A P NE UBLIC MEETING - RJAH · 2020-05-11 · U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Agenda - January.doc Russell Hardy 4358 Chairman BOARD OF DIRECTORS

$Page 1: A P NE UBLIC MEETING - RJAH · 2020-05-11 · U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Agenda - January.doc Russell Hardy 4358 Chairman BOARD OF DIRECTORS$
U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Agenda - January.doc

Russell Hardy �� 4358 Chairman

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1.0 Apologies: Professor Iain McCall

2.0 Minutes of the previous meeting held on 1st December 2011 Paper 1

3.0 Matters Arising

4.0 Declarations of Interest

SSTTRRAATTEEGGYY 5.0 NHS Outpatient Survey Paper 2/

Presentation

PPEERRFFOORRMMAANNCCEE 6.0 Month 9 Integrated Performance Report Paper 3

7.0 Q3 Infection Control Report Paper 4

8.0 Q3 Monitor Return Paper 5

GGOOVVEERRNNAANNCCEE,, QQUUAALLIITTYY AANNDD SSAAFFEETTYY 9.0 Board Assurance Framework Paper 6

10.0 Monitor Consultation on the Compliance Framework for 2012 Paper 7

11.0 FT Annual Reporting Requirements Paper 8

12.0 Board Business Programme Paper 9

13.0 Report from Board Sub Committees

� Quality and Safety – 8th December 2011 � Business Risk and Investment – 14th December 2011

� Audit – 15th December 2011

Paper 10 Paper 11 Paper 12

14.0 Annual Report for Safeguarding Children and Young People Paper 13

15.0 FT Bulletin Paper 14

16.0 Update on FT Membership Paper 15

17.0 Any Other Business: None notified

18.0 Questions from the Public

19.0 Date and time of next meeting: 9.30 a.m. on 1st March 2012, The Board Room, RJAH Orthopaedic Hospital NHS Foundation Trust, Oswestry

Questions from the Public on Agenda items – time limit of 15 minutes There will be an opportunity for the public to ask questions on agenda items. These should be limited to two questions per person and the time in total for each person should be limited to five minutes. If topics are likely to exceed this, they should be the subject of discussions between the hospital management and the individual concerned or there should be a formal request agreed by the Trust Board or the item to be included on the next agenda. If questions are detailed and require information that is not instantly available, the hospital will respond to the question within ten working days.

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Agenda - January.doc

To resolve, in accordance with Trust Standing Orders, that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

(Section 1(2) Public Bodies (Admission to Meeting) Act 1960)

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20.0 Minutes of the previous meeting held on 1st December 2011 Paper 16

21.0 Matters Arising

22.0 Chief Executive’s Report Paper 17

23.0 Outline 2012/13 Plan Paper 18

24.0 Minutes from Board Sub Committees:

� Quality and Safety – 8th December 2011 � Business Risk and Investment – 14th December 2011

� Audit – 15th December 2011

Paper 19 Paper 20 Paper 21

25.0 Update on Legal Claims Paper 22

26.0 Any Other Business

27.0 Date and Time of Next Meeting: 1st March 2012 following the Public Board of

Directors meeting

Paper 1

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11 DDEECCEEMMBBEERR 22001111 MMIINNUUTTEESS OOFF MMEEEETTIINNGG

PPRREESSEENNTT:: Russell Hardy, Chairman Wendy Farrington Chadd, Chief Executive

David James, Director of Operations

John Grinnell, Director of Finance Nicki Bellinger, Interim Director of Nursing

Professor Iain McCall, Medical Director Glen Lawes, Non Executive Director

Peter Jones, Non Executive Director

Richard Clarke, Non Executive Director

IINN AATTTTEENNDDAANNCCEE:: Ruth Tyrrell, Associate Director of HR Margaret Surrage, Head of Board Governance (Trust Secretary)

Janet Cox, Minutes Secretary

PPAARRTT OONNEE –– PPUUBBLLIICC MMEEEETTIINNGG

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01/12/1.0 AAPPOOLLOOGGIIEESS There were no apologies.

01/12/2.0 MMIINNUUTTEESS OOFF TTHHEE PPRREEVVIIOOUUSS MMEEEETTIINNGG

The minutes of the previous meeting were agreed as an

accurate record.

01/12/3.0 MMAATTTTEERRSS AARRIISSIINNGG

The Chairman went through the actions which were either actioned or diaried for future agendas.

