toTr

en

d

YTD

15-

16

15-1

6

Fore

cast

SHM

I (ro

llin

g ye

ar t

o d

ate

)Q

Exp

ect

ed

1.04

1.05

Sep

-14

n/a

G

HSM

RM

<=10

083

.05

74.1

9D

ec-

14n

/aG

C-D

iff

M<=

5572

1A

pr-

151

G

MR

SAM

06

1A

pr-

151

tbc

Cle

anin

g sc

ore

sM

>=88

.5%

94.7

%95

.2%

Ap

r-15

95.2

%G

% H

arm

Fre

e C

are

- A

ll h

arm

sM

tbc

94.5

%94

.0%

Ap

r-15

94.0

%

Ne

ver

Eve

nts

M0

10

Ap

r-15

0G

Seri

ou

s U

nto

war

d In

cid

en

tsM

tbc

7627

Ap

r-15

Nat

ion

al S

afe

Sta

ffin

g R

AG

Rat

ing

M>=

Blu

en

/aB

lue

Feb

-15

Ne

wn

/aG

Safe

Sta

ffin

g le

vels

- o

vera

ll f

ill

rate

M>=

80%

97.5

%97

.6%

Ap

r-15

97.6

%G

Nu

mb

er o

f w

ard

s b

elo

w 8

0%

fil

l ra

teM

n/a

60

Ap

r-15

0

Han

do

ver

of

care

co

mm

(IP

<24h

r)M

>=95

%92

.7%

95.1

%M

ar-1

5n

/aG

Han

do

ver

of

care

co

mm

(O

P<1

0dy)

M>=

95%

84.9

%80

.3%

Mar

-15

n/a

Mar

-16

Inco

mpl

ete

canc

er p

athw

ay le

tter

s M

049

13A

pr-

15n

/a

Op

en

can

cer

pat

hw

ay s

tep

do

wn

sM

074

83A

pr-

15n

/a

Re

adm

issi

on

s ra

te (

28 d

ay)

Q<=

100

111

111

Jul-

Sep

111

tbc

Mix

ed

Se

x A

cco

mm

od

atio

nM

00

0A

pr-

150

G

FTT

- P

atie

nt

fee

db

ack

targ

ets

me

tM

12N

ew

12M

ar-1

5N

ew

n/a

G

Item

6a

Page 23 of 196

(4

.3)

Fo

cu

s o

n E

lec

tive

Ac

ce

ss

Performance

All

3 R

TT t

arge

ts w

ere

ach

ieve

d f

or

the

7th

mo

nth

.

The

Dia

gno

stic

6 w

eek

targ

et w

as m

isse

d in

Ap

ril d

ue

to in

crea

ses

in c

ance

r d

eman

d a

nd

med

ical

wo

rkfo

rce

cap

acit

y co

nst

rain

ts li

mit

ing

incr

ease

s in

cap

acit

y to

mee

t th

e in

crea

sed

sco

pin

g d

eman

d –

Clin

ical

ly u

rgen

t w

ork

is b

ein

g p

rio

riti

sed

.

The

Ove

rall

No

n-A

dm

itte

d b

ackl

og

red

uce

d in

Mar

-15

- G

astr

o N

on

-Ad

mit

ted

an

d 6

we

ek d

iagn

ost

ic t

arge

ts r

emai

n r

isks

du

e to

an

inab

ility

to

re

cru

it t

he

med

ical

wo

rkfo

rce

that

was

pla

nn

ed f

or

Q4

an

d r

eq

uir

ed t

o m

eet

incr

ease

d s

pec

ialt

y d

eman

d –

Su

bje

ct t

o im

ple

men

tati

on

of

pla

ns

to

mit

igat

e sh

ort

falls

in m

edic

al w

ork

forc

e ca

pac

ity,

it w

ill t

ake

6 m

on

ths

to m

eet

the

targ

et.

Ther

e w

ere

35

sp

ecia

lty

targ

et p

asse

s an

d 9

sp

ecia

lty

targ

et f

ails

incl

ud

ing:

Gas

tro

(In

com

ple

te),

Gen

eral

Su

rger

y (a

ll 3

), U

rolo

gy (

No

n-A

dm

itte

d),

T&

O (

Ad

mit

ted

+ N

on

-Ad

mit

ted

), E

NT

(A

dm

itte

d +

No

n-A

dm

itte

d).

All

spec

ialt

y b

ackl

ogs

we

re w

ith

in t

ole

ran

ce a

t m

on

th e

nd

exc

ept:

EN

T an

d

Gen

eral

Su

rger

y –

ENT

bac

klo

gs h

ave

rem

ain

ed t

he

sam

e (6

ab

ove

to

lera

nce

) an

d G

en

eral

Su

rger

y h

as r

edu

ced

by

6 (

49

abo

ve t

ole

ran

ce).

Bo

th

spec

ialt

ies

hav

e ex

per

ien

ced

sit

e b

ed p

ress

ure

s. G

ener

al S

urg

ery

/ C

olo

rect

al is

als

o b

ein

g ad

vers

ely

affe

cted

by

Gas

tro

cap

acit

y p

ress

ure

s. –

It is

an

tici

pat

ed t

hat

a r

edu

ctio

n o

f b

ackl

ogs

will

res

ult

in s

pec

ialt

y le

vel t

arge

t fa

ils f

or

thes

e sp

ecia

ltie

s d

uri

ng

Q1

of

15

-16

. Up

dat

es h

ave

bee

n

pro

vid

ed t

o C

CG

s.

B

ench

mar

ks (

Mar

-15)

Nat

ion

al p

erfo

rman

ce r

emai

ns

bel

ow

tar

get

Ad

mit

ted

- E

ng

86

.8%

, (fa

il) w

ith

87

ou

t o

f 1

67

fai

ling

– 5

GM

tru

sts

faile

d

No

n-a

dm

itte

d E

ng

95

.1%

wit

h 5

5 o

ut

of

195

fai

ling

– 4

GM

tru

sts

faile

d

Inco

mp

lete

– E

ng

93

.1%

wit

h 4

0 o

ut

of

194

faili

ng

– 2

GM

tru

sts

faile

d

52

wee

ks –

En

g to

tal 4

71

acro

ss 4

5 p

rovi

der

s –

GM

9 a

cro

ss 1

pro

vid

er

6 w

eeks

dia

gno

stic

– E

ng

1.5

% (

fail)

wit

h 8

5 f

ails

ou

t o

f 3

84 p

rovi

der

s –

4 G

M f

ails

Ele

ctiv

e A

cce

ss S

tan

dar

ds

Fre

qTa

rge

t14

-15

Cu

rre

nt

Pe

rf

Dat

a u

p

toTr

en

dY

TD

RTT

- A

dm

itte

dM

>=90

%87

.491

.0A

pr-

1591

.0

RTT

- N

on

-Ad

mit

ted

M>=

95%

96.0

96.7

Ap

r-15

96.7

RTT

Inco

mp

lete

M>=

92%

94.6

96.9

Ap

r-15

96.9

Nu

mb

er

of

RTT

sp

eci

alty

fai

lsM

015

29

Ap

r-15

9

RTT

- 5

2 w

ee

k In

com

ple

teM

00

0A

pr-

150

Ad

mit

ted

bac

klo

gM

<=35

021

823

7A

pr-

1523

7

No

n-A

dm

itte

d b

ackl

og

M<=

1345

494

354

Ap

r-15

354

6 w

ee

k d

iagn

ost

icM

<1%

0.4

2.3

Ap

r-15

2.3

Tota

l in

com

ple

te p

ath

way

sM

n/a

M24

,857

Ap

r-15

24,8

57

0

20

0

40

0

60

0

80

0

1,0

00

21-Sep-14

05-Oct-14

19-Oct-14

02-Nov-14

16-Nov-14

30-Nov-14

14-Dec-14

28-Dec-14

11-Jan-15

25-Jan-15

08-Feb-15

22-Feb-15

08-Mar-15

22-Mar-15

05-Apr-15

19-Apr-15

03-May-15

Ad

mit

ted

Ba

cklo

g

To

lera

nc

e

Tra

jec

tory

To

tal

02

00

40

06

00

80

01

,00

01

,20

01

,40

01

,60

0

30-Mar-14

30-Apr-14

31-May-14

30-Jun-14

31-Jul-14

31-Aug-14

30-Sep-14

31-Oct-14

30-Nov-14

31-Dec-14

31-Jan-15

28-Feb-15

31-Mar-15

30-Apr-15

No

n-A

dm

itte

d B

ack

log

To

lera

nce

Tra

ject

ory

To

tal

Page 24 of 196

(4

.3)

Fo

cu

s o

n C

an

ce

r A

cc

es

s

Performance

The

Tru

st a

chie

ved

all

of

the

nat

ion

al c

ance

r ta

rget

s m

on

ito

red

by

the

TDA

in M

arch

, bu

t m

isse

d t

he

62

day

scr

een

ing

targ

et f

or

Q4

du

e to

2

un

avo

idab

le p

atie

nt

pat

hw

ay b

reac

hes

(o

ne

was

a la

te r

efer

ral f

rom

an

oth

er t

rust

aft

er d

ay 6

2 a

nd

th

e o

ther

was

fo

r cl

inic

al r

easo

ns)

.

The

loca

l Gre

ater

Man

ches

ter

62

GP

rea

lloca

ted

per

form

ance

tar

get

for

Jan

-15

was

no

t ac

hie

ved

an

d it

is a

nti

cip

ate

d t

hat

it w

ill m

iss

for

Feb

-15–

C

linic

al p

ath

way

var

iati

on

is a

co

ntr

ibu

tory

fac

tor

that

has

bee

n id

enti

fied

th

rou

gh b

reac

h a

nal

ysis

.

2w

w d

eman

d a

cro

ss a

ll tu

mo

ur

site

fo

r Q

3 o

f 2

014

-15

incr

ease

d b

y 1

9%

co

mp

ared

to

Q3

of

20

13-1

4 –

Nat

ion

al d

eman

d (

stan

dar

dis

ed f

or

the

Tru

st’s

cas

e m

ix)

incr

ease

d b

y 1

2%

. Po

ten

tial

ch

ange

s in

NIC

E gu

idel

ines

du

rin

g 1

5-1

6 m

ay c

on

trib

ute

to

fu

rth

er in

crea

ses

in c

ance

r d

eman

d.

The

can

cer

imp

rove

men

t p

lan

(d

iscu

ssed

wit

h T

DA

an

d c

om

mis

sio

ner

s) is

bei

ng

imp

lem

ente

d. A

tra

ject

ory

of

refe

rral

s re

ceiv

ed f

rom

Dec

emb

er

has

bee

n a

gree

d f

or

the

62

day

tar

get

and

was

met

fo

r Ja

n-1

5, F

eb-1

5, a

nd

Mar

-15

. Th

e m

ain

co

mp

on

ents

of

the

pla

n a

re: (

1)

imp

rove

men

t in

sy

stem

s an

d p

roce

sses

(2

) cl

ear

clin

ical

dec

isio

n m

akin

g b

y co

nsu

ltan

ts, (

3)

incr

ease

d c

ance

r ca

pac

ity

at t

he

fro

nt

of

the

pro

cess

, in

par

ticu

lar

focu

ssed

in a

reas

wh

ere

can

cer

awar

enes

s ca

mp

aign

s ar

e d

ue.

The

Inte

nsi

ve S

up

po

rt T

eam

has

als

o b

een

invi

ted

to

rev

iew

sys

tem

s an

d p

roce

sses

– T

he

IST

rep

ort

will

be

com

ple

ted

in J

un

e.

It is

pre

dic

ted

th

at a

ll 9

can

cer

stan

dar

ds

will

be

met

fro

m J

uly

on

war

ds.

Follo

win

g En

glan

d’s

fai

lure

of

the

nat

ion

al 6

2 d

ay G

P r

efe

rral

tar

get

for

the

fift

h c

on

secu

tive

qu

arte

r th

e TD

A in

tro

du

ced

wee

kly

can

cer

PTL

re

po

rtin

g co

mm

enci

ng

20

th M

ay f

or

all o

f it

s p

rovi

der

s.

Nat

ion

al B

ench

mar

kin

g (Q

4):

–

Nat

ion

al p

erfo

rman

ce w

as s

imila

r to

Q3

:-

2 w

w –

En

g 9

4.7

% -

(24

pro

vid

er f

ails

)– N

o G

M f

ails

Bre

ast

2w

w -

En

g 9

4.7

% (

21 f

ails

) –

No

GM

fai

ls

31

day

fir

st –

En

g 9

7.5

%, (

18

fai

ls)

- N

o G

M f

ails

31

day

dru

g –

Eng

99

.5%

(9

fails

) -

No

GM

fai

ls

31

day

su

rger

y –

Eng

94

.9%

(31

fai

ls)

– N

o G

M f

ails

62

day

GP

nat

ion

al –

En

g 8

2.3

% (

fail

for

5th

co

nse

cuti

ve q

uar

ter)

(8

3 f

ails

) -

1 G

M t

rust

s fa

il

62

day

scr

een

ing

– En

g 9

1.4

% (

51 f

ails

) –

5 G

M f

ails

62

day

up

grad

e –

Eng

89

.4%

- n

o n

atio

nal

tar

get

62

day

loca

l rea

lloca

ted

GM

sta

nd

ard

- J

an-1

5

62

day

rea

lloca

ted

– E

ng

n/a

–G

M 8

4.4

% (

fail)

- 5

G

M f

ails

Can

cer

Acc

ess

Sta

nd

ard

sFr

eq

Targ

et

Last

year

Cu

rre

nt

Pe

rf

Dat

a u

p

toTr

en

dY

TDQ

1Q

2Q

3Q

4

2 w

ee

k A

ll c

ance

rsM

>=93

%96

.897

.2Fe

b-1

595

.295

.295

.195

.295

.5

2 w

ee

k b

reas

t sy

mp

tom

atic

M>=

93%

93.8

98.7

Feb

-15

93.2

89.3

93.0

94.6

97.7

31 d

ay in

itia

l de

cisi

on

to

tre

atM

>=96

%99

.710

0.0

Feb

-15

99.8

99.8

99.8

99.8

99.6

31 s

ay s

ub

seq

ue

nt

dru

gM

>=98

%99

.710

0.0

Feb

-15

100.

010

0.0

100.

010

0.0

100.

0

31 d

ay s

ub

seq

ue

nt

surg

ery

M>=

94%

99.7

100.

0Fe

b-1

510

0.0

100.

010

0.0

100.

010

0.0

62 d

ay G

P r

efe

rre

d n

atio

nal

M>=

85%

89.3

81.5

Feb

-15

85.3

85.6

85.1

85.9

83.8

62 d

ay G

P r

efe

rre

d r

e-a

llo

cate

dM

>=85

%86

.481

.9Ja

n-1

580

.082

.078

.979

.181

.9

62 d

ay s

cre

en

ing

M>=

90%

92.9

71.4

Feb

-15

94.9

94.1

100.

091

.984

.6

62 d

ay u

rge

nt

up

grad

eM

>=85

%91

.189

.7Fe

b-1

588

.488

.189

.387

.281

.9

20

14

-15

Item

6a

Page 25 of 196

(4

.3)

Fo

cu

s o

n U

rge

nt

Ca

re A

cc

es

s

Performance K

ey p

oin

ts:

The

4 h

ou

r ta

rget

was

ach

ieve

d f

or

Q1

an

d Q

2 o

f 1

4-1

5. W

hils

t p

erfo

rman

ce h

as im

pro

ved

th

e ta

rget

was

mis

sed

fo

r th

e la

st 7

mo

nth

s.

Pre

ssu

res

rem

ain

hig

h a

cro

ss t

he

hea

lth

eco

no

my

as a

re

sult

of:

-

o

Hig

her

dem

and

acu

ity,

wh

ich

has

co

ntr

ibu

ted

to

ext

end

ed le

ngt

hs

of

stay

s

o

Del

ayed

dis

char

ges,

wh

ich

bu

ilt u

p o

ver

the

win

ter

ho

liday

per

iod

hav

e su

bse

qu

entl

y n

ot

bee

n c

lear

ed –

Th

ere

are

curr

entl

y 1

47

m

edic

ally

fit

pat

ien

ts in

th

e d

isch

arge

pro

cess

acr

oss

th

e h

osp

ital

sit

es,

wh

ich

is c

irca

30

% h

igh

er t

han

it w

as la

st y

ear.

14

7 p

atie

nts

in t

he

dis

char

ge p

roce

ss e

qu

ate

s to

19%

of

the

Med

ical

bed

sto

ck. A

cute

bed

occ

up

ancy

incr

ease

d f

rom

88

% in

Q3

to

91

% in

Q4

, hig

her

th

an t

he

reco

mm

end

ed 8

5% t

o c

op

e w

ith

dem

and

an

d f

low

vo

lati

lity.

Del

ays

attr

ibu

tab

le t

o s

oci

al c

are

asse

ssm

ents

rem

ain

an

issu

e, w

hic

h is

b

ein

g e

scal

ated

acr

oss

th

e h

ealt

h e

con

om

y. T

he

TDA

has

ad

op

ted

th

e Tr

ust

’s a

pp

roac

h a

nd

inst

itu

ted

we

ekly

rep

ort

ing

of

pat

ien

ts

med

ical

ly f

it f

or

dis

char

ge f

or

all o

f it

s p

rovi

der

s co

mm

enci

ng

20

th M

ay.

The

pla

n a

gree

d w

ith

th

e TD

A t

o im

ple

men

t “T

he

Per

fect

We

ek”

init

iati

ve s

tart

ing

in J

un

-15

on

a s

ite

-by-

site

ro

tati

on

al b

asis

is b

ein

g p

rogr

esse

d.

Fro

m r

evie

w o

f fi

nd

ings

wh

ere

this

init

iati

ve h

as a

lrea

dy

bee

n u

sed

, it

is a

nti

cip

ated

th

at t

he

ou

tco

mes

of

“Th

e P

erfe

ct W

eek”

will

hig

hlig

ht

the

nee

d t

o m

eet

bes

t p

ract

ice

stan

dar

ds

that

th

e Tr

ust

is a

war

e o

f fr

om

wo

rk p

revi

ou

sly

un

der

take

n w

ith

EC

IST.

E.g

., A

ccu

rate

est

imat

ed

dat

e o

f d

isch

arge

; ou

tco

me

focu

ssed

dai

ly b

oar

d r

ou

nd

s in

th

e m

orn

ing;

ad

her

ence

to

Inte

rnal

Pro

fess

ion

al S

tan

dar

ds

by

clin

ical

te

ams;

tim

ely

asse

ssm

ent

at t

he

fro

nt

do

or

(A&

E); d

isch

arge

pro

cess

es c

om

ple

ted

ear

lier

in t

he

day

; rev

iew

of

pat

ien

ts s

tayi

ng

mo

re t

han

a w

eek.

Act

ion

s su

pp

ort

ed b

y th

e n

atio

nal

Sys

tem

Res

ilien

ce f

un

din

g w

ill g

rad

ual

ly c

ease

du

rin

g M

ay.

Nu

rsin

g va

can

cies

acr

oss

inp

atie

nt

med

ical

ser

vice

s an

d A

&E

med

ical

wo

rkfo

rce

vaca

nci

es c

on

tin

ue

to b

e an

issu

e.

The

Tru

st is

co

nti

nu

ing

to w

ork

wit

h h

ealt

h e

con

om

y p

artn

ers

at t

he

syst

em R

esili

ence

Gro

up

Mee

tin

gs a

nd

dai

ly e

scal

atio

n c

alls

to

exp

edit

e

issu

es a

nd

imp

rove

per

form

ance

. It

is p

red

icte

d t

hat

th

e A

&E

targ

et w

ill b

e ac

hie

ved

fro

m O

ct-1

5.

Ben

chm

arki

ng

(Ap

r-1

5)

Engl

and

per

form

ance

was

93

.31

% (

fail)

, wit

h 9

8

fails

fro

m 1

40

pro

vid

es w

ith

a t

ype

1 A

&E

– 5

of

the

8 G

M p

rovi

der

s fa

iled

Engl

and

per

form

ance

was

bel

ow

th

e 9

5%

tar

get

for

the

8th

co

nse

cuti

ve m

on

th -

per

form

ance

fo

r th

e ye

ar w

as 9

3.3

1%

- p

erfo

rman

ce w

as 9

5.2

1%

fo

r th

e p

revi

ou

s ye

ar

In M

arch

En

glan

d r

epo

rted

52

bre

ach

es o

f th

e 1

2

ho

ur

tro

lley

wai

t st

and

ard

– G

M h

ad n

o b

reac

hes

o

f th

e st

and

ard

Urg

en

t C

are

Acc

ess

Sta

nd

ard

sFr

eq

Targ

et

14-1

5C

urr

en

t

Pe

rf

Dat

a u

p

toTr

en

dQ

2Q

3Q

4Y

TDQ

1

4 h

ou

r Tr

ust

urg

en

t ca

reM

>=95

%93

.691

.5A

pr-

1595

.191

.592

.291

.591

.5

4 h

ou

r FG

H u

rge

nt

care

M>=

95%

90.2

84.6

Ap

r-15

93.5

85.7

88.0

84.6

84.6

4 h

ou

r R

OH

urg

en

t ca

reM

>=95

%91

.491

.2A

pr-

1593

.788

.589

.791

.291

.2

4 h

ou

r N

MG

H u

rge

nt

care

M>=

95%

95.2

92.4

Ap

r-15

95.2

94.3

94.3

92.4

92.4

4 h

ou

r R

I urg

en

t ca

reM

>=95

%98

.598

.1A

pr-

1599

.398

.098

.398

.198

.1

12 h

ou

r tr

oll

ey

wai

tsM

00

0A

pr-

150

00

00

2014

-15

2015

-16

Page 26 of 196

(4

.4)

Fo

cu

s o

n F

ina

nc

e

Finance

The

fin

al 2

015/

16 A

nn

ual

Fin

anci

al P

lan

was

su

bm

itte

d t

o t

he

NH

S Tr

ust

Dev

elo

pm

ent

Au

tho

rity

on

14

th M

ay 2

01

5 f

ore

cast

ing

a ye

ar e

nd

def

icit

o

f £

25.8

m, c

om

par

ed t

o t

he

bre

akev

en p

osi

tio

n r

epo

rte

d a

t th

e en

d o

f 2

014

-15

.

The

un

der

lyin

g d

efic

it h

as d

eter

iora

ted

by

£8

.4m

fro

m £

20

.7m

in 2

01

4-1

5 t

o a

yea

r e

nd

fo

reca

st o

f £

29.1

m in

201

5-1

6.

The

thre

e ke

y ar

eas

for

the

Tru

st t

o f

ocu

s o

n a

re: e

nsu

rin

g d

eliv

ery

of

inco

me

wit

hin

del

egat

ed

bu

dge

ts; d

eliv

ery

of

£3

3.8

m C

IP; a

nd

clo

se

mo

nit

ori

ng

of

the

cash

po

siti

on

.

The

Co

nti

nu

ity

of

Serv

ice

Ris

k R

atin

g ye

ar t

o d

ate

has

red

uce

d t

o 2

, an

d a

fo

reca

st y

ear

en

d r

atin

g o

f 1

- b

oth

of

wh

at a

re b

elo

w t

he

rati

ng

of

3

req

uir

ed o

f as

pir

ant

FTs

* I &

E S

urp

lus/

(Def

icit

) b

efo

re im

pai

rmen

ts a

nd

tec

hn

ical

ad

just

men

ts

Div

isio

nal

per

form

ance

aga

inst

201

5-1

6 C

IP t

arge

t o

f £

33

.8m

Fin

anci

al t

arge

ts: T

he

Tru

st r

epo

rte

d a

£3

.3m

def

icit

wh

ich

is £

0.5

m b

elo

w

pla

n a

t th

e en

d o

f A

pri

l 20

15.

Tota

l in

com

e p

osi

tio

n a

t M

on

th 1

sh

ow

s an

un

der

per

form

ance

of

£0

.8m

Mai

nly

du

e to

un

der

per

form

ance

aga

inst

Pb

R e

xclu

ded

hig

h c

ost

d

rugs

, wh

ich

are

fu

nd

ed o

n ‘p

ass

thro

ugh

’ bas

is (

off

sets

exp

end

itu

re)

Po

siti

on

ass

um

es t

hat

th

e Tr

ust

has

ach

ieve

d it

co

ntr

acte

d a

ctiv

ity.

H

ow

ever

, ear

ly in

dic

atio

ns

are

ther

e m

ay b

e u

nd

er p

erfo

rman

ce -

Th

is

will

be

valid

ated

an

d r

ep

ort

ed

in t

he

Mo

nth

2 f

inan

ce r

epo

rt.

Op

era

tin

g e

xpe

nd

itu

re p

osi

tio

n s

ho

ws

an u

nd

er s

pen

d o

f £

0.2

m.

Ho

wev

er, t

his

incl

ud

es:

CIP

an

d d

eco

mm

issi

on

ing

slip

pag

e o

f £

0.6

m; a

nd

No

n p

ay b

ud

get

ove

rsp

end

of

£0

.3m

mai

nly

in m

edic

al a

nd

su

rgic

al

con

sum

able

s (e

xclu

din

g u

nd

er-s

pen

d o

n P

bR

exc

lud

ed h

igh

co

st d

rugs

o

ffse

t b

y in

com

e).

Pay

bu

dge

ts h

ow

ever

, are

un

der

-sp

ent

by

£0

.4m

mai

nly

du

e to

si

gnif

ican

t n

um

ber

of

vaca

nci

es m

ain

ly in

Co

rpo

rate

an

d D

iagn

ost

ics.

Th

e p

osi

tio

n in

clu

des

a r

ise

in a

gen

cy s

pen

d b

y £0

.4m

ab

ove

pla

n.

Ris

ks o

P

rem

ium

co

sts

staf

f b

oth

nu

rsin

g an

d m

edic

al

o

Man

agin

g co

st o

f n

urs

ing

inve

stm

ents

wit

hin

th

e fu

nd

ing

iden

tifi

ed f

or

20

15-1

6

o

The

del

iver

y in

fu

ll o

f th

e £

33

.8m

CIP

tar

get

o

Del

iver

y o

f co

ntr

act

KP

Is a

nd

CQ

UIN

s

Pla

n (

£'m

)

Actu

al

(£'m

)

Va

ria

nce

£'m

I&E

Surp

lus/(

Defic

it)

-2.8

-3.3

-0.5

Capital E

xpenditure

1.1

0.9

0.2

Cash B

ala

nce

51.1

44.4

-6.7

Item

6a

Page 27 of 196

(4

.5)

Fo

cu

s o

n W

ork

forc

e

Workforce

Seve

ral i

nte

r-re

late

d W

ork

forc

e K

PIs

co

nti

nu

e to

be

mis

sed

. o

O

ngo

ing

vaca

nci

es h

ave

incr

ease

d s

ince

last

mo

nth

as

a re

sult

of

an in

crea

se in

est

ablis

hm

ent

(46

FTE

) an

d a

dec

reas

e o

f st

aff

actu

ally

in

po

st (

16

FTE)

.

o

S&A

incr

ease

d s

ince

last

mo

nth

, was

hig

her

th

an A

pri

l 20

14

, an

d m

isse

d t

he

seas

on

ally

pro

file

d t

arge

t.

o

Spen

d o

n t

emp

ora

ry s

taff

ing

rem

ain

s h

igh

wit

h t

he

incr

ease

ove

r th

e la

st y

ear

bei

ng

dri

ven

by

agen

cy s

taff

ing.

o

St

aff

Frie

nd

s an

d F

amily

Tes

t St

aff

FFT

resu

lts

Q4

imp

rove

d f

or

bo

th in

dic

ato

rs, w

ith

th

e re

com

men

dat

ion

fo

r tr

eatm

ent

hit

tin

g 7

1%

(ab

ove

tar

get)

an

d r

eco

mm

end

atio

n a

s a

pla

ce t

o w

ork

bei

ng

bel

ow

tar

get

at 5

9%.

Imp

rovi

ng

atte

nd

ance

an

d r

ecru

itm

ent

and

ret

enti

on

are

hig

h p

rio

riti

es f

or

new

act

ion

in o

rder

to

en

sure

: (1

) su

stai

ned

qu

alit

y o

f ca

re;

(2)

per

form

ance

tar

gets

are

met

; (3

) th

e in

crea

sin

g sp

end

ing

on

tem

po

rary

sta

ff is

ad

dre

ssed

. New

act

ion

s in

clu

de:

o

Th

e ‘P

rid

e in

Pen

nin

e’ C

EO c

hal

len

ge e

ven

t o

n “

Hea

lth

an

d A

tten

dan

ce”

– A

pla

n w

ill b

e d

raft

ed a

nd

pu

blis

hed

at

the

end

of

May

bas

ed

on

sta

ff e

nga

gem

ent

resp

on

ses

at t

he

May

larg

e m

eeti

ng

and

th

e o

nlin

e w

ork

sho

p w

hic

h r

an d

uri

ng

Mar

ch a

nd

Ap

ril.

o

Rec

ruit

men

t in

itia

tive

s ar

e al

so o

ngo

ing

A

nn

ual

S&

A b

ench

mar

kin

g d

ata

(20

13-1

4)

so

urc

e i-

view

NH

S En

glan

d w

ide

3.9

5%, N

HS

Engl

and

Acu

te P

rovi

der

s 3

.73

%

No

rth

Wes

t re

gio

n a

ll p

rovi

der

s 4

.44

%,

Ind

icat

or

nam

eFr

eq

Targ

et

14-1

5C

urr

en

t

Pe

rf

Dat

a u

p

toTr

en

d

YTD

15-

16

15-1

6

Fore

cast

Ban

k &

Age

ncy

Sp

en

dM

<=8%

11.0

%11

.3%

Ap

r-15

11.3

%tb

c

S&A

- T

ota

lM

<=4.

2%5.

67%

5.65

%A

pr-

155.

65%

tbc

S

&A

- S

ho

rt T

erm

Mn

/a2.

74%

2.74

%A

pr-

152.

74%

S

&A

Lo

ng

Term

Mn

/a2.

91%

2.91

%A

pr-

152.

91%

Turn

ove

r R

ate

M>=

8 &

<=1

1%9.

72%

9.94

%M

ay-A

pr

n/a

G

Staf

f FF

T -

reco

mm

en

d t

reat

me

nt

Q>=

67%

65%

71%

Jan

-Mar

n/a

G

Staf

f FF

T -

reco

mm

en

d a

s p

lace

to

wo

rkQ

>=61

%56

%59

%Ja

n-M

arn

/atb

c

Man

dat

ory

tra

inig

- A

ll s

taff

M>=

85%

89%

88%

Ap

r-15

n/a

G

PD

R c

om

ple

tio

n (

12 m

on

th r

oll

ing)

Q>=

90%

68%

68%

Ap

r-M

arn

/atb

c

Vac

ancy

Rat

eM

n/a

9.29

%9.

94%

Ap

r-15

n/a

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Apr-13May-13Jun-13Jul-13

Aug-13Sep-13Oct-13

Nov-13Dec-13Jan-14Feb-14Mar-14Apr-14

May-14Jun-14Jul-14

Aug-14Sep-14Oct-14

Nov-14Dec-14Jan-15Feb-15Mar-15Apr-15

S&

A %

Ra

te O

ve

r T

ime

To

tal

S&

A r

ate

Sh

ort

Te

rm r

ate

Lo

ng

te

rm r

ate

0%

2%

4%

6%

8%

10%

12%

14%

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

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

Ban

k &

Age

ncy

Sp

en

d a

s a

% o

f To

tal P

ay

% T

arge

t le

vel

% b

ank

and

age

ncy

rate

Page 28 of 196

(4

.6)

Fo

cu

s o

n R

eg

ula

tor

Pers

pe

cti

ve

s

CQ

C I

nte

llig

en

t M

on

ito

rin

g R

ep

ort

- P

ub

lis

he

d M

ay 2

01

5 (

So

urc

e:

CQ

C)

The C

QC

cate

gorises tru

sts

into

one o

f 6 s

um

mary

bands,

with b

and 1

repre

senting

hig

hest risk a

nd b

and 6

with t

he low

est. T

hese b

ands h

ave

been a

ssig

ned b

ased o

n t

he p

roport

ion o

f in

dic

ato

rs that have b

een identified a

s ‘risk’ or

‘ele

vate

d r

isk’ or

if there

are

know

n s

erious c

oncern

s

(e.g

. tr

usts

in s

pecia

l m

easure

s)

trusts

are

cate

gorised a

s b

and 1

*. F

or

the tru

sts

assig

ned a

cate

gory

based o

n the p

roport

ion o

f in

dic

ato

rs,

the

CQ

C h

as u

sed the follo

win

g thre

shold

s:

Perc

enta

ge s

core

(ro

w 7

in t

able

belo

w)

Band 1

>=

7.0

%, B

and 2

>=

5.5

%, B

and 3

>=

4.5

%, B

and 4

>

=3.5

%,

Band 5

>=

2.5

%,

Band 6

<2.5

%

1

Pri

ori

ty b

an

din

g f

or

ins

pe

cti

on

6

(L

ow

est

ris

k b

an

din

g)

Ba

nd

6 r

ati

ng

fo

r 4

co

ns

ec

uti

ve

qu

art

ers

1

Nu

mb

er

of

‘Ele

va

ted r

isks’

1

Nu

mb

er

of

risks e

xce

ed

ing

th

e ‘e

leva

ted

’ th

resh

old

s

2

Nu

mb

er

of

risks

2

Nu

mb

er

of

risks id

en

tio

fie

d t

hat

do n

ot e

xce

ed

th

e ‘e

leva

ted

’ th

resh

old

3

Ov

era

ll s

co

re

4

Nu

mb

er

of

risks +

2 x

Nu

mb

er

of

Ele

va

ted

ris

ks

4

Nu

mb

er

of

app

lica

ble

in

dic

ato

rs

96

N

um

ber

of

indic

ato

rs t

hat

are

ap

plic

ab

le to

th

e T

rust

for

the

se

rvic

es it

pro

vid

es

5

Maxim

um

possib

le s

co

re

192

T

he s

co

re t

hat

the

Tru

st

wo

uld

re

ce

ive

if

it h

ad f

lag

ged

as e

leva

ted r

isk fo

r e

ve

ry s

ingle

a

pp

lica

ble

in

dic

ato

r in

th

e m

ode

l (r

ow

4 x

2)

6

Pe

rcen

tag

e s

co

re

2.0

8%

O

ve

rall

risk s

co

re (

row

3)

/ m

axim

um

possib

le s

co

re (

row

5)

De

tails

of

ris

ks

C

om

me

nt

1

Ele

va

ted

Ris

k

NH

S S

taff

Su

rve

y –

KF

9 T

he p

rop

ort

ion

of

sta

ff r

ece

ivin

g s

up

port

fro

m im

me

dia

te m

ana

ge

rs (

1 S

ep

-14

to

31 D

ec-1

4)

Ne

w r

isk

2

Ris

k

Co

mp

osite

in

dic

ato

r: I

n-h

osp

ita

l m

ort

alit

y -

Pa

ed

iatr

ic a

nd c

on

gen

ita

l d

iso

rde

rs a

nd

pe

rin

ata

l m

ort

alit

y

R

isk r

edu

ce

d

from

Ele

va

ted

3

Ris

k

Co

mp

osite

ris

k r

atin

g f

or

Sic

kn

ess A

bse

nce

(so

urc

e E

SR

1 J

an

-14 –

31

De

ce

mb

er-

14)

– [5

out

of

6 s

ub-i

nd

ica

tors

mis

se

d]

Exis

tin

g r

isk

Deta

ils

of

ris

ks

re

mo

ve

d s

inc

e t

he D

ec

em

ber

rep

ort

1.

