Balanced Score Card Review of May 2015 Data
Balanced Scorecard
Patient and Service User
Finance
CUH Group Budget 2015
Budget 2015
Group Budget €283.6m (2014 €284.9m)
Group projected expenditure €283.3m (2014 €284.2m)
Group Projected Surplus €0.3m (2014 surplus 0.7m)
CUH Budget €264.1m (2014:€262.8m)
CUH projected actual €264.1m (2014 €265.2m)
CUH projected Deficit €20k (2014 €2.4m)
MGH Budget €17.3m (2014:€17.5m)
MGH Projected Actual €17.0m (2014 €16.8m)
MGH Projected Surplus €0.3m
Actual Outturn YTD - May 2015
• Group budget €116.95m (2014 €113.6m)
• Group actual expenditure €116.86m (2014 €118.7m)
• Group actual deficit €91k ( 2014 €5.1m)
• CUH Budget €109.8m (2014:€105.5m)
• CUH /SMOH actual expenditure €110.1m (€110.3m)
• CUH /SMOH actual deficit €247k (2014 €4.8m)
• Mallow Budget €7.1m (2014:€6.9m)
• Mallow actual expenditure €6.8m (2014 €7.3m)
• Mallow actual surplus €338k ( 2014 deficit €404k)
CUH Summary Budget v Actual Expenditure May 2015
Pay €k Non-Pay €k Income €k Total
CUH -271 -538 787 -22
SMOH -2 19 17
CUH-SMOH -271 -540 806 -5
Mallow 98 -143 199 154
Total -173 -683 1,005 149
CUH Actual Non-pay Expenditure €k YTD May 2015 v 2014
CUH Group –Surplus / (Deficit) percentage %
CUH AGENCY COSTS €k 2013– May 2015
CUH Agency Costs – April 2015
CUH Average Nursing & HCA Agency WTE’s per Week 2013-15
CUH Average Specials /Other Nursing & HCA Agency WTE’s per Week 2014-15
Patient Income 2013 – May 2015
Cost Containment
Consultant Private Insurance Claims O/s Consultant claims at 29th May 2015
Directorate Value €k
Prev Value €k Current
Diagnostics 17 19
Medicine 3,299 3,818
Surgery 2,148 2,293
Women and Children CUH 401 430
Total-CUH Primary 5,864 6,560
Women & Children CUMH 500 500
Total-CUH /CUMH Primary
6,364 7,060
Consultants at 16th June
No of claims Value €k
HARTY, JAMES 169 529,945
POWER, DEREK 240 331,388
CROSBIE, ORLA 20 280,233
ANDREWS, EMMET J. 76 245,273
TAYLOR, COLM 56 223,890
PLANT, WILLIAM 46 193,670
KAAR, GEORGE 18 169,432
GILMORE, JENNIFER 1 149,341
KEARNEY, PETER 56 136,655
O'MAHONY, DENIS 10 112,194
FLEMING, PAT 23 109,286
O'HALLORAN, D. J. 24 104,411
O'CONNOR, MICHAEL 15 102,430
KELLY, PETER 38 100,093
PLANT, BARRY 15 98,147
GUERIN, SHANE 19 96,869
HARTY, JAMES 169 529,945
O'LEARY, PAULA 28 95,219
TOTAL 3,168,791
Access
CUH Weekly INMO Trolley Report
Week ending 19th June 2015
Daily Trolley Numbers – May - June 2015 ( 21/06/2015)
ED – 6hr Target (April Dashboard)
R
ED – 9hr Target (April Dashboard)
R
ED >24hrs (April Dashboard)
R
ALOS for all Patients (April Dashboard)
G
Medical ALOS (April Dashboard)
A
Surgical ALOS (April Dashboard)
R
ALOS – Excluding LOS over 30 days (April Dashboard)
G
HIPE Coding (April Dashboard)
G
Day of Procedure Admission Rate for Surgical Inpatients (April Dashboard)
G
Delayed Discharges - 2015 January – June (9th June)
Inpatient – Day case Waiting Lists
Total Adult Waiting List (Active – 1310) May (1310) and June (1245)
0 100 200 300 400 500 600
Breast Surgery
Cardiology
Cardio Thoracic
Gastro
Gen Surgery
Gynaecology
Neurology
Neurosurgery
Orthopaedics
Plastic Surgery
Respiratory
Urology
Vascular
June
May
Prospective View – June 2015 (48 Active)
Cardio Thoracic – 1 suspended per patients Gen Surgery – I TCI, 4 Suspension per patients, I date to be arranged Gynaecology – presently being transferred to outside provider Urology – 2 Suspensions per patient Vascular - 6 to Outpatients per consultant
Prospective View – December 2015 (381)
0
20
40
60
80
100
120
140
160
180
15 8
43
170
2 3 1
15
3
21
74 June
Scopes Urgent - April 2015 G
Scopes Routine – April 2015 G
Outpatient Waiting Lists
Medical Patients to be seen by the 30th of June 2015
Surgical Patients to be seen by the 30th of June 2015
Women and Children Patients to be seen by the 30th
of June 2015
OPD Potential Breach Report Count of ID
Specialty
18Mth by
June 30th 17.6.15
Expected
Total as of
22.6.15 for
June 30th
deadline
Comments /Update 22.6.15
Current RAG
Status
Expected RAG
Status
Diabetes Mellitus Yes 287 287 • Regular Clinics fully booked to 30th June
• Discussed Registrar post & GP Clinics with
Michael Murphy - No further update