01/12/4.0

DDEECCLLAARRAATTIIOONNSS OOFF IINNTTEERREESSTT There were no additional Declarations of Interest to record.

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The Chief Executive gave a presentation on the 2012/13 Operating Framework which had been launched by David

Nicholson, Chief Executive at the Department of Health and

his team on 24th November 2011. The document had been circulated to the Board of Directors on email and in hard copy.

She explained that the Operating Framework had four key themes:

� Putting patients first and getting the basics right

� Building the new system

� Increased pace on QIPP � Maintaining strong performance

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She added that the issues for RJAH would be continued focus on waiting times; finances; CQUIN opportunities and detail

around the 2012/13 plan.

Peter Jones, Non Executive Director mentioned a report about

care for older people and was there any acknowledgement about inequalities between regions as the West Midlands

region was at the ‘bottom of the pile’. The Chief Executive confirmed that this was recognised and is a wider issue. She

added that the national view is that older people aren’t

necessarily treated well and that this is an area which the Clinical Commissioning Groups will focus on.

The Board of Directors noted the information contained within the presentation.

01/12/6.0 UUPPDDAATTEE OONN IIMM&&TT SSTTRRAATTEEGGYY Andrew Smith, Head of IM&T updated the Board of Directors

on progress with the IM&T Strategy. He explained what progress had been made with the following areas:

� EPR � Direct Access DXA reporting

� Community Rheumatology Service � Scanned Medical Records

� Theatre System

� Website development � Self “check in” kiosks

� Patient internet (WiFi) � Business Planning Software

� Electronic transmission of discharge summaries direct to GP systems

� Intranet replacement

� Data Warehouse and reporting system � Information Governance

The Chairman asked whether RJAH had a different philosophy to other hospitals. The Head of IM&T confirmed that the

Trusts in the local area all have similar ideas.

Peter Jones, Non Executive Director asked whether

transcription was done via voice recognition or manually. The Medical Director said that voice recognition had been

implemented in the Radiology Department.

Richard Clarke, Non Executive Director asked whether

consideration had been given to replacing Microsoft with

Opensource and the equivalent of Sharepoint. The Head of IM&T said that various options had been looked at but there

are a number of constraints that would prevent the change at this point but that it maybe reviewed again in the future.

Richard Clarke, Non Executive Director said that by changing

significant savings could be achieved. The Head of IM&T responded that this was a national agreement which was paid

for centrally.

Peter Jones, Non Executive Director asked whether the Trust

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had a data warehouse. The Head of IM&T said that there

was one implemented but it was not fully populated with data although some data from the PAS and Theatre systems had

started to be input. Peter Jones, Non Executive Director

suggested that contact be made with Stoke PCT as they have got an advanced data warehouse and it maybe helpful to

meet with them to share learning. The Head of IM&T said that visits to University Hospitals Birmingham and Coventry

had been arranged but he would consider this suggestion.

Glen Lawes, Non Executive Director asked whether the

delivery of cost improvements was as the projects progress or

whether these were at the end. The Head of IM&T responded that it was a mixture as some of the projects are being

implemented in different phases and some individual phases are delivering cost improvements whilst others will be at the

end of the implementation of all the phases.

The Director of Operations said that the ability to look at

some of the data already available was very useful operationally.

Peter Jones, Non Executive Director asked whether the different internal systems were able to ‘talk’ to each other and

with the implementation of the data warehouse would

everything be in the same place. The Head of IM&T said that the data warehouse can produce reports across all specialties

but some inter-connectedness still had to happen ‘system to system’ at a more detailed level. Peter Jones, Non Executive

Director then asked whether the external systems were

connected as it was important for the Trust to be able to ‘talk’ to other hospitals. The Head of IM&T said that the local

health economy had implemented the PCTi solution but this does not include social care at this point.

The Director of Finance commented that a lot of progress had been made during the year on catch up work as some parts of

the systems had stagnated. He added that the next stage is

more developmental and there will be a need to focus on this to ensure that the efficiency programmes move forward.

The Chairman said that it would be helpful to find out from users of the systems their thoughts on these improvements.

He added that from the patient perspective, the introduction

of free wi-fi had been a great improvement and they were very pleased with this development. He suggested that for

the next update to the Board of Directors, the thoughts of users of the system be included.