TD

A e

sca

latio

n s

co

re (

leve

l 2

– in

terv

en

tio

n f

or

Ju

n-1

4)

Item

6a

Page 29 of 196

T

DA

– O

ve

rsig

ht

an

d e

sc

ala

tio

n r

ep

ort

- P

ub

lis

he

d M

arc

h 2

015 (

so

urc

e:

TD

A)

O

utc

om

e o

f m

odera

tion m

eeting

Su

mm

ary

: D

ue t

o f

inancia

l positio

n a

nd a

ccess targ

ets

the T

rust cannot be d

e-e

scala

ted u

ntil suitable

fin

ancia

l pla

ns a

nd a

ccess r

ecovery

tr

aje

cto

ries h

ave b

een p

rovid

ed a

nd im

ple

mente

d.

Qu

ality

: Q

ualit

y T

eam

are

support

ing the T

rust on a

num

ber

of Q

ualit

y I

mpro

vem

ent

are

as,

inclu

din

g f

urt

her

work

to r

espond t

o t

he f

indin

gs

of

the r

ecent exte

rnal m

ate

rnity r

evie

w.

Desk T

op R

evie

w is t

akin

g p

lace o

n t

he 1

3 M

ay 2

015 a

nd the T

rust

aw

aitin

g a

Chie

f In

specto

r of

Hospitals

(C

IH)

inspection d

ate

. T

he T

rust fa

iled

to m

eet

A&

E 4

hour

wait (

92.8

%)

for

Marc

h 2

015. T

he T

rust

did

not m

eet th

e h

arm

fre

e c

are

sta

ndard

(93.9

%)

for

Marc

h 2

015.

Fin

an

ce:

M12 is b

reakeven,

£11.9

m a

head o

f th

e p

lanned d

eficit o

f £11.9

m. T

his

positio

n is d

riven b

y n

ational str

uctu

ral support

fu

ndin

g a

nd

over-

perf

orm

ance o

n n

on e

lective a

ctivity w

hic

h is o

ffset by b

ank a

nd a

gency c

osts

to c

over

sic

kness a

nd a

dditio

nal capacity a

s w

ell

as n

on

-deliv

ery

of

both

work

forc

e a

nd L

OS

CIP

schem

es.

CIP

deliv

ere

d in y

ear

was £

21.4

m; £12.7

m b

ehin

d p

lan a

nd w

ith £

7.7

m d

eliv

ere

d n

on

-re

curr

ently.

Su

sta

inab

ilit

y:

The T

rust m

ust deliv

er

a s

usta

inable

fin

ancia

l pla

n,

a p

ositiv

e o

utc

om

e fro

m a

CIH

s v

isit a

nd a

ccess targ

ets

.

Page 30 of 196

M

on

ito

r R

isk A

ss

es

sm

en

t F

ram

ew

ork

– S

ha

do

w m

on

ito

rin

g r

ep

ort

Ta

rge

tQ

1Q

2Q

3Q

4Q

1P

eri

od

Co

nti

nu

ity o

f S

erv

ice

s R

isk R

ati

ng

42

2.5

3.0

4.0

2.0

Ap

r-1

5

Liq

uid

ity

43

33

43

Ap

r-1

5

Capital serv

icin

g c

apacity

41

23

41

Ap

r-1

5

Gre

en

Re

dR

ed

Re

dR

ed

Re

dV

ar

18 w

eeks A

dm

itte

d [

C]

90%

11

00

0A

pr-

15

18 w

eeks N

on-A

dm

itte

d [

C]

95%

10

00

0A

pr-

15

18 w

eeks Incom

ple

te [

C]

92%

00

00

0A

pr-

15

A&

E 4

hours

[D

]95%

00

11

1A

pr-

15

GP

refe

rred

85%

Scre

enin

g r

efe

rred

90%

Surg

ery

94%

Dru

gs

98%

31 d

ay c

ancer

initia

l tr

eatm

ent

96%

00

00

n/a

Ma

r-1

5

GP

refe

rred

93%

Bre

ast

sym

pto

matic

93%

C-

Diff

icile

vs o

bje

ctive

61

11

11

0A

pr-

15

refe

rral to

tre

atm

ent

info

50%

refe

rral in

fo50%

treatm

ent

activi

ty info

50% 0

53

33

2V

ar

0A

pr-

15

n/a

n/a

n/a

Ma

r-1

5

n/a

Ma

r-1

5

2015-1

6

n/a

Ja

n-1

5

2014-1

5

Finance

Go

ve

rna

nce

Ris

k R

ati

ng

(in

tern

al

ass

ess

me

nt)

ACCESS & OUTCOMES METRICS

62 d

ay

cancer

0

11

11

31 d

ay

cancer

00

2 w

eek

cancer

10

Go

ve

rna

nce

Ris

k R

ati

ng

Sco

re f

or

Acce

ss &

Ou

tco

me

s

Data

com

ple

teness

: com

munity

serv

ices

Cert

ification a

gain

st

com

plia

nce v

s r

equirem

ents

regard

ing

access t

o h

ealth c

are

for

people

with learn

ing d

isabili

tyP

ass

0

n/a

00

0 n/a

n/a

0 0 n/a0

Key

Po

ints

:-

This

sh

ado

w m

on

ito

rin

g re

po

rt is

in

clu

ded

to

fac

ilita

te f

amili

arit

y w

ith

M

on

ito

r’s

asse

ssm

ent

syst

em in

su

pp

ort

of

pro

gres

s to

FT

stat

us.

P

erfo

rman

ce a

gain

st b

oth

Fin

ance

an

d

Acc

ess

& O

utc

om

es M

etri

cs n

eed

s to

su

stai

nab

ly im

pro

ve in

ord

er t

o

pro

gres

s to

FT

stat

us.

Th

e C

oSR

R is

cu

rren

tly

a 2

.0, t

he

year

en

d f

ore

cast

is 1

.0, b

oth

of

wh

ich

are

b

elo

w t

he

sco

re o

f 3

.0 r

equ

ired

fo

r an

as

pir

ant

FT.

Taki

ng

the

mo

st r

ece

nt

per

form

ance

, w

hils

t th

e n

um

ber

of

Acc

ess

&

Ou

tco

mes

fai

ls r

emai

ns

bel

ow

th

e tr

igge

r th

resh

old

of

4, t

he

follo

win

g w

ou

ld t

rigg

er a

red

sta

tus

(1)

A&

E 2

q

uar

ters

fai

led

ou

t o

f la

st 4

; (2

) P

red

icte

d 6

2 d

ay G

P r

eallo

cate

d t

arge

t n

on

-ach

ieve

men

t fo

r 3

or

mo

re

con

secu

tive

qu

arte

rs.

Acc

ess

& O

utc

om

e F

ails

: -

(1)

4 h

ou

r A

&E

(2)

It is

est

imat

ed t

hat

th

e 62

day

GP

loca

l rea

lloca

ted

tar

get

is n

ot

ach

ieve

d Q

4 t

o d

ate

(Ja

n-1

5 d

ata

pu

blis

hed

by

Net

wo

rk)

– it

is a

nti

cip

ate

d t

hat

all

can

cer

targ

ets

will

be

ach

ieve

d f

or

Q2

an

d A

&E

for

Q3

of

15

-16

.

Item

6a

Page 31 of 196

(5)

AP

PE

ND

ICE

S

(Ap

pe

nd

ix 1

) A

cu

te C

on

tra

ct

Pe

rfo

rma

nc

e S

um

mary

Re

po

rt

The a

ssessed f

inancia

l im

pact of

contr

act

KP

Is a

nd C

QU

INs is facto

red into

the T

rust’s f

inancia

l perf

orm

ance

report

s.

Co

ntr

ac

t K

PIs

The T

rust

is c

urr

ently n

ot

achie

vin

g t

he f

ollo

win

g c

ontr

act

KP

Is that pote

ntially

have a

fin

ancia

l penalty:-

1.

MR

SA

(M

1 is 1

) 2.

A&

E 4

hour

targ

et

– 9

5%

(M

1 9

1.5

%)

3.

Am

bula

nce H

andovers

(181 o

ver

30 m

inute

s b

ut le

ss t

han 6

0 m

inute

s,

and 2

5 o

ver

60 m

inute

s)

4.

28 d

ay c

ancelle

d o

pera

tions s

tandard

(1 b

reach Q

1 to d

ate

) 5.

Inpatient ele

ctive d

ischarg

e s

um

maries w

ithin

24 h

ours

(pro

vis

ional in

form

ation t

o b

e v

erified)

CQ

UIN

s 1

4-1

5

The r

isk t

o incom

e is d

ependent

on t

he d

eta

ils o

f in

div

idual C

QU

INs –

96%

of

CQ

UIN

s w

ere

achie

ved f

or

14-1

5,

com

pare

d to 9

6%

in 1

3-1

4.

Q4 e

vid

ence h

as b

een s

ubm

itte

d f

or

r re

vie

w b

y c

om

mis

sio

ners

.

CQ

UIN

s 1

5-1

6

The C

QU

IN v

alu

e is £

11

.1m

. T

he n

ational A

EC

CQ

UIN

(£1.7

m)

has b

een a

gre

ed in p

rincip

le w

ith t

he f

inal deta

ils to b

e a

gre

ed w

ith

com

mis

sio

ners

. A

ll C

QU

IN d

ocum

enta

tion is b

ein

g c

onsolid

ate

d a

nd r

e-r

evie

wed a

s p

art

of th

e a

ssessm

ent

and r

eport

ing

pro

cess.

Page 32 of 196

(A

pp

en

dix

2)

Sa

fe N

urs

ing

& M

idw

ifery

Sta

ffin

g b

y W

ard

Are

a (

Ap

r-15)

Sit

e N

am

e

To

tal

mo

nth

ly

pla

nn

ed

sta

ff h

ou

rs

To

tal

mo

nth

ly

actu

al

sta

ff

ho

urs

To

tal

mo

nth

ly

pla

nn

ed

sta

ff h

ou

rs

To

tal

mo

nth

ly

actu

al

sta

ff

ho

urs

To

tal

mo

nth

ly

pla

nn

ed

sta

ff h

ou

rs

To

tal

mo

nth

ly

actu

al

sta

ff

ho

urs

To

tal

mo

nth

ly

pla

nn

ed

sta

ff h

ou

rs

To

tal

mo

nth

ly

actu

al

sta

ff

ho

urs

Ave

rag

e f

ill

rate

- r

eg

iste

red

nu

rse

s/

mid

wiv

es

(%

)

Ave

rag

e

fill

ra

te -

ca

re s

taff

(%)

Ave

rag

e f

ill

rate

-

reg

iste

red

nu

rse

s/

mid

wiv

es

(%

)

Ave

rag

e

fill

ra

te -

ca

re s

taff

(%)

Bir

ch H

ill H

osp

ital

900

908

1,11

01,

125

600

550

630

630

100.8

%101.4

%91.7

%100.0

%

Fair

fie

ld G

en

era

l Ho

spit

al20

,040

18,9

5316

,395

15,5

6311

,300

11,2

756,

405

6,30

594.6

%94.9

%99.8

%98.4

%

No

rth

Man

che

ste

r G

en

era

l Ho

spit

al45

,068

44,7

0024

,559

23,5

1325

,340

26,0

1011

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10,4

9599.2

%95.7

%102.6

%93.2

%

Ro

chd

ale

Infi

rmar

y2,

014

1,98

41,

084

1,08

091

093

063

062

098.5

%99.7

%102.2

%98.4

%

Ro

yal O

ldh

am H

osp

ital

49,4

1048

,094

26,4

5625

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28,7

2528

,325

12,0

0011

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97.3

%96.8

%98.6

%94.1

%

Tru

st T

ota

l11

7,43

111

4,63

869

,604

66,8

8566

,875

67,0

9030

,920

29,3

4097.6

%96.1

%100.3

%94.9

%

Da

yN

igh

t

Day

Fil

l Rat

eN

igh

t Fi

ll R

ate

Re

gis

tere

d m

idw

ive

s

/nu

rse

sC

are

Sta

ffR

eg

iste

red

mid

wiv

es

/nu

rse

sC

are

Sta

ff

War

d n

ame

Ma

in W

ard

Sp

ecia

lty

To

tal

mo

nth

ly

pla

nn

ed

sta

ff h

ou

rs

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tal

mo

nth

ly

actu

al

sta

ff

ho

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tal

mo

nth

ly

pla

nn

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sta

ff h

ou

rs

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tal

mo

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ly

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al

sta

ff

ho

urs

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tal

mo

nth

ly

pla

nn

ed

sta

ff h

ou

rs

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tal

mo

nth

ly

actu

al

sta

ff

ho

urs

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tal

mo

nth

ly

pla

nn

ed

sta

ff h

ou

rs

To

tal

mo

nth

ly

actu

al

sta

ff h

ou

rs

War

d 1

(C

CU

)32

0 -

CA

RD

IOLO

GY

1848

.75

1605

1383.7

51207.5

1235

1230

620

490

86.8

%87.3

%99.6

%79.0

%

War

d 1

0 (I

TU/H

DU

)19

2 -

CR

ITIC

AL

CA

RE

MED

ICIN

E24

152257.5

412.5

202.5

1550

1510

240

130

93.5

%49.1

%97.4

%54.2

%

War

d 1

1a31

4 -

REH

AB

ILIT

ATI

ON

1395

1522.5

1792.5

1672.5

620

800

970

935

109.1

%93.3

%129.0

%96.4

%

War

d 1

1b (

Stro

ke)

314

- R

EHA

BIL

ITA

TIO

N13

87.5

1312.5

1417.5

1357.5

620

650

620

610

94.6

%95.8

%104.8

%98.4

%

War

d 1

410

0 -

GEN

ERA

L SU

RG

ERY

1117

.51132.5

1035

945

620

640

310

290

101.3

%91.3

%103.2

%93.5

%

War

d 1

831

4 -

REH

AB

ILIT

ATI

ON

1530

1477.5

1822.5

1635

930

1270

600

590

96.6

%89.7

%136.6

%98.3

%

War

d 2

130

0 -

GEN

ERA

L M

EDIC

INE

1395

1425

1728.7

51702.5

930

1000

635

630

102.2

%98.5

%107.5

%99.2

%

War

d 5

110

- TR

AU

MA

& O

RTH

OP

AED

ICS

915

922.5

517.5

510

620

590

210

210

100.8

%98.6

%95.2

%100.0

%

War

d 6

300

- G

ENER

AL

MED

ICIN

E16

27.5

1635

1380

1327.5

940

955

640

650

100.5

%96.2

%101.6

%101.6

%

War

d 7

300

- G

ENER

AL

MED

ICIN

E31

802925

2662.5

2527.5

1780

1750

530

560

92.0

%94.9

%98.3

%105.7

%

War

d 8

430

- G

ERIA

TRIC

MED

ICIN

E12

52.5

1162.5

1087.5

1102.5

670

650

620

530

92.8

%101.4

%97.0

%85.5

%

War

d 9

300

- G

ENER

AL

MED

ICIN

E27

82.5

2415

1965

1725

1250

1310

970

930

86.8

%87.8

%104.8

%95.9

%

Fair

field

Gen

era

l H

osp

ital

Ave

rag

e f

ill

rate

-

reg

iste

red

nu

rse

s/

mid

wiv

es

(%

)

Ave

rag

e

fill

ra

te -

ca

re s

taff

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Item

6a

Page 33 of 196

War

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1331

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Page 34 of 196

War

d n

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Ma

in W

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Sp

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To

tal

mo

nth

ly

pla

nn

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sta

ff h

ou

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War

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ICIN

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2962

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Item

6a

Page 35 of 196

The

pre

vio

us s

ectio

n o

utlin

es fo

r th

e T

rust B

oa

rd t

he

actu

al sta

ffin

g le

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ga

inst

pla

nn

ed

on

da

y a

nd

nig

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ifts

acro

ss t

he

Tru

st

an

d illu

str

ate

s th

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va

ilab

ility

of

sta

ff h

ou

rs r

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d a

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ally

ava

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t th

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ca

re.

Futu

re r

ep

ort

s w

ill b

e r

efine

d o

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e w

ith

in

clu

sio

n o

f qu

alit

y m

etr

ics. T

he

fo

llow

ing s

ectio

n inclu

de

s a

n o

ve

rvie

w o

f th

e “

sta

ffin

g s

tatu

s”

of

wa

rds. T

he

sta

ffin

g s

tatu

s

is a

n a

sse

ssm

en

t m

ade

by t

he

nu

rse in

cha

rge

of

the s

hift

rela

tive

to t

he

actu

al sta

ff o

n d

uty

an

d t

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de

ma

nd f

or

nu

rsin

g c

are

. T

he

sta

tus info

rms t

he

ris

k a

sse

ssm

en

ts t

ha

t m

ust b

e u

nde

rtaken

wh

en

a w

ard

is d

ecla

red

“am

be

r” o

r “r

ed

”:

Gre

en

A

ctu

al sta

ffin

g le

ve

ls a

t o

r gre

ate

r th

an

100

% o

f p

lan

ned

Y

ell

ow

S

taff

ing v

ery

slig

htly le

ss t

han

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ed

(le

ss th

an

8 h

ou

rs o

r 2

5%

, w

hic

he

ve

r is

re

ache

d f

irst)

, b

ut n

o c

are

lik

ely

to

be

“mis

sed

” as a

resu

lt;

no

“R

ed

Fla

g”

eve

nts

rep

ort

ed

A

mb

er

Sta

ffin

g le

ss th

an

pla

nn

ed

(gre

ate

r th

an

8 h

ou

rs o

r 2

5%

, w

hic

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ve

r is

re

ach

ed

first)

, som

e e

lem

en

ts o

f ca

re m

issed

or

defe

rred

until sta

ffin

g im

pro

ve

d,

“Red

Fla

g”

eve

nts

ma

y o

ccu

r B

UT

lo

ca

l op

era

tion

al a

rran

ge

men

ts h

old

ing w

he

re th

ey

are

in

pla

ce

. T

he

wa

rd w

ill r

eco

rd t

he

sta

tus, m

itig

atio

n a

nd e

sca

latio

n a

rran

ge

men

ts o

n the

Te

chn

oH

ud

dle

; th

e

resp

on

sib

le D

ivis

ion

al N

urs

e M

an

age

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atr

on

or

loca

l b

leep

ho

lde

r (o

ut

of

hou

rs)

will

un

de

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Page 36 of 196

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Item

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Actual RN: Bed ratio (April) – Wards where 1 nurse is looking after more than 8 beds (shaded cells). The Harm Free Care score from the National Safety Thermometer has been added to this month’s report - Scores below 95% are shaded in the table.

Site Ward Division

Trained Nurse:

Bed ratio - Early

Trained Nurse:

Bed ratio - Late

Trained Nurse:

Bed ratio - Night

ST Harm Free

Score

BHH Floyd Unit - BHH Medicine 9.00 9.30 10.50 100.00%

FGH Ward 6 Medicine 7.01 9.15 8.93 65.22%

FGH Ward 11a Medicine 6.89 6.99 9.33 100.00%

FGH Ward 11b (Stroke) Medicine 6.94 7.17 9.78 95.00%



NMGH C3 Surgery 6.28 5.35 11.20 100.00%

NMGH C5 Surgery 6.23 7.13 9.50 94.44%

NMGH D5 Surgery 4.52 5.03 8.18 100.00%

NMGH E1 Medicine 7.53 8.83 7.28 88.89%

NMGH E3 Medicine 7.50 8.90 8.08 89.90%

NMGH F1 Medicine 5.87 8.36 7.20 91.67%

NMGH F3 Surgery 6.18 6.49 9.39 64.74%

NMGH F5 Surgery 5.93 7.73 11.37 95.65%

NMGH F6 Surgery 5.33 7.35 10.62 95.24%

NMGH I5 Surgery 7.76 9.35 9.84 90.62%

NMGH I6 Surgery 6.62 8.27 10.76 100.00%

NMGH J6 Medicine 5.67 6.55 8.17 94.12%

ROH A2 Medicine 7.45 9.30 8.60 94.44%

ROH F1 W&Cs 8.55 8.43 11.26 100.00%

ROH F7 Medicine 8.03 8.37 8.11 92.00%

ROH F8 Medicine 7.79 8.59 8.50 90.00%

ROH F9 Medicine 8.19 8.82 8.28 79.17%

ROH F10 Medicine 7.20 8.20 8.13 87.50%

ROH G1/Discharge Unit Medicine 7.63 8.38 10.68 90.48%

ROH G2 Surgery 7.29 8.47 12.50 100.00%

ROH T3 Surgery 6.44 8.56 13.93 85.71%

ROH T5 Surgery 6.67 8.61 12.22 96.00%

ROH T6 Surgery 4.68 6.41 10.93 100.00%

ROH T7 Surgery 6.95 8.00 9.43 87.10%

Page 38 of 196

New national ward staffing RAG rating system A new ward staffing level RAG rating scoring system will be introduced in 2015-16.

Provisional information published shows that the Trust is rated as Blue (ok). Trusts rated as Red will be contacted by their regulatory body (TDA, etc.)

Details There are 3 possible ratings based on a comparison of results:-

Green is amongst the best / better than other providers

Blue is okay / within expected ranges

Red is amongst the worst / worse than other providers

Grey is no data available, or not relevant for the provider The Trust appears to be ranked within the middle band of providers. Our overall rating is blue (ok) because all of the KPIs are within their expected ranges - see details below:-

Measure Result Rating Inpatient Survey Q30: whether there enough nurses on duty to care for you in hospital? Weighted response (0-10). Q30 Weighted mean

Within expected range 7.65

Blue (OK)

Staff Survey Q7g whether sufficient staff (5-1) Q7 Weighted response

Within expected range 3.68

Blue (OK)

Staff Survey Q3a % staff having an appraisal in last 12 months (%) Q3a.1 Percentage "Yes"

Within expected range 84.62%

Blue (OK)

Staff Survey Q1 Mean % staff completing mandatory training (%) Q1a-f Mean Percentage "Yes"


Blue (OK)

Percentage Staff Sickness data 12 Month Average to Aug 2014, Acute vs Other trusts (%) - 12 Month to Aug 2014 Average


Blue (OK)

Safer staffing November Fill rates (%) Overall Fill Rate

Within expected range 98%

Blue (OK)

Total All within expected ranges Blue (OK)

The aggregate score is based on the “weakest link” -

Red if any of the 5 measures are red - 31 Trusts are rated as red overall

Green if any of the 5 are green AND there are no reds - green and reds do not cancel each other out - 23 Trusts are rated as green overall

Blue = all of 5 measures are blue Work will be undertaken to cross reference the data to ESR reports in relation to nursing staff Sickness,

Item

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Page 39 of 196

Title of Report Strategic Risk Register

Executive Summary

The report outlines the Trust’s current strategic risks. It had previously been agreed that the strategic risks would be considered by the Quality & Performance Committee monthly to enable discussion and thereafter proposals to the Trust Board. The Q&P Committee asked for a risk relating to maternity services to be included on the strategic risk register. The attached wording was submitted to the Q&P Committee on 26 May 2015. A verbal update will be provided to the Board meeting.

Actions requested

The Board is asked to review and if appropriate, make any changes to the Strategic Risk Register.

Corporate Objectives supported by this paper: All corporate objectives.

Risks: As outlined within the paper.

Public and/or patient involvement: N/A.

Resource implications: There are potential resources implications within all of the actions needed to mitigate the strategic risks. These will be considered by each executive director and an assurance given that these are in the planning round for 2015/16.

Communication: For the Board.


Assurance X

Contract X



HR X


IM&T X



Sustainability X

Item

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Name Gavin Barclay

Job Title Assistant Chief Executive

Date May 2015


Page 41 of 196

Strategic Risk Register

1. Introduction This report outlines the Trust’s current strategic risks. It had previously been agreed that the strategic risks would be considered by the Quality & Performance Committee monthly to enable discussion and thereafter proposals to the Trust Board. Two risk scores are depicted; residual risk and target risk. For the purpose of this document, the residual risk is the risk today, when all of the existing controls and mitigations that we currently have in place are taken into consideration. The target risk is the risk which the organisation will find acceptable. This is linked to the Trust’s risk appetite, which is the level of risk that an organisation is prepared to accept, before action is deemed necessary to reduce it. The Trust’s risk appetite framework is outlined within the Trust’s risk management policy and this will be reviewed, as part of the review of risk management processes within the Trust. The scoring system is outlined below.

Score Level of harm (NPSA Cat.)

Risk category

15 - 25 Catastrophic Significant

10 – 12

Major High

8 - 9 Moderate Moderate

4 - 6 Minor Low

1 - 3 Negligible Very Low

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The Trust’s current strategic risks are:-

Strategic Risk Residual Risk

Rating

Target Risk

Rating

Failure to achieve operational performance targets, caused by increased demand and lack of capacity, resulting in potential regulatory involvement, reputational damage to the Trust and compromising the FT application.

20 10

Failure to become a financially and clinically viable Trust, caused by internal and external factors, leading to enforcement/regulatory action being taken.

20 10

Failure to meet financial duties for due to income and expenditure issues and failure to implement CIP plans in a timely manner resulting in a COSRR which would adversely impact on the FT timetable

16 12

Failure to provide adequate nursing staffing levels in some wards caused by wards not having required establishments and inability to fill vacancies which may result in pressure on ward staff, potential impact on patient care and impact on Trust access and financial targets.

16 12

Failure to recruit/retain consultant and middle grade doctors in some specialities, caused by inadequate NHS workforce planning and increased competition within the NHS and beyond, leading to increased locum usage with potential quality, operational (e.g. increased Length of Stay) and financial implications.

16 12

Failure to manage attendance effectively, caused by a number of contributing factors – e.g. vacancy rates, sickness rates, variation in applications of policy (especially triggers) may result in increased sickness absence costs and increased bank and agency costs and adversely impact on patient safety and care

16 12

Lack of staff engagement caused by a number of contributing factors (disaffection, site focus, lack of processes, lack of management focus (capability), lack of communication, variation in holding to account), resulting in a significant strategic and operational impact, potential harm to patients and staff, sickness absence, recruitment and retention difficulties and reputational damage

16 12

Clinical variation, caused by lack of systems/process or failure of systems/to follow process leading to potential patient harm, inefficiencies and potential regulatory action for the organisation.

16 12

Increased incidence of Carbapenemase Producing Enterobacteeriaceae (CPE) within the Trust, caused by higher prevalence with the Greater Manchester area, may result in patient harm from sporadic infections, clusters and outbreaks and adversely impact on operational activity and patient flow.

15 10

Service failure caused by lack of systems/process or failure of systems/to follow process leading to operational

15 12

Page 43 of 196


Rating

Target Risk

Rating

disruption, patient harm and / or regulatory involvement.

Inability to influence the external strategic environment caused by uncertainty due to Healthier Together, Devo Manc, integrated care agenda and other strategic agendas resulting in others determining the services and future of the Trust

12 8

Aggregate impact of commissioning decisions leading to the Trust becoming clinically or financially unsustainable

12 8

2. Proposed New Risk


Rating

Target Risk

Rating

Service failure affecting individual patients, regulatory involvement and / or reputational damage arising from failure to fully implement, to a level which meets the assurance needs of the Board and Commissioners, the improvement plan arising from the external review of maternity services.

20 6

3. Recommendations The Quality & Performance Committee is asked to review and if appropriate, make proposals to the Trust Board in relation to any changes to the Strategic Risk Register. The Committee is asked to approve or amend the description and grading of the additional Risk relating to maternity services. Gavin R Barclay Assistant Chief Executive May 2015

Item

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Title of Report Care Quality Commission Registration Annual Review

Executive Summary

This paper confirms that the Trust has maintained unconditional registration with the Care Quality Commission throughout 2014/15 and details the various inspections that have taken place throughout the year across all sites. The paper also highlights:

Changes from Essential Standards to Fundamental Standards against which the CQC will focus on key lines of enquiry relating to safe, effective, caring, responsive and well-led

A Maternity Outlier Alert in respect of Perinatal Mortality

Chief Inspector of Hospitals, Intelligent Monitoring Report and the Trust’s risk banding

Statement of Purpose updates

Change to Nominated Individual with the CQC for registration purposes.

With effect from 1 April 2015, responsibility for the management of the entire CQC regulations, processes and assurance transferred from the Assistant Chief Executive to the Chief Nurse’s portfolio. The Director of Clinical Governance will ensure compliance with the CQC regulations and processes on behalf of the Chief Nurse.

Actions requested

The Board is asked to consider whether any further actions are required to ensure compliance with the CQC Standards in order to maintain the Trust’s unconditional registration.

Risks: Failure to maintain unconditional registration will highlight poor patient care or staff experience, attract negative comment, undermine relationships with stakeholders and affect the Foundation Trust application.

Public and/or patient involvement: None

Resource implications: None

Communication: Reports from CQC visits are publicised when they occur and details are included in the Quality Account.

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Assurance X

Contract X




HR X

IM&T X



Sustainability X

Name Gavin Barclay

Job Title Assistant Chief Executive

Date May 2015


Page 46 of 196

C:\Users\244991-Admin\AppData\Local\Temp\cd949330-eaa1-42c7-b5ab-6bdc523949c6.doc

CARE QUALITY COMMISSION REGISTRATION ANNUAL REVIEW 2014-15

1. Introduction

The Pennine Acute Hospitals NHS Trust is required to register with the Care Quality Commission (CQC) and its current registration status is compliant with the regulations. The CQC has not taken enforcement action against the Pennine Acute Hospitals NHS Trust during the period 2014/15 nor has the CQC taken any enforcement action against The Pennine Acute Hospitals NHS Trust since its inception. The Pennine Acute Hospitals NHS Trust has not been required to participate in any special reviews or investigations by the CQC during the reporting period. The CQC is an independent national body responsible for regulating the quality of care provided by NHS trusts, social services and independent care providers. The CQC continually monitors whether The Pennine Acute Hospitals NHS Trust, and other care providers, are meeting their essential standards of quality and patient safety. Their particular focus is on patient outcomes in terms of the delivery of a quality experience of care. The CQC pays particular attention to what people say about the service. The intelligence which is used by the CQC to make an assessment upon the Trust’s performance against the statutory standards is obtained from external sources, including the Parliamentary Health Service Ombudsman, service users through a dedicated web site, mortality alerts, national inpatient and staff surveys and through Health watch, local charities and voluntary organisations. The Trust also undertakes a rigorous annual cycle of self assessment, evidence production and assurance against the quality standards. The CQC carries out a routine formal review of services to audit and review service outcomes against the essential standards for each service location. The review includes unannounced visits to the Trust premises so that teams of CQC Inspectors can speak with and observe the interactions between patients and staff and the quality of care being provided. The CQC has recently change the basis on which it will assess services. CQC inspections are now focused on five key lines of enquiry domains, determining whether services are:-

Safe

Effective

Caring

Responsive to people’s needs

Well-led

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2. Inspections during the Year

The Board will be aware that the Trust was inspected by the CQC on 8 & 9 November 2013 as part of a routine inspection to check that essential standards of quality and safety were being met. Although this was a routine inspection, it was unannounced. The following outcomes were assessed and standards met:- Outcome 1 Respecting and involving people who use services Outcome 5 Meeting nutritional needs Outcome 13 Staffing Outcome 16 Assessing and monitoring the quality of service provision Action was needed for Outcome 4 - Care and welfare of service users. The CQC judged that this had a minor impact on people using the service. The Trust produced and submitted an action plan which aimed to return the Trust to a compliance state by 31 March 2014. The detailed action plan addressed the points raised by the CQC, these being:-

Malnutrition Universal Screening Tool (MUST) to be completed within 24 hours of admission.

MUST and rescreening to be completed as per Trust guidelines.

Individualised care plans to be in place for all patients who are nutritionally compromised.

Fluid balance and food charts to be completed. North Manchester General Hospital was re-inspected by the CQC on 26 June 2014. The Trust subsequently received a compliance report from the CQC on which shows the standard with regard to Outcome 4 – Care and welfare of users was being met. Other than the above re-inspection, the Trust has not been inspected during 2014/15. Future CQC inspections will be in the form of Chief Inspector of Hospitals visit. The Trust does not yet have a date for the CIH visit, although in line with the national timetable a visit can be expected prior to 31 March 2016.

3. Maternity Outlier Alert For Perinatal Mortality On 13 October 2014, the Trust received an outlier alert from the CQC. The Trust’s response was submitted to the CQC on 21 November 2014.

The alert noted a statistical increase in perinatal mortality. However, when this was investigated it was found that the data used by the CQC did not take into account the reconfiguration of maternity and neonatal services in Greater Manchester and the Trust’s designation as a level 3 unit at The Royal Oldham

Page 48 of 196


Hospital. Once this had been taken into account the Trust was found to be “as expected”.

4. Chief Inspector of Hospitals As reported to the Board in last year’s annual report, as part of the Trust’s preparation for our Chief Inspector of Hospital’s visit, the former Governance Director led a series of mock inspections during 2014/15. The results of the inspections were considered by the former Clinical Governance & Quality Committee in the summer of 2014. With the publication of the fundamental standards, and the new inspection process, the Trust will be reviewing its clinical governance arrangements to ensure they align to the new standards. This agenda will be led by the newly appointed Director of Clinical Governance and Deputy Chief Nurse, reporting to the Chief Nurse. This will include, commissioning an external ‘mock Keogh’ review inviting peer review from external Trusts, ensuring that the existing ward metrics are aligned to the fundamental standards, that a safety walk round programme is put in place, again aligned to the fundamental standards and to further improve ward to Board reporting, working to develop composite quality reporting as part of the Integrated Performance Report.

5. Intelligent Monitoring Report (IMR) The IMR is a surveillance model which sets out a range of information held for each acute and specialist Trust. The IMR is issued quarterly by the CQC and subsequently shared and discussed at the Quality & Performance Committee. Summary level data is included in the monthly Integrated Performance Report for the Trust Board. The CQC surveillance model sets out a range of information held for each acute and specialist Trusts. The information is based on over 150 indicators that look at a range of information including patient experience, staff experience and statistical measures of performance. Each Trust is banded into six bands - Band 1 is the highest level of risk and band 6 is the lowest level of risk. Since the CQC has been producing the Intelligent Monitoring Report, the Trust’s bandings have been as follows:-

October 2013 - band 3 (mid range)

March 2014 - band 6 – (lowest risk)

July 2014 – band 6

October 2014 – band 6 The CQC has taken the results of their intelligent monitoring work and grouped the 160 acute NHS trusts into six priority bands for inspection based on the likelihood that people may not be receiving safe, effective, high quality care.