• Dr. Sean Manning sees additional patients when his schedule allows
Endocrinology Yes 159 ?150 • Regular Clinics fully booked to 30th June
• Discussed Registrar post & GP Clinics with
Michael Murphy today - No further update
• 9 to be removed pending confirmation of their attendance privately
General Surgery Yes 42 0 • 3 returned for capacity in Mr. McCourt's Clinic
• 39 Purchased Care
Gynaecology Yes 1057 1057 • Discussed again with Miriam - there was agreement
to put on additional clinics however the service has now requested
this be used for urgent patients
• Dr. Babiker left end of May
• Routine patients that were booked with agreement have since been
cancelled by the service - so numbers may actually increase
Neurosurgery Yes 45 0 • Out of Hours Clinics held
• Physiotherapists commenced clinics
• Registrar to do Saturday Clinics - - last one on 27th June
• Entire list will be cleared
Ophthalmology Yes 81 0 • SLA agreed for purchased care with Dr. Mr. Traynor
• Referrals transferred and all patients notified by letter
Plastic Surgery Yes 138 0 • Met with consultants who agreed to request their teams to see
suitable patients on a See & Treat Basis - 30 deemed suitable -
Additional funding required for Theatre time (CUH) to treat these
patients.
• 59 + 6 agreed under Purchased Care - Additional funding required for
Theatre time in SIVUH to treat these patients
• 41 previously seen in Mater Private to receive required treatment under
purchased care
• 2 Patients suspended per validation as unavailable to attend on 30th
June
Rheumatology Yes 0 0 • Clerical Error - Patient cancelled appointment for 1.5.15
Urology Yes 41 0 • 39 Referrals transferred to Mallow General Hospital
• 1 Suspended to later date per patient request
• 1 to go to Purchased Care
Vascular Surgery Yes 62 0 • SLA for purchased care agreed with consultant
• Clinics commencing 25th June
Grand Total 1912 1606
Quality
Emergency Hip Fracture Surgery – April R
Emergency Re-admission - Medical
R
Emergency Readmission - Surgical
R
Cancer KPI – Breast-Lung-Prostate -Jan – May
Radiotherapy -New Treatments - May
CUH Patients undergoing Radical Radiotherapy commenced treatment within 15 working days of being deemed ready to treat
Treatment Delay
New Patients Treated Within Target January 2014 - May 2015
Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15
Outside Target 11% 12% 9% 12% 10% 9% 14% 5% 7% 11% 19% 14% 21% 16% 18% 18% 20%
In Target 89% 88% 91% 88% 90% 91% 86% 95% 93% 89% 81% 86% 79% 84% 82% 82% 80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Complaints Management - Action Plan
CUH Hygiene Quality Improvement Team A
CUH Hygiene Quality Improvement Plan
B
Jul-05 C
D
2015
Quarter
Recommendation Action Required Measurement/Evidence of Implementation Responsible Person for Action Due Day for full Implementation 2 Standard 3 & 6 Improve Governance, improve reporting systems
1. Under the leadership of the CEO, continue a focussed team driving improvements in the area of hand hygiene and cleanliness of environment and facilities.
Minutes of CEO led team meetings Chief Executive Officer 30th June 2015 A
2. IPCC to develop portfolio of qualitative and quantative measures of compliance, reporting and frequency of reporting to timely identify & address poor compliance and/or incidents.
Portfolio to be presented to CEO Chair IPC Committee 30th June 2015 B
3. Revise the outbreak management policy to ensure significant outbreaks are notified, reviewed to identify possible areas of poor compliance and /or incidents, escalated and managed appropriately.
Update policy with defined escalation & communication criteria Chair IPC Committee 30th June 2015 A
4. Revise bedside alerts for effective communicational and identification of patients requiring isolation precautions (particularly in six bedded / recovery).
Update IPC Policy with revised bedside alerts IPC Team 30th June 2015 A
5. Reporting structure for IPCN Team, IPC Committee, Hygiene walkabout team, CEO Team, SMT Lead for hand hygiene in addressing audit report, outbreaks and incidents requires definition.