The Medical Director commented that a big step forward will be when the EPR is the only system which is run. The

Chairman asked when this was likely to happen. The Head of IM&T said that there were two elements to this : the scanning

of historical records and the creation of forms so that data can be entered onto EPR in the future. He added that the

plan was to get the technology to start scanning in a

controlled area and then roll it out further when this has proven successful. It is likely that this will happen within the

next 6 months. The Chairman said that getting user feedback

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and understanding the benefits of this would be useful.

The Chief Executive said that the Executive Team have been

discussing the changes as some are incremental and some

will require change in how the Trust works and functions. She added that the Executive Team have not yet decided how

these changes will be implemented i.e. sudden or incremental change. In addition some roles may be affected where tasks

have been done manually and she cautioned that not everyone may think change is a good idea. The Head of

IM&T said that the phasing of the future improvements may

well change as the change management process is key to making the IT and financial changes work.

Richard Clarke, Non Executive Director commented that the problem with drip feeding change is that people develop ‘work

arounds’ which makes things difficult to manage and drive

efficiency. He suggested that the ‘big bang’ approach maybe the best way as he had found that this had been more

successful in his experience. The Medical Director agreed with this, providing that the technology was ready and able to

cope.

Glen Lawes, Non Executive Director said that it was

advantageous to the hospital that it was able to choose an appropriate system to ensure we remain a leading hospital, as

the system was not being imposed.

The Chairman thanked the Head of IM&T for his update.

The Board of Directors noted the presentation.

PPEERRFFOORRMMAANNCCEE

01/12/7.0 MMOONNTTHH 77 IINNTTEEGGRRAATTEEDD PPEERRFFOORRMMAANNCCEE RREEPPOORRTT The Chief Executive introduced the Month 7 performance

report explaining that overall October had been a positive

month. She said that activity levels had shown improvement as a result of the efficiency measures introduced which would

be discussed in more detail later in the agenda. She added that the focus remains on delivering Commissioner

requirements for the rest of the year which is key as the

negotiations for 2012-13 will commence shortly. She concluded her introduction by highlighting that an assessment

of each domain by the lead Director has now been included in the report for information.

Domain 1 Patient safety The Medical Director reported that overall performance

remains strong for this domain and highlighted the following:

� Infection Control overall is rated as amber owing to

the demanding target although there had been no instances of MRSA Bacteraemia or Clostridium Difficile

in month.

� There had been one surgical death in October which had been fully investigated and found that the care

provided was not at fault. The full report will be presented and reviewed at the Quality and Safety

Committee.

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� Patient falls are rated as red owing to an increase in

October. All have been reviewed in detail and no common themes have been identified. Regrettably

some patients are still not following medical advice

with regards to mobilisation and a new system to explain about the risk of falls will be introduced when

patients are admitted. The Medical Director commented that he was disappointed with this

increase as a lot of effort had been made to reduce this.

� The CQUINs are all on target with the exception of

the pre-operative waiting time in the Theatre suite. Work is continuing to ensure this is achieved.

Peter Jones, Non Executive Director suggested that the patient falls may have a commonality of the ward and age of

the patients involved. The Medical Director reiterated that the

falls are across different wards.

Peter Jones, Non Executive Director asked whether the 30 day re-admission rate data was reviewed. The Medical Director

confirmed that these are reviewed with Commissioners. He then suggested that it would be helpful to include in the

commentary that all re-admissions are investigated. This was

agreed.

Glen Lawes, Non Executive Director asked whether the insurers have any input into the form that patients will be

completing regarding falls. The Medical Director explained

that all patients are rated as low, medium or high for the risk of falls and the introduction of the form is to ensure that there

is a mechanism in place to monitor the information patients have been given.

The Chairman asked what the metric on pressure ulcer assessments was identifying. The Medical Director responded

that the metric is showing that every patient is assessed on

admission to the hospital. The Chief Executive added that the Cluster have asked the Interim Director of Nursing to give a

presentation to the other Trusts as the RJAH is held as an exemplar Trust in its treatment of pressure sores.

The Chairman suggested that pressure sore data be included in the report.

Domain 2 Patient experience The Interim Director of Nursing reported that performance

within this domain overall is excellent and highlighted that:

� Patient Satisfaction is at 96%

� There had been 10 complaints against a target of 9.

� There had been a slight increase in delayed discharges. Close working with the Social Services

team is continuing to ensure these are minimised.

The Director of Operations reported that:

� All core English and Welsh waiting time targets were

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achieved including the English 18 week referral to

treatment target, the 95th percentile and cancer access targets.