The indicators will be used to raise questions about the quality of care but will not be used on their own to make final judgements. The judgements will

Item

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continue to be based on a combination of what is found at inspection, national surveillance data and local information.

6. Statement of Purpose It is a statutory obligation of the Trust to notify the CQC of any changes in our premises or the type of services provided. The Statement of Purpose has been updated in December 2014 and is next due for review in June 2015 as part of its 6-monthly review cycle.

7. Nominated Individual From 1 April 2014, Mr Gavin Barclay, Assistant Chief Executive / Board Secretary has been the Nominated Individual for the Trust’s CQC registration. In line with the portfolio change described in section 10 a new nominated individual is required. This action remains outstanding.

8. Regulatory Update

A number of new measures are being introduced as part of the government’s response to the Francis Inquiry’s recommendations and are intended to help improve the quality of care and transparency of providers by ensuring that those responsible for poor care can be held to account.

These include:-

New fundamental standards which will define the basic standards of safety and quality that should always be met, and introduce criminal penalties for failing to meet some of them. These came into force in April 2015. The Quality & Performance Committee received a report on this in December 2014.

A new fit and proper persons requirement means that all Directors of NHS bodies must pass a test proving they are fit and proper persons. The CQC will be able to insist on the removal of Directors that fail. This came into effect on 27 November 2014. The Board received a report on this in November 2014.

The duty of candour will require NHS bodies to be open and transparent with service users about their care and treatment, including when it goes wrong. This came into effect on 27 November 2014. The Quality & Performance Committee received a report on this in December 2014.

9. Management / Portfolio Change With effect from 1 April 2015, responsibility for the management of the entire CQC regulations, processes and assurance transferred from the Assistant Chief Executive to the Chief Nurse’s portfolio. The Director of Clinical Governance will ensure compliance with the CQC regulations and processes on behalf of the Chief Nurse.

Page 50 of 196


10. Action Required The Board is asked to consider whether any further actions are required to ensure compliance with CQC essential standards in order to maintain the Trust’s unconditional registration. Gavin Barclay Assistant Chief Executive April 2015

Item

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1

Title of Report

Mortality Information Report (December 2015 position)

Executive Summary

Mortality report providing the Board with an update on progress with the mortality reduction project. The report offers a series of key performance indicators (KPIs) to assist the Board with monitoring the progress of this work. These indicators incorporate those required to monitor the mortality corporate objectives.

Actions requested

The Board is asked to note the contents of this report, progress against the plan, and suggest any new actions identified to improve the current position with regards to mortality.

Corporate Objectives supported by this paper: Objective 1 – Improving Patient Safety - Reduction in standardised mortality

Risks: Board Risk Register: – Poor quality of care provided to patients as measured by HSMR if higher than expected mortality is not noticed and addressed at Trust site and speciality level.

Public and/or patient involvement: N/A

Resource implications: N/A

Communication: Regular mortality reduction bulletin to staff. Communications through the Trust governance structures. Dedicated section on Trust Intranet site. Regular programme of visits to teams


Assurance √

Contract √

Equality and Diversity √

Financial / Efficiency √

HR √

Information Governance Assurance √

IM&T √

Local Delivery Plan / Trust Objectives √

National policy / legislation √

Sustainability √

Name Anton Sinniah

Job Title Medical Director

Date May 2015


Item

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Page 52 of 196

2

Mortality Information Report May 2015 Contents

Section Sub Title Page

1.0 Introduction 3

2.0 Approach

3

3.0 Summary

3

4.0 HSMR and Crude Mortality Rates 4

4.1 North West Peers 4

4.2 HSMR by Month 5

4.3 HSMR by Site 5

4.4 Acuity by Site 6

4.5 HSMR by Day of Admission 7

4.6 SHMI 10

4.7 Crude Mortality Rate 12

5.0 KPIs 12

5.1 Palliative Care Coding 12

5.4 Depth of Coding (Co-morbidities) 14

5.7 Consultant Review of Death Alerts 14

Page 53 of 196

3

Mortality Information Report May 2015 (December position) 1.0 Introduction

This report reflects the rebased Mortality position for the Trust up to the end of December 2014 and includes the latest data from Dr Foster updated on 13th April 2015.

2.0 Approach

The Dr Foster data is reviewed routinely with in-depth analysis particularly for areas showing no improvement or an adverse variance.

3.0 Summary

3.1 HSMR.

December April to December Pennine 74.3 83.05 (NW 93.0) Oldham 71.07 87.11 North Manchester 69.2 87.7 Bury 86.03 81.65 Rochdale 22.5 33.6

3.2 The Mortality Validation Tool is now fully live across the Trust. Following on from the winter pressures for the consultants and the staffing issues within the coding department, the compliance of the consultants using the tool has not been monitored effectively. A report from the software company is being amended to provide details of the number of patients signed off by the consultant and the number of patients reviewed. The second version of the Tool will allow Consultants to carry out a clinical review at the same time as validating the coding. This is still in development with Woodward Associates Ltd (company who developed the tool) the latest update is that this will be ready for a demonstration by the 14/5/15.

3.3 Mortality Reduction Partnership (CQUIN: Mortality Reduction) - An audit was undertaken of 50 consecutive death casenotes and 45 were analysed. The audit tool is based on the NHS Institute Mortality Review Tool combined with the global trigger tool. The audit included a clinical review by Deputy Medical Directors. Meetings have taken place with CCG mortality leads for North Manchester and Bury. An education event has also taken place in February for Bury GP’s.

Item

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4

4.0 HSMR and Crude Mortality Rates 4.1 North West Peers

The graphs below show how the Trust is performing against its North West peers* for the period April to December 2014 plus April 2013 to March 2014. The Trust is below the North West average of 93.0 with an HSMR for the 9 month period to December 2014 of 82.7. The Trust is in the best position within the North West (when using 2013/14 as the benchmark)

108.0107.0105.2104.799.9 99.7 98.2 97.0 94.9 94.7 93.2 92.6 92.2 89.9 88.6 88.6 88.4 86.5 84.9 84.6 83.1 82.7

0

20

40

60

80

100

120

140

HSMR NW Acute Providers - April to December 2014

HSMR NW Average

119.3110.5107.9107.5106.0105.9104.8104.4104.1103.7102.8101.7100.8 98.8 98.7 98.6 97.1 96.0 94.0 93.9 91.1

85.2

0

20

40

60

80

100

120

140

HSMR NW Acute Providers - April 2013 to March 2014

HSMR NW Average

Page 55 of 196

5

*The peer performance includes any patients treated at Pennine who were also seen at other providers for related

care during their spell, known as the super spell. The number of super spells during the period may vary and

therefore the impact on the HSMR will differ slightly when comparing Pennine only based reports as a result.

4.2 HSMR by Month The 12 month rolling HSMR up to the end of December is 85.83.This is a decrease of 1.62 compared to the November refreshed and rebased position of 87.45. The chart below shows the trend over the last 33 months comparing month by month and year on year.

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

2012/13 100.3 110.2 93.2 97.4 98.9 107.7 93.9 90.2 100.8 107.0 96.3 95.4

2013/14 100.5 84.2 95.0 81.1 92.6 97.4 89.8 92.7 78.3 92.4 93.0 95.2

2014/15 90.2 80.6 93.4 77.7 78.7 85.2 81.1 89.7 74.3

20

30

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60

70

80

90

100

110

120 HSMR Year on Year 2012/13, 2013/14 and 2014/15

4.3 HSMR by Site

A further breakdown by site is displayed below.

102.3

92.5

125.0

74.280.478.579.1

91.5

71.7

89.1

75.9

95.0

87.5

78.1

94.5

85.1

92.0

69.2

83.477.6

67.4

78.083.6

86.9

78.2

93.086.3

30.8

42.3

23.226.3

19.3

48.2

91.9

0.0

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ROHROHROHROHROHROHROHROHROHNMGHNMGHNMGHNMGHNMGHNMGHNMGHNMGHNMGHBuryBuryBuryBuryBuryBuryBuryBuryBury RI RI RI RI RI RI RI RI RI

HSMR by Site of Diagnosis and Month of Discharge

April to December 2014

The graphs below show the comparison between the rebased 2013/14 and the most recent 9 months to December 2014. All sites are now showing an improvement on last year’s position.

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87.11 84.7 81.65

36.67

0

20

40

60

80

100

120

Royal Oldham Hospital North Manchester General Hospital

Fairfield General Hospital Rochdale Infirmary

HSMR April to December 2014 , by Site

HSMR PAT HSMR Target

4.4 Acuity by Site (Actual % HSMR against Expected % HSMR April – December 2014) It is clear from the graphs below that FGH has the sicker patients as on average 9.6% of all non-elective patients in the 9 month period were expected to die compared to both Oldham and NMGH.

7.9 7.58.3 8.6

6.57.4

8.9

7.6

9.6 9.8 9.510.2

9.2 8.99.6

10.2

0

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ALL ALL ALL ALL ALL ALL ALL ALL

ALL Sunday Monday Tuesday Wednesday Thursday Friday Saturday

FGH Acuity (Non Elective) - April to December 2014

Rate (%) Exp. (%)

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7

5.4

6.8

4.5

6.0 6.2

4.5

5.64.6

6.3 6.55.9 6.2

6.75.9 6.3 6.4

0

2

4

6

8

10

12



Oldham Acuity (Non-Elective) - April to December 2014

Rate (%) Exp. (%)

5.0

6.7

4.65.1 5.3

3.7

5.1 4.95.8

6.9

5.7 5.8 5.75.2

5.76.2

0

2

4

6

8

10

12



NMGH Acuity (Non-Elective) - April to December 2014

Rate (%) Exp. (%)

4.5 HSMR by Day of Admission The graphs below show the comparison between the rebased 12 month period 2013/14 and the most recent 9 month period to December 2014.

79.4487.4 83.76

75.8287.84

73.76

92.83

0

20

40

60

80

100

120

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

HSMR by Day of Admission - April to December 2014

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92.48 91.46 87.55 90.04 85.67100.56

90.55

0

20

40

60

80

100

120


HSMR by Day of Admission - April 2013 to March 2014

The breakdown by site shows that patient admitted to Oldham on Sundays having a HSMR greater than 100. This is mirrored in the HSMR observed deaths by day of admission.

Monday TuesdayWednesd

ayThursday Friday Saturday Sunday

Bury 87.8 84.17 71.05 82.25 92.47 74.71 76.26

NMGH 80.15 88.5 93.46 71.16 89.54 79.94 96.73

RI 41.52 31.48 59.68 32.76 42.62 0 0

ROH 77.31 96.81 91.57 75.63 88.98 71.05 106.08

020406080

100120140

Non-Elective HSMR by day of the week - April to December 2014

Bury

NMGH

RI

ROH


Bury 87.91 75.94 87.68 80.11 82.45 86.63 89.29

NMGH 91.7 93.55 90.66 88.68 90.41 104.64 82.7

RI 44.1 44.32 36.92 22.07 51.65 62.46 84.76

ROH 101.25 107.51 92.28 108.09 88.93 109.55 98.36

0

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Non-Elective HSMR by day of the week - April 2013 to March 2014

Bury

NMGH

RI

ROH

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87 88101 106

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100

6576

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83 80

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6153

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6169

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ROH ROH ROH ROH ROH ROH ROHNMGHNMGHNMGHNMGHNMGHNMGHNMGHBury Bury Bury Bury Bury Bury Bury

HSMR Observed Deaths (Non-Elective)- April to

December 2014

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4.6 SHMI

The graph below shows the quarterly SHMI trend for the last 3 years. The latest data available is Quarter 1 2014/15 which has decreased from Quarter 4 2013/14 to 100.77. Oldham has the highest SHMI for Trust as 119.57. There is a small improvement for Oldham from previous quarter. Pennine

FGH Oldham NMGH

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11

Pennine (yellow) has a lower confidence interval above 100 like the other ‘red’ Trusts. In the graph below actual in-hospital deaths in SHMI is 97.61 compared to 90.01 for HSMR. SHMI has over twice as many spells (127,916) as HSMR (60,626) due to the fact that HSMR only looks at 56 diagnosis groups.

On the graph below you can see how SHMI compares across sites. Oldham now has the highest SHMI at 116.9.

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4.7 Crude Mortality Rate

The graph below reflects the crude mortality rate for the Trust over the last rolling 24

months.

050100150200250300350

0.0%

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5.0%

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%)

Crude Mortality Rate - All Admissions

Crude Mortality rate (%) Deaths

A breakdown for the last 24 months by age shows the marked higher mortality rate

for patients 75+ who account for 70% of all deaths.

0

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Crude Mortality Rate - Aged 75+

Crude Mortality rate (%) Deaths

5.0 Key Performance Indicators

5.1 Palliative Care Coding

Title Description/Rationale Metric Target/ Outcome

Palliative Care Coding

Compared to peers, our Palliative Care Coding remains around the median. We need to ensure that we are capturing all spells where Specialist Palliative Care is involved.

[Number of Spells with Z515 (Specialist Palliative Care)] / [Total Number of Spells]

This will be a dynamic target to continuously achieve the North West average. This will be realigned as rebased data is loaded into Dr. Foster

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5.2 Key Performance Indicators - Percentage of Spells with Palliative Care Coded

4.0%3.8%

2.7% 2.6% 2.6% 2.6% 2.5% 2.5% 2.4% 2.3% 2.3% 2.1% 2.1% 2.1% 2.0% 2.0% 1.9% 1.8% 1.8%1.5% 1.5%

0.6%

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%

% Spells with Specialist Palliative Care - April to December 2014

% Palliative NW Avge

4.1%

3.3%

2.6% 2.5% 2.5% 2.4% 2.3% 2.2% 2.2% 2.2% 2.2% 2.2% 2.2% 2.1% 2.1%1.9% 1.8% 1.8%

1.5% 1.5%1.2%

0.9%

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%

% Spells with Specialist Palliative Care - April 2013 to March 2014

% Palliative NW Avge

5.3 Actions & Ongoing work

The Trust remains slightly above the NW average but continues to be monitored.

A regular report is sent to the coding department of all Specialist Palliative Care visits for inpatients to assist in ensuring that the activity is captured correctly.

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5.4 Depth of Coding


Depth of Coding

To ensure that appropriate relative risks are applied we need to ensure that all co-morbidities are captured by clinicians and then coded accordingly

Average number of co-morbidities per FCE (finished consultant episode)

National mean average from Trust Quality Dashboard = 4.51

5.5 Key Performance Indicators – Average Number of co-morbidities per FCE

1.0

3.0

5.0

Average co-morbities Non-Elec - March 2013 to February 2015

PAT Avge Co-morb. National Mean Q1 13/14

5.6 Actions & Ongoing work

Clinical Coding Specialty Leads work closely with the clinicians to improve the recording in the clinical documentation for co-morbidities.

Clinical Coding Co-morbidity Awareness Training has been provided to the clinical coders and will be refreshed annually.

5.7 Consultant review of Death Alerts prior to coding of episodes


Consultant review of Case notes

Consultants will be asked to review all deaths before the casenote is sent to clinical coding.

[Number of cases reviewed by Consultant] / [Total number of deaths]

Arising from comments from a previous Trust Board, the target now needs to be agreed following the completion of the pilot for the Mortality Validation tool.

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15

5.8 Key Performance Indicators – Percentage of Deaths that have been reviewed

before being coded

Actions & Ongoing work

The Mortality Validation tool The Clinical coding team have had a new validation tool built to support the Trust in ensuring that the deaths are coded correctly before the data is submitted to SUS for Dr Foster. This is an electronic tool which allows a two way conversation between the coding team and the consultant who was responsible for the care of the patient at time of death. The consultant is asked to sign off the coding as correct or provide additional information through the tool to improve the accuracy of the coded data.

Version 1 of the Mortality Validation Tool is fully rolled out for use across the Trust.

Clinical coding speciality leads will now monitor Consultant compliance in using the tool.

The second version of the Tool will allow Consultants to carry out a clinical review at the same time as validating the coding. This is still in development with Woodward’s and is due for demonstration on the 14/5/15. An initial demonstration of the tool was shown to Dr Anton Sinniah, Dr Roger Prudham and Dr Jason Raw who all gave good and positive feedback regarding the next version and the ability to record clinical information regarding the death alongside the validation of the coding to assist in the analysis into hospital deaths.

Anton Sinniah Medical Director May 2015

Appendix 1

Glossary & Terms

Ref Explanation/Detail

HSMR Hospital Standardised Mortality Ratio

SHMI Summary Hospital-Level Mortality Indicator

FCE Finished Consultant Episode

RR Relative Risk

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Title of Report Medical Revalidation & Appraisal

Executive Summary

This report contains an update on Medical Revalidation & Appraisal

Actions requested

The Board is asked to note the report.

Corporate Objectives supported by this paper: Quality Improvement - patient safety, patient experience & clinical effectiveness Leadership & Personal Responsibility

Risks: Failure to meet statutory obligations Failure to revalidate the Doctors licences would have a negative impact on service.

Public and/or patient involvement: Each Doctor has a 360 degree patient feedback within a five year period

Resource implications: Admin & Clerical PA time for medics both appraisees and appraisers

Communication:


Assurance

Contract

Equality and Diversity

Financial / Efficiency

HR

Information Governance Assurance

IM&T

Local Delivery Plan / Trust Objectives

National policy / legislation

Sustainability

Name Dr Anton Sinniah

Job Title Acting Executive Medical Director/Responsible Officer

Date April 2015


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THE PENNINE ACUTE HOSPITALS NHS TRUST

Medical Revalidation & Appraisal Report

Background 1. The Health Secretary introduced Revalidation of doctors in the UK with effect from 3 December 2012. Revalidation is the process that assures patients, the public, employers and other health care professionals that licensed doctors are up to date and fit to practise. 2. A rigorous appraisal process is needed to ensure that GMC requirements will be met. Revalidation will require annual appraisals to be completed, with 5 yearly cycles leading to personal recommendation of the individual medical practitioner by the Responsible Officer (RO) of the organisation, usually the Medical Director. This will be based on a summation of 5 summative annual appraisals, and supporting portfolio of evidence. The doctor must demonstrate fitness to practise in relation to each of the four domains of good medical care as defined by the GMC in “Good Medical Practice” 2013. The four domains are: knowledge, skill and performance; safety and quality; communication, partnership and teamwork and maintaining Trust. 3. The Trust uses the PremierIT Appraisal system and this has been used for all medical appraisals since April 2013. 4. The Trust has purchased licences for doctors to undertake their annual job plans on the PremierIT system. The Directorate Managers have all been invited to training on the system and the roll out has commenced. Purpose of the Paper 5. The purpose of this paper is to provide the Trust Board, members of the public, patients, employers and other health care professionals with the assurance that the Trust has the necessary resources and processes in place which will support the appraisal and ultimately the revalidation for all doctors not on a training scheme. Management of Appraisal & Revalidation 6. At the 1st April 2015 there were 531 doctors with a prescribed connection to the Trust on GMC Connect and active on PremierIT; of these doctors 100% had completed an annual appraisal in the 2014/15 appraisal cycle. Appendix A shows the breakdown of the appraisals for the 2014/15 cycle.

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7. Appendix B shows the details of all missed or incomplete appraisals during the 2014/2015 appraisal cycle. 8. Any Locums appointed by the Trust are treated, in relation to appraisal and revalidation, as a permanent member of staff and are appraised and revalidated according to Trust policies. The Trust are currently working with Locum agencies and work is underway to revise the service level agreement through the framework to ensure they track revalidation and appraisal of locums to improve the quality assurance and those figures are reported to the Revalidation Steering Group. 9. The Trust currently has 116 active trained appraisers. 10. The Revalidation Team found that having the Trust appraisal cycle run from 1st April to 28th February greatly assisted in ensuring that all doctors met the NHS England criteria of an appraisal in the cycle 1st April to 31st March and the Trust will continue to work with a shorter appraisal cycle as detailed above, this will ensure that any last minute unforeseen circumstances will not adversely affect the appraisal process. 11. Appendix C shows the appraisal statistics as at 12th May 2015. 12. Monthly updates on statistics are sent by email to all Exec Directors, Clinical Directors, Divisional Directors, Divisional Medical Directors and Directorate Managers. 13. The Responsible Officer has successfully recommended for revalidation 378 doctors to date, with a further 55 doctors being deferred, (of which 35 were consultants and 20 were other grades). The reason for deferral has been ‘insufficient evidence to support a recommendation’ and the cause of this has predominately been that the doctors are on sabbaticals, long term sick or maternity leave. Where a deferral has been made the Appraisal and Revalidation team work closely with the doctor to ensure that they are fully prepared for their new revalidation date to ensure the Responsible Officer can make a successful recommendation for revalidation. The audit of revalidation recommendations for the period 1 April 2014 to 31 March 2015 is shown at Appendix D. 14. To date the appraisal and revalidation team are currently working to prepare the revalidation folders for the doctors due to be revalidation in August/September/October 2015. These are presented to the Responsible Officer for review on a two weekly basis. 15. The Trust Board receives from HR an annual report which covers any doctors in difficulty and concerns raised. 16. A review of the revalidation & appraisal policy has been undertaken due to the evolving and changing environment for appraisal and revalidation and this is in the process of being ratified by the JLNC. 17. The PremierIT system has been aligned to the new directorate structures to include the directorate of Integrated and Community Structure and work will be

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carried out to realign the system again once the newly announced directorate changes/structures are known. Quality Assurance 18. The revalidation team have randomly selected 50 appraisers to have 1 appraisal reviewed by The Revalidation & Clinical Appraisal Lead and the Head of Medical Business and Professional Support (with the remit for Trust Appraisal & Revalidation Lead) for QA purposes and this is currently in progress. Any concerns will addressed via the appraisal team leaders and feeds into the performance review of appraisers, see paragraph 19 below. A summary of the findings of this audit will be included in the next Medical Revalidation & Appraisal Board paper submitted. Please see paragraphs 23-25 for details of some of the QA work the Appraisal Team Leaders are carrying out. 19. At the end of each appraisal the appraisee has to complete a feedback form on how they felt their appraiser conducted the appraisal. At the end of the appraisal cycle these reports are collated and the Trust Appraisal Team Leaders are each provided with a portfolio of results for them to discuss with their individual appointed appraisers. Any areas for improvement identified will be addressed at future training events. 20. In 2014 NHS England introduced a framework for quality assurance to provide assurance to patients, the public, the service and the profession that the systems and processes underpinning revalidation are in place and working effectively. This framework is known as the Annual Organisational Audit (AOA) and consists of mandatory returns and these are currently being reviewed by the Trust Revalidation & Appraisal Lead. 21. NHS England have now included in the 2015 AOA documentation the requirement for us to report on our internal process to ensure that Trusts are completing the transfer of information between Responsible Officers as part of their recruitment checks and this is being raised at the Revalidation Steering Group with the Executive Directors of HR and Executive Medical Director for our current systems to be amended to incorporate this element. 22. Internal Audit has conducted a second Internal Audit of the Appraisal Process with the only recommendation made around the performance of the speed of the appraisal system. IM&T are looking into this. Performance Review, Support & Development of Appraisers. 23. Five Appraisal Training events have been run during the year and these are planned to continue moving forward. In house appraisal training has been approved by the RO and the Revalidation & Clinical Appraisal Lead holds a minimum of two full day Appraiser training events per appraisal cycle for both new appraisers and those who are required to attend for their 3 yearly update.

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24. After attending the Appraisal Training all newly appointed appraisers have to have their first appraisal peer reviewed by an Appraisal Team Leader. If this is found to be conducted satisfactory then the appraiser is recorded as being qualified, if however, any issues are identified at this first appraisal then these will be discussed with the appraiser and appraisal team leader and further peer reviews may be undertaken before the appraiser is recorded as being qualified. 25. A number of Appraisal Training workshops are held during the appraisal cycle and all appraisers have to attend at least one workshop in an appraisal cycle to remain compliant with their training. Clinical Governance 26. A number of documents are uploaded to the PremierIT system for discussion at appraisal, examples of these include complaints received, consultant dashboard data, audit data, declaration of interests and job plans. Access, Security & Confidentiality 27. The PremierIT system provides a fully auditable log with access being restricted and controlled by the Appraisal & Revalidation Team. 28. All Information Governance protocols are followed at all times. Remediation 29. A review of the conduct and capability policy has been undertaken by HR and a new policy titled remediation, capability & conduct for medical staff has been introduced and is available on the Trust intranet. Conclusion 30. The Trust are currently revalidating all doctors in a timely and responsible manner. 31. The Trust are actively encouraging and engaging with doctors to ensure that annual appraisals are carried out and that these are of a higher quality than previously. 32. Where there is statistical evidence of specific divisions responding very late to requests for appraisals to be undertaken and then failing to meet the 100% requirements a discussion between the Revalidation & Clinical Appraisal Lead and the Divisional Manager will be arranged to see if there are any underlying contributing factors and/or assistance required to improve the compliance rate.

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Recommendations 33. The Board are asked to note the contents of this report. 34. To approve the ‘statement of compliance’ confirming that the Trust, as a designated body, is in compliance with the regulations. Statement of Compliance is attached at Appendix E. DR ANTON SINNIAH Acting Executive Medical Director/Responsible Officer May 2015

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APPENDIX A

Appraisals breakdown by Division

Completed Appraisals

Overall 487 Diagnostics 148 HR 4 Medicine 106 Women’s and Children’s 81 Surgery 132 Integrated & Community Services 16

Appraisals completed on another system Overall 4

Diagnostics 0 HR 0 Medicine 1 Women’s and Children’s 0 Surgery 3 Integrated & Community Services 0

Appraisals escalated to RO Overall 1

Diagnostics 0 Facilities 0 Medicine 1 Women’s and Children’s 0 Surgery 0

Integrated & Community Services 0 Missed Appraisals (Maternity leave & Sabbatical

leave)

Overall 9

Diagnostics 1

HR 0

Medicine 2

Women’s and Children’s 2

Surgery 3

Integrated & Community Services 1

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APPENDIX B

Audit of all missed or incomplete appraisals

Doctor factors (total) Number

Maternity leave during the majority of the ‘appraisal due window’ 4

Sickness absence during the majority of the ‘appraisal due

window’

1

Prolonged leave during the majority of the ‘appraisal due

window’

3

Suspension during the majority of the ‘appraisal due window’ 0

New starter within 3 month of appraisal due date 1

New starter more than 3 months from appraisal due date 0

Postponed due to incomplete portfolio/insufficient supporting

information

0

Appraisal outputs not signed off by doctor within 28 days 0

Lack of time of doctor 0

Lack of engagement of doctor 0

Other doctor factors (describe) 0

Appraiser Factors

Unplanned absence of appraiser 0

Appraisal outputs not signed off by appraiser within 28 days 0

Lack of time of appraiser 0

Other appraiser factors (describe) 0

Organisational Factors

Administration or management factors 0

Failure of electronic information systems 0

Insufficient numbers of trained appraisers 0

Other organisational factors (describe) 0

TOTAL 9

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APPENDIX C

These statistics are taken from the system on 12th May 2015.

Overall

Successfully completed appraisals

0

Appraisal progress within guidelines

526 (98%)

Appraisal progress not within guidelines

4 (1%)

Appraisal due date not defined

0

Appraisals closed prior to completion

0

A milestone for these appraisals has been missed 7 (1%)

Appraisals with escalations to RO

0

Total

537

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APPENDIX D Audit of revalidation recommendations

Revalidation recommendations between 1 April 2014 to 31 March 2015

Number Recommendations completed on time (within the GMC recommendation window) including the recommendation of deferral

207

Late recommendations (completed, but after the GMC recommendation window closed).

0

Missed recommendations (not completed)

0

TOTAL

207

Primary reason for all late/missed recommendations For any late or missed recommendations only one primary reason must be identified

No responsible officer in post

0

New starter/new prescribed connection established within 2 weeks of revalidation due date

0

New starter/new prescribed connection established more than 2 weeks from revalidation due date

0

Unaware the doctor had a prescribed connection

0

Unaware of the doctor’s revalidation due date

0

Administrative error

0

Responsible Officer error

0

Inadequate resources or support for the responsible officer role

0

Other (describe)

0

TOTAL 0

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A Framework of Quality Assurance for Responsible Officers and Revalidation

Annex E - Statement of Compliance Version 4, April 2014

APPENDIX E

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NHS England INFORMATION READER BOX

Directorate

Medical Operations Patients and Information

Nursing Policy Commissioning Development

Finance Human Resources

Publications Gateway Reference: 01142

Document Purpose Guidance

Document Name A Framework of Quality Assurance for Responsible Officers and Revalidation, Annex E - Statement of Compliance

Author NHS England, Medical Revalidation Programme

Publication Date 4 April 2014

Target Audience All Responsible Officers in England

Additional Circulation List

Foundation Trust CEs , NHS England Regional Directors, Medical Appraisal Leads, CEs of Designated Bodies in England, NHS England Area Directors, NHS Trust Board Chairs, Directors of HR, NHS Trust CEs, All NHS England Employees

Description The Framework of Quality Assurance (FQA) provides an overview of the elements defined in the Responsible Officer Regulations, along with a series of processes to support Responsible Officers and their Designated Bodies in providing the required assurance that they are discharging their respective statutory responsibilities.

Cross Reference The Medical Profession (Responsible Officers) Regulations, 2010 (as amended 2013) and the GMC (Licence to Practise and Revalidation) Regulations 2012

Superseded Docs

(if applicable)

Replaces the Revalidation Support Team (RST) Organisational Readiness Self-Assessment (ORSA) process

Action Required Designated Bodies to receive annual board reports on the implementation of revalidation and submit an annual statement of compliance to their higher level responsible officers (ROCR approval applied for).

Timings / Deadline From April 2014

Contact Details for further information

[email protected]

http:// www.england.nhs.net/revalidation/

Document Status

This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet

Page 78 of 196

Annex E – Statement of Compliance

Designated Body Statement of Compliance

The Trust Board – of the Pennine Acute Hospitals NHS Trust has carried out and submitted an annual organisational audit (AOA) of its compliance with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013) and can confirm that:

1. A licensed medical practitioner with appropriate training and suitable capacity

has been nominated or appointed as a responsible officer;

Comments: I can confirm that this is correct

2. An accurate record of all licensed medical practitioners with a prescribed

connection to the designated body is maintained;


3. There are sufficient numbers of trained appraisers to carry out annual medical

appraisals for all licensed medical practitioners;


4. Medical appraisers participate in ongoing performance review and training /

development activities, to include peer review and calibration of professional

judgements (Quality Assurance of Medical Appraisers or equivalent);


5. All licensed medical practitioners1 either have an annual appraisal in keeping

with GMC requirements (MAG or equivalent) or, where this does not occur,

there is full understanding of the reasons why and suitable action taken;


6. There are effective systems in place for monitoring the conduct and

performance of all licensed medical practitioners1, which includes [but is not

limited to] monitoring: in-house training, clinical outcomes data, significant

events, complaints, and feedback from patients and colleagues, ensuring that

information about these is provided for doctors to include at their appraisal;


7. There is a process established for responding to concerns about any licensed

medical practitioners1 fitness to practise;


1 Doctors with a prescribed connection to the designated body on the date of reporting.

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8. There is a process for obtaining and sharing information of note about any

licensed medical practitioners’ fitness to practise between this organisation’s

responsible officer and other responsible officers (or persons with appropriate

governance responsibility) in other places where licensed medical

practitioners work;


9. The appropriate pre-employment background checks (including pre-

engagement for Locums) are carried out to ensure that all licenced medical

practitioners2 have qualifications and experience appropriate to the work

performed; and

Comments: The Trust has appropriate checks in place; however

weaknesses have been identified and are subject to ongoing discussions

between the Executive Director of HR and the Acting Medical

Director/Responsible Officer.

10. A development plan is in place that addresses any identified weaknesses or

gaps in compliance to the regulations.

Comments: An action plan is in place for improvements where required.

Signed on behalf of the designated body

Name: DR GILLIAN FAIRFIELD Signed: _ _ _ _ _ _ _ _ _ _

[chief executive or chairman a board member (or executive if no board exists)]

Date: _ _ _ _ _ _ _ _ _ _

2 Doctors with a prescribed connection to the designated body on the date of reporting.

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C:\Users\244991-Admin\AppData\Local\Temp\e63c7da6-3a16-445f-9453-b0c4fec601be.doc

Title of Report Dr Kershaw’s Hospice

Executive Summary

The paper updates the Board on the review of the relationship between Hospice and the Trust

Actions requested

The Board is asked to note the report.

Corporate Objectives supported by this paper: 9. To be an influential organisation working in partnership with others across the health and social care system to improve the health of the population.

Risks: Financial –through employment issues

Public and/or patient involvement:

Resource implications:

Communication:


Assurance X

Contract



HR X


IM&T X



Sustainability X

Name Mr J Wilkes

Job Title Director of Estates and Facilities

Date May 2015


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Dr Kershaw’s Hospice update

Introduction 1. This paper outlines the progress that has been made in reviewing the

relationships between the hospice and the Trust with the aim to ensure there are clear lines of accountability and responsibility and where needed formal service level agreements are in place.

Strategic context 2. As the board will recall there was a formal investigation into the

Hospice following a patient complaint. This led to Oldham CCG raising concerns with the Hospice about its over reliance on Trust policies and procedures.

Review 3. The Hospice has now reviewed all its clinical policies and procedures

and taken ownership of them. However, due to historical arrangements 56 staff currently working at the Hospice have been employed on Trust terms and conditions of service. Working together the aim is for the Trust to transfer the staff over to Dr Kershaw’s on 1st September 2015.

4. The Trust supported the Hospice during this period by seconding a

Matron to them to give them the clinical leadership it required. The Matron has now been recruited by the Hospice on a permanent basis.

5. A major barrier has been the NHS Pension scheme and getting the

hospice to apply for membership to the scheme to enable the transfer of the staff under the Transfer of Undertakings regulations (TUPE). This has now been actioned by the Hospice and supporting information from the Trust was sent back to the Pension agency at the beginning of May.

6. A task and finish group has been set up following agreement by the

hospice directors in February to ensure the transfer and supporting processes are delivered by the agreed timescale. The group is led by the Director of Governance and supported by Deputy Director of Workforce. Other trust officers will be included as and when needed for their expertise.

7. Besides the staffing issues the group is looking at Recruitment,

Occupational health, Training, Financial services, Nurse bank and I&MT.

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Conclusion 8. The Task and Finish group has been set up and the Director of Support

Services will be kept aware of progress. The Director has also met with the Hospice Secretary and Director, and agreed to meet with him on a quarterly basis.