Organisational flow chart for reflecting reporting structure IPC Team 30th June 2015 B
6. Plan for every ward to improve hand hygiene and cleanliness to be developed by CNM / CNMs under the leadership of the DON / DOM and monthly progress against the plan to be reported to CEO Led team.
Individual documented Ward Plan with monthly progress reports Chair IPC Committee 30th June 2015 A
7. Assess progress against planned timelines for implementation of QIPs.
Formal periodic reports on achievement of QIPs to CEO Director of Nursing & Director of Midwifery & CNM/CMMs
30th June 2015 A
8. Business Case to progress a Senior Nursing Leadership post dedicated to Infection Control across the hospital group
Business Case to progress a Senior Nursing Leadership post dedicated to Infection Control across the hospital group
Chief Executive Officer 30th June 2015 B
Standard 3 The physical environment, facilities and resources are developed and managed to minimise the risk of service users, staff and visitors acquiring a Healthcare Associated Infection.
Ward Managers 1. Implement across all ward/department accountability and responsibility for ensuring patient equipment is clean through the individual identification of staff to check compliance on cleaning with identified types of equipment. 2. Immediate notification to Ward Manager where there is visual contamination of equipment sent for repair.
Daily allocation checklists records in all wards/departments 1. Director or Nursing & Director of Midwifery. 2. Biomedical Engineering Manager
30th June 2015 B
Bio Medical Engineering Planned preventative programme introduced
Formal documented Programme
Biomedical Engineering Manager
A
National Standards for Safer Better Healthcare
Theme Status
Theme 1 - Peron Centred Care & Support
Self Assessment Completed
Theme 2 – Effective Care & Support
Self Assessment Completed
Theme 3 – Safe Care & Support
Self Assessment Completed
Theme 4 – Better Health & Wellbeing
Self Assessment Completed
Theme 5 – Leadership, Governance &
Management
Self Assessment Completed
Theme 6 – Standards for Workforce
Self Assessment Completed
Theme 7 – Use of Resources
Self Assessment Completed
Theme 8 – Use of Information
Self Assessment Completed
Clinical Adverse Event Report 2014
Count of Incident Type Incident Near Miss
Slips/Trips/Falls 679 18
Treatment Incident 108 24
Medication Incident 95 15
Equipment/Devise Incident 49 40
Absconsion 39 0
Peri-operative/Perif -procedure Incident 28 7
Indentification/Records/Documentation Incident 28 29
Discharge Incident 15 0
Infection Control Incident 13 1
Unplanned Events 7 0
Blood Transfusion Incident 6 3
Other 6 3
Diagnosis Incident 4 1
Unexplained Injury/Unknown Cause 4 0
Consent/confidentiality Incidents 3 1
Radiation Harm 1 0
Self-Harm 1 0
Total 1086 142
Clinical Adverse Event Report 2014
• 406,631 episodes of patient care activity in CUH in 2014
• 1228 clinical adverse events reported ( 0.3% clinical adverse rate – national average 2.9%)
• Patient Safety Culture Survey of staff highlighted that 53% of staff surveyed CUH staff believe clinical incidents or near miss incidents are reported
• Data quality is key in the analysis of clinical adverse events
Recommendations
Area for Improvement Recommendation
Data Quality
(a) Incomplete incident report received to be
returned to the line manager to ensure that all data is complete
(b) (b) the progression of an electronic reporting system to allow for prompt reporting
Adverse Incidents
Trending of adverse outcomes to be undertaken
HIQA Report - Portlaoise
• An overview of the report was presented to the Executive Quality and Safety Committee in May with a focus on the recommendations on governance.
• A large volume of the report is in relation to governance structures and the report was critical of the governance structures in place in Portlaoise hospital.
• HIQA have identified in all their recent reports that the sustainable delivery of safe, effective and reliable person-centred care depends on service providers having competent capacity and capability in areas of leadership, governance & management.
• There were 47 non compliances with National Standards at hospital level, 28 at HSE level and 9 at a governance level.
Human Resource
Sick Leave – April 2015
4.01
3.793.74
3.16
4.58 4.444.16 4.09
3.683.37 3.7
3.74 3.89 3.8
3.86
4.22
00.5
11.5
22.5
33.5
44.5
5
Jan
Feb
Mar
Ap
ril
May
Ju
ne
Ju
ly
Au
g
Sep
t
Oct
No
v
Dec
%
Month
CUH - Total % Sick Leave 2014 v 2015
% 2015 Sick Leave % 2014 Sick Leave % Target
EWTD Compliance (April Dashboard)
G
Challenges
• Recruitment of Nursing staff
• Management of Unscheduled Care
Implementation of Change Programme Initiatives
• Scheduled Care
Implementation of plan to meet waiting list targets –Hospital
Group approach to maximise capacity
• Budget Control and Cost Containment measures
• Mental Health Service