� The Trust is not meeting the Department of Health’s

median waiting times guidelines but plans are in place to improve performance.

Glen Lawes, Non Executive Director commented that the

median wait times trend has been reducing. The Chief Executive responded that the real issue for the Trust is that

the median is close to the 18 week RTT.

The Chairman said that it maybe useful to include a

comparison to the patient satisfaction of private providers in the report if this data can be obtained.

Domain 3 Efficiency The Director of Operations reported that overall performance

within the domain is improving and said that this was a key area of challenge for the Trust. He highlighted the following

areas:

� Activity on the scorecard has been divided to ensure

clarity between the Medicine and Surgery Divisions.

� Surgical activity is ahead of plan and in line with the financial plan.

� Outpatient Medicine activity is on plan but Inpatient activity is below plan as a result of the service

redesign within Metabolic Medicine.

� Additions to the Outpatient waiting list have reduced in month but the Outpatient waiting list has increased

partly due to the North Wales transfers and high demand within spines, upper limb and foot and ankle

sub specialties. The Inpatient waiting list reduced as a result of the improved Inpatient activity.

� The Day Case rate has increased to 52%

� Utilisation of Theatre sessions remained strong. � Cases per session have improved to 2.27 against a

target of 2.4. � The overall average length of stay remained within

target at 2.49 although the average length of stay for

hip and knee patients are both above target. � Bed occupancy is low at 81% against the target of

87%.

Richard Clarke, Non Executive Director asked for an

explanation as to how the cases per session target of 2.4 had been decided and whether this was realistic. The Director of

Operations responded that as this number of sessions had had previously been achieved it was therefore felt that this

was realistic. Richard Clarke, Non Executive Director then asked whether this would achieve delivery of the IBP – the

Director of Operations confirmed that it would. Richard

Clarke, Non Executive Director queried whether the increased theatre throughput had had any impact on the backlog from

earlier in the year. The Director of Operations responded that this would be discussed later on the agenda.

Glen Lawes, Non Executive Director commented that the issue

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of complications which influence the extended length of stay

has been highlighted previously and asked whether the model needs to be reviewed. The Director of Finance responded

that there were a number of metrics which drive this and it

would be wrong to look at one in isolation.

Glen Lawes, Non Executive Director then asked whether the payment differential between standard and best practice

which was detailed in the Operating Framework was applicable to RJAH. The Director of Finance confirmed that

the Trust was already on best practice tariff for hips and

knees, having been part of the trial previously. He added that this brings in the quality and outcome aspect into tariff setting

and the RJAH is well positioned to take advantage of this. The Chief Executive added that if the Day Case levels do not

increase next year, this will be one area where the Trust may

be penalised.

Domain 4 Resources The Director of Finance reported that performance within the domain remains strong as the Trust continues to track ahead

of its overall financial plans. He highlighted the following:

� A £26k surplus was recorded for October and

cumulatively the Trust is now recording a £1m surplus which to date is ahead of plan.

� Income exceeded plan in month as a result of increased private patient activity and above average

casemix for NHS activity.

� The cash position is £7m which his £3m ahead of plan.

� The Financial Risk Rating remains at Level 4. � The year end position of a £1.3m surplus is forecast

to achieve.

The Associate Director of Human Resources reported that:

� Staff sickness had increased to 3.68% in October.

� 532 staff had received the flu vaccination. � Staff appraisal had reduced slightly but the Trust

remains in the upper quartile for the West Midlands.

Peter Jones, Non Executive Director congratulated the Trust

on increasing private patient activity. He added that he did not underestimate how difficult it will be to reduce the length

of stay whilst having a richer casemix and patients with more

co-morbidities.

The Medical Director said that there were still areas for improvement and one of the areas to focus on is the early

discharge.

The Chairman suggested that EBITDA (Earnings Before

Interest, Taxes, Depreciation and Amortization) should be included in the report in the future. The Director of Finance

agreed to consider this suggestion.

The Board of Directors noted the October (Month 7)

integrated performance report.