Recommendations 9. The Board is asked to note the contents of the report. John Wilkes Director of Estates and Facilities May 2015

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Title of Report Trust Programmes Update

Executive Summary

This paper sets out progress with Programme arrangements for the Trust.

Actions Requested:

The Board is asked to:

Note the role of a Trust Programme Board

Note individual Programme progress

Note PMO structure and potential developments

Risks: 1) Failure to deliver programme management approach may lead to; 2) – failure to achieve service transformation 3) – failure to deliver CIPs 4) – failure to progress SLR 5) – failure to deliver safe services 6) – failure to develop a workforce fit for the future 7) – failure to achieve Foundation Trust status

Public and/or Patient Involvement: 8) Not applicable to this paper.

Resource Implications: 9) Funding to support PMO previously agreed.

Communication: Through normal Trust communication channels in due course. Progress of individual programmes will be via the Programme Board to the Board of Directors


Assurance X

Contract X



HR X


IM&T X



Sustainability X

Name Sandra Good

Job Title Director of Strategy and Commercial Development

Month and Year May 2015


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Trust Programmes Update 1. Purpose This briefing sets out the progress with Trust Programme arrangements. 2. Background Following approval of revised Trust governance arrangements in June 2014, and introduction of the programme management approach, this paper provides an update from the December 2014 written briefing and March presentation update. 3. Overarching Programme Governance Framework Trust-wide Programmes Board (time limited committee) In order to support the main Trust business and operational delivery of services the Trust has established six core programmes of work. The Trust-wide Programmes Board provides assurance to the Trust Board in relation to the delivery of the activities of the Trust Programmes, ensuring programmes of work are appropriately governed, aligned with the Trust strategic goals and that interdependencies within programmes are managed effectively. There are six core programmes reporting into the Trust-wide Programmes Board:

Service Transformation Programme

Safety Programme

Workforce and Leadership Programme

CIP Programme

Service Line Reporting (SLR) Programme

Foundation Trust Programme 4. Programme Structure The Trust describes within its five year Integrated Business Plan (IBP) a significant transformation agenda, in order to improve quality whilst maintaining financial stability. The key delivery vehicle is the Programme Management approach. 4.1. Service Transformation Programme The Service Transformation Programme oversees the development and implementation of new service models ensuring that the programme realises the expected benefits to:

increase quality for the patient;

reduce cost in accordance with agreed 5 year CIP plans; and

ensure that the Trust remains clinically and financially sustainable. The outputs of this programme will be a five year service development strategy which is a central plank of the Trust IBP.

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4.21 Safety Programme The Safety Programme will:

Identify emerging themes and develop programmes of themed work through the review of SUIs, Complaints, Incidents, Disciplinaries and other quality indicators.

Examine in detail the safety implications of the transforming services agenda, assessing the risk and suggest monitoring arrangements.

4.3. Workforce and Leadership Programme The workforce and leadership programme will:

Create the future workforce to deliver transformed services in order to increase quality for the patient;

Develop leadership strategy and programmes for the Trust

Address key workforce metrics including sickness absence

Reduce cost in accordance with agreed 5 year CIP plans; and

Ensure that the Trust remains sustainable. 4.4. Cost Improvement Plan (CIP) Programme The Cost Improvement Plan (CIP) programme will:

Oversee, develop, initiate and discuss all activities associated with the delivery of the Cost Improvement Programme.

Problem-solve delivery issues so that any obstacles to success are managed and eliminated.

Ensure alignment and delivery against the associated five year plan. 4.5. Service Line Reporting (SLR) Programme The Service Line Reporting (SLR) Programme will:

Develop and implement robust service line reporting Trustwide

Provide assurance to the Trust-wide Programme Board that Service Line Reporting (SLR) programme is being managed effectively and is delivering.

4.6. Foundation Trust Programme The Foundation Trust Programme will:

Lead the Foundation Trust application, ensuring all actions collectively meet the needs of the organisation, TDA and Monitor to achieve FT status.

Ensure alignment between individual FT work streams and with other strategy, policy and operational need.

Manage strategic risk and issues relating to FT programme and strategic external dependencies.

5. Progress Since previous updates, progress has been made as follows:

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Substantive role of Foundation Trust Programme Director subsumed into role of Director of Strategy and Commercial Development 1st January 2015

Substantive Transformation Director commenced 1st February 2015. Secondee’s substantive post as Divisional Director of Diagnostics removed as part of recent Divisional restructuring.

PMO Administrator commenced 11th May 2015 as part of recent Divisional restructuring.

Project Manager posts filled. Start dates to be confirmed for 2 candidates.

Time limited interims will be reduced over time to reduce financial burden and increase long term commitment to the Trust. Planned end dates June 2015.

Transformation delivery Managers are being recruited to support Divisions with implementation of transformation and cost improvement plans (short delay due to conclusion of recent Divisional restructuring).

Key changes to Senior Responsible Officers operationalized –

- Jon Lenney, Director of Workforce and Organisational Development lead on Workforce and Leadership

- Dr Anton Sinniah, Acting Medical Director lead on Service Transformation

- Gill Harris, Chief Nurse lead on Safety Programme

Trust wide Programme Board operational

Service Transformation Programme. Progressing. Supported by 2 wte Project Managers and McKinsey.

Safety Programme. Progressing. Work streams identified as Sepsis, Diabetes, Failure to Rescue, Learning Lessons and Falls. Supported by 1.4 wte Project Managers.

Workforce and Leadership Programme. Early stages of development in terms of work streams now identified as modernisation, engagement, leadership and Health & Wellbeing. Interim legacy Project Manager in place.

Cost Improvement Programme. Board fully established. Supported by 2 wte Project Managers (1 appointed, 1 interim Project Manager in place) and Ernst & Young.

Service Line Reporting Programme. Board fully established. External input from Ernst & Young completed. Implementation focused going forwards. Project Manager appointed.

Foundation Trust Programme. Board fully established. FT Project Manager

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returned from long term sickness absence January 2015, graded basis – requested move to Corporate Governance from 1st June 2015 (agreed). No interim arrangements identified – for review.

6. Future Arrangements As a result of the convergence of the transformation and cost improvement work streams, discussions are planned for 8th June 2015 to consider a merger of the two Programme Boards. This will improve synergy and reduce the meetings commitments of participants and Divisional staff, particularly clinicians. This approach is supported by planned changes to external support. 7. Conclusion As a new approach for the Trust a variable start was anticipated, but the new financial year has demonstrated a renewed commitment to the approach driving progress forward across each of the Programme Boards to ensure delivery against key milestones and outcomes, and to provide the Board of Directors with the necessary assurance. Sandra Good Director of Strategy and Commercial Development 28th May 2015

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Title of Report IM&T Strategy

Executive Summary

The purpose of this paper is to present the IM&T Strategy 2015 to 2018 to the Trust Board.

The Strategy was approved by the Senior Management Team on 11 May 2015, and noted by the Finance, Infrastructure and Business Development Committee on 26 May 2015.

The Strategy examines the Trust’s business and strategic drivers that will guide activities and prioritise investment in IM&T for the next 3 years. The Strategy describes the current IM&T capabilities and assesses progress against the previous Strategy identifying key gaps to be addressed.

Ten strategic objectives have been defined in support of the Trust’s transformation and quality agenda:

Supporting the Trust’s Transformation Map

Digitising patient records and clinical workflow

Integration across the care-continuum

Improving patient access to care and information

Providing high quality information and business intelligence

Flexible and innovative working

Enhancing IT infrastructure

Optimising existing technology

Efficient and effective IM&T service

Improving clinical engagement.

Delivery of the Strategy requires immediate additional revenue investment of £400k and capital investment of £7.3m in 2015/16, £10m in 2016/17 and £7.7m in 2017/18. There is an identified shortfall in the Trust’s capital plans in 2016/17 and 2017/18 to meet the IM&T funding requirements.

In principal the Strategy should deliver cash-releasing

benefits, but as a minimum be self-funding.

Actions requested

To approve the IM&T Strategy until 2018 and undertake annual review of progress against objectives

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Corporate Objectives supported by this paper:

All

Risks:

Adequate capital and revenue funds are not made available to deliver the strategy and to provide a business as usual IT Service that supports the operational needs of the organisation

Sufficient project resources and management cannot be secured risking delays or abandonment of projects

Projects run late or over-budget, delaying delivery of benefits

Projects completed, but benefits not fully realised

Loss of efficiencies and disruption to organisation arising from out-of-date or redundant systems

Failure to attract and retain high quality staff leads to heightened risk of project failures and unreliable systems and processes

Failure to identify project and programme risks

IM&T are not involved early enough in hospital projects

Trust culture does not change to one of “IT is not optional, it is part of the day job”

Clinicians see IT as purely administration

Lack of flexibility and response to change

Increased demand for IT solutions as cost improvement enabler cannot be met by current IM&T resource establishment

IM&T strategy is impacted or delayed by Devolution of Manchester and/or other political changes in local area

Increased demands on the finite business as usual resources due to the expansion of IM&T systems delivered as part of the strategy

Public and/or patient involvement:

Not applicable


Assurance √

Contract √



HR √

IM&T √



Sustainability √

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Name Brian Steven

Job Title Deputy Chief Executive / Finance Director

Date 28 May 2015


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Information Management and

Technology Strategy 2015-2018

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The Pennine Acute Hospitals NHS Trust IM&T Strategy 2015 – 2018

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Version Date Amendment

V1.0 01/04/15 Created

V1.1 15/05/15 Minor revisions further to comments from SMT

Approvals:

Name Lead Date of Review Date of sign-off

Version

Senior Management Team

Gillian Fairfield

11th May 2015

Trust Board John Jesky

28th May 2015

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Contents

1 EXECUTIVE SUMMARY ..............................................................................................4

2 INTRODUCTION ...........................................................................................................7

3 STRATEGIC CONTEXT ...............................................................................................9

3.1 NATIONAL CONTEXT ........................................................................................................ 9

3.2 SOCIAL CONTEXT........................................................................................................... 13

3.3 LOCAL CONTEXT ............................................................................................................ 14

3.3.1 The Pennine Acute Hospitals NHS Trust ........................................................... 14

3.3.2 Greater Manchester Devolution Agreement ...................................................... 16

3.3.3 North East Sector .................................................................................................. 17

3.3.4 Healthier Together ................................................................................................. 17

3.3.5 Living Longer, Living Better ................................................................................. 18

3.3.6 Greater Manchester Academic Health Science Network ................................ 18

3.3.7 CQUINs ................................................................................................................... 18

3.4 SUMMARY OF THE STRATEGIC ENVIRONMENT ............................................................ 20

3.5 STAKEHOLDER ANALYSIS .............................................................................................. 21

4 CURRENT IM&T ENVIRONMENT ............................................................................. 22

4.1 PROGRESS AGAINST PREVIOUS IM&T STRATEGY ....................................................... 22

4.2 STATUS OF CURRENT IM&T INFRASTRUCTURE AND SERVICES PROVISION ............... 22

4.3 CURRENT STATE OF CLINICAL SYSTEMS ....................................................................... 25

4.4 IM&T STAFFING ............................................................................................................. 28

4.5 DIGITAL RECORD MATURITY AND ADOPTION MODELS .................................................. 29

5 VISION AND STRATEGIC OBJECTIVES ................................................................. 30

5.1 VISION AND MISSION ..................................................................................................... 30

5.2 IM&T STRATEGIC OBJECTIVES ..................................................................................... 30

5.2.1 Supporting the Trust’s transformation ................................................................ 31

5.2.2 Digitising patient records and clinical workflows ............................................... 32

5.2.3 Integration across the care-continuum ............................................................... 35

5.2.4 Improving patient access to care and information ............................................ 36

5.2.5 Providing high quality information and business intelligence ......................... 37

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5.2.6 Flexible and innovative working .......................................................................... 39

5.2.7 Enhancing IT infrastructure .................................................................................. 42

5.2.8 Optimising existing technology ............................................................................ 43

5.2.9 Efficient and effective IM&T service ................................................................... 44

5.2.10 Improving clinical engagement ............................................................................ 44

6 ACTIONS AND IMPLEMENTATION PLAN .............................................................. 46

7 GOVERNANCE ........................................................................................................... 51

7.1 INFORMATION ASSURANCE FRAMEWORK - IM&T DEPARTMENT ................................ 51

7.2 CALDICOTT AND INFORMATION GOVERNANCE COMMITTEE - TERMS OF REFERENCE51

7.3 IM&T AND INFORMATION QUALITY ASSURANCE COMMITTEE - TERMS OF REFERENCE 51

7.4 CLINICAL STRATEGY GROUP – TERMS OF REFERENCE ............................................. 52

7.5 IM&T PROGRAMME / PROJECT FUNDING APPROVAL ................................................. 52

8 METHODOLOGIES AND BEST PRACTICE ............................................................. 53

8.1 PROGRAMME MANAGEMENT ......................................................................................... 53

8.2 PROJECT MANAGEMENT ................................................................................................ 53

8.3 SERVICE MANAGEMENT ................................................................................................. 53

8.4 SECURITY MANAGEMENT ............................................................................................... 53

9 BENEFITS ................................................................................................................... 55

10 RISKS .......................................................................................................................... 56

11 CONCLUSION ............................................................................................................ 59

12 GLOSSARY OF TERMS ............................................................................................ 60

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1 Executive Summary

The Trust’s previous Information Management and Technology (IM&T) strategy was presented to the Trust Board in June 2013. The strategy has been revised to reflect the priorities of the Trust under the leadership of its new Chief Executive and the planned ambitious clinical service transformation programme that is currently underway. It also reflects the opportunities presented to the Trust through healthcare integration activities with the North East Sector Consortium, the devolution of Greater Manchester health and social care, and advances in technology and innovation. The strategy emphasises the significant progress made against the previous strategy and describes the changes to the context and direction of approach.

IM&T supports and underpins the strategic direction of the Trust. It acts as a catalyst to enable more efficient processes and new and innovative ways of working. These will ultimately enhance the health of the North East Sector of Greater Manchester population and the working lives of Trust staff.

This document examines the Trust’s business and strategic drivers and identifies those objectives that will guide activities and prioritise investment in IM&T over the next three years. It describes the current IM&T capabilities and assesses progress against the previous strategy, identifying the key gaps that need to be addressed in order to achieve the strategic objectives.

The national strategic agenda focuses on engaging patients in their own care and providing them with information they need to make informed choices. There is currently a strong emphasis on preventative care and better integration of services across the care continuum and organisational boundaries. The NHS recognises the role information, technology and innovation can play to support quality and efficiency of services, improve patient access to care and combat the increasing national budgetary gap. This is highlighted in NHS England’s recently published report, the Five Year Forward View (FYFV).

The environment in which the Trust now exists requires it to operate as a competitive business and to take a lead in the local community. The specific needs of the local population will be addressed working alongside the North East Sector Consortium and within the context of the Greater Manchester devolution and the Healthier Together programme.

These forces drive The Pennine Acute Hospitals NHS Trust to improve efficiency and effectiveness of services at an ambitious but realistic rate. IM&T has a critical role to play in enabling the Trust to overcome these challenges through modernising business critical systems and transforming how information is shared with its partners and peers.

Since the last strategy was approved the IM&T Department has made significant progress in a number of areas. All clinical areas have wireless networking and a range of mobile devices have been deployed. Development and rollout of electronic prescribing (ePMA), order communications and results reporting (OCRR) and handover of care summaries are near full completion within the Trust inpatient areas. The Trust’s achievements have been recognised through NHS England’s

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Clinical Digital Maturity Index (CDMI), receiving a ranking of 24 out of 160 Trusts across the country, and improving significantly on its 2013 ranking of 77.

The Trust have recently approved the extension of the existing Electronic Patient Record (EPR) approach in light of the significant progress made, and on the basis of a cost benefit analysis of continuing the best of breed approach versus procuring a single vendor integrated EPR. In order to keep up with the accelerated pace of change the Department has set itself ambitious but realistic goals for the future.

The strategic vision for IM&T is:

Improving patient care through technology and innovation

The strategic mission for IM&T is:

To provide the Trust with IT systems, information and services to enable staff to deliver excellent and efficient patient care anytime, anywhere

The following IM&T strategic objectives have been developed to support the Trust’s transformation and quality agenda. The approach to each objective is explored in further detail.

1. Supporting the Trust’s transformation: create a robust and innovative IM&T foundation to underpin the Trust’s transformation of clinical services.

2. Digitising patient records and clinical workflows: extend the development and rollout of the Trust’s acute EPR and clinical portal with the aim of achieving a digitised patient record by 2018.

3. Integration across the care-continuum: lead development of a community wide, integrated patient record in collaboration with acute, primary care, community, mental health and social care partners to improve access to patient data.

4. Improving patient access to care and information: provide the structure and support to enhance patient’s access to their own records, to services and to safe healthcare.

5. Providing high quality information and business intelligence: deliver a high quality information service which supports the Trust’s clinical and business processes real-time, such as service line reporting and business intelligence dashboards.

6. Flexible and innovative working: improve productivity and access to care by leveraging technology and telecommunications.

7. Enhancing IT infrastructure: continue to update and improve the Trust’s infrastructure to form a robust foundation for future IM&T delivery.

8. Optimising existing technology: optimise and standardise use of existing IM&T software and devices to provide efficient clinical, corporate and back office systems.

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9. Efficient and effective IM&T service: review and strengthen the capacity and capabilities to improve the efficiency and effectiveness of the IT services provided to Trust personnel.

10. Improving clinical engagement: improve clinical engagement in Trust IM&T and transformation activities through strengthen clinical leadership to promote clinical innovation through the better utilisation of technology.

An action plan is set out in section six which outlines key developments over the next three years to deliver reliable and robust infrastructures, systems and processes.

In conclusion, this strategy aims to maximise the benefit from investment in IM&T by focusing on achieving the Trust’s strategic objectives and by supporting the goals of Greater Manchester in the most efficient, cost effective and collaborative way. It highlights the need to build on the solid capabilities already in place and the need to strengthen areas such as system optimisation, clinical engagement and service delivery.

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2 Introduction

The NHS environment is one of constant change driven by shifts in economic conditions, politics, society and technology. The ability for the NHS to prosper rests on how quickly it responds to these emerging market forces. Technology, in particular, advances at an increasingly rapid rate. The NHS must adequately plan for change as well as leverage such changes to its competitive advantage.

Advances in technology can improve access to healthcare information and our ability to predict, diagnose, treat and prevent illness. Individuals in today’s society are immersed in technology. Users have an expectation of immediate access to reliable information and systems, wherever and whenever they need it. This demand, by both staff and patients, is increasingly evident within healthcare.

In addition to these external forces, the NHS must respond to governing pressures which require it to provide the highest quality of care with increasing budgetary constraints. It is imperative that NHS organisations shift their focus to increasing quality of care and productivity gains through more streamlined and efficient services. These factors create an opportunity for IM&T departments to provide the most fitting technology to help their organisations meet these challenges.

To achieve this, NHS IM&T departments will need to create reliable and responsive services using affordable, dependable and up-to-date technology. At the same time they need to future proof implementations against evolving technology and ever changing landscapes. Systems need to provide information to support the organisation’s business needs including decision making, risk management and transformational activities.

Purpose of this document

The purpose of an IM&T Strategy is to help the organisation to achieve these end points by guiding them towards a coherent and integrated setting for delivering and managing technology services.

The Trust is committed to the effective use of informatics to support the delivery of excellent patient care, facilitate the work of our clinicians and deliver efficiency gains. This strategy sets out the roadmap to achieving these aims. It examines the Trust’s business and strategic drivers and derives relevant strategic objectives to guide the activities of the IM&T Department and prioritise investment in healthcare IT. It identifies the key gaps in the Department’s capability that will need to be addressed in order to achieve the vision. Finally, the strategy presents a pragmatic and achievable programme of work against which progress can be measured and the vision can be achieved.

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Process used for the development of this strategy

The process used for the development of this strategy is summarised in the diagram below:

Approvals

The document will be reviewed and approved by the Clinical IM&T Strategy Group, the Senior Management Team, the Finance Infrastructure and Business Development Committee and the Trust Board.

Determining the Strategic Environment

Analysing Stakeholder

Requirements

Future Vision for IM&T

Determining the Current IM&T Environment

IM&T Current Capability Statement

Strategic Gap

Strategic Choices

Actions and Implementation Planning, Prioritisation, Costing

Staffing Structures Standards Governance Policies

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3 Strategic Context

This section describes the context in which the Trust operates and identifies the key strategic drivers at a national and local level.

3.1 National Context

The national context for NHS organisations across the country is increasingly challenging. In October 2014, NHS England produced the NHS Five Year Forward View (FYFV) which aims to articulate why change is needed, what change might look like and how to achieve it. It indicates that the estimated £30 billion gap in NHS funding predicted to appear by 2020-21 could be closed completely if the health service receives additional funding to develop new, more efficient care models. The Five Year Forward View states that the biggest challenges for the NHS are:

1. Changes in patient health needs and personal preferences.

2. Changes in treatments, technology and care delivery and the need to provide

care that is genuinely co-ordinated around what people need and want.

3. Changes to funding/continued decline in funding growth.

The Five Year Forward View sets out a number of key themes that need to be addressed to overcome these challenges. The eight themes are captured and discussed below.

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1. Quality The events at Mid Staffordshire from 2008 onwards have led to an increased focus on quality, safety standards and governance within the NHS. The subsequent reports of Francis (2010, 2013), Keogh (2013), Cavendish (2013) and Berwick (2013) have all called for a change to a truly patient-focussed culture, greater transparency and more rigorous management of standards. The FYFV continues the focus on quality stating that NHS organisations must narrow the gap between the best and the worst whilst raising the bar for all. 2. Prevention Prevention is increasingly becoming the most important area of focus for healthcare providers. As populations are living longer with more chronic health conditions, communities must work towards reducing causes of preventable illness such as obesity and lifestyle risks. If organisations can successfully incentivise and support healthier behaviours then we can prevent ill health and increasing demands on healthcare. The FYFV focuses on targeted prevention, supporting a healthier workforce and working across healthcare partners to enable local, democratic leadership. 3. Patients and communities In 2012 The White Paper, Equity and Excellence: Liberating the NHS (2012) set out the Government’s vision of an NHS that puts patients and the public first, where “no decision about me, without me” is the norm. The FYFV builds on this stating that patients must have more access to their healthcare information and must have increased control over the care that is provided to them supporting them to manage their own health in a way that is suitable for them. However, the paper also expands on this stating that the wider community, including carers, third sector and general citizens, also play a vital role and must be engaged in new ways to support the challenges ahead and work together for healthier futures. 4. New models of care Over the next five years and beyond the NHS will increasingly need to flex its traditional care boundaries to support truly integrated, patient centred care. The FYFV takes a radical approach by defining its own view of what healthcare should look like over the next five years and introduces new organisational types/care models including;

Multi-specialty Community Providers

Primary and Acute Care Systems

The document also focuses on how smaller hospitals can remain viable, how specialised care can be provided into a wider array of providers, modern maternity services and enhanced healthcare in care homes. It has long been understood that in order to meet the rising demand on resources while actively achieving financial savings and high quality care, providers will need to come together to deliver truly integrated care but the focus on this as a solution is definitely intensifying with the FYFV.

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5. Leadership and workforce No change, let alone radical change, can be achieved without leadership and people to make the changes happen. However, change in the NHS will always be a constant and so greater support is needed to help mobilise leaders and workforces to work differently, develop the newly needed skills, values, behaviours and numbers to deliver the improvements required. The FYFV also states it will work to better align national leadership.

6. Efficiency and productivity In 2009, the NHS set out plans for providers and commissioners to prepare to operate in more austere times than many had experienced before. By 2015, the NHS needs to make savings of £20 billion with an additional £30 billion required by 2021. It has been estimated that funding growth will remain at 1.2% per annum, which will be half of what is needed to fund future services. With the Better Care Fund shifting a significant amount of NHS funding to Social care in 2015/16, the financial future of the NHS is increasingly challenging. Greater efficiency and productivity continues to be key to delivering the NHS vision for the future as demand increases and funding decreases. 7. Information and technology The FYFV focuses heavily on the importance of information and technology in achieving the required changes the NHS has to make. It talks of a national focus on key systems that will provide the ‘electronic glue’ to enable different parts of the NHS to work better together. During the summer of 2015 the National Information Board (NIB) will publish a set of ‘road maps’ to set out who will do what to transform digital care. Key elements will include:

comprehensive transparency of performance data

expanding set of NHS accredited health apps to support digital inclusion

fully interoperable electronic health records continuing the move towards

paperless

family doctor appointments and prescriptions online, everywhere

better audit data

increased focus on technology including smart phones

support to help build capacity and help those unwilling or unable to use

technology.

8. Health innovation Finally, the FYFV focuses on the need for health innovation in relation to research, personalised care, accelerated innovation in ways of delivering clinical care and the unexploited opportunity to combine different technology such as mobile apps and telemedicine. The National Information Board (NIB) proposes to make England a leading digital health economy with new resources to support research and maximise the benefits of new medicines and treatments. This would include genomic science to combat long-term conditions and tackling infectious diseases.

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Implementing the Five Year Forward View

The National Information Board (NIB) has subsequently published a framework outlining proposals to transform outcomes for patients and the wider population. The National Information Board plans to issue a set of road maps and standards which will provide a more detailed approach to transforming digital care. Key milestones include:

• from March 2015, all citizens will have online access to their GP records

• by 2017, 100,000 individual genomes will have been sequenced

• by 2018, clinicians in primary care, urgent and emergency care and other key

transitions of care contexts will be operating without the use of paper records

• by 2020, all care records will be digital real-time and interoperable.

The Health and Social Care Information Centre (HSCIC) have published a draft strategy for 2015-2020 which further emphasise these goals and outlines ways in which HSCIC will support organisations to achieve them.

NHS England’s Business Plan for 2015-2016, Building the NHS of the Five Year Forward View, demonstrates how information and technology will provide the foundations for improvement. Priorities for the next two years will include: harnessing the information revolution, and developing capability and infrastructure for transformational change.

In addition to this, the Health Secretary, Jeremy Hunt, has set out how the Government intends to implement the Five Year Forward View. During his statement to the House of Commons on 1 December, 2014, he announced four “pillars” of work:

• Pillar one: strong economy – £1.95 billion for frontline care was confirmed,

and the establishment announced of the Genomics England Clinical

Interpretation Partnership to stimulate development of diagnostics, treatments

and therapies for rarer diseases and cancers.

• Pillar two: new models of care – to address demographic changes and the

need for greater emphasis on prevention and improved out of hospital care.

• Pillar three: innovation and efficiency – to access the additional funding

hospitals will need to show plans about how they will be more efficient and

sustainable and deliver their commitment to a paperless NHS by 2018.

• Pillar four: culture – the Government will announce work culture initiatives

such as new measures to improve safety training for clinical staff, and a

campaign to reduce sepsis.

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3.2 Social Context

Technology is dramatically changing how we run our day-to-day lives. Mobile and social technology is becoming more and more accessible to all and, as a result, is revolutionising how we interact with businesses and services.

The NHS is already seeing how social technology can positively impact the lives of staff and customers, and is beginning to understand how IM&T could support the challenges the NHS faces. Key to its success will be ease of use for staff and patients alike.

In 2013, the King’s Fund published their view of the key social trends that will affect how health and social care is delivered in the next 20 years. The key messages from an information technology perspective are as follows:

THE KINGS FUND: FUTURE OF HEALTH AND SOCIAL CARE 2013-2033

Our use of the internet continues to grow

Four out of five people in the UK can currently access the internet at home

and three out of ten use a smart phone to do so. It is expected that by

2023, everyone will have access to the internet.

Computing power and data is increasing exponentially

The increase in computing power, new devices, sensors and screens

combined with improving access to ever-expanding quantities of data will

support the shift to what is known as ‘ubiquitous computing’. In health and

social care there will be new opportunities to capture, relay and interpret vital

signs and other health information, both in the home and in other care

settings.

Social media will grow rapidly in importance

The impact of social media on health and social care can be expected to

grow, particularly alongside increased public availability of information.

Patients and doctors are already using social media such as Twitter and

Facebook to post medical problems and seek help finding diagnoses.

The rise of the app

Apps have a wide array of uses in health and social care, including providing

information about conditions and supporting self-diagnosis.

Changing the relationships between professionals and service users

Information technology is changing the way in which professionals manage

and make use of their knowledge. This is likely to drive changes in the

relationship between professionals, and between professionals and service

users.

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3.3 Local Context

3.3.1 The Pennine Acute Hospitals NHS Trust

The Pennine Acute Hospitals NHS Trust serves the communities of North Manchester, Bury, Rochdale and Oldham, along with the surrounding towns and villages. This area is collectively known as the North-East Sector of Greater Manchester and has a population of around 820,000. It is a large Trust with a total operating budget of £560m. The main commissioners are NHS Bury CCG, NHS Heywood, Middleton and Rochdale CCG, NHS Oldham CCG and NHS Manchester CCG.

NATIONAL CONTEXT – IMPLICATIONS FOR IM&T

IM&T that is flexible and agile to adapt, change and integrate services.

Systems that provide the ability to capture, monitor and audit clinical information to support safe, high quality care.

IM&T that is smart, real-time and accessible to support right care at the right time in the right location.

Systems and information that support people, processes, timely communication and learning.

Digital records that provide direct access to data by staff, patients and public, and communicated across organisational boundaries such as primary care and social services.

A strategic approach to IM&T that provides rigorous structure and governance to the required change as well as a culture of innovation.

Information that is complete, accurate and transparent to enable the public to become involved in decisions about how services are provided.

IM&T that allows organisations to identify, diagnose, treat, manage and prevent illness within their community.

Strategies that enable patients to take control of their information and make informed choices about their care and treatment options, including research and clinical trials.

IM&T infrastructures which can enable innovative healthcare models and promote a culture of innovation amongst patients and clinicians.

Innovative and effective informatics to support the Trust in making quality and productivity gains in line with the national agendas such as the Five Year Forward View.

Interoperability and healthcare standards to enable integration with local and national systems.

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The Trust provides a range of elective, emergency, district general services and specialist services operating within the community and from five sites.

Fairfield General Hospital

North Manchester General Hospital

Royal Oldham Hospital

Rochdale Infirmary

Floyd Unit

The values that underpin the Trust’s mission statement determine how the Trust works and the promises made to patients, their families, the public and staff. The Trust’s values are:

Quality Driven

Responsible

Compassionate

The Trust’s corporate priorities for 2015/16 align to its mission:

1. To provide high quality, evidence based, safe services delivered in a personal

and compassionate way

2. To be a financially and clinically sustainable organisation

3. To modernise, transform and integrate services across our sites

4. To improve productivity and reduce variation

5. To engage and support patients, carers, volunteers, staff, public and

communities in our work

6. To drive up quality and performance, reaching all our targets

7. To develop and embed leadership and personal responsibility across the

Trust

8. To create an environment so staff choose to work with us, sickness absence

is reduced and morale increased

9. To be an influential organisation working in partnership with others across the

health and social care system to improve the health of the population

10. To progress Foundation Trust status.

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3.3.2 Greater Manchester Devolution Agreement

The recent devolution agreement between the government and Greater Manchester (“Devo Manc”) emphasises the urgency of reform that is required to meet budgetary, health and social pressures as outlined in the Five Year Forward View.

As a result of the agreement, a Memorandum of Understanding (MoU) has been drafted between all local authority members of the Association of Greater Manchester Authorities (AGMA), all Greater Manchester CCGs and NHS England.

The purpose of the MoU is to ensure the “greatest and fastest possible improvement to the health and wellbeing of the 2.8 million citizens of Greater Manchester (GM)”. It sets out a more integrated approach to utilising the £6bn of health and care resources allocated for 2015/16. It also highlights the transformation changes and collaborative working that will be required to deliver services across the city.

The MoU recognises that integrated health and social care services; along with a digitally-integrated health economy is vital to improving efficiencies and health of the GM population.

GREATER MANCHESTER HEALTH AND SOCIAL CARE DEVOLUTION MOU

Shared objectives:

To improve the health and wellbeing of all of the residents of Greater

Manchester (GM) from early age to the elderly, recognising that this will

only be achieved with a focus on prevention of ill health and the promotion

of wellbeing. We want to move from having some of the worst health

outcomes to having some of the best.

To close the health inequalities gap within GM and between GM and the

rest of the UK faster.

To deliver effective integrated health and social care across GM.

To continue to redress the balance of care to move it closer to home

where possible.

To strengthen the focus on wellbeing, including greater focus on

prevention and public health.

To contribute to growth and to connect people to growth, e.g. supporting

employment and early years’ services.

To forge a partnership between the NHS, social care, universities and

science and knowledge industries for the benefit of the population.

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3.3.3 North East Sector

More than ever, there is an emphasis placed on integrating care across the Trust’s local healthcare community. To this end the North East Sector Health and Social Care Leadership Group has been established and, in support of this Group, the Trust has set up an IM&T sub-group with local NHS and non-NHS representatives to address the IT requirements of this programme. The stakeholder consortium comprises Pennine Acute, Pennine Care (Community and Mental Health), CCGs, Local Authorities and out-of-hours GP services.

The Consortium is in the process of seeking funding and actively developing a final business case to support an integrated care portal. The portal is a critical piece in the integration of services across the healthcare community. The first implementation phase will provide a view only summary of a patient’s record which incorporates primary care, acute, mental health and social care information to authorised users. The second implementation phase will provide write back and alerts to the authorised users.

3.3.4 Healthier Together

Healthier Together is a review of health and care in Greater Manchester. The Association of Greater Manchester Authorities (AGMA) Executive has challenged all partners to work together to deliver new models of integrated care. This includes primary, community and hospital services and the impact on social care. It is led by NHS Greater Manchester on behalf of the area’s twelve Clinical Commissioning Groups (CCGs).

The Healthier Together outline model of care aims to develop integrated care services that will help the NHS and other care providers provide quality services that are safe, accessible and sustainable. It will provide enhanced levels of specialist, senior medical and nursing staffing creating ‘champions’ across organisations.

A number of options have been proposed all based on the need to significantly improve primary care and community based services with a particular emphasis on the delivery of integrated services and the innovative use of technology. The Royal Oldham Hospital is proposed as one of the four or five key specialist hospitals in the region. The other Trust sites will continue to operate as local hospitals and retain the current emergency department profile. This plan will help shape future priorities of the IM&T deployment across the Trust.

At the time of writing this report the Healthier Together programme had completed its public consultation phase. Healthier Together has welcomed the Government’s recently proposed new partnership for health and social care. It clearly aligns with the Healthier Together proposals, as they share the same principles and goals.

Integrated, efficient IM&T services are required to enable ‘joined up’ care across Greater Manchester. The Trust’s IM&T capabilities will be key to delivering successful outcomes from the programme.

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3.3.5 Living Longer, Living Better

The ‘Living Longer, Living Better’ initiative for integrated healthcare across Greater Manchester is the basis for a collaborative working platform where patients as individuals are placed at the centre of care. The programme is an integrated care blueprint for Manchester led by Manchester City Council. Integrated care has been led by the three health and social care systems in North, Central and South Manchester. The joint programmes of work cross the boundaries of the CCGs, acute and community sector, primary care, mental health, social care and other agencies. The initiative focuses on service delivery and the integration of care to provide holistic care pathways that encompass diagnostics, treatment and therapeutic aspects of care.

With the aspirations of the ‘Living Longer, Living Better’ initiative it is important that each participating Trust maintains a high level of digital maturity with an emphasis on integration, interoperability and mobility to achieve their goals.

3.3.6 Greater Manchester Academic Health Science Network

The Pennine Acute Hospitals NHS Trust is one of 16 NHS provider members of the Greater Manchester Academic Health Science Network (AHSN). The AHSN covers Greater Manchester, East Lancashire and East Cheshire and is a collaborative network of NHS organisations, higher education institutes and industry. It aims to deliver a change in health outcomes, to integrate the health ecosystem, and leverage health spending and expertise for the benefit of local community through innovative health initiatives.

3.3.7 CQUINs

The Trust’s CQUINs for 2015/16 will reflect the Trust, Greater Manchester (GM) and National Information Board (NIB) goals for transformative information and technology. A GM CQUIN has been proposed that will run alongside local arrangements, focussing on the aims of the Five Year Forward View and GM Strategic Plans. A key CQUIN for GM providers will be provision of a plan to achieve the NIB’s 2020 Vision.

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LOCAL CONTEXT – IMPLICATIONS FOR IM&T

Systems and solutions that enable real time data capture, feedback and reporting to drive accurate business decisions.

An infrastructure that enables integration and sharing of data between departments, other Trusts and community healthcare providers and social care including opportunities for collaboration on population health and preventative care.

Systems and connectivity to provide remote working across acute and community locations.

Supporting the achievement of Foundation Trust status.

Actively leading local collaborations such as the North East Sector Health and Social Leadership Group and establishing initiatives in support of its agenda to integrate care across the healthcare community.

Making contributions to the Trust Cost Improvement Plan.

Providing reliable and flexible IM&T services and infrastructure that are responsive to partnership requirements.

Assisting the business in its financial recovery plan through the optimisation of systems and solutions leading to full recognition of both qualitative and financial benefits.

Providing IT solutions and support that can be marketed to the Trust’s partners providing the business with revenue potential.

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3.4 Summary of the Strategic Environment

The strategic drivers were analysed using a PESTLE analysis, looking at the political, economic, social, technological, legal and environmental factors in the strategic environment. The results are shown below:

Political

Political complexity re: multiple authorities / MPs/ unitary and non-unitary authorities make it difficult to get consensus

Differing priorities at local government level

Political and hospital boundaries are not co-terminus

General election May 2015 – health policy may change again

Political desire to foster more private competition

Global political instability – impact on financial markets/costs

Public health remit transferring to LAs

National policy re clinical commissioning

Impact of health bill

Influence of a range of campaign groups

Economic

Potential introduction of Personal health budgets

Private sector investment in NHS

Public sector spending cuts, CCG finances/ decommissioning intentions

Costs increasing (power, utilities, drugs, NHS inflation, etc.)

Imposition of CIPS

Changes to tariff

Changes in land values

Changes to public sector pensions

Deprivation in local area

Social

Deprivation and impact on health

Ageing/growing population

Ethnic diversity, immigration and impact on specific needs

Health inequalities both nationally and locally

Desire for more community based services

Strong local identities

Decline of nuclear families in some areas

Access to transport both public and private

Public’s changing expectations of what a healthcare provider should do

Increasing consumerist approach to health

Wider view of the role of a hospital as a part of the community

Role of media on lookout for “news”

Employment patterns / impact of unemployment on health

Technological

Influence of social networking

Information available on the internet

Patient opinion/rating sites

Use of social media to mobilise opinion/ objections

New treatments / drugs / techniques

Growth in home monitoring

Increasing professionalism of roles

Increasing subspecialisation

Technology creep : the expectation that healthcare should use technology because it is available

Legal

Increasing litigious society

Cost of settlements

Increasing levels of regulation and scrutiny

The need to be seen to act immediately in event of a “crisis”

Right to die / euthanasia debate

Consent / mental capacity debate

Francis report

European working time directive (EWTD)

Environmental

Carbon footprint

Local transport links

Local transport policies

Town planning : where will new estates be built

Global warming : impact on energy consumption

Scarcity of resources pushing up prices

Changing weather patterns – colder winters? Hotter summers? Floods? Drought? Impact of these on health

Source: Business Development Team @ PAHNT

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3.5 Stakeholder Analysis

Stakeholder engagement interviews and workshops were held with the following Trust groups and individuals during the development of the strategy. These themes and ideas have been incorporated into the current document and revisited with particular groups of stakeholders.

the patient forum

medical staff

nursing staff

community and allied health professionals (AHPs)

GPs

corporate teams

providers of core solutions

commissioners

senior management

IM&T staff.

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4 Current IM&T Environment

This section describes progress made to date against the previous IM&T strategy and describes the current status of IM&T capabilities.

4.1 Progress against previous IM&T strategy

The IM&T Department has made good progress against the previous strategy. The installation of resilient and standardised infrastructure within the Data Centre has improved systems availability.

The single sign on virtualised environment will be fully rolled out to clinical areas by August 2015, significantly improving and accelerating access to key clinical systems.

Rollout of electronic prescribing (ePMA), order communications and results reporting (OCRR) and handover of care communications (formerly referred to as discharge summaries) are complete within the Trust inpatient areas. Outpatient requesting will follow before the end of 2015. IM&T are currently engaging with clinicians and pharmacy to prepare for rollout of emergency prescribing.

There is a keen focus on integrated care solutions across the Trust, community and wider sector partnerships. Progress has been made in a number of key areas which are highlighted below.

4.2 Status of current IM&T infrastructure and services provision

Infrastructure

The Trust has developed its infrastructure significantly over the past three years. Wireless networking is now in place in all clinical areas and suitable mobile technology is made available on the wards including tablets and laptops-on-wheels. Further work to understand what the right tools are for each environment is continuing.

Virtual desktops have recently been rolled out to support flexible ways of working. Minimising the need to travel is a key objective of this initiative that is yet to be fully achieved.

Data is one of the most valuable assets of the Trust. To facilitate the sharing of data, the IM&T Department has consolidated its storage resources centrally using Storage Area Network technology. This allows for an efficient use of storage so servers can access the same pool to remove waste by unused storage and significantly reduce operating costs. To further secure the integrity of Trust data and improve its resilience, 150 of approximately 340 servers have now been moved to a new facility with minimum disruption to clinical services. The remainder of the migration will be complete by July 2015. As well as improving the Trust’s ‘green’ footprint, the programme has secured the capacity and security necessary to support the Trust’s strategic direction.

The Trust has invested in a number of other infrastructure initiatives which support the need for flexible and scalable technology, such as upgrading the remote area network thus improving accessibility for clinicians working away from the Trust.

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Increased use of wireless technology infrastructure is being deployed to support the Electronic Document and Record Management System (EDRMS) and other solutions. These initiatives have improved resilience, performance and availability of operational systems within the Trust, and will also help to deliver the medium to longer term strategic IM&T objectives.

Two varieties of the Connect Anywhere solution have been developed and are being deployed to acute, community and non-clinical locations. Connect Anywhere (plus) is a virtual desktop solution that enables a user to access their unique desktop within 15 seconds at any location. The solution includes single sign on and provides availability of applications and information at any device. Connect Anywhere (standard) is a non-virtual desktop solution that allows access to the same services with a significantly faster log-on speed than previously provided.

The Connect Anywhere solution is managed in a highly centralised manner with a thin app deployment for all services. It allows changes and new services to be provisioned rapidly to meet user needs at all times, at lower operational cost and high reliability and performance.

The solution can be accessed regardless of location, for example on the ward, in community settings or the back office. This ensures services can be accessed by users at all times allowing patient care to be provided at any location. Connect Anywhere allows services to be accessed on a mobile basis using both online and offline clients, providing portable and accessible information and services.

Service management

The current hardware estate of the IM&T Department has grown considerably and developed as technology has been deployed throughout the Trust. As the Trust has grown and harnessed the benefits of technology, the reliance on a robust support function has also increased. This is an area that requires significant focus. Work has begun to reconfigure and streamline processes and procedures within the IT Helpdesk function with an emphasis on automation and self-service. Computer password self-service will be fully implemented to give end users responsibility for managing their computer accounts, along with automated workflows for computer account and system access management, creating time efficiencies within the Helpdesk.

An IT support portal has been rejuvenated enabling the organisation to self-serve incidents and requests and review and update those requests throughout their lifecycle. A major service improvement program is currently underway, with the primary aim of improving response times and ensuring that the majority of incidents are fixed first time. On an ongoing basis this will include delivery of a new ITIL orientated helpdesk tool. This tool will provide workflow automation and management for non-clinical services outside of IM&T. An example of this is the recent improvements realised in portering services.

In 2014 the Estate Help Desk management was reassigned to IM&T. During 2015 work will be undertaken to provide a single help desk function for IM&T and Estates to ensure that a more efficient service is provided, particularly at peak times.

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The Trust will continue to identify ways to support service management staff by growing capacity and capability.

Integration

The Trust’s Integration Engine (TIE) is a critical system that provides the interoperability for sharing information across systems. This sharing of information extends beyond the Trust’s boundaries into areas such as GP practices, clinical portals and remote-hosted systems such as Radiology.

The Ensemble integration tool was procured and implemented as the new TIE, and all interfaces residing on the legacy TIE were successfully migrated by 30 March 2014, as planned.

Information provision

InView is the Trust’s new management information system that provides a single source of clinical, operational, financial and management information. In addition to replacing the existing data content, InView includes planned support for further datasets such as pathology, radiology, theatre, maternity and pharmacy. It is the Trust’s chosen solution to support all its information provision needs for the term of this strategy.

The Trust has been using the Qlikview dashboard development software for the last two years to support the reporting of Trust financial, activity and performance information. Use of dashboards has been extended across all Trust services. Dashboards developed include:

Consultant Performance

Speciality Performance

Trust-wide Activity Monitoring

Surgical Division Performance

Medical Division Performance

Women and Children Division Performance

Diagnostics Division Performance

Service Line Reporting (SLR)

Patient Safety

Safety Thermometer

Unscheduled Care (A&E)

Cancer Two Week Waits

Clinical Letters / Automated Letter System (inc Discharge Summaries)

Clinical Coding

Dashboard Usage Report

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Evolve (Record Scanning)

ePMA (Electronic Prescribing)

G2 (Clinical Dictations)

Information Governance

Nursing and Midwifery

Paediatric Pathway

Trauma Tracker

Various Finance Dashboards.

Communications and web services

Comprehensive condition-specific information is available to patients via the Trust website and the Trust is a certified member of The Information Standard.

The Trust-hosted intranet and public facing website had been developed in-house over time and had become very dated. A business case was approved for the replacement of the content management system (CMS) to provide a new and modern Intranet, Internet and Extranet (allows controlled access for non-Trust users such as GPs, Local Councils, etc.). All supporting IM&T infrastructure and software for this project has been delivered. The first phase of the project is complete and the Trust launched its new public-facing website in 2014. The second phase to replace the intranet is currently in development being managed by the Trust Communications team.

The Trust currently has a social media presence on Twitter, a social networking site. It is used to share news, events and information about the Trust. The Trust uses YouTube as a platform for hosting short promotional videos produced by the Trust. This is an effective method of sharing video content internally and externally which the Trust plans to invest in and expand.

The Trust is currently utilising crowdsourcing techniques to obtain contributions from staff for needed services, ideas and content.

4.3 Current state of clinical systems

Good progress has been made across a number of clinical areas, greatly improving the local environment.

Patient Administration System (PAS)

PAS infrastructure was upgraded in 2011 to provide a more resilient foundation. PatientCentre was rolled out in inpatient areas prior to the EPR clinical system implementations to improve the quality and timeliness of admission, discharge and transfer information. Enhanced bed management functionality and reporting provides the Trust with the ability to identify occupied or available beds.

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PatientCentre and Clinicom undergo regular upgrades and were last upgraded in August 2014 to support CDS 6.2.

Options to replace PAS have been appraised. However, since the options appraisal there has been a commitment from the PAS supplier to support PatientCentre and Clinicom for the next nine years. This provides the Trust with a tangible option going forward and allows the Trust to focus on clinical systems as priority.

Unified communications

Digital dictation is now fully rolled out across the Trust enabling restructuring of administrative support services. A pilot of speech recognition has recently begun. The Trust will be developing a strategy to contract with a single VoIP telecommunication supplier.

Electronic Patient Record (EPR) programme

Accelerated by a Technology Fund Award, Phase 1 of the Electronic Prescribing rollout (Adult Medicine and Surgical Inpatients, Theatres and Critical Care) was completed in Q2 2014. A fully integrated handover of care communications has been rolled out alongside electronic prescribing. Work has been completed to refine handover of care workflows and templates to enable the Trust to attain CQUIN targets.

The rollout to complex prescribing areas was completed in February 2015 when Paediatrics went live with ePMA. 99% of Trust inpatients now have an electronic prescription. Neonatal units at Royal Oldham Hospital and North Manchester do not yet prescribe electronically. Deployment has been deferred with clinical agreement until 3 decimal place weight prescribing is available. Revised milestones have been negotiated and completed with NHS England in view of this. An upgrade which includes infusions and iPad support is planned in 2015.

The next release of Medchart, which goes live early summer 2015, allows Phase 3, a pilot of A&E prescribing, to be undertaken at Royal Oldham. If the pilot is successful clinically and operationally, a business cases for Trust wide rollout in A&E will be raised. Phase 4, a pilot in Outpatients, has been deferred until 2016, due to supplier roadmap delays.

There are a number of other specialist clinical systems in constant use across the Trust’s wards and departments, some standalone, causing duplication of effort and frustration to Clinicians. IM&T has started to make some in-roads to resolve this by integrating the electronic prescribing system with Healthviews, along with the automated letters look up system, PACS and the electronic handover of care communications, which itself includes integrated clinical data from a variety of systems. The Trust is now the leading sender of electronic handover of care communications across Greater Manchester, reaching 152 practices in the region. The Evolve electronic casenote can be launched under Healthviews or as a standalone module. Healthviews invocation will be replaced by the Trust’s clinical portal due to be deployed in 2015/2016 – the key building block in the Trust’s EPR strategy.

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A programme of work to start replacing paper began in 2013, as the Ophthalmology Outpatient Clinic at The Royal Oldham Hospital went digital. This was followed by the introduction of the electronic dementia assessment form. The programme has not been without its problems, as it was the first of type for the Trust. A small number of tactical electronic form solutions have been developed in Healthviews. Electronic forms will be introduced in Evolve from Q2 2015/16 to replace paper Trust wide. The approach, approved by the Forms Steering Group, is to focus on generic forms and strategic pipeline developments initially. Initial priorities are:

Generic Nursing Forms (the main assessment, mandatory risk assessments

and generic care plan).

Outpatient and Elective Documents to reduce forward scanning and clinic

preparation (paediatric growth charts, clinical history sheets, clinic outcome

forms and questionnaires, elective booking and pre-operative assessments).

Strategic pipeline focusing on 15/16 CQUINS, Doctor’s Handover and

Clerking, End of Life and Social Work Referrals.

The rollout of radiology and pathology orders and results is now complete in inpatient areas and theatres. Rollout to outpatients and A&E is due to complete before April 2016 facilitated by the deployment of a major software release in May 2015, which adds blood transfusion results, microbiology and cellular pathology ordering.

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EPR Programme Roadmap

Other clinical systems

A business critical theatre system was procured to help drive improvements in theatre utilisation and improve productivity and efficiency within the Surgical Division. The system is now live in all theatres across all four sites. Risks associated with the support and maintenance of the previous system have also been mitigated. Reports to assist with performance and efficiency are being developed and phase two to implement stock-taking is being planned.

The IM&T Department has been successful in having a number of business cases approved since the last strategy was published. These will enhance the clinical systems estate and include major upgrades of the pharmacy system, A&E system, maternity modules and a diabetes system. In addition to this, a number of other specialist clinical systems have been regularly upgraded.

The challenge for the IM&T Department is now to build on what has already been achieved by ensuring future systems meet the changing needs of the organisation. They need to be timely, agile in their development, flexible in their capabilities, and scalable as the Trust moves towards supporting integrated services across the North East Sector and Greater Manchester.

4.4 IM&T staffing

Capability of the department is reviewed on a regular basis to ensure it is responsive and adaptive to business requirements and can support the IM&T strategy. The last review took place early 2015.

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4.5 Digital record maturity and adoption models

There are two key healthcare digital maturity or adoption models currently in use within the UK. The first, the Clinical Digital Maturity Index (CDMI) was developed by EHI Intelligence in partnership with NHS England specifically for NHS Trusts. The second, HIMSS Electronic Medical Record Adoption Model (EMRAM) model is used widely across the globe but has only recently been used by UK organisations.

CDMI is a benchmarking tool which aims to provide NHS Trusts with a better understanding of how investing in, and using information technology can provide benefits. The index is based on a nine-level electronic patient record rating. Trusts are divided into quartiles to make an effective benchmarking tool against which to gauge progress with the Government’s objectives for paper-free digital patient records. At their most recent CDMI review in 2014 the Trust achieved a strong ranking of 24 out of 160 acute NHS Trusts, placing them in the first quartile and showing significant progress since 2013 when they were ranked 77/160. Data has recently been submitted to obtain the current status.

HIMSS Analytics Europe has developed a European EMR Adoption Model (EMRAM) based on the model established across the U.S. and Canada. It aims to identify the levels of electronic medical record (EMR) capabilities ranging from basic departmental systems through to a paperless EMR environment. The methodology and algorithms automatically score hospitals based on their IT enabled clinical transformation status.

During the course of this strategy the Trust will investigate the use of HIMMS to benchmark its progress in achieving digital adoption and transformation, as well as using it to assist in strategic decision making.

Summary of actions arising

In summary, IM&T needs to perform the follow actions:

Complete implementation of EPR projects such as ePMA, clinical portal, electronic case notes and electronic forms.

Introduce new IT solutions when business cases have been approved.

Improve IT support focussing on responsiveness and resolving incidents first time.

Embedding a culture of self-service and self-help within the organisation by the automation of processes, systems and implementation of workflow.

Continue to refresh and improve client services to achieve best practice.

Improve the provision of information, data quality, service line reporting and BI dashboards.

Undertake options appraisals for proposed solutions and infrastructure.

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5 Vision and Strategic Objectives

This section aims to describe the vision for IM&T across the Trust, and to identify the key strategic objectives for the IM&T Department to achieve their vision.

5.1 Vision and Mission

The strategic vision for IM&T is:

Improving patient care through technology and innovation

The strategic mission for IM&T is:

To provide the Trust with IT systems, information and services to enable staff to deliver excellent and efficient patient care anytime, anywhere

5.2 IM&T Strategic Objectives

The following set of objectives for IM&T support the Trust’s transformation agenda. The primary aspects of this strategy which set it apart from previous strategies are its focus on integrated services across the care community and patient engagement.

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5.2.1 Supporting the Trust’s transformation

Fundamental to this IM&T Strategy is the need to provide the infrastructure, information and technology to underpin the Trust’s ambitious transformation plans. Specifically, IM&T will support the following areas of work from the Trust’s transformation agenda:

Transformation of services

IM&T will provide robust, flexible and adaptable infrastructure and devices that supports users moving across sites and locations of care. The implementation of

IM&T STRATEGIC OBJECTIVES 2015-18

1. Supporting the Trust’s transformation: create a robust and innovative IM&T foundation to underpin the Trust’s transformation of clinical services.

2. Digitising patient records and clinical workflows: extend the development and rollout of the Trust’s acute EPR and clinical portal with the aim of achieving a digitised patient record by 2018.

3. Integration across the care-continuum: lead development of a community wide, integrated patient record in collaboration with acute, primary care, community, mental health and social care partners to improve access to patient data.

4. Improving patient access to care and information: provide the structure and support to enhance patient’s access to their own records, to services and to safe healthcare.

5. Providing high quality information and business intelligence: deliver a high quality information service which supports the Trust’s clinical and business processes real-time, such as service line reporting and business intelligence dashboards.

6. Flexible and innovative working: improve productivity and access to care by leveraging technology and telecommunications.

7. Enhancing IT infrastructure: continue to update and improve the Trust’s infrastructure to form a robust foundation for future IM&T delivery.

8. Optimising existing technology: optimise and standardise use of existing IM&T software and devices to provide efficient clinical, corporate and back office systems.

9. Efficient and effective IM&T service: review and strengthen the capacity and capabilities to improve the efficiency and effectiveness of the IT services provided to Trust personnel.

10. Improving clinical engagement: improve clinical engagement in Trust IM&T and transformation activities through strengthen clinical leadership to promote clinical innovation through the better utilisation of technology.

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virtual desktops and mobile devices means that clinicians will be able to access information and provide care regardless of location.

The Business Intelligence team will provide data for service line reporting and business intelligence tools that will enable the Trust to monitor performance and measure benefits of service transformation.

Partnerships The integrated care platform will improve patient pathways across Greater Manchester. It will facilitate the evolving delivery models such as shared care, Devo Manc and Healthier Together initiatives. As part of this Strategy the IM&T Department will initiate approaches to support the anticipated health and social care integration within Greater Manchester.

People

The IM&T Department will help the Trust strengthen relationships with staff through optimising technology such as virtual desktops, remote working and e-rostering to improve the working lives of staff.

Premises and facilities

Technology and infrastructure will provide a foundation for the Trust’s substantial capital investment in clinical services over the next four to five years.

Quality, governance and performance

IM&T will continue to contribute to improving quality of care, and clinical transformation projects by digitising patient records and clinical processes to improve quality and accessibility of data.

Trust management and executives will be supported in their transformation goals through the provision of Integrated Performance Dashboards and Service Line Reporting. Information will assure performance on targets and continuing compliance with external bodies such as CQC, Monitor and the TDA.

Finance and systems

The revision of this IM&T strategy is integral to the transformation of the Trust’s systems. How this is achieved is outlined in the strategic objectives below.

5.2.2 Digitising patient records and clinical workflows

EPR

Over the next three years the Trust will continue to build upon the capabilities and momentum within its existing EPR programme. This progress is reflected in the Trust’s CDMI rating which shows substantial progress in a shortened timeframe when compared to other NHS Trusts nationwide and against its own baseline data.

The Trust has decided to continue with the existing best of breed approach for extending the functional scope and rollout acute electronic patient records. An options paper was presented to the Clinical IM&T Strategy Group, the Senior Management Team and the Trust Board providing a cost benefit analysis of continuing the best of breed approach versus procuring a single vendor integrated

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EPR. The risks and benefits of each approach were highlighted and it was agreed that continuing along the current trajectory is the most appropriate approach at this juncture. EPR options will be reappraised at the end of year three of this strategy.

Over the next three years the IM&T Department plans to extend existing acute EPR functionally to additional roles such as nurses, AHPs and community healthcare workers. Other priorities for the next three years include:

Complete rollout of the Evolve casenote solution.

Accelerated replacement of paper with electronic workflow and workflow in

Evolve.

Configuration of a Trust-wide, clinical portal to further enhance the

experience for patients and clinicians.

Procurement of eObservations and patient flow solution to better alert its staff

to change in patient conditions.

Initiation of an Electronic Referral Management Solution.

Community systems to support the goal of the new Community Division.

Improved integration between the EPR and Symphony.

Rollout of order communication and result reporting in Outpatients and

Emergency.

Rollout of ePMA in emergency departments.

Initiate replacement of Healthviews with an alternative handover of care

communication document and ordering solution due to sun setting of the

solutions.

Community Services System

The Trust provides an increasing number of services delivered in a community setting, including domiciliary visits. Current systems are largely paper-based or managed using disparate databases. To support the aims of the new Division of Integrated and Community Services, a common EPR and care activity management system is required, which will provide flexible remote and mobile working

Evolve casenotes

The rollout of the Evolve casenotes is proceeding to plan at a pace and completes in autumn 2015. This is a significant milestone on the Trust’s EPR programme and is a key enabler for the Trust achieving a paper-light status, and being able to achieve its clinical service transformation plans. The Evolve eforms toolkit will be used to develop electronic forms and workflow to replace paper Trust-wide. Paper replacement is expected to start with generic nursing assessment documents and outpatient and elective forms which reduce the forward scanning bills.

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functionality, and will integrate with other Trust systems for information sharing and reporting.

The system will ensure that community nursing staff are able to work more efficiently and effectively by having direct access to up-to-date patient information at point of care; avoid duplication of effort between recording information in both paper and electronic systems which will also improve data quality; reduce time spent travelling which in turn will provide opportunities for increased patient contact.

Many community services are delivered under contract to the area CCG. A common system will enable service performance statistical reporting and activity returns to be generated more efficiently and accurately.

In the longer term, deployment of an integrated Community Services System will also support the achievement of the national objective to allow patients greater access to their care record.

Requirements analysis and options appraisal of suitable systems is currently underway with the intention to go to procurement by mid-2015.

eReferral Management

A key component of digitising clinical and administrative workflows will be implementation of an electronic referral system. The Trust will redesign their outpatient referral process to improve quality and patient care and implement a fully electronic referral system as part of a wider strategy to become paper-light.

The goals of the implementation are to improve referral processing times, relieve the pressure of referral to treatment targets and improve utilisation off outpatient services. Through streamlining and standardising referral processes the Trust aim to decrease administrative effort, improve patient and GP experience and reduce cancellations of appointments. The Trust will benefit from improved reporting, tracking and auditability of referrals as a by-product of digitising the system.

The eReferral system will capture referrals through a variety of means including scanning, faxing, electronic transfer and Choose and Book. It will build on existing

Clinical portal

Intersystems have been approved as preferred supplier of the Clinical Portal. The business case is expected to be approved in May 2015 and a pilot deployment to at least one staff group will take place in 2015/16. The portal will be used by clinicians and other health professionals to consolidate vital information from the 148 clinical information systems currently in use within the Trust, with a single sign-on. It will allow them to record patient information pertinent to the care setting used and has built in alerting capabilities. The portal will improve efficiency, facilitate sharing of information and give users rapid access to patient information with the aim of improving productivity and quality of care. It will also provide the flexibility to evolve with the Trust’s needs and enable the Trust to transition to an integrated EPR over time.

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hub and electronic document transfers to integrate with local GP practices within the area and beyond.

eObservation and early warning system

Inpatients will be monitored through a combination of electronic documentation of vital signs and early warning decision support based on national guidance and criteria. Staff will be alerted real-time, either on-site or remotely through mobile devices. Patients at risk of infection, or deteriorating conditions will be managed earlier and more effectively, leading to more efficient use of high dependency resources and improved patient outcomes.

Standards

As part of this strategy the IM&T Department will be reviewing the necessary regulatory and interoperability standards for achieving their vision of a digitised environment. This will include GS1 and interoperability standards outlined within NIB and HSCIC roadmaps. Where needed these will be included in the action plan and the Trust will work with suppliers to ensure standards are met within published timeframes.

5.2.3 Integration across the care-continuum

Achieving a single patient record across their entire health and care community is a key goal for the Trust. This objective aims to improve coordination of care, prevent illness and manage care across all care settings including the home and community. A consortium of ten local organisations led by The Pennine Acute Hospitals NHS Trust has fully supported this initiative and is currently seeking funding to achieve this goal.

A proof of concept will take place over summer 2015 with the Trust, Bury CCG and the local council using the InterSystems integration solution. This proof of concept will cover a small subset of patients with an end of life pathway, and aims to give GPs the confidence in the project to support a business case for further funding.

The costs of providing a single portal are being assessed on behalf of the North East Sector consortium. The first phase of the portal will bring together and make available read-only data from all the stakeholder organisations, to enhance efficiency and reduce the costs of discharge planning, end-of-life care and support services. The intention is to proceed beyond acceptance of the business case to full implementation of the service, to be hosted by Pennine Acute. Services using the portal will include out of hours services, primary care, secondary care, mental health and local councils which will, amongst other benefits, minimise the patient’s stay in hospital and improve end of life care.

It is anticipated that the underlying architecture of this Integrated Care Record is a federated database contributed to, and accessed by authorised health and care professionals via a portal. With funding in place, implementation of the integrated

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care record will begin in the first year of this strategy and integration activities will continue into the second year.

This initiative aligns directly with the Greater Manchester Devolution and national imperatives for the development of new models of care, integration of services, and the personalisation of care.

5.2.4 Improving patient access to care and information

IM&T will provide the infrastructure and IT solutions to offer patients access to their own records, and safe healthcare services.

Improving patient engagement with and access to healthcare is a central goal of NHS England. By achieving this, patients will build up their experience and capabilities to help manage their own care and symptoms. Enabling citizens to interact directly with healthcare services can improve convenience, satisfaction and lead to earlier, more cost effective interventions.

Within the NIB’s framework, Personalised Health and Care 2020, a milestone has been set to provide all citizens with online access to their GP record from March 2015 and this will extend to other care providers, including acute, by 2018.

NHS England’s goal is for individuals to create and manage their own personal care record. The patient engagement roadmap will be published by June 2015 and will include aspects such as booking appointments and online repeat prescriptions for all care services. It will leverage mobile technology and smart phone apps to maximise engagement.

The Trust will evaluate the published roadmap to determine implications for Trust systems and interoperability standards. It will also examine how it can use existing and future capabilities to optimise the healthcare of the local population. A patient portal is planned for year 3 of this strategy and government roadmaps will inform development of this initiative.

Patient Portal

In year three of this strategy the portal will be extended to patients with a focus on resource intensive, and high cost conditions such as HIV which are suitable for management in the home. It is essential that Trust strategies and infrastructure are sufficiently robust to support such access. The Patient Portal will promote patient engagement and self-care through a self-service approach. Ideas at this stage include access to the patient record, scheduling and management of appointments and patient forums. Self-care could be extended for use in clinical processes such as performing investigations, and is discussed in more detail below.

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5.2.5 Providing high quality information and business intelligence

As noted, the IM&T Department has made significant progress over the past year by providing business intelligence dashboards and migrating to a new data warehouse. They will continue improving the quality of information with bespoke and operational reporting to support Service Line Reporting (SLR), commissioning data, and monitoring of targets, standards and priorities. A comprehensive set of dashboards has been developed and work is in progress to extend this to cover external benchmarking information such as Dr Foster.

Service Line Reporting and Patient Level Costing

A key area of focus for the Trust is improvement to their Service Line Reporting (SLR) and Patient Level Costing (PLICS). An external review was undertaken which found that these reporting mechanisms could be optimised through greater automation, integration of new data sources and better governance through improving accessibility and ownership of data. These aspects are being addressed by the Business Intelligence team in the development of dashboards outlined below. The development will align with Trust’s overall SLR/PLICS strategy.

Business Intelligence

The Information Department has developed a number of BI dashboards for the purpose of providing performance, efficiency and productivity data in a visual format. The focus over the next few years will be on automation, accessibility and quality of data. This includes:

Integrated Performance Dashboards – accessible, automated dashboards for

performance monitoring are currently in development and will provide high

quality, timely data to support decision making and benchmark performance.

Dashboards will provide executives and managers with clear oversight of

corporate performance indicators such as quality or financial targets. Users

will be able to drill down to understand where performance has improved or

where attention should be focussed. The dashboards will also allow staff to

self-monitor their own metrics and compliance. Dashboards will target

different tiers of the organisational groups – strategic, divisional,

operational/service and personal level.

Self-service - The BI team will improve accessibility by automating report

generation through self-service. Clinicians, managers and executives will be

provided with an interactive, personal dashboard capability. Users will

configure settings based on a predefined set of favourites. For example,

consultants will be interested in viewing data such as training, activity data,

average length of stays and readmissions. Users will be able to filter

information and drill down to a level of detail which meets their needs as they

arise.

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Remote and mobile access - Another means of improving accessibility is to

provide remote and mobile access to data. The personalised dashboards will

initially be available on any thin client device across the organisation as

defined by the user’s personal settings. Over time this will be extended to

cover mobile devices such as tablets and smart phones.

Other key goals over the next two years include:

collaborating with the Finance and HR Departments to support Service Line

Reporting (SLR) from a single access point

supporting benchmarking and audit data such as Dr Foster

provision of mandatory and operational reporting for Community Services

working with the data quality team to identify where data quality can be

improved

production of real-time reports and dashboards

extending the number of data sources to feed the data warehouse.

Longer term goals will build on these foundations and further explore areas such as:

forecasting and modelling to provide more analytical and predictive data

mechanisms for reporting data across care settings and patient pathways to

align with the Trust’s integrated care initiatives.

In order to achieve these goals the Departments will need to update their BI tools. An assessment of the latest BI software will be undertaken with the aim of providing intuitive, interactive and functionally rich solutions that will work across multiple data sources and mobile devices.

The Trust is also establishing a new team of information analysts based within the Divisions. Their aim will be to help the Trust achieve the top quartile for outcomes (e.g. mortality rates, lengths of stay, readmissions) and tariffs.

Coding and data quality

Changes to Coding Department processes are currently underway which include a reduction of coding deadline targets while maintaining the same level of coding staff. This will have implications for the coding workflows to ensure that the most efficient and accurate processes are in place.

In order to meet Trust financial objectives there is a greater need for coded activity to be available sooner. This will enable financial reporting to the Board to be made earlier in the month with robust coded and costed activity providing early indications of the true financial position of the Trust. In order to achieve this in 2015/16 a formal options appraisal will be undertaken with clear plans of how this will be achieved including resilience at times of absence. The plan for the Coding Department is to code 95% of discharges by the third working day which will be implemented during 2015.

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The Department has a number of projects planned to improve turnaround times and data quality including:

Electronic coding of co-morbidities by clinicians. This is expected to improve

audit capabilities and quality of coding significantly as clinicians adapt to the

system. Coders will use the electronic handover of care component as a real

time summary of the patient episode to assist coding, rather than rely on

paper notes. This is expected to commence in Q1 2015/16 and be completed

by the end of 2015.

A new coding dashboard will be built during 2015/16 with the aim of improving

quality of coding providing specific tools and techniques which will deliver a

richness and depth in audit quality. Ad hoc audits will allow management to

drill down and identify specific individuals or specialties where improvement

may be required (for example, HRG by specialty). These areas can then be

acted on expediently before affecting performance ratings or commissioning;

Use of a live audit tool for a six month pilot.

A mortality validation tool that was rolled out across the Trust in 2014/15 will

continue to be monitored via ongoing review and support as part of the

Improvement Programme.