FFIINNAANNCCEE

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GGOOVVEERRNNAANNCCEE,, QQUUAALLIITTYY AANNDD SSAAFFEETTYY

01/12/8.0 RREEPPOORRTT OONN MMAANNDDAATTOORRYY TTRRAAIINNIINNGG

The Associate Director of Human Resources updated the Board of Directors on the progress being made against the

Trust targets for statutory and mandatory training for 2011-12. She explained that statutory training is the training which

the Trust is required to undertake by law and includes training such as annual fire training, health and safety and manual

handling. Mandatory training covers those areas which the

Trust wants staff to undertake. She added that since April 2011, when the e-learning modules had been introduced, over

5300 modules have been completed.

The Chairman commented that it would be helpful for future

updates to include the amount of modules completed. The Associate Director of Human Resources agreed to look into

this suggestion.

The Board of Directors noted the information contained in the report.

AASSSSOOCCIIAATTEE


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AANNNNUUAALL RREEPPOORRTTIINNGG MMAANNUUAALL FFOORR 22001111//1122

The Director of Finance reported that Monitor has recently

issued a consultation document on the proposed changes to the Annual Reporting Manual and the Foundation Trust

Network (FTN) have asked members for their views in order to submit a joint response. He said that there were five areas

that the FTN had highlighted as significant :

1. The new requirement which brings FTs within the scope of the DH resource accounts, which gives rise to new approaches on the capitalisation thresholds for fixed assets; and recharges within mandated agreement of transactions and balances;

2. Treatment of government grants and donated assets; 3. Accounting for carbon reduction commitment

transactions;

4. References to the SIC (Statement of Internal Control) being replaced by references to the Annual Governance Statement;

5. The arrangements for external assurance of quality reports (a further consultation is anticipated on the content of Monitor’s quality reports once the DH has made clear their requirements for quality accounts, including any mandated indicators).

He then explained that the first four areas were either not

applicable to the Trust or had already been addressed. However the fifth area was the area which had the most

material affect on the Trust as this would require the Trust to

have the Quality Report ready for audit by mid April 2012 to allow for it to be submitted in line with the deadline of 31st

May 2012 to Monitor.

The Board of Directors approved that the Trust responds via

the FTN and approved the response as outlined in the report.

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01/12/10.0 MMAAJJOORR IINNCCIIDDEENNTT PPLLAANN

The Interim Director of Nursing presented the updated major incident plan which covers both internal and external

responses to disasters and is required to be revised regularly.

She explained that the RJAH remains a decanting hospital for other hospitals within the area with SaTH receiving primary

casualties. She added that the full version of the major incident plan outlines the Trust’s responsibilities and uses

action cards to guide staff through what to do and when during an incident. She concluded by confirming that an

exercise had been held earlier in the year to test the

robustness of the plan and this will be followed up by a second exercise before the end of the financial year.

The Board of Directors approved the information contained

within the Major Incident Plan.

01/12/11.0 WWIINNTTEERR PPLLAANN 22001111//1122

The Interim Director of Nursing presented the 2011/12 winter plan which had been rewritten to take account of the new

guidance standards. She explained that the Trust is part of

the local network which takes orthopaedic patients from SaTH to enable SaTH to admit acute patients. She added that there

are daily conference calls between the organisations to ensure full understanding of where escalation levels are at. She

added that the plan has been written with the co-operation of

SaTH and no issues are anticipated.

The Chairman asked that the Board of Directors are informed when the winter plan is enacted. The Chief Executive

confirmed that an email would be circulated in the event of this happening.

The Board of Directors approved the 2011-12 Winter Plan.

01/12/12.0 FFTT BBUULLLLEETTIINN

The Chief Executive presented the latest edition of the FT Bulletin for information. She explained that a summary of any

actions required will be produced by the Head of Board Governance (Trust Secretary) and will be presented to the

Board alongside the Bulletin.

The Board of Directors noted the FT Bulletin.

01/12/13.0 AANNYY OOTTHHEERR BBUUSSIINNEESSSS There was no additional business to discuss.

01/12/14.0 QQUUEESSTTIIOONNSS FFRROOMM TTHHEE PPUUBBLLIICC

There were no questions from the public.

01/12/15.0 DDAATTEE OOFF NNEEXXTT MMEEEETTIINNGG::

Thursday 26th January 2012 at 9.30 a.m. in The Board Room.

CCHHAAIIRRMMAANN’’SS CCLLOOSSIINNGG RREEMMAARRKKSS

The Chairman thanked everyone for their contribution and closed the public session of the meeting.