There is a dedicated Data Quality team within the IM&T Department who work

to an annual programme of audits agreed by the governing IM&T and

Information Quality Assurance Committee. These structures help to meet

overarching governance and auditing requirements such as Information

Governance Toolkit, as well as addressing accuracy for day to day business

and clinical purposes.

5.2.6 Flexible and innovative working

The IM&T Department will improve the ways clinicians access technology to support safe and effective care of patients, whenever and wherever it is required. This in turn will increase efficiency, productivity and satisfaction of Trust staff. Likewise, patient satisfaction and access to care will also be improved by providing more flexible care delivery options.

The Trust will improve access to care delivery, data and systems through four innovative mechanisms:

1. Remote working

2. Mobile devices

3. Telehealth and telemedicine initiatives

4. Patient self-service.

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Remote working

There are currently three workstreams of IM&T activity occurring within the Trust: acute, community and integrated care. While remote working is a central requirement for community and integrated care, these needs will primarily be addressed through other strategies. Strategies for all these areas will be developed in collaboration and be compatible in their recommendations to ensure the Trust’s integration goals are fully met. The strategy will address the needs of Trust clinicians accessing the acute patient record from anywhere within the organisation or from home.

The Trust has begun to meet this need through Connect Anywhere. This initiative aims to address the increasing costs of ownership, administration, support and management arrangements of the desktop estate across the Trust. The infrastructure strategy must ensure that departments will not be able to purchase software unless it can run on a virtual desktop.

Connect Anywhere will be the strategic solution for supporting end user device provision into the future including support of home working. Throughout the life of this strategy defined users will be allowed to access almost any service at home, this facilitates flexible working patterns and will improve productivity. Other initiatives include proximity card access, which is currently being piloted, and unified communications that will deliver voice, instant messaging, presence and video.

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The diagram below illustrates the key deliverables of the initiative:

Community workers will be able to access acute clinical solutions using Connect Anywhere over the telecoms network. Offline capability is also supported through Connect Anywhere’s ‘briefcase’ functionality.

Analysis of requirements to enable more efficient working specifically for community midwives is also underway to minimise travel time and avoid duplication of manual and electronic system updates, by providing remote mobile or offline access to the maternity system from the mother’s home or community clinic location. This includes review of system functionality and provision of mobile technology to support this objective.

The remote working plans align with the Trust’s thin client strategy which allows users to access their own personal settings on any thin client desktop across the organisation; the IM&T Department will continue rolling this out across the hospital in year one of the strategy.

Mobility

The current mobile platform (Good) provides smart phone access to administrative tools such as email and calendars. There is currently limited access to clinical information. However, this will be extended to provide access to clinical information wherever and whenever it is required.

A Bring Your Own Device (BYOD) strategy has been adopted to enable clinicians to access administrative systems. It is anticipated that this will not be extended to clinical access due to the need for greater control over access to patient data and management of devices. Consultants will be provided with their own iPad tablets during 2015.

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The Trust will determine a schedule for rolling out further mobile devices, based on staff role and benefits derived. Certain roles will benefit more from greater mobile access than others, for example, access to electronic information at the bedside for nurses and access from multiple different locations for bed managers or Allied Health Professionals (AHPs).

Telehealth and telemedicine

The Trust will leverage advances in telecommunication and introduce telehealth and telemedicine initiatives into their roadmap in year two of the strategy. Plans are currently in early stages but enthusiasm has recently increased. A number of potential projects have been identified by clinicians to ensure that the Trust and patients benefit from advances in technology. Current proposals include:

Remote monitoring of patients – in an effort to prevent hospital visits and

promote self-care the Trust will investigate introducing telehealth initiatives

such as home monitoring of physiological observations.

Remote visits and consultations – Clinicians at the Trust will derive great

benefit in using telehealth and telemedicine technology to review patients or

provide consultations to patients with chronic conditions. This can be

undertaken remotely from community-based clinics, nursing homes or in the

patient’s home. Restructured models of care will be highly dependent on

clear, agreed, evidence based pathways and protocols. The Trust plan to

pilot such an approach initially with an agreed care pathway for managing a

single condition.

Patient self-service

Departments such as A&E will be equipped with kiosks to check in at reception and guide patients to where they need to be. The Trust will also work in collaboration with Greater Manchester initiatives to develop a means for patients to become more engaged with their healthcare and encourage self-care and self-service tools. Other self-service initiatives will be explored, for example, kiosk technology could be extended for use of providing samples and receiving test results.

To take this concept further the Trust have identified groups of patients who are suitable candidates to undertake appropriate routine tests themselves and record the results within the patient record. This will not only empower these patients with the ability to monitor and manage their own conditions, but will also present cost savings for the NHS for conditions that are expensive to manage through traditional means.

5.2.7 Enhancing IT infrastructure

The IM&T Department has made progress with IT infrastructure improvements but recognises there is further progress to be made. They aim to provide an infrastructure which:

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is service-orientated, flexible and responsive to users’ needs

is efficient, green and effective

provides opportunities for generating income

improves the user experience of IT

reduces cost and risk related to IT services.

Investment in hardware and underlying infrastructure is crucial for the Trust to achieve fundamental goals such as integrating services and improving access to information. The IT infrastructure underpins the Trust’s transformation activities. The Trust has a complex legacy environment that will require ongoing strategic revision to replace its aging technology. In the early stages of this strategy an options appraisal will be performed to determine the relative benefits and cost of available options.

Following the options appraisal, the IM&T Department will produce a detailed strategy to bring together all aspects of infrastructure planning including networks, telecommunications, hardware, and devices. The strategy will ensure that performance and availability issues are addressed through proactive monitoring and remote servicing using a blend of in-house and third party services.

The options appraisal will also include an assessment of Voice over Internet Protocol (VoIP) telephony options. VoIP has the benefit of potentially reducing costs for both the Trust and its patients, as well as enabling integrated video calls and data transfer. This allows doctors and nurses to be contacted and provide care wherever and whenever needed. It is envisaged that specialists will be contracted to perform the installation to ensure a fast, secure and high quality service.

As outlined above, significant progress has already been achieved against the previous strategy with data centres, remote working and rollout of Connect Anywhere. However, the Trust needs to continue to develop its approach to meet the rate of technological change and the changing operational requirements of its users.

5.2.8 Optimising existing technology

The IM&T Department plans to optimise and standardise use of existing software and devices to provide more efficient clinical, corporate and back office systems. IM&T will implement processes to ensure existing systems are best utilised wherever they are suitable for use.

Solutions will be assessed to understand where savings and efficiencies can be made. It is important to ensure they fit in with and align to the IM&T and Trust strategy. This assessment will take into account emerging infrastructure and technology, including the NHS’s interoperability standards framework and roadmaps.

The Trust will redesign workflows to transform corporate and back office systems bringing in elements of e-service and self-service as appropriate. Workflow will be streamlined and more efficient through the introduction of:

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e-requisitioning

e-procurement

self-service HR.

5.2.9 Efficient and effective IM&T service

The Department will review its capacity and capabilities to improve the effectiveness of the service provided to the Trust on a regular basis. Plans will reach across the Department and include all personnel and include:

support for attainment of professional qualifications

embedding best practice such as PRINCE2 and ISO standards

roll-out of up-to-date training to support new technology

achieving the ISO 27001 standard

implementing ITIL Best Practice

appropriate succession planning

undertaking a full options appraisal to examine IT Service Models

development and publication of a service catalogue

updating its methodology for the management of projects.

5.2.10 Improving clinical engagement

The success of a clinical system implementation is largely dependent on engagement from clinicians and productive relationships with the relevant Trust services. IM&T is an enabler and catalyst for improvement - not an end in itself. It is therefore crucial that clinical engagement drives the transformation activities that underpin IM&T implementations.

As the Trust widens its adoption of their IM&T solutions it is clear that further strengthening of relationships with stakeholders will be beneficial. A number of approaches will be taken to optimise clinical stakeholder engagement;

Active leadership - leadership, direction and effective relationships built within the Trust and with its partnership organisations. Top down support and direction from leadership will provide encouragement and governance to adopt new policies and procedures which capitalise on IM&T initiatives. Plans need to ensure the correct governance and structures are put in place to leverage the benefits. The Trust currently has clinicians on its Project Boards but this will be strengthened further to include the recently appointed lead physician and nursing roles for each of the Divisions.

Clinical champions - clinical leaders who champion transformation activities within the workplace. This approach has already been applied through the formation of the Clinical IM&T Strategy Group. The Trust will

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consolidate the role of clinical leaders in their implementation plans and review how this can further drive adoption and clinical transformation.

Innovation - The IM&T Department will use the appeal of innovation and new technology to leverage further engagement from clinicians. Innovation will not only support efficiencies but also encourage a culture of creative thinking and incentivise adoption of IM&T. Now more than ever there is an interest from clinicians in using technology. This trend can be harnessed to develop innovative solutions to problems as well as improve the likelihood of success by ensuring there is clinical buy-in from the outset. For example, the development of BI dashboards is identified as one area where both users and developers will benefit from clinical involvement.

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6 Actions and Implementation Plan

Key areas of focus for 2015/16

The IM&T Department is continuing to build on the progress made against the previous strategy with priority areas of focus for 2015/16:

Complete the Trustwide rollout of EPR projects for ePMA, OCRR and

Evolve

Broaden the scope of electronic communications to GPs and patients

to eliminate paper

Commence deployment of the Trust clinical portal solution

Procure e-Observations / Patient flow system

Procure a centralised diagnostic and alerting system for Maternity

Identify a solution to support Community Services

Continue deployment of core infrastructure enhancement, including

back end server upgrades, client refresh and additional mobile

equipment on wards, Connect Anywhere rollout and improved network

connectivity to community locations

Further develop business intelligence dashboards and reporting

capability

Improve governance of and compliance with project management

methodology

The planned timetable for these and other projects to support achievement of the strategy over the next three years is provided in the table below:

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ulat

ory

and

inte

rope

rabi

lity

stan

dard

s (e

.g. G

S1)

2.13

Prod

uce

revi

sed

EPR

opt

ions

app

rais

al e

nd

of 2

017/

18

1.

Su

pp

ort

ing

th

e Tr

ust

’s t

ran

sfo

rma

tio

n -

cre

ate

a r

ob

ust

an

d in

no

vati

ve IM

&T

fou

nd

atio

n t

o u

nd

erp

in t

he

Tru

st’s

tra

nsf

orm

atio

n o

f cl

inic

al s

erv

ice

s

2.

D

igit

isin

g p

ati

ent

reco

rds

an

d c

lin

ica

l wo

rkfl

ow

s: e

xte

nd

th

e d

eve

lop

me

nt

and

ro

llo

ut

and

of

the

Tru

st’s

acu

te E

PR

an

d c

lin

ical

po

rtal

wit

h t

he

aim

of

ach

ievi

ng

a d

igit

ise

d p

atie

nt

reco

rd b

y 20

20

2015

/16

2017

/18

2016

/17

2015

/16

2016

/17

2017

/18

Page 139 of 196

The

Pe

nn

ine

Acu

te H

osp

ita

ls N

HS

Tru

st

IM

&T

Str

ate

gy 2

01

5 –

20

18

48

| P

ag

e

IDH

igh

-lev

el A

ctiv

ity

3.1

Hea

lthc

are

com

mun

ity

inte

grat

ion

port

al p

ilot

3.2

Subm

it b

usin

ess

case

for

fun

ding

3.3

Init

iate

and

hos

t he

alth

care

com

mun

ity

inte

grat

ion

port

al p

roje

ct

IDH

igh

-lev

el A

ctiv

ity

4.1

Eval

uate

HSC

IC a

nd N

IB r

oadm

aps/

spec

ific

atio

ns

4.2

Eval

uate

loca

l hea

lthc

are

econ

omy

need

s

4.3

Eval

uate

sup

plie

r ca

pabi

litie

s to

mee

t ne

eds

and

asse

ss g

aps

4.4

Dev

elop

str

ateg

y fo

r im

prov

ing

pati

ent

acce

ss

IDH

igh

-lev

el A

ctiv

ity

5.1

Sing

le d

ata

war

ehou

se t

o be

use

d t

o fe

ed r

epor

ting

5.2

All

data

to

be m

oved

to

new

vir

tual

ser

ver

envi

ronm

ent

5.3

Cha

nge

SLR

qua

rter

ly t

o m

onth

ly a

nd n

ew d

ashb

oard

for

clin

icia

ns/m

anag

ers

5.4

All

lega

cy d

ashb

oard

s to

be

rep

lace

d w

ith

a ne

w c

omm

on t

hem

e

5.5

Incl

ude

self

-ser

vice

dat

a fo

r PA

S an

d A

&E

sour

ces

5.6

Dr

Fost

er b

ench

mar

k da

ta a

dded

to

cons

ulta

nt-l

evel

das

hboa

rds

and

rep

orts

5.7

Rea

l-ti

me

dash

boar

ds t

o be

rel

ease

d f

or k

ey in

form

atio

n

5.8

All

dash

boar

ds t

o ha

ve s

elf-

serv

ice

data

ext

ract

s av

aila

ble

for

end-

user

s

5.9

Rad

iolo

gy, P

harm

acy,

Pat

holo

gy, m

ater

nity

dat

a to

be

adde

d t

o da

ta w

areh

ouse

5.10

All

BI r

epor

ting

to

be a

vaila

ble

on m

obile

dev

ices

5.11

Fore

cast

ing

and

mo

de

llin

g to

pro

vid

e m

ore

an

alyt

ical

an

d p

red

icti

ve d

ata

5.12

Mec

hani

sms

for

rep

orti

ng d

ata

acro

ss c

are

sett

ings

and

pat

ien

t pa

thw

ays

5.13

Ass

ess

and

upda

te B

I too

ls

5.14

Dep

loy

codi

ng d

ashb

oard

5.15

Dep

loy

mor

talit

y va

lidat

ion

tool

5.16

e-Le

arni

ng t

ool f

or ju

nior

doc

tors

2015

/16

2016

/17

2017

/18

4.

Im

pro

vin

g p

ati

ent

acc

ess

to c

are

an

d in

form

ati

on

: pro

vid

e t

he

str

uct

ure

an

d s

up

po

rt t

o e

nh

ance

pat

ien

t’s

acce

ss t

o t

he

ir o

wn

re

cord

s, t

o s

erv

ice

s, a

nd

to

saf

e h

eal

thca

re.

2015

/16

2016

/17

2017

/18

3.

In

teg

rati

on

acr

oss

th

e ca

re-c

on

tin

uu

m:

lead

de

velo

pm

en

t o

f a

com

mu

nit

y w

ide

, in

tegr

ate

d p

atie

nt

reco

rd in

co

llab

ora

tio

n w

ith

acu

te, p

rim

ary

care

, co

mm

un

ity,

me

nta

l he

alth

an

d

soci

al c

are

par

tne

rs t

o im

pro

ve a

cce

ss t

o d

ata

2015

/16

2016

/17

2017

/18

5.

P

rovi

din

g h

igh

qu

ali

ty in

form

ati

on

an

d b

usi

nes

s in

tell

igen

ce:

de

live

r a

hig

h q

ual

ity

info

rmat

ion

se

rvic

e w

hic

h s

up

po

rts

the

Tru

st’s

cli

nic

al a

nd

bu

sin

ess

pro

cess

es

real

-tim

e s

uch

as

serv

ice

lin

e r

ep

ort

ing

and

BI d

ash

bo

ard

s

Item

9a

Page 140 of 196

The

Pe

nn

ine

Acu

te H

osp

ita

ls N

HS

Tru

st

IM

&T

Str

ate

gy 2

01

5 –

20

18

49

| P

ag

e

IDH

igh

-lev

el A

ctiv

ity

6.1

Com

plet

e ro

llout

of

Con

nect

rem

ote

wor

king

6.2

Rol

lout

Goo

d m

obile

pla

tfor

m f

or a

cces

sing

clin

ical

app

licat

ions

6.3

Dev

elop

long

er t

erm

str

ateg

y fo

r m

obile

acc

ess

6.4

Ass

ess

tele

hea

lth/

tele

med

icin

e op

port

unit

ies

6.5

Dev

elop

tel

ehea

lth/

tele

med

icin

e st

rate

gy

6.6

Rol

lout

A&

E ki

osk

func

tion

alit

y

6.7

Ase

ss o

ther

pat

ien

t se

lf-s

ervi

ce o

ppor

tuni

ties

acr

oss

inte

grat

ed c

are

netw

orks

IDH

igh

-lev

el A

ctiv

ity

7.1

7.2

7.3

7.4

7.5

IDH

igh

-lev

el A

ctiv

ity

8.1

Iden

tify

exi

stin

g Tr

ust

syst

ems

whi

ch a

re u

nder

utili

zed

8.2

Iden

tify

sys

tem

s w

hich

do

not

alig

n w

ith

Trus

t IM

&T

stra

tegy

or

road

map

8.3

Prod

uce

road

map

to

mig

rate

, ext

end,

impl

emen

t or

dec

omm

issi

on e

xist

ing

syst

ems

8.4

Red

esig

n pr

oces

ses

usin

g e-

req

uesi

stiio

ning

, e-p

rocu

rem

ent

and

self

ser

vice

7.

En

ha

nci

ng

IT in

fra

stru

ctu

re:

con

tin

ue

to

up

dat

e a

nd

imp

rove

th

e T

rust

’s in

fras

tru

ctu

re t

o f

orm

a r

ob

ust

fo

un

dat

ion

fo

r fu

ture

IM&

T d

eli

very

8.

O

pti

mis

ing

exi

stin

g t

ech

no

log

y: o

pti

mis

e a

nd

sta

nd

ard

ise

use

of

exi

stin

g IM

&T

soft

war

e a

nd

de

vice

s to

pro

vid

e e

ffic

ien

t cl

inic

al, c

orp

ora

te a

nd

bac

k o

ffic

e s

yste

ms

2015

/16

2016

/17

2017

/18

2015

/16

2016

/17

2017

/18

2015

/16

2016

/17

2017

/18

6.

Fl

exib

le a

nd

inn

ova

tive

wo

rkin

g:

imp

rove

pro

du

ctiv

ity

and

acc

ess

to

car

e b

y le

vera

gin

g te

chn

olo

gy a

nd

te

leco

mm

un

icat

ion

s

Page 141 of 196

The

Pe

nn

ine

Acu

te H

osp

ita

ls N

HS

Tru

st

IM

&T

Str

ate

gy 2

01

5 –

20

18

50

| P

ag

e

IDH

igh

-lev

el A

ctiv

ity

9.1

Supp

ort

for

atta

inm

ent

of p

rofe

ssio

nal q

ualif

icat

ions

9.2

Embe

d b

est

prac

tice

- P

rinc

e 2

9.2

Embe

d b

est

prac

tice

- I

SO s

tand

ards

9.3

Rol

l-ou

t of

up-

to-d

ate

trai

ning

to

supp

ort

new

tec

hnol

ogy

9.4

Ach

ieve

the

ISO

270

01 s

tand

ard

9.5

Impl

emen

t IT

IL B

est

Prac

tice

9.6

App

ropr

iate

suc

cess

ion

plan

ning

9.7

Und

erta

ke a

ful

l opt

ions

app

rais

al t

o ex

amin

e IT

Ser

vice

Mod

els

9.8

Dev

elop

men

t an

d pu

blic

atio

n of

a s

ervi

ce c

atal

ogue

9.9

Upd

ated

met

hodo

logy

and

han

dboo

k fo

r th

e m

anag

emen

t of

pro

ject

s

IDH

igh

-lev

el A

ctiv

ity

10.1

Enga

ge e

ach

Div

isio

nal P

hysi

cian

and

Nur

sig

lead

in I

M&

T in

itia

tive

s

10.2

Wor

k w

ith

Div

isio

nal l

eads

to

deve

lop

clin

ical

cha

mpi

ons

10.3

Iden

tify

opp

ortu

niti

es f

or c

linic

ians

to

enga

ge in

IM

&T

inno

vati

on

10.4

Dev

elop

str

ateg

y fo

r lo

nger

ter

m c

linic

al e

nga

gem

ent

to s

uppo

rt f

utur

e EP

R p

lans

2015

/16

2016

/17

2017

/18

2015

/16

2016

/17

2017

/18

10.

Im

pro

vin

g c

lin

ica

l en

ga

gem

ent:

imp

rove

cli

nic

al e

nga

gem

en

t in

Tru

st IM

&T

and

tra

nsf

orm

atio

n a

ctiv

itie

s th

rou

gh le

ade

rsh

ip a

nd

inn

ova

tio

n t

o p

rom

ote

ad

op

tio

n o

f te

chn

olo

gy.

9.

Ef

fici

ent

an

d e

ffec

tive

IM&

T se

rvic

e: r

evi

sio

n o

f th

e IM

&T

serv

ice

te

am’s

str

uct

ure

, cap

acit

y an

d c

apab

ilit

ies

to im

pro

ve t

he

eff

icie

ncy

an

d e

ffe

ctiv

en

ess

of

the

se

rvic

es

to T

rust

pe

rso

nn

el

Item

9a

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51 | P a g e

7 Governance

This section sets out the governance arrangements for the implementation of this strategy.

7.1 Information Assurance Framework - IM&T Department

7.2 Caldicott and Information Governance Committee - Terms of Reference

Purpose

Ensures integrated information governance as the primary performance review committee for the Trust

Ensures assurance of the effective management of information governance risk across the Trust

Ensure compliance with law, best practice, governance and regulatory standards.

7.3 IM&T and Information Quality Assurance Committee - Terms of Reference

Purpose

The IM&T and Information Quality Assurance Committee will monitor the implementation of the Trust’s IM&T Strategy focusing on the wider local IM&T programme.

It will monitor the operational IM&T service and support the management of IM&T within the Trust.

It will support the development of initiatives to promote a culture of Information Quality Assurance across the Trust, and to further promote

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52 | P a g e

consistent practice in the area of activity classification and its application.

7.4 Clinical Strategy Group – Terms of Reference

Purpose

The IM&T Clinical Strategy Group will direct the Trust’s IM&T Strategy focusing on the use of IM&T systems in operational clinical settings

It will monitor the delivery of the IM&T Strategy, the EPR Programme and other clinical projects

It will provide clinical advice IM&T related issues which impact clinical users.

It will act as the Project Board for key projects that affect clinical staff globally, specifically the Clinical Portal.

7.5 IM&T Programme / Project Funding Approval

Programmes and projects have been included in the IM&T capital programme five year plan for funding in principle. The plan is reviewed on an annual basis to agree the priorities for a detailed programme of work.

Detailed business cases will be presented to the relevant approval authority based on investment needs for each of the major projects, to ensure that value for money and return on investment is demonstrated using a cost / benefit analysis.

In principle, projects should deliver cash-releasing benefits, but as a minimum be self-funding for impact on service revenue.

Item

9a

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53 | P a g e

8 Methodologies and Best Practice

The IM&T Department will adopt best practice and methodologies in order to manage this ambitious programme of work effectively. This section sets out the standard methodologies to be adopted by IM&T.

8.1 Programme management

Managing Successful Programmes (MSP) is a structured, flexible framework that allows the management and control of all activities involved in managing a programme. MSP is the de facto standard used for managing programmes in the NHS. Senior Staff within the IM&T Department responsible for managing programmes are expected to follow the MSP methodology as part of the IM&T Department’s drive to improve its services.

8.2 Project management

PRINCE2 is the de facto standard used for managing projects in the NHS. It is a generic, tailorable project management methodology, covering how to organise, manage and control projects. PRINCE2 has been adopted as the in-house standard for project management and key staff receive training and mentoring in project management techniques. All projects have a Project Board with a sponsor and clinical engagement. A recent audit confirmed that this implementation is robust.

To provide further governance and auditability of compliance with the methodology, a project portfolio management system is being implemented to allow consolidation of project and progress reporting.

8.3 Service management

ITIL is the most widely accepted approach to IT service management in the world. ITIL provides a cohesive set of best practice, drawn from the public and private sectors internationally.

As part of the IM&T Department’s structure review a capability and training review scheme will be introduced to ensure ITIL best practice is fully implemented and adhered to.

8.4 Security management

The ISO/IEC 27000 series consists of information security standards published by the International Standards Organisation (ISO) and the International Electrotechnical Commission (IEC). The series is designed to give best practice recommendations on information security management including risks and controls within the context of an overall Information Security Management System (ISMS).

The Trust intends to gain certification to the ISO/IEC 27001 standard in order to achieve:

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54 | P a g e

better management of information security risks, now and in the future

increased access to new customers and business partners

demonstration of legal and regulatory compliance

potential for reduced public liability insurance costs

enhanced status and competitive advantage

overall cost savings (reduced errors and re-work).

Item

9a

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9 Benefits

The overarching aim of the IM&T Strategy is to support the objectives of national, local and Trust goals to improve patient care through technology and innovation by delivering the following benefits:

Real time information available and accessible at the point of care

Reduction in time accessing multiple systems and searching for patient

information through further system integration and consolidation, and

use of portal technology

Eliminate duplication of entering information across disparate systems

thereby improving patient safety and use of clinicians’ time

Availability of complete and accurate comprehensive information for

clinicians to support care management and decision making which

could impact length of stay or increased readmissions

Reduce the amount of time patients spend avoidably in hospital

through better and more integrated care in the community

Faster management of the patient journey to recovery through

improved communication and sharing of information between patients,

clinicians and other care providers

Enhance continuity of care with provision of timely electronic

communications to GPs and other care providers

Efficiency improvements in clinical practices as the Trust progresses

with the move to electronic records and removal of paper

Increase positive patient experience of both inpatient care and care

outside the hospital

Enable harm-free care and avoidance of financial penalties through

comprehensive monitoring and reporting systems to support service

improvement initiatives

Improved data quality and reporting to maximise income generation

Demonstrate consistent working practices across the Trust’s services

and departments

Use business intelligence reporting and dashboards to enable service

improvement strategies and develop enhanced models of care to

support delivery of cost improvement plans

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10 Risks

The IM&T programme is large and complex and there is significant risk of delay and over spend which would constitute a threat to the delivery of benefits and achievement of the Trust’s objectives. Additionally, failure to support the complex configuration of live systems would have a serious effect upon the ability to achieve organisational goals.

The main areas of risk are summarised below:

No Risk Probability (H/M/L)

Severity (H/M/L)

Mitigation

1 Sufficient project resources and management cannot be secured risking delays or abandonment of projects.

H H Agree PAHT funding through this strategy.

Agree external funding with Commissioners; prepare bids to apply for other strategic funding offered by the Government.

Prepare contingency plans for resourcing shortfalls.

2 Project run late or over-budget, delaying delivery of benefits.

M H Use ‘best practice’ project management methods (PRINCE 2).

Adopt a development methodology to ensure projects and developments are managed in a quality controlled and consistent manner.

3 Projects completed, but benefits not fully realised.

M M Prepare and monitor Benefits Realisation plans for all major projects.

Appoint Business Change owners within Services to ensure benefits realised.

4 Loss of efficiencies and disruption to organisation arising from out of date or redundant systems.

M H Undertake regular upgrade and system reviews as ongoing business and usual.

Monitor via System Manager meetings

Item

9a

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57 | P a g e


Severity (H/M/L)

Mitigation

5 Failure to attract and retain high quality staff leads to heightened risk of project failures and unreliable systems and processes.

M H Develop IM&T managers with strong focus on leadership and people management skills.

Ensure effective communications at all levels of IM&T staff.

Ensure staff qualifications are updated to meet industry standards and best practice.

6 Failure to identify project and programme risks.

M H Ensure MSP & PRINCE 2 methodologies are followed.

Implementation of Project in A Box to consolidate project and portfolio risks.

7 IM&T are not involved early enough in hospital projects.

M M Continually educate or reinforce that the business MUST involve IM&T from the outset.

Divisional pipeline process implemented as precursor to capital planning.

8 Trust culture does not change to one of “IT is not optional, it is part of the day job”.

M M Recent significant rollout of Clinical IT systems but requires Senior Clinical leadership.

Greater alignment of clinical strategy group and project leadership with changes in Trust Divisional structures.

Switch off old ways of working.

Appoint Business Analysts and Clinical Trainers to ensure IT is fully utilised and business processes are changed.

9 Clinicians see IT as purely administration.

L L Secure Senior Clinical leadership to address shortfall in uptake on clinical systems.

Enforce new ways of working by changing JDs, judge as part of PDR process.

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Severity (H/M/L)

Mitigation

10 Lack of flexibility and response to change.

M M Continued review of IM&T Strategy in line with national and organisational strategies including Trust transformation map.

11 Increased demand for IT systems as cost improvement enabler (e.g. electronic forms and workflow and complex pathway solutions with associated interfacing) cannot be met by current IM&T resource establishment.

H M Additional resource requirements built into business cases and revenue to support ongoing strategy.

12 IM&T strategy is impacted or delayed by Devolution of Manchester and other political changes in local area

H H Proactive participation of Trust and IM&T in local and national initiatives.

Harnessing of opportunities arising from change.

13 Increased demands on the finite business as usual resources due to the expansion of IM&T systems delivered as part of strategy

H H Additional resource requirements built into business cases and revenue to support ongoing strategy.

Service review, monitoring and improvement

These risks, and associated action plans, will be managed and monitored through a combination of project risk logs, a programme risk log and the departmental risk register.

Item

9a

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11 Conclusion

This strategy has assessed the Trust’s current IM&T provision and identified the challenges and opportunities to come. The Trust has made considerable progress with its current best of breed EPR and has decided to continue building on this capability over the life of this strategy. The overarching goal of the strategy is to support the Trust in meeting its ambitious transformation plans by providing robust and agile IM&T services. The strategic objectives laid out in the strategy highlight the opportunities for the Trust, staff and patients by achieving fully digital patient records and clinical workflows. It identifies the strong lead role the Trust can play by supporting Greater Manchester in its aims for truly integrated pathways within the wider health community, including GPs, community health, social care and patients. It also provides a path to delivering efficiencies through the latest innovation and technology, and making them accessible to patients and staff alike. Over the next three years the IM&T Department should build on the solid capabilities already in place, and strengthen areas such as system optimisation, clinical engagement and service delivery. By focusing on these areas over the life of this strategy the Trust will be better prepared to manage future possibilities, such as migrating to a single integrated EPR.

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12 Glossary of Terms

AGMA Association of Greater Manchester Authorities

AHP Allied Health Professionals

AHSN Allied Health Science Network

BI Business Intelligence

BYOD Bring Your Own Device

CCG Clinical Commissioning Group

CDMI Clinical Digital Maturity Index

DoH Department of Health

EDRMS Electronic Document Record Management System

ePMA Electronic Prescribing and Medicines Administration

EPR Electronic Patient Record

FYFV Five Year Forward View

HRG Healthcare Resource Group

HSCIC Health and Social Care Information Centre

IM&T Information Management and Technology

IT Information Technology

ITIL Information Technology Infrastructure Library

MoU Memorandum of Understanding

NIB National Information Board

OCRR Order Communications and Results Reporting

PAS Patient Administration System

PLICS Patient Level Information and Costing System

SAN Storage Area Network

SLR Service Level Reporting

TDA Trust Development Authority

TIE Trust Integration Engine

VoIP Voice Over Internet Protocol

Item

9a

Page 152 of 196

Title of Report Audit Committee Minute – 7 April 2015

Executive Summary

The minute of the Audit Committee meeting held on 7 April 2015 is attached. The Committee:

Noted the interim External Audit Report for 2014/15

Reviewed the Internal Audit Progress Report

Received the interim Internal Audit Opinion for 2014/15

Reviewed the draft Internal Audit Plan for 2015/16

Noted the arrangements for producing the annual accounts and annual report for 2014/15

Noted the draft Annual Governance Statement

Received the Counter Fraud Update

Approved the Counter Fraud Plan for 2015/16

Received the Information Governance Audit.

Actions Requested:

The Board is asked to note the contents of the minute.

Corporate objectives supported by this paper: The Audit Committee supports all corporate objectives of the Trust.

Risks: Not relevant for this paper.

Public and/or Patient Involvement: Not relevant for this paper.

Resource Implications: Not relevant for this paper.

Communication: Not relevant for this paper.


Assurance X

Contract X



HR X


IM&T X



Sustainability X

Name Riaz Ahmad

Job Title Non-Executive Director


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C:\Users\244991-Admin\AppData\Local\Temp\9ee7b031-249f-4d70-b5be-a26d01b11e87.doc

Minute

Audit Committee Executive Directors’ Meeting Room, Trust HQ

7 April 2015 1.30pm – 3.15pm

Owner Timescale

Present Mr R Ahmad, Non Executive Director (Chair) Mrs W Cardiff, Non Executive Director Mrs C Guereca, Non Executive Director In Attendance Mr G Barclay, Assistant Chief Executive Mr T Cutler, KPMG Ms S Flaherty, Corporate Governance Manager Miss W Jones, Deputy Director of Finance Ms R Ghelani, KPMG Mrs D Pullen, Head of Corporate Governance Mrs L Squires, MIAA Mrs K Wheatcroft, MIAA Apologies Mrs U Martin, Director of Clinical Governance Mr A Smith, KPMG Mr B Steven, Deputy Chief Executive/Director of Finance

19/15 Introductions Mr Ahmad led the introductions and apologies

20/15 Declarations of Interest There were no interests declared.

21/15

Minutes of Meeting held on 10 February 2015 The Minutes of the meeting were submitted. Mr Cutler stated that in respect of agenda item 11/15, KPMG had been appointed as auditors for 2015/16 and 2016/17. With this clarification, the minutes were approved.

22/15

Matters Arising Mr Ahmad referred to the brought forward action log. 08/15 Audit Plan The Audit Plan had been discussed with Mr Barclay and other key individuals in the Trust. Mr Barclay would ensure that a copy of the Audit Plan was submitted to SMT for consideration.

GB

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13/15 Counter Fraud – Whistleblowing The whistleblowing case discussed at the last meeting was included on the log which had been submitted to the Trust Board. 17/15 The Terms of Reference of the Finance, Infrastructure and Business Development Committee These still needed to be ratified by the Trust Board. The other actions had been updated on the brought forward actions log and were noted.

GB

23/15 Chairman’s Remarks Mr Ahmad had no specific comments to make.

24/15

External Audit – Interim Audit Report 2014/15 Ms Ghelani spoke to the report and provided the committee with the key highlights. In relation to the controls over key financial systems, it was reported that the controls were generally sound. One best practice recommendation around journals had been identified in relation to segregation of duties and timeliness. Work continued in relation to purchase order data analytics. Internal Audit work was not relied upon during the interim testing, however dialogue continued with Internal Audit to avoid duplication and to use the highlights of their work to aid a focused approach. Good progress was noted in relation to the accounts production for the year and there was confidence that the un-audited accounts would be submitted on time. Work was completed on the high level review of the financial management processes which had been found to be robust. It was also reported that the Trust had posted a deficit of £1.9m at Month 11, representing an improvement due to the £9m non-recurring funding received from NHS England to cover the initial deficit position of £10.9m. The report was noted.

25/15 External Audit - Technical Update The content of the technical update report was received. The report was noted.

26/15 Internal Audit – Progress Report Mrs Squires presented the internal audit progress report covering the period April 2014 to March 2015. The report contained findings and recommendations from the monitoring work undertaken by internal audit and provided details of the Trust’s progress in implementing agreed

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recommendations. In relation to the Assurance Framework, this was designed and operated to meet the requirements of the Annual Governance Statement and provided reasonable assurance that there was an effective system of internal control. Mrs Squires took the Committee through the completed audits as follows:

Data Quality: Referral to Treatment – DNA – limited assurance

Recruitment Process – limited assurance

Absence Management – limited assurance

E-procurement – significant assurance

Information Governance – significant assurance

IT Service Continuity – significant assurance

Mortality Reduction Project – significant assurance Mrs Squires then took the committee through the specific areas of concern for the limited assurance reports, as detailed in the papers, and described the actions being taken to address the limited assurance. Mrs Squires said good progress was being made in relation to follow up recommendations, commenting that the majority of the recommendations were due to be cleared by July 2015. Mrs Squires provided an update on the critical and high level risk action plans, stating that she was content with the actions being taken. The report also provided an update on progress against the plan, an overview of the output delivery, upcoming events and a summary of the MIAA events and conferences. Members of the committee asked various questions in relation to the limited assurance reports. In response, Mrs Squires confirmed that Dr Sinniah was the lead executive for the Data Quality: Referral to Treatment – DNA – limited assurance audit. Mr Ahmad sought assurance that everything possible was being done to rectify this limited assurance review which had an impact on patients and that time was of the essence to improve compliance. It was agreed that Mr Mullen and Dr Sinniah would be approached to provide a written update to members. In addition, Mrs Squires would forward confirmation that 6 out of the 9 recommendations had already been completed. In relation to response notice for appointments, Mrs Squires said that staff had been working to 3 weeks, rather

DP LS

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than 2 weeks as per policy but this had since been rectified. Concerning with the Recruitment Audit, the audit sample was from the current year; all positions had been authorised prior to advert. Insufficient ID documentation was being addressed. In relation to Absence Management, Mrs Squires said the key failures were in relation to staff not attending Occupational Health and then managers not always following this up. Confirmation was given that as this was a limited assurance audit, it would be detailed in the follow up section of a future report to the committee. The report was noted.

27/15 Internal Audit Briefing Notes The briefing notes had been included for information purposes. The report was noted.

28/15 Internal Audit – Interim Opinion Statement Mrs Wheatcroft advised that the purpose of the Director of Internal Audit Opinion was to contribute to assurance available to the Accountable Officer and the Board which underpinned the Board’s own assessment of the effectiveness of the system of internal control and to assist in completion of the Annual Governance Statement. The overall opinion was that significant assurance could be given that there was a generally sound system of internal control designed to meet the organisation’s objectives and that controls are generally being applied consistently. Some weaknesses in the design or inconsistent application of the controls put the achievement of a particular objective at risk. The opinion had been formed by review of the Assurance Framework, assurance across the critical business systems and contribution to governance, risk management and internal control enhancements. Mrs Cardiff sought to understand the where the Trust was positioned from a benchmarking perspective. Mrs Wheatcroft advised that during the year, MIAA may have 1-2 clients whose opinion statement was limited. Mrs Wheatcroft further stated that she considered the balance of the Trust’s internal audit reports and their scope of coverage was good on the basis that there was a mixture of significant assurance and limited assurance audits. The report was noted.

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29/15 Internal Audit Draft Plan – 2015/16 Mrs Squires presented the draft plan which was based on their local risk assessment and demonstrated how their work was aligned with the Trust’s Strategic Risk Assessment. The plan included the 3 year audit strategy and a detailed operational plan for 2015/16. It was noted that whilst this had been developed with key individuals in the Trust, Mr Steven was yet to provide comments so it may still alter. Members of the committee asked questions in relation the plan which included potential audits for 2016/17. In response, it was confirmed that bank, agency and locum spend had been pulled forward into 2014/15 from 2015/16 due to its importance. Discussion followed in relation to vacancy management; members expressed the view that this should be brought forward into 2015/16. Additionally, it was expressed that bank, agency and locum spend should also be brought forward into 2015/16 in order that the impact of the recommendations from the 2014/15 could be monitored. Linkage with the areas to be assessed by the Chief Inspector of Hospitals visit expected by the end of the calendar year was raised. After discussion, it was agreed that the draft plan would be considered in its entirety by the Executive Team for an overall discussion. The report was noted.

GB

30/15 Arrangements for Annual Accounts and Annual Report Mr Barclay spoke to the report which set out the process for finalising and approving the statutory annual accounts and annual report for the Trust. The Quality Accounts had been tabled at the last Trust Board and was now subject to consultation. The Annual Report was being drafted and the Annual Accounts were underway. The report was noted.

31/15 Audit Committee Terms of Reference Annual Review The Terms of Reference were discussed and reference to the Audit Commission was to be removed and replaced with “independently appointed”. The changes would be made and thereafter submitted to the Trust Board for ratification. The report was noted.

DP/GB

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32/15 Review of Assurance Statements: Quality & Performance Committee and the Finance, Infrastructure & Business Development Committee Both Annual Assurance Statements were considered by the committee. Mr Barclay asked whether the committee had assurance that the two sub-committees of the Board had fulfilled their terms of reference. Mrs Cardiff said that she felt both committees had made progress since they were established particularly in relation to attendance and contributions. Mrs Guereca, who was a member of the Quality and Performance Committee, commented on the large and complex agenda, stating that the committee was now more effective and was turning its attention to seeking assurance rather than reassurance. Mrs Cardiff said that she would like to see more triangulation of issues across the sub-committees and requested that this be drawn to the Board’s attention. The Annual Assurance Statements were noted.

GB

33/15 Annual Governance Statement Mr Barclay spoke to the Annual Governance Statement, advising the committee that it reflected new guidance issued by the TDA and also the significant amount of change around governance processes and restructuring of committees which had occurred in the year. Mr Barclay took the committee through each section of the document. In relation to the risks contained within the document, Mr Cutler said that he found this to be particularly detailed and helpful. After discussion, it was suggested that the assurance against the controls in place in relation to the risks could be removed and reference to the Board Assurance Framework, which was in the public domain, could be inserted into the statement. Mr Barclay said that he had not yet discussed the detail of the statement with the Chief Executive and discussion followed in relation to whether any specific quality issue should be included within the end of the statement. Mr Cutler suggested that the Trust Board considered what was reflected within the Board Assurance Framework. Mr Cutler summarised that he was very happy with the content of the statement but suggested that further to the discussion in the earlier agenda item, reference was included in the statement to the embeddedness of the committees. He also felt that reference to the Corporate Governance Code was helpful but suggested “shareholders” be changed to “stakeholders”.

DP/GB GB DP/GB

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Mr Cutler agreed with the significant issue included in the statement but queried whether the Strategic Risk Register risk number 3 was broad enough, referencing reputation and going concern elements. The draft Annual Assurance Statement was noted.

34/15 Draft Audit Committee Annual Report – 2014/15 The report was included for comment. Members were asked to provide updates of their resumes for inclusion together with any relevant training for section 5. Mr Barclay said that within section 2, the Audit Committee did not oversee the work of the sub-committees and this should be changed to “reviews and seeks assurance of…”. Dates also needed to be amended in section 5. The updated Terms of Reference discussed earlier would also need to be appended to the Annual Report. In relation to the section referring to approval of the report and accounts, Mr Cutler said that within this section a paragraph should be included to explain the main risks, discussions and challenges around the approval: it was noted that this could only be updated following the May 2015 meeting.

NEDs DP GB

35/15 Counter Fraud Progress Report Mr Gordon attended the meeting at this point and provided the committee with an update on progress against plan and key issues. Underachievement on plan was due to the retirement of the former LCFS. Mr Gordon said that the committee could be assured that the Counter Fraud status was “green”. During the period before Mr Gordon came into post, the service was being managed by the Deputy Director of Finance with assistance from the NHS Protect Specialist. Mr Gordon requested and received approval of the interim Counter Fraud Policy changes until 31 July 2015, by which time Mr Gordon would have completed a further review and update. Discussion followed in relation to Overseas Visitors, Pride in Pennine comments around working whilst off sick and Mr Gordon’s intention to work with HR to fraud-proof the Sickness Absence Policy. Mr Gordon then took the committee through the ongoing cases report. The report was noted.

36/15 Counter Fraud Annual Plan – 2015/16 Mr Gordon spoke to the plan, reporting that it mirrored the

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NHS Protect standards for provider requirements. The plan included 200 days in total, which was the same as the previous year, split by strategic governance (39), inform and involve (33), prevent and deter (48) and hold to account (80). Mr Gordon informed the committee that overseas visitors would be a particular focus in the year ahead, commenting about the reward scheme which had been introduced whereby if the Trust was able to identify overseas visitors but was unable to recover the money, 50% of the costs would still be recouped. This was noted by the committee to be an important piece of work with financial benefits. The plan was approved. Mr Gordon then left the meeting

37/15 Waivers to Trust Standing Financial Instructions It was noted that the report had been amended to include the name of the supplier, following a request at the last meeting. Mrs Cardiff said that there had been significant challenge at the Procurement Committee in relation to software support for IT solutions as this was felt to be an area where costs could escalate once an IT solution was in place. The report was noted.

38/15 Minutes of other Board Sub-Committees The minutes of the Quality and Performance Committee from January and February, together with the highlight report, were received and noted. Mrs Guereca said that the highlight report demonstrated clearly the issues which had been escalated to the Board, for which there had been extensive discussion and challenge at the Quality & Performance Committee. The minutes of the January and February Finance, Infrastructure & Business Development Committee were received and noted. Mrs Cardiff had no specific comments to draw to the committee’s attention upon items discussed at the meetings.

39/15 Information Governance Audit Paper The committee received and noted the paper which had been approved by the Caldicott & Information Governance Committee. It noted that the Information Governance Toolkit required Confidentiality Audits to be undertaken. The report was noted.

40/15 Any Other Business – Quality Accounts Mr Barclay said that the Trust was no longer required to use the existing External Auditors to audit the Quality

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Accounts but rather could chose. A quote had been received from KPMG which was discussed and approved.

41/15 Any Other Business – Committee Administration Mr Ahmad said that it was Mrs Pullen’s last Audit Committee and expressed appreciation for her assistance.

42/15 Date & Time of Next Meeting The next meeting would be held on Tuesday 26 May 2015 at the earlier time of 9.30 am in the Executive Directors’ meeting room, Second Floor, Trust HQ, NMGH.

There was no private meeting between the NEDS and Internal Audit.

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Title of Report Trust Programmes Board – 24 March 2015

Executive Summary

The minutes from the Trust Programmes Board held on 24 March 2015 are attached.

Actions Requested:

The Board is asked to note the minutes.

Corporate objectives supported by this paper: The Trust Programmes Board oversees the six programmes which in turn drive the corporate objectives of the Trust. The programmes are:

Service Line Reporting

Cost Improvement Programme

Foundation Trust

Clinical Service Transformation

Safety

Workforce and Leadership

Risks: Noted in the relevant section of the minutes

Public and/or Patient Involvement: Not relevant for this paper

Resource Implications: Noted in the relevant section of the minutes

Communication: Details of progress communicated through the line management structure.


Assurance X

Contract X



HR X


IM&T X



Sustainability X

Name Ms S Good




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U:\Transformation Programme\PROGRAMME CONTROL DOCUMENTS\PMO Operational Files\Programme Boards\Trust Programme Board\20150324

Notes of Trust Programme Board

Executive Directors’ Meeting Room, Trust HQ 24th March 2015 4pm – 5.30pm

Owner & Timescale

Present S Good, Director of Strategy and Commercial Development (Chair) H Mullen, Director of Operations J Lenney, Director of Workforce and OD J Wilkes, Director of Estates C Sleight, Director of Transformation A Ennis, Head of PMO C Mayer, Non-Executive Directors (NED). M Ollerenshaw, Non-Executive Directors (NED).

In Attendance Nicola Rhodes, Programme Office Project Manager

1) Apologies Dr G Fairfield, Chief Executive B Steven, Deputy Chief Executive / Director of Finance K Salmon-Jamieson, Acting Chief Nurse

2)

Minute The notes of the last meeting were agreed as a true and accurate record.

3)

Matters Arising None

4) a)

Programme Progress Update The Trust Programme report was reviewed by the board and the summary report presented by A Ennis. Trust Programmes board Report attached for information. CIP Programme AE advised the board that the CIP Programme is on track to deliver the £22.5 million target. At month 11 the forecast out-turn position was £22.4m, the final month is reliant upon the cost control measures delivering as expected, and remaining schemes detailed on delivery tracker to deliver within month 12. Cost controls are expected to remain in place entering 15/16. There are currently £8 million of 15/16 CIP schemes with Project Initiation Documents in place; aiming to achieve 100% of the proposed CIP schemes by the end of March 2015.

20150324 Trust Programme Board v1.pptx

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b) c)

JL asked for clarification as to the process for approving CIP schemes. The board were advised that the PMO approves all CIP schemes which then reports to the Medical Director and Chief Nurse for QIA sign off. These are then reported to the CIP Programme Board. There are currently 220 CIP schemes within the pipeline tracker for 15/16. A schedule of approved CIP approved schemes is produced on a weekly basis and reported to the CIP Programme Board. It was agreed that this report will in future include QIA approved schemes and will be included within future CIP Programme Board & Trust Board Reports. Action: Nicola Rhodes to ensure that the PID & QIA schedule is included within the next Trust Programme Board Report. SG raised concerns regarding the commissioner discussions regarding the QIA Process and the approved schemes. Action: CS to meet with commissioners to understand the agreed process and organise necessary meetings to provide assurance. It was suggested that in September the systems and processes for CIP schemes should be reviewed. Service Transformation Programme CS advised the board that the Phase 1 modelling is now coming to an end, and that the 4 specialities (Cardiology, Obstetrics, ID & Orthopaedics) have developed more detailed Transformation plans using a “bottom up” approach. A stakeholder event including input by commissioners is organised for 25th March to discuss and further shape ideas for the proposed models. Work is scheduled to commence on Phase 2 which focuses on A&E, Acute Medicine, Paediatrics and General Surgery. Work will now begin on the development of the Strategic Outline Business Case (SOC) for Transformation. This will be led by Steve Brooks. SG advised the Board that recruitment within the Commercial Development Team would be accelerated to support this. JL sought clarification as to activities within Phase 1. An approach to shape the workforce plans has been discussed with Harsh Choudhry (McKinseys) however the board were asked to note that a lot of work within the workforce plan will be required. AE advised the board that there is a need to correlate the workforce plan with CIP. Safety Programme AE advised the Board that Key Milestones have been identified for 6 areas to develop to Safety Improvement Plan. The areas for safety improvement include:

Prevention of Perinatal harm & deaths

Diabetes

Sepsis

Failure to Rescue

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d) e) f)

Falls

Lessons Learned

Bids have been submitted to NHSLA / Sign up to Safety Programme to fund the safety improvement work. The outcome of the bid is yet unknown. SLR Programme AE advised the board that the SLR dashboard was presented within the work-stream meeting that allows divisions to view their SLR position at specialty level. It was acknowledged that there is a gap in delivery resource, which is proving a challenge. A meeting is scheduled to discuss SLR and the approach to SLR. G Fairfield has advised that she would like to take a lead on this work-stream. Workforce and Leadership Programme JL advised the board that the Workforce and Leadership Terms of Reference (ToR) and membership has been amended. The Board received and formally approved these Terms of Reference. (The ToR approved are attached for information ) JL raised concerns with regards to resource issues in relation to Workforce & Leadership programme. Action: JL, SG and CS to discuss resource for the Workforce and Leadership Programme Board Foundation Trust Programme SG advised the Board that work continues on the Foundation Trust Application. The constitution has been reviewed by the legal team. The desktop exercise with the TDA is going ahead however the Board to Board preparation has been deferred to June 2015. The Membership strategy has been agreed and work continues on this, plans are being developed with a focus on meaningful and active engagement. Work continues on the IBP. The assumptions within Workforce chapter will need to be revisited. The IBP is scheduled for submission in October 2015.

Workforce and Leadership PB Terms of Reference (230614).doc

5)

PMO Support to Trust Programmes – Update CS advised the board that the PMO structure currently contained 8 project manager positions supporting the six work streams. There are currently two interim project managers (occupying the 2 of the 6 Project Manager posts). The previous recruitment drive was successful in appointing one Senior Project Manager. A second round of interviews has taken place this week and 3 successful appointments were offered and accepted, the next step is to

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assign the Project Managers to work streams. SG advised the board that an agreement has been reached to introduce Transformation Support Managers. The Job Description and Person Specification are in draft format. The associated cost of the additional posts still needs finalisation. SG advised the board that a review of the effectiveness of the PMO would take place after it had been fully staffed for 6 months. Ernest Young have had their contract extended until the end of May. A further specification for external support has been tendered. At the end of the term of engagement it is expected that the PMO will self-sustaining. The tender will be released on Monday 30th March. JL suggested that General Management Training schemes for graduates could be considered as further support.

6) Priorities and Main Effort for the Next Period To finalise the Transformation Delivery Managers Job Description & Person Specification. HM asked any advertisements were held until consultation had completed on the divisional restructure work. This was agreed acknowledging this placed risk on the necessity for prolonged external support to the Programmes.

7) Date and Time of Next Meeting The next meeting is scheduled to meet on Tuesday 21st April 2015,

4.00-5.00pm in the Executive Meeting Room

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Title of Report Trust Programmes Board – 21 April 2015

Executive Summary

The minutes from the Trust Programmes Board held on 21 April 2015 are attached.

Actions Requested:

The Board is asked to note the minutes.

Corporate objectives supported by this paper: The Trust Programmes Board oversees the six programmes which in turn drive the corporate objectives of the Trust. The programmes are:

Service Line Reporting

Cost Improvement Programme

Foundation Trust

Clinical Service Transformation

Safety

Workforce and Leadership

Risks: Noted in the relevant section of the minutes


Resource Implications: Noted in the relevant section of the minutes

Communication: Details of progress communicated through the line management structure.


Assurance X

Contract X



HR X


IM&T X



Sustainability X

Name Ms S Good




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1

Notes of Trust Programme Board

Executive Directors’ Meeting Room, Trust HQ 21st April 2015 4pm – 5.30pm

Owner & Timescale

Present S Good, Director of Strategy and Commercial Development (Chair) J Lenney, Director of Workforce and OD C Sleight, Director of Transformation B Steven, Deputy Chief Executive / Director of Finance Dr A Sinniah, Acting Medical Director Dr M Moonan, Director of Service Improvement

In Attendance Nicola Rhodes, Programme Office Project Manager

1) Apologies Dr G Fairfield, Chief Executive G Harris, Chief Nurse Dr R Prudham, Deputy Medical Director H Mullen, Director of Operations J Wilkes, Director of Estates

2)

Minutes of Previous Meeting The notes of the 24th March 2015 meeting were agreed as a true and accurate record.

3)

Matters Arising CS advised the board that Job Descriptions and Person Specifications were completed for the Transformation Delivery Managers. These positions will be offered on a secondment basis at existing grades. JL advised that the Job Description would need to go through banding process. CS to speak to Nick Hayes.

CS

4) a)

Programme Progress Update The April Trust Programme report (distributed on the agenda) was reviewed by the board and the summary report presented by CS. Cost Improvement Programme (CIP) CS advised the board that CIP Delivery for month 12 is £21,583. The current forecast CIP delivery position is £22.95 million, £563k of this is cost avoidance, with an additional £210k expected forecast within month and £599k of extreme measures. The final figures for cost controls are yet to be finalised and will published in the CIP Programme Board on Monday 24th April 2015. Work continues on the development of 2015/16 CIP schemes. The Trust is required to deliver a minimum CIP target of £27.5m in 2015/16.

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2

This is based upon a £20.76m efficiency target and a £6.78m decommissioning target. In addition the Trust needs to deliver £6m of non-recurrent savings. There are currently £14.7 million of CIP schemes identified. £9.9 million PIDs have been completed with an additional £4.8 million of schemes have been PMO accepted and QIA approved. A discussion took place regarding the requirement to finalise the CIP phasing by the end of April for submission in the final version of the Trusts Annual Plan. Concerns were expressed on CIP delivery in M1 and M2. It was agreed that the phasing would be reviewed and agreed at the next CIP Programme Board. BS raised concerns regarding the 2015/16 schemes advising the group that there is currently £19m of 2015/16 CIP schemes in place against a target of £28.5 million; a discussion took place on the best methods to bridge the gap. It was agreed that there may a need to change the approach to CIP delivery and that a large engagement event focussing on innovation would be a sensible option. Concerns were raised that previous engagement events lacked consultant and nurse leadership, and that the engagement was required with the whole clinical workforce. Action: H Mullen, G Harris, Dr A Sinniah & Dr M Moonan to explore this further and feedback at the next event. BS suggested that focus groups be considered to explore specific topics, i.e. Agency spend. JL agreed that this would be the biggest opportunity within the Workforce CIP Schemes as the Trust currently has 10% temporary staffing levels, the national average is 6%. BS noted that the Royal College paper on the reduction of clinical waste had been received by SMG and JLNC but hasn’t been progressed any further, it was agreed that this could be included within one of the workstreams. Action: J Lenney to consider the reduction of clinical waste within the Workforce Transformation Programme. CS suggested that the work emerging from the Clinical Services Transformation programme needed to be reviewed by divisions to establish if there were any schemes that could be progressed without consultation. This has already been identified as a CIP target but as yet there are no schemes firmly identified. This need for consultation needs clarity. SG reminded the Board there was a stakeholder event on 11th May where this could be discussed further. CS advised the board that there is a need to ensure that everyone is aware of the process for CIP schemes. There is a schedule of engagement events planned throughout April and May. The CIP PID & QIA schedules were reviewed. BS asked that scheme values be included at the next meeting. Action: Nicola Rhodes to ensure that future iterations of the PID & QIA schedule include values against the schemes.

HM/GH/AS/MM JL SG CS/NR NR

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3

b) c)

Clinical Service Transformation Programme Work has commenced on Phase 2 which focuses on A&E, Acute Medicine, Paediatrics and General Surgery and is progressing at pace. Two Senior Project Managers (Reyhana Khan and Julie Owen) have been assigned to this Clinical Services Transformation Programme, working with McKinsey. Clinical Leads for next phase are yet to be identified. Urgent Action: CS and SG to discuss the identification of Clinical Leads with Dr Roger Prudham. Concerns were raised regarding the support required to hit the end of June deadline. The activity and financial modelling team led by Imtiaz Bala were suggested as additional resource, as well as the four Information Managers that have been recently appointed within the divisions. CS to speak to Christine Walters to ascertain if these posts could provide support to the Clinical Services Transformation modelling. JL raised concerns that intelligence regarding assumptions may be lost when McKinsey complete their assignment at PAHT. It was agreed that the assumptions need to be more explicit and understood in more detail. JL to discuss workforce assumptions with McKinsey and Imtiaz Bala. CS to approach McKinsey to ensure all assumptions are articulated. It was suggested that a session with the executive team to explore the assumptions further be organised. CS to discuss this with G Barclay to see if it was possible to utilise a Board Development session. It was agreed that it was essential that once were the assumptions were understood that the directorate management teams would need to buy into the options and understand the degree of difficulties, complexities, risks and implications involved within the Transformation programme. A Stakeholder event took place on Wednesday 25th of March where the options were presented. A second event is being organised for Wednesday 24th of June. Work has begun on the development of the Strategic Outline Business Case (SOC) for Transformation. This will be led by Steve Brooks. SLR Programme BS advised the board that an appointment had been made into the Director Performance and Contracting post who would be joining the Trust in May 2015. Work continues on the development of the SLR Dashboard. The programme board did not meet in April. A meeting is scheduled to discuss SLR and the approach to SLR. It was acknowledged that there is a gap in delivery resource, which is proving a challenge. It was suggested that the SLR Project Manager could be shared with another a workstream.

CS/SG CS JL CS CS CS

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4

d) e)

Workforce and Leadership Programme JL advised the board that the Workforce and Leadership Terms of Reference (ToR) and membership has been amended. The Workforce & Leadership Programme Board did not meet in April. The next meeting has been scheduled for 14th of May however this will need to be rearranged. It is hoped that the next meeting will take place on 21st May. JL advised the board that there is an opportunity to develop an internal Graduate Training Programme as a joint venture with Central Manchester to help develop capacity and capability. Foundation Trust Programme SG advised the Board that work continues on the Foundation Trust Application. The constitution has been reviewed by the legal team. The consultation has been put on hold until after the Chief Inspector visit which is expected in the Autumn. SG provided feedback on the IBP chapters, detailed below: Chapter 2

The background information requires continuous updating

Agreement of cut off dates for information to be included in this

chapter

Chapter 3

Requires a stronger link between our values, corporate priorities,

transformation map etc.

TDA noted our ten corporate objectives will take more than a

year to deliver and therefore we need to explain how we will

achieve these over time.

TDA commented on the language used; we advised that we are

already reflecting on this but that is reflects staff input

Chapter 4

It was felt that we did not articulate strongly enough the

complexity of the landscape in which we operate and therefore

how we will respond/are responding.

Chapter 5

Need to articulate detailed response to how we intend to deliver

our services and what they will look like in view of the complex

position we are working with, i.e. DevoManc, Heathier Together.

Chapter 6

Advised that financial information required should be the current

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5

year and the previous two financial years.

Chapter 7

This section should identify top 10 risks

TDA stressed that the level of detail regarding the risks is

important but that mitigation is key, and also needs to line up with

our strategy

Chapter 8

This needs be better linked to our service development and

strategy development

Chapter 9

Noted that it was based on structure of Monitor guidance,

however TDA requested that we bring forward the structure of the

Board and how it fits in with the Strategy

Need to ensure Risk section reflects what is noted in Chapter 7

It was noted that the TDA re-iterated that they have not put anyone forward for approval without a breakeven financial position in the year they will be progressing, and therefore this is something the Trust will need to work hard on. Action S Good and S Statom

SG

5)

PMO Support to Trust Programmes – Update CS advised the board that the PMO structure currently contained 8 senior project manager positions supporting the six work streams. One substantive Senior Project Manager is now in post and has been assigned to the Clinical Services Transformation Programme. A further Senior Project Manager starts in post on Monday 27th of April and will be assigned to the Safety Programme. Two other applicants have now received unconditional offers of employment, start dates to be determined. Two other positions filled by internal secondments (Julie Owen – Clinical Services Transformation; and Su Statom – Foundation Trust Programme/Safety (Falls) work-stream). A discussion took place regarding the funding for Transformation Delivery Managers. This will need to be considered further. CS to progress the job description in the meantime (as item 3).

CS

7) Date and time of the next meeting: Tuesday 26th May at 4 pm in the Executive Meeting Room

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Title of Report Quality & Performance Committee Minute – 24 March 2015

Executive Summary

The minutes of the Quality & Performance Committee held on 24 March 2015 are attached. Items for escalation to the Trust Board were:-

Sickness and Absence rates

Resource and capability issues

Maternity Service Staffing Levels

Birthrate Plus

Bowel Cancer Progress

GI Bleed Rota

Level of Clinical Leadership and Decision Making

Actions Requested:

The Board is asked to note the content of the minutes

Corporate objectives supported by this paper: All Corporate Objectives are supported by the work of the Quality & Performance Committee

Risks: Any risks identified at the meeting are referred to the relevant manager for possible inclusion on the relevant part of the risk register.


Resource Implications: Not relevant for this paper

Communication: The Quality & Performance Committee communicates its work through the Trust Board and the Divisional Quality & Performance Committees.


Assurance √

Contract √



HR √


IM&T √



Sustainability √

Name Shauna Dixon



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C:\Users\244991-Admin\AppData\Local\Temp\b6068410-34ff-41bb-9f8c-e966e69829bf.docx

Minute

Quality and Performance Committee Room 237, Second Floor, Trust HQ

24 March 2015 9am – 12 noon

Owner

Timescale

Present Mrs S Dixon, Non-Executive Director (Chair) Mrs D Ashton, Divisional Director, Surgery Mr G Barclay, Assistant Chief Executive/Board Secretary Dr I Conyon, Performance Manager Mr V Crumbleholme, Divisional Nurse Director, Surgery Mrs C Guereca, Non-Executive Director Ms P Jones, Chief Pharmacist Mrs S Jones, Head of Clinical Professions Mrs U Martin, Director of Clinical Governance Mrs C Mayer, Non-Executive Director Mrs J Moore, Divisional Director, Medicine Mr H Mullen, Director of Operations Mrs K Salmon-Jamieson, Acting Chief Nurse Dr A Sinniah, Acting Medical Director Mrs C Trinick, Director of Midwifery Mr J Wilkes, Director of Estates & Facilities

In Attendance Mrs B Cook, Programme Manager Mrs A Dalton, Interim Turnaround Manager, RTT & Cancer Ms S Flaherty, Corporate Governance Manager Dr J Moise, Divisional Medical Director, Women & Children Mrs C Parker, Lead Nurse, Patient Experience Mrs D Pullen, Head of Corporate Governance

Apologies Dr G Ahmad, Divisional Director, Women & Children Mrs A Barker, Acting Divisional Director, Diagnostics Mrs J Keogh, Divisional Director, Women & Children Dr R Prudham, Deputy Medical Director (Quality) Mr B Steven, Deputy Chief Executive/Director of Finance Mr S Taylor, Divisional Director, Integrated & Community Care Dr S Woby, Director of Research and Development

Procedural Business

80/15 Welcome and Apologies Mrs Dixon welcomed everybody to the meeting, commenting that there was no triumvirate representative from the Diagnostics Division. Ms P Jones said that she would answer questions and would refer any further points back to the Division.

81/15 Declarations of Interest There were no declarations of interest relevant to items on the agenda.

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82/15 Chairman’s Remarks Mrs Dixon said that it was a long agenda and asked that when reports and items were presented that attendees concentrated on assurance, impact and outcomes for patients as the role of the committee was to provide assurance to the Trust Board. Mrs Dixon asked that everyone thought about quality, outcomes and impact on patients during the agenda items.

83/15 Minutes of the Previous Meeting The minute of the meeting held on 24 February 2015 was accepted as a true record with the addition under 40/15, Mrs Dixon had asked that “everyone thought about quality, outcomes and its impact on patients during the agenda items”.

84/15 Review of Action Checklist/Matters Arising From the Previous Meeting Mrs Dixon took the committee through the action checklist and spoke to the updates provided therein. It was noted that many of the items were included as a separate agenda item or updates were included in the highlight reports submitted to the committee. 21/14 D&T Review as Sub Structure of Quality & Performance Committee Ms Jones said that the review would not be ready for the April meeting. This item was deferred until May 2015. 33/15 Diagnostics Highlight Report It was noted that the updated version of the January highlight report had not yet been received or circulated to members. In Alex Barker’s absence, this item was deferred until April 2015. New Items added to the Action Checklist Vascular Mr Mullen said that this item was linked to specialist commissioning: a hybrid theatre would be available from mid-April. It was agreed that an update on “Vascular” would come back to the Committee in April 2015. HpB Pathology Services It was noted that Dr Benatar had agreed a SLA with CMFT and it was agreed that Ms P Jones would follow this up on behalf of the Division with Dr Benatar and thereafter provide an update.

PJ AB DA PJ

May 15 April 15 April 15 April 15

85/15 Quality & Performance Committee Chart Mr Barclay spoke to the updated chart which included one amendment of the Non Clinical Records Management Committee as a sub-committee of the Caldicott and Information Governance Committee. He said that there was one outstanding action to confirm the parent committee for the Safeguarding Committee. The reporting arrangements for the Performance Management Group would be discussed by the Executive team. Mr Barclay said that he and Mrs Martin were going to be working to realign and remove duplication in the structures and committee reports and would report back next month.

GB

April 15

86/15 Annual Assurance Statement – Various Committees Mrs Pullen advised that at the February meeting the majority of the annual assurance statements had been received and noted. Included in the pack were the remaining annual assurance

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statements which combined had led to the production of the annual assurance statement for the Quality & Performance Committee which was the next Agenda item. In relation to the Clinical Audit and Effectiveness Committee, Mrs Salmon-Jamieson said she would liaise with Gill Harris as to her view on nursing representation at that committee. Mrs Guereca raised the level of attendance at some of the committees and asked whether there was a minimum criteria for attendance and then escalation if that was not met. Discussion then followed as to the minimum criteria and it was agreed that Mr Barclay and Mrs Martin would look at this and come back with an attendance figure to the April meeting. A couple of other minor points were noted against the submitted annual assurance statements. Mrs Dixon commented that there was lots of reassurance within the statements submitted and felt there was the need for an increased focus on upward assurance to the Trust Board. Mrs Dixon commended the detail of the annual assurance statement for the division of Community and Integrated Services, particularly as this division had only recently been established.

KSJ GB

April 15 April 15

87/15 Annual Assurance Statement – Quality & Performance Committee Mrs Dixon noted the annual assurance statement provided assurance that the committee had effectively discharged its responsibilities since its inception in September 2014. The annual assurance statement was approved and would be submitted to the Audit Committee.

DP

April 15

Safety

88/15 External Review – Maternity Service – Report and Action Plan Both Dr Moise and Mrs Trinick were present at the committee and presented the overview of the external independent review into 9 serious incidents within Maternity Services at the Trust. The report included the paper to be considered by the Board of Directors on 26 March 2015, the terms of reference, the independent report, draft improvement plan and draft Internal Serious Incident Management Group Terms of Reference. The Trust’s draft improvement plan also took into account the recommendations from the report into Morecambe Bay FT which had been published in February 2015. The following points were noted during discussion, questions and answers:-

One further case would be added to the review and lessons learnt would be included in the action plan.

A monthly update in relation to the improvement plan would be submitted to the committee.

Assurance would be provided by the internal incident management group which would provide assurance internally to the Q&P Committee and externally to CCGs, TDA and NHS England.

Arising from the Morecambe Bay review, a National Enquiry into maternal deaths may take place.

CT

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Further work was needed on leadership and this would be taken forward with the Director of Workforce.

Timely decision making was a key theme. The Royal College of Gynaecologists had developed a toolkit to support this.

Bespoke leadership training would be considered and SMT would look at decision making processes.

Mr Mullen noted that there were some imminent completion dates within the improvement plan and he asked whether these would be delivered. It was agreed that the committee needed assurance that the improvement plan was on track post. Mrs Salmon-Jamieson said that the initial external report had been limited to a case note review and there were other elements of the original terms of reference which still needed to be completed. In addition one further case, which was being heard by the Coroner that day, needed to be added to the review. Mrs Salmon-Jamieson said that the recommendations from the review highlighted a number of issues related to process and risk and the RCA process and action planning. Mrs Martin said that she felt that the improvement plan needed further actions on staffing. Mr Wilkes queried whether there were any issues related to organisational culture which needed to be included. Mrs Salmon-Jamieson said such matters would be covered by the leadership programme. Work streams would be established to implement the improvement plan. Mrs Dixon asked that the divisional quality and performance committee monitor the improvement plan and to report to this Committee. Mrs Mayer said that the report implied that safety was compromised due to staffing levels being insufficient. She asked how that would be addressed. Mrs Salmon-Jamieson replied that in advance of the outcome of the review being known a separate review of midwifery staffing, known as Birthrate plus, had been carried out. This review had indicated that while the Trust currently met that national recommended ratio of one midwife for every 28 births, the acuity, case mix and staffing skill mix in the Trust’s hospitals meant that additional staff would be required. Mr Mullen said that while the Trust had 134 hours of consultant cover per week on the labour wards (24/7 cover would be 168 hours) and that this was one of the highest ratios in the country for the type of unit, further improvements were required. Mrs Dixon suggested that the Trust volunteer for any forthcoming national review of maternity services. Mr Mullen said that the Board could discuss this later in the week. In relation to the Serious Incident Management Group Terms of Reference, Mrs Salmon-Jamieson said she would take any comments from the Committee to the Trust Board and then to the first meeting of the group. In conclusion it was agreed that more actions would be included in the improvement plan relating to staffing levels and the work streams being implemented to deliver the plan. It was noted that additional resource capacity had been requested to support delivery

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of the plan and this item would remain an agenda item at the Committee until completed. Maternity staffing levels (Midwifes and Obstetricians) was an area that needed to be considered by the Senior Management Team and the Trust Board.

89/15 National Bowel Cancer Audit – progress on actions Dr Sinniah spoke to the update which had been previously circulated by email from Dr Prudham on 23/03/15 in relation to the 18 month stoma reversal and 2 year mortality data. Dr Sinniah said that the Royal College of Surgeons review was expected to complete in September 2015. The Committee noted that actions were now in place for unification of the MDT process from June 2015. A PTL for stoma reversal within 12 months was now in place. Mrs Mayer asked about the variation between individual consultants and Mrs Ashton responded. Mrs Dixon asked about confidence in the measures in place to ensure safe service provision. Dr Sinniah described various changes which had been put in place and said that he felt assured that the service was safe and actions had been taken which would improve this further. Mrs Dixon asked for the action plan to be written up and shared with the Royal College of Surgeons. Mrs Mayer said that the Trust needed unequivocal assurance from the Royal College of Surgeons review.

AS/ RP

April 15

90/15 SUI Report Mrs Martin spoke to the report which included confirmation of the base line assessment of serious incidents and red incidents. As a component of moving forward to a new policy and process in relation to serious incidents and incident management, Mrs Martin said a review needed to be undertaken regarding outstanding investigations and actions. This would involve transparent governance processes, shared with commissioners. After discussion the committee supported the actions to finalise current investigations and requested an update for the June meeting. It was agreed to escalate to the Trust Board the level of resource currently available to divisions in order to finalise all current investigations. Mrs Martin said that once in post, the Head of Patient Safety would work with divisions. Work to close all current investigations would be undertaken within the next 2 months and then agreement would be reached on the timescale to ensure that all actions arising had been consolidated and actioned appropriately.

UM SD

June 15

91/15 GI Bleed – Patient Impact Report Mr Crumbleholme presented the report which contained information on the impact on patients and staff arising from lack of a dedicated GI bleed rota. Mrs Dixon said that the Trust still had a high level of risk. Mrs Moore updated the Committee on the current situation with consultation on establishing a dedicated GI bleed rota. Establishment of a dedicated GI bleed rota would also require changes to the General Medical rota and the establishment of a stroke rota. Mrs Moore said that the stroke rota would be implemented from 1 April 2015 and the GI rota had a likely implementation date of 1 June 2015. The Senior Management Team had asked Mrs Moore whether an interim GI rota could be established in advance of the formal rota. Dr Sinniah said that Mrs

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Moore had explored all options and an interim solution was not feasible. Mrs Guereca asked whether GI bleed patients could be treated in other hospitals until a GI bleed rota was established. Mr Mullen said this was not practical as it was not usually known that a patient had a GI bleed until they had been admitted and undergone some investigations. The only way to prevent admitting GI bleed patients would be to close to all surgical admissions, and this was not practical and would create a much greater risk. Mr Mullen said that by establishing a separate GI bleed rota the Trust would be putting in place a service which was of a much higher standard than in most hospitals across the country as very few hospitals had separate GI bleed rotas. Mrs Mayer said that she was disappointed that a period of consultation was required and that an interim solution could not be found. She asked whether individual consultants had seen the impact report and had given thought to the implications for their own and the Trust’s reputation. Mrs Mayer was keen that a new rota was put in place as soon as possible. Dr Sinniah said that progress was being made as quickly as possible but that it was essential that staff were brought on board with the new arrangements. Mrs Dixon commended the work being undertaken and urged resolution as quickly as possible.

92/15 Nursing Metrics Assurance Process Reports Mrs Salmon-Jamieson spoke to the overview report which detailed the process within Medicine and Surgery to meet compliance against the nursing metrics. Only one ward (at TROH) had been red for two consecutive months. Mr Crumbleholme described the detailed review undertaken which would report back to the committee and was linked to leadership on that ward. A further eight wards which had been amber for more than two consecutive months. In relation to T3 ward. In response to a question from Mrs Guereca, Mrs Salmon-Jamieson confirmed that an escalation plan was in place, monitoring arrangements were being revised and would be considered by the Nursing & Midwifery Board meeting later in the day. Mrs Salmon-Jamieson then went on to describe ward accreditation which would be very closely linked to the CQCs new fundamental standards which would be developed after discussion with Gill Harris. Confirmation was given that actions were in place and being tracked and an escalation process for rapid review was in place. Progress was noted.

93/15 NHS England – Peer Review of Colorectal & Upper GI MDTs As mentioned earlier in the meeting, Mr Mullen said that the Trust was working to a date of June 2015 for a unified MDT.

94/15 Safety Committee Highlight Report Dr Sinniah spoke to the report drawing the Committee’s attention to C Diff being over trajectory and another issue in relation to downgrading of wrong blood in tube incidents to orange which would be reclassified as red incidents.

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Clinical Effectiveness

95/15 NICE: Specialty Level Report – Non Compliance Mrs Martin spoke to the report stating that a review of all NICE guidelines was undertaken with each of the directorate / specialties required to review the relevant guidance and complete the appropriate baseline assessment tool. Currently there were 41 NICE guidelines under review of which 17 (41%) required immediate completion as they were outside the allocated timeframe for completion. Mrs Martin asked that divisions clarified their timescales and plan for ensuring that all NICE guidance documents had been reviewed and actions identified for any areas of partial non-compliance. Discussion then followed in relation to the need for more clinical leadership and increased resources to deal with such matters. It was agreed that within 6 months the divisions would complete all the work required.

UM

Sept 15

96/15 Clinical Audit Forward Programme 2015/16 Mrs Martin spoke to the report which provided an overview of the development of the Clinical Audit Forward Programme for 2015/18. Mr Mullen noted reference to readmissions within the clinical audit programme at directorate level. Mrs Mayer asked whether maternity and infection were appropriately covered within the plan, to which Mrs Martin said yes but that these would need to be built into the scope for future items.

Patient Experience

97/15 Highlight report and the minutes were not due yet.

Quality Accounts

98/15 Quality Accounts Highlight Report The report was noted.

99/15 Quality Account Minutes There had been no meeting since the last Q&P.

100/15 Draft Quality Priorities 2015/16 Mr Barclay tabled the Quality Accounts report for 2014/15 which included quality priorities for 2015/16. These consisted of 9 priorities (3 patient safety, 3 clinical effectiveness and 3 patient experience). Mrs Martin said that the proposed priority regarding ward accreditation needed more discussion as whilst there was real value in terms of preparing for the Chief Inspector of Hospitals visit, there were resource requirements. Mr Barclay said that the draft quality account was being considered by the Trust Board later in the week and then would be sent to stakeholders for comment on the overall content. Any comments were welcomed and should be forwarded to Andrew Lynn as the author of the document.

ALL

Research & Development

101/15 The highlight report and minutes are not due this month.

Caldicott & Health Informatics

102/15 Caldicott & Health Informatics Committee Highlight Report The highlight report was received and noted.

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103/15 Caldicott & Health Informatics Committee – 23 Jan 2015 The highlight report was received and noted.

Medicines Management

104/15 Medicines Management Quarterly Report The quarterly report was received and noted.

105/15 Medicines Management – Omitted Medication Audit Report Ms Jones said the summary report had been received and compared with the last audit. The use of EPMA had made improvements due to more information now being available on why doses were missed. Ms Jones said that the missed dose figure was 12% which related to drug unavailability or clinical reasons. In relation to missed doses due to drug unavailability, Ms Jones said that 65% of the doses were actually available as ward stock in another area or via pharmacy’s emergency stock. In summary Miss Jones said that this was generally moving in the right direction. In response to a question from Mrs Dixon, Ms Jones said that she currently only had site level information and ward level would follow and be shared.

PJ

May 15

External Performance Monitoring and Reports

106/15 External Reviews – Horizon Scanning Mrs Martin said that in relation to the PHSO, 2 of the Trust’s complaints which had been referred to the PHSO would be featured in the report published that week. In addition, in relation to the Health and Safety Executive, a Notice of Contravention report had been received for non-compliance with EU Directive on safer sharps. It was noted that there had been investment agreed to be compliant and a plan in place which would be rolled out in high risk areas first: Infectious diseases and A&E. Mrs Martin suggested that the Horizon scanning agenda item be merged with the external visits log. It was discussed that there was a peer review underway in pathology and also a trauma review. It was agreed that the external visits log would come back to the Committee in April.

GB

April 15

Policies

107/15 Document Management Highlight Report The document management highlight report was received and noted.

Performance

108/15 Monthly Integrated Performance Report Dr Conyon spoke to the report highlighting initially that there were new National ward staffing RAG rated scoring systems being introduced for 2015/16 and included in the report was the Trust’s performance in shadow format, for which the Trust had an overall rating of blue (OK) because all of the KPIs were within their expected ranges. In relation to the 6 domains reported monthly on the summary integrated scorecard, all were stable with the exception of finance which had improved due to the allocation of support funding from the TDA. In respect of business capability, there had been a slight improvement in the specialties which earned sufficient income to

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cover their direct and indirect costs. Activity performance versus plan deteriorated in February and remained behind plan for Elective and Day Case. In relation to quality, C. Diff had exceeded the annual plan with 1 month remaining in 2014/15 at a rate of 67 cases against a plan of 62. In addition, one never event would be reported during March which was an incident from 2008. A root cause analysis was being undertaken as a priority. In relation to operational performance, the 4 hour standard was achieved in Q1 and Q2 but was not achieved in Q3, February and Q4. Pressure remained high with demand above plan. Mrs Moore said that from mid-February it was evident that the Trust statistically would not achieve the year end target as a Trust and pressures continued well into March. North Manchester had recovered and achieved every day and that site would achieve for the year, being 1 of only 3 sites in the North West to do so. Mrs Moore described the unprecedented number of attendees with 1012 attendees the day before. Monday’s were described as being very high for the number of attendances and Mrs Moore described her concern around the TROH site and gave an example of 54 patients arriving in 1 hour. Mrs Moore also described the succession plan issues for general medical doctors at the TROH site. Mrs Mayer acknowledged the significant work undertaken in the Trust in relation to both the RTT and the 4-hour targets. She noted that infections and pressure care continued to be issues. Mrs Salmon-Jamieson discussed the “don’t wait, isolate” infection control initiative and described the further work which would be undertaken at divisional level. In relation to finance, the Trust had recently received non-recurrent deficit funding from NHS England for 2014/15 and as such the Trust had revised its forecast outturn to achieve its statutory duty to break even. The year to date continuity of service rating had improved to 4 due to the TDA funding with a forecast year-end continuity of service risk rating of 3.5 which was above the level of an aspirant FT Trust of 3. In relation to workforce, sickness absence decreased at 6.05% missing the 4.2% trajectory every month and therefore missed the 2014/15 target. Bank and Agency spend had decreased but remained above target. Action was being taken to alleviate vacancies, backfill sickness absence to support safe nursing and midwifery staffing levels and support achievement of access targets. The National Staff Survey in relation to Staff Friends and Family test were below target for both indicators. In relation to CQUINs and particularly the NHS Safety Thermometer/Prevalence of Pressure sores, Mrs Salmon-Jamieson described work which was underway which could take 3-6 months for the full impact to be noted.

109/15 Cancer Performance Mrs Dalton attended the committee and presented her paper which provided assurance on the improvement in the delivery of the 62 day cancer waiting time standard by sharing an analysis of breaches of the 62 day standard, articulating improvements made internally to systems and processes and detailed the findings and recommendations of a GM wide review of pathways. Mrs Dalton

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went through the tracking practices and improvements to systems which included daily exception reporting and significantly enhanced cancer patient target lists resulting in improved efficiency of the tracking process, ability to escalate delays in between events and developing a prompt delivery approach to booking and scheduling of appointments. In January 2015, all cancer waiting time standards with the exception of 62 days were achieved and Mrs Dalton explained that the majority of pathways were 2 and 3 centre pathways so were complex and as such had been incorporated within the cancer improvement action plan which was monitored weekly. The development of a GM wide cancer access policy was a significant step in improving performance across the conurbation and Mrs Dalton said that the cancer commissioning lead was supportive of such an approach and a timescale set for completion was Q1 in 2015/16. Mrs Dixon commended Mrs Dalton for her improvement work. Mr Mullen described the need for commissioners to buy the right level of activity to enable the Trust to guarantee compliance for Q1.

110/15 Handover of Care Performance – Outpatients Mrs Cook attended the Committee and confirmed that the compliance report in relation to inpatient discharge summaries, as discussed last month, was included in the pack for information. Mrs Cook then took the committee through the report. In relation to outpatient letters first attendances, these needed to be sent to patients’ GPs within 10 working days of all first attendances. Mrs Cook went through the report and confirmed that there was now a more stable IT solution for dictation and described the Trust’s exclusion criteria which was the largest challenge as not all clinics should be included in the performance target. Mr Mullen said that the report showed significant progress in non-elective performance and hopes that the combined figure for February and March was 95%. It was noted that the errors due to poor communication between primary and secondary care were reducing.

112/15 Performance Management Group Highlight Report The report was for noting as the items had already been discussed.

113/15 Performance Management Group Minutes – Feb 15 The minutes were noted.

Reports from Divisional Quality and Performance Committee

114/15 Surgery Q&P Highlight Report Mrs Ashton said that Mrs Martin had observed their last meeting which had been useful. Mrs Martin said that she had asked that directorate managers talk to their own incidents and complaints at the divisional Q&P meetings in order to ensure ownership. Mrs Martin asked that this be replicated across all the divisions.

DDs

115/15 Diagnostics & Clinical Support The report was noted.

116/15 Medicine

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Mrs Moore said that there were a high number of nursing vacancies and staff sickness was at 7%. The division had a number of complaints and incidents to close down: it was at this point that clinical governance resource capacity relating to all divisions ability clear complaints, incidents and ensure compliance with NICE guidelines, update Trust policies, guidelines and patient group directives as well as delivering on quality, performance and finances was discussed.

117/15 Integrated & Community Services Mrs Dixon noted the good progress which was being made with this relatively new division.

118/15 Women & Children’s Division Mrs Trinick said that the Morecambe Bay Report had been received and would be included within the Trust’s internal improvement plan. It had been shared within the multidisciplinary team.

119/15 Divisional Quality & Performance Minutes The divisional Q&P committee minutes from the Division of Medicine’s meeting on 11 March 2015 were submitted and noted. Mrs Pullen requested that copies of all divisional Q&P committees be provided to her for inclusion in future agendas together with the highlight reports. It was acknowledged that the highlight report each month was for the divisional Q&P committee held that month with a month's time lag for provision of the minutes.

DDs

Monthly

Risk

120/15 Issues for Escalation to the Trust Board The immediate items noted for escalation to the Trust Board were:

Sickness and Absence rates

Resource and capability issues

Maternity Service Staffing Levels

Birthrate Plus

Bowel Cancer Progress

GI Bleed Rota

Level of Clinical Leadership and Decision Making Mrs Mayer asked in relation to the mortality report whether this would be coming back to the Q&P committee. Mrs Martin said that a detailed mortality report was received by the Safety Committee which was a subcommittee of Q&P. It was agreed that all reports would be mapped out in the work to take place between Mr Barclay and Mrs Martin.

GB/ UM

121/15 Date of Next Meeting The next meeting would be held on the Tuesday 28 April 2015 at 9:00-12:00 in room 237.

Review of Meeting Roundtable Feedback

Lots covered, better discussion

Open discussion

Helpful steer

Learning from Maternity Improvement Plan – all divisions

Understanding complexity of agenda items, balanced with timeframes

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Welcome support from Mrs Salmon-Jamieson and Mrs Martin regarding the Maternity Review – there is a cohesive team but there are resource issues.

Themes across directorates

Good to focus on a couple of main items

Right agenda topics being considered by the committee but papers to be more focused

Need to identify the difference between assurance and reassurance

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Title of Report Quality & Performance Committee Minute – 28 April 2015

Executive Summary

The minutes of the Quality & Performance Committee held on 28 April 2015 are attached. Items for escalation to the Trust Board were:-

Clarity of escalation and assurance on the maternity review via the Incident Management Group

Clinical Audit & Effectiveness Committee – not assured around its operation

Resource and capability issues, particularly in relation to governance and divisional changes – 2 month time lag

Diagnostic 6 week standard missed – could take 6 months to resolve

Maternity Review to be included on Strategic Risk Register

Handover of Care (Inpatient) – March 2015 95% target achieved

Interim GI bleed rota solution identified

Monitoring progress against the SUI policy of which Duty of Candour would be an element

Actions Requested:

The Board is asked to note the content of the minutes

Corporate objectives supported by this paper: All Corporate Objectives are supported by the work of the Quality & Performance Committee

Risks: Any risks identified at the meeting are referred to the relevant manager for possible inclusion on the relevant part of the risk register.


Resource Implications: Not relevant for this paper

Communication: The Quality & Performance Committee communicates its work through the Trust Board and the Divisional Quality & Performance Committees.


Assurance √

Contract √



HR √


IM&T √


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Sustainability √

Name Shauna Dixon



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C:\Users\244991-Admin\AppData\Local\Temp\cd78f3d0-e758-40f1-be1b-d2d14049d2ed.docx

Minute

Quality and Performance Committee Room 237, Second Floor, Trust HQ

28 April 2015 9am – 12 noon

Owner

Timescale

Present Mrs S Dixon, Non-Executive Director (Chair) Mrs D Ashton, Divisional Director, Surgery Mr G Barclay, Assistant Chief Executive/Board Secretary Dr I Conyon, Performance Manager Mrs C Guereca, Non-Executive Director Ms P Jones, Chief Pharmacist Mrs S Jones, Head of Clinical Professions Mrs C Mayer, Non-Executive Director Mrs J Moore, Divisional Director, Medicine Mr H Mullen, Director of Operations Mrs K Salmon-Jamieson, Acting Chief Nurse Dr A Sinniah, Acting Medical Director Mr B Steven, Deputy Chief Executive/Director of Finance Mr S Taylor, Divisional Director, Integrated & Community Care Mrs C Trinick, Director of Midwifery Dr S Woby, Director of Research and Development

In Attendance Mrs K Hingley, Head of Patient Safety Mrs C Parker, Lead Nurse, Patient Experience Mrs D Pullen, Head of Corporate Governance

Apologies Mrs G Harris, Chief Nurse Mrs U Martin, Director of Clinical Governance Dr R Prudham, Deputy Medical Director (Quality) Mr J Wilkes, Director of Estates & Facilities

Procedural Business

122/15 Welcome and Apologies Mrs Dixon welcomed everybody to the meeting.

123/15 Declarations of Interest There were no declarations of interest relevant to items on the agenda.

124/15 Chairman’s Remarks Mrs Dixon said that it was important that the meeting started on time due to the long agenda and asked that when reports and items were presented that attendees concentrated on assurance, impact and outcomes for patients as the role of the committee was to provide assurance to the Trust Board.

125/15 Minutes of the Previous Meeting The minute of the meeting held on 24 March 2015 was accepted as a true record.

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126/15 Review of Action Checklist/Matters Arising From the Previous Meeting Mrs Dixon took the committee through the action checklist and spoke to the updates provided therein. It was noted that many of the items were included as a separate agenda item or updates were included in the highlight reports submitted to the committee. 89/15 – National Bowel Cancer Audit Dr Sinniah advised that Dr Prudham had an agreement that the review would be completed before September and that the action plan would be completed and shared with the reviewer. 84/15 – HpB Pathology Services Miss Jones said that this item related to fine needle aspiration activity and Pathology had an SLA in place, although due to pricing, alternatives were being considered. It was agreed that Mr Mullen would take forward this action with his fellow Executive colleagues at Central Manchester.

HM

May 15

127/15 Governance Arrangements Mr Barclay said that a detailed review of the governance arrangements had taken place with the Chief Nurse, Chief Executive and Director of Governance: to be discussed at the Board’s Confirm and Challenge on Thursday.

Safety

128/15 External Review – Maternity Service Mrs Trinick provided assurance to the Committee that the Division was making progress on the improvement plan, which was being monitored via the Internal Management Group. The plan followed the CQC domains and clinicians and midwives were committed to delivery of the improvement plan. The Trust had agreed to work with another NHS tertiary maternity provider and reciprocal learning could be achieved. The TDA/CCGs were noted to be supportive and impressed with the improvements undertaken to date. A look back exercise had been completed with no new themes emerging. The importance of liaising with families and the offer of meetings which had been extended to the families was discussed. Mrs Mayer said that the improvement plan was now very comprehensive and she felt more assured. Cultural and team working improvements were discussed. Mr Mullen felt that this was an area that needed further consideration; this was included in the improvement plan. Mrs Dixon felt that the culture of the organisation should enable staff to set internal standards with the staff having the pride and passion to be the best. Mrs Salmon-Jamieson said that the ward accreditation scheme created the internal want and buy-in from staff to improve and then maintain standards. Maintaining standards in the future was also discussed: the Kirkup review required the Trust to undertake a self assessment which had already been completed. Mr Barclay asked what assurance the Committee required in relation to this important agenda item. It was discussed and agreed that:-

Exception reporting of any slippages against the improvement plan

Maternity would be a feature of a future clinical audit

Div UM

May and ongoing

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129/15 National Bowel Cancer Audit – progress on actions Mrs Ashton provided the Committee with an update on actions. It was noted that a single MDT needed to be in place before assurance could be provided to the Committee: this was expected by August 2015. It was agreed that the updated action plan would come back to the Committee in May 2015 and it had already been noted in previous meetings that this agenda item would stay as a regular item until the matter was concluded.

DA

May 15

130/15 NHS England – Peer Review of Colorectal & Upper GI MDTs Mr Mullen said that the Trust had been notified that the colorectal MDT had been stood down by the Peer Review team, however, he stated that it would be sensible to leave the single colorectal MDT open on the agenda and ask the Surgical Division for a monthly update until the single MDT commenced. It was agreed that the Upper GI and colorectal updates would come to the Committee in June 2015.

HM

June 15

131/15 SUI Report Mrs Hingley spoke to the report. Focus would be on investigating incidents appropriately, delivering of recommendations and actions and ensuring investigations were closely linked to any inquests, so that RCAs were supplied to HM Coroner in a timely manner. GM Police were investigating a death in 2012 on behalf of the Coroner: discussion followed in relation to the need for full support to staff, which the Division was providing. The assurance in relation to the Duty of Candour was discussed and it was noted that oversight of this would be via the Serious Incident Management Review rollout. Mr Steven raised the role of the Audit Committee if incidents were not being closed down: discussion followed in relation to personal accountability and the final escalation processes which existed, including the Chief Nurse and the role of the Audit Committee.

132/15 Safety Committee Highlight Report & Minutes Dr Sinniah spoke to the report drawing the Committee’s attention to C Diff being over trajectory and resuscitation documentation and ceilings of treatment. The minutes of the March meeting were noted.

Clinical Effectiveness

133/15 Clinical Effectiveness Committee Highlight Report The report submitted on behalf of Dr Prudham was noted. The Committee was not assured about the role of the Clinical Audit & Effectiveness Committee as the April meeting had been cancelled. It was noted that the next meeting was planned for 18 June 2015. It was agreed that Dr Sinniah would feedback to Dr Prudham; in addition to one division not being aware that Mrs Hingley was reviewing mortality.

AS

May 15

Patient Experience

134/15 Patient Experience Committee Highlight Report & Minutes Mrs Parker spoke to the highlight report and minutes from the March

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meeting. There were no items for exception or escalation reporting. The CQUIN had been achieved and text messaging as a way of obtaining feedback was discussed. Work continued on nursing metrics which had escalation built into the process. Friends and Family Test was discussed, including the improvement works undertaken. It was agreed that more information on the Friends and Family Test would be specifically reported to the Committee in May.

CP

May 15

Quality Accounts

135/15 Quality Accounts Highlight Report The report was noted.

136/15 Quality Account Minutes There had been no meeting since the last Q&P.

Research & Development

137/15 Research & Development Highlight Report

Dr Woby spoke to the highlight report and took the Committee through the various items of assurance in relation to the performance, initiation and delivery of clinical trials. He said it was very pleasing to see how favourably the Trust compared with teaching hospitals. In relation to initiation, the trust had met 71.4% of its studies within the 70 day target, compared with the mean percentage of 44.8%.

Caldicott & Health Informatics

138/15 Caldicott & Health Informatics Committee Highlight Report Not due.

139/15 Caldicott & Health Informatics Committee – 23 Jan 2015 Not due.

Medicines Management

140/15 Medicines Management Quarterly Report Not due.

141/15 Medicines Management – Omitted Medication Audit Report Not due.

External Performance Monitoring and Reports

142/15 External Reviews – External Log & Horizon Scanning Mr Barclay said that whilst there was an outstanding action to fully review the external log, members had been asked to identify any other external reviews of which they were aware. Mr Barclay said that the value of the log was identifying commonalities within different reviews. Mrs Dixon said that the divisions should be using the external log within their own Q&P meetings and it was agreed that they would do so.

Trium. Rep

May 15

Policies

143/15 Document Management Highlight Report The document management highlight report was received and noted.

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Mrs Salmon-Jamieson drew attention to the worsening position in relation to out of date documents, including priority1 documents. Mrs Dixon stated that this was disappointing as the Committee had been reviewing this report and performance for some time. A risk based approach had already been taken on the Trust’s priority documents: 137 of 730 trust-wide documents had passed their expiry dates. Mrs Guereca stated that she was aware that previously the approach had been considered to be appropriate in the way in which documents were reviewed and updated but the process was being simplified. Resources were noted to be an issue and this was discussed at length. Mrs Salmon-Jamieson was confident that the nursing policies would be completed. It was agreed that if Divisions were unable to meet the target reduction included in the report, they needed to advise Mrs Martin directly. It was also agreed that the Committee supported the recommendations in the report, with the exception of not agreeing the recommendation about withdrawing some documents from the Document Management System.

Trium. Rep

Performance

144/15 Monthly Integrated Performance Report Mr Steven spoke to the report: a new indicator for readmissions was now included. An expanded suite of mortality KPIs was being developed and the report was being refreshed to meet the 2015-16 national and local requirements. The summary integrated scorecard trends were up to 31 March 2015. In respect of business capability, work was underway to make better use of SLR, elective length of stay reduction was ahead of target and non-elective length of stay was behind target. Activity versus plan deteriorated in month and was behind plan for elective and day case. In relation to quality, the handover of care inpatient communication had improved and the 95% target was achieved for the first time in March 2015. C. Diff had exceeded the annual plan in 2014/15 at a rate of 72 cases against a plan of 62. There were a total of 6 MRSA cases in year. Mrs Salmon-Jamieson said that the key items to note were the “don’t wait, isolate”, the difficult strain of O27 and the new assessment form for positive C.Diff patients. There was an EU and Non-EU campaign to recruit an additional 110 nurses. One never event was reported in March and a full investigation was underway. In relation to operational performance, all 3 national RTT standards were achieved for the sixth consecutive month. Future reporting by individual CCG level would be needed from 1 April 2015. The diagnostic 6 week standard was narrowly missed by 0.01%: short and long term solutions were discussed and the 6-month lead in time to resolve was noted. Mr Mullen said that the TDA needed to be notified that the target would be missed and the improvement

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plan discussed with the 4 CCGs to provide them with assurance of the actions to achieve this target. The 4 hour standard was achieved in Q1 and Q2: March had seen an improvement but was still below target. Mrs Moore said the situation was exacerbated by 162 patients being medically fit for discharge, which equated to 20% of the bed stock. The availability of social workers on site was discussed and the impact on surgery at Fairfield. Inter-site transfers were discussed as was substantive versus agency staff ratios in A&E, which equated to approximately 50% of the staffing. It was agreed that the ratio of substantive versus agency staff would be included in future reports. The month 12 financial position would be discussed at the Finance, Infrastructure & Business Development Committee. In relation to workforce, sickness absence was 5.55% against a trajectory of 4.2%. Bank and agency spend had increased and was above target for the year. Staff Friends and Family Test scores for Q4 had improved for both indicators. Regulatory assessments levels were noted: the TDA escalation score was unchanged and the draft CQC Intelligent Monitoring Report showed the Trust to be Band 6 (lowest risk). In relation to contract KPIs, Mr Steven said that there was no guarantee that penalties would be reinvested in 2015-16. There was the opportunity for bespoke items to be included in the Integrated Performance report for time-limited periods and any suggestions would be considered.

IC

June 15

145/15 Handover of Care Performance – Year End Position Mr Mullen reported on the contractual KPI compliance for inpatient handover of care communications. In March, 95% had been achieved which was tremendous and would be shared with CCG colleagues. Mr Mullen paid tribute to Libby Woodcock from IT who trains all the junior doctors. Members agreed that another year of sustained focus was needed on achievement of this important target which spoke to quality and performance/financial agendas. Junior doctors were key to this process and it was confirmed that training would continue for the new intake of juniors in August.

146/15 Performance Management Group Highlight Report The report was for noting as the items had already been discussed.

147/15 Performance Management Group Minutes – March 15 The minutes were noted.

Reports from Divisional Quality and Performance Committee

148/15 Surgery Q&P Highlight Report Mrs Ashton provided an updated on matters of exception and assurance. In relation to escalation, there was willingness by clinicians to start the GI Bleed rota and an update was provided on the point prevalence survey. Gap analysis work was being undertaken for the next 10-12 weeks of the rota. Mrs Ashton spoke

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of the impact of the reduction from 12 to 8 clinicians on the rota. Assurance was given around the amount of work undertaken in both permanent and interim solutions prior to the July implementation date. Lists would commence in the new hybrid theatre at Oldham on 15 April. The new stroke rota was in place.

149/15 Diagnostics & Clinical Support Miss Jones spoke to the highlight reports from January, February and March and said she would establish the whereabouts of the divisional Q&P minutes as Mrs Pullen had been advised that these were no longer produced. After discussion, it was agreed that Miss Jones would arrange for the wording of the February highlight report around the patient story to be amended, although it was noted that the system for patient stories was under review.

PJ PJ

May 15 May 15

150/15 Medicine Mrs Moore spoke to the highlight report and provided an update on matters of exception and assurance. In relation to escalation, the division was clearing the backlog of red incidents and the division planned to review all RCAs on 1 May. Nursing vacancies were high at 70 qualified and 17 unqualified as was staff sickness at just below 7%. Clearly the backlog of complaint responses was being addressed. Mrs Moore said that the divisional risk register had been discussed.

151/15 Integrated & Community Services Ms Jones spoke to the highlight report including matters of assurance. There were no exception items. In relation to escalation, the division was working towards their health and social care integrated governance framework. In relation to the major trauma review, action plans were being developed for rehabilitation. Mrs Mayer raised the absence of mortality and morbidity reference in Divisional Q&P minutes. Members of the committee agreed that structures needed to be reviewed to ensure input and inclusion of M&M at Divisional Q&P meetings. Mr Barclay commented that standardisation would come following the Confirm and Challenge event, although he expected the timeframe for the output to be 2 months. Mrs Dixon asked where community worker risks were being assessed: Ms Jones said that staff undertake an informal risk assessment upon entering community premises and there was a Lone Worker Policy and Procedure followed by staff.

152/15 Women & Children’s Division Mrs Trinick spoke to the highlight report including matters of exception and assurance. In relation to escalation, Mrs Trinick said that all staff had been advised regarding the escalation policy for staff shortages. Outstanding NICE guidelines had been redistributed to all the applicable reviewers for urgent review and feedback. Mrs

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Trinick reported that no formal audit of the Trust guideline on Foetal Monitoring in Labour appeared to have been undertaken. Work on the divisional risk register had been undertaken.

153/15 Divisional Quality & Performance Minutes The divisional Q&P committee minutes from the following were received and noted:- Surgery – January, February March 2015 Medicine - March 2015 Integrated & Community Services – January, February, March 2015 Women & Children – March 2015 It was acknowledged that the highlight report each month was for the divisional Q&P committee held that month with a month's time lag for provision of the minutes.

Risk

154/15 Strategic Risk Register The Committee was asked to review and if appropriate, make proposals to the Trust Board in relation to any changes to the Strategic Risk Register. In particular, the Committee was asked to consider whether, in addition to the potential service failure and reputational damage risks described more widely in the register, whether there was a specific issue in relation to maternity and whether this merited inclusion on the strategic risk register as a specific risk. This would impact on the Board Assurance Framework and the Trust’s strategic risks which were included in the Annual Governance Statement.

Members felt maternity should be a specific risk.

Mrs Trinick was also asked to reflect on the content of Women & Children’s divisional risk register.

GB CT

May 15 May 15

155/15 Issues for Escalation to the Trust Board The immediate items noted for escalation to the Trust Board were:

Clarity of escalation and assurance on the maternity review via the IMG

Clinical Audit & Effectiveness Committee – not assured around its operation

Resource and capability issues, particularly in relation to governance and divisional changes – 2 month time lag

Diagnostic 6 week standard missed – could take 6 months to resolve

Maternity Review to be included on Strategic Risk Register

Handover of Care (Inpatient) – March 2015 95% target achieved

Interim GI bleed rota solution identified

Monitoring progress against the SUI policy of which Duty of Candour would be an element

156/15 Date of Next Meeting The next meeting would be held on the Tuesday 26 May 2015 at 9:00-12:00 in room 237.

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Public Agenda...28 May 2015 9.30am Owner Attached Time 1) Welcome and Apologies JJ Verbal 0930 2)...

Documents

Transcript of Public Agenda...28 May 2015 9.30am Owner Attached Time 1) Welcome and Apologies JJ Verbal 0930 2)...