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TTRRUUSSTT BBOOAARRDD MMEEEETTIINNGG

11 DDEECCEEMMBBEERR 22001111

SSUUMMMMAARRYY OOFF KKEEYY AACCTTIIOONNSS

Action Lead

Responsibility

Progress

0011//1122//66..00 UUPPDDAATTEE OONN IIMM&&TT

• Views of service users to be included in future

updates.

Director of

Finance

Diaried for November

2012.

0011//1122//77..00 IINNTTEEGGRRAATTEEDD PPEERRFFOORRMMAANNCCEE RREEPPOORRTT

• Investigation of all re-admissions to be included in

the commentary.

• Pressure sore data to be included in report.

• EBITDA to be included in the commentary.

Medical Director

Interim Director

of Nursing

Director of

Finance

Completed.

Completed.

Completed.

0011//1122//88..00 RREEPPOORRTT OONN MMAANNDDAATTOORRYY TTRRAAIINNIINNGG

• Number of modules completed to be included in the

report.

Associate Director

of Human Resources

Under review.

0011//1122//99..00 CCOONNSSUULLTTAATTIIOONN OONN PPRROOPPOOSSEEDD AAMMEENNDDMMEENNTTSS TTOO

TTHHEE NNHHSS FFTT AANNNNUUAALL RREEPPOORRTTIINNGG MMAANNUUAALL FFOORR 22001111//1122

• Response to be sent to the FTN.

Head of Board Governance

(Trust Secretary)

Completed.

Paper 02

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2266TTHH JJAANNUUAARRYY 22001122


Executive Responsible Nicki Bellinger, Interim Director of Nursing

Paper prepared by (if different from above)

Picker Institute

Category of Item Strategic Direction and

Development

�

Performance and Governance �

Context Previous Board discussion

Link to National Policy

Link to Trust’s Strategic Objectives

�

Risk if no action taken

Executive Summary

The Picker Institute Outpatient Survey has again highlighted a very positive position regarding patient care and experience at the

Trust’s Outpatient Department. There were 49 questions where the Trust performed better than others and only 2 questions where

the Trust scored worse. An action plan has been drafted and

actions are being implemented.

Subject/Title NHS Outpatient Survey

Nature of Report For Information �

For Discussion �

For Approval

Received or approved by

Legal Implications

Recommendation The Board of Directors are requested to note the summary paper.

Acronyms and Abbreviations

Outpatient Survey 2011

ROBERT JONES AND AGNES HUNT ORTHOPAEDIC AND DISTRICT HOSPITAL NHS TRUST

NOVEMBER 2011

Executive Summary

Copyright 2011 Picker Institute Europe. All rights reserved. Trust ID: RL1 UKOUT2011/09

Outpatient Survey 2011 Robert Jones And Agnes Hunt Orthopaedic And District Hospital NHS Trust Copyright 2011 Picker Institute Europe. All rights reserved. Page 1


Introduction This document summarises the findings from the National Outpatient Survey, carried out by Picker Institute Europe, on behalf of Robert Jones And Agnes Hunt Orthopaedic And District Hospital NHS Trust. The Care Quality Commission report is due for publication in February 2012. A total of 850 outpatients from your Trust were sent a questionnaire. 844 patients were eligible for the survey, of which 509 returned a completed questionnaire, giving a response rate of 60%.

Your results at a glance

Have we improved since the 2009 survey? A total of 62 questions were used in both the 2009 and 2011 surveys. Compared to the 2009 survey, your Trust is:

Significantly BETTER on 5 questions

Significantly WORSE on 2 questions

The scores show no significant difference on 55 questions

How do we compare to other trusts in the 2011 survey? The survey showed that your Trust is:

Significantly BETTER than average on 49 questions

Significantly WORSE than average on 2 questions

The scores were average on 23 questions


Understanding your results Survey results highlight areas that need improvement to provide a better service for your outpatients. When deciding upon the improvements you would like to make there are a number of ways of looking at the results to choose which issues to focus on first.

Compare results over time - have you improved since the 2009 survey? The National Outpatient Survey usually runs every 2-3 years. It was last conducted in 2009. Looking at trends over time helps to focus attention on improvements and on those areas where performance might be slipping. Comparisons to your data prior to 2009 to present are available in the full report.

The Trust has improved significantly on the following questions:

2009 2011

Outpatients Department not clean 1 % 0 %

Hand-wash gels not available or empty 12 % 8 %

Did not have enough time to discuss medical problem with other health professional 21 % 13 %

Did not receive copies of all letters sent between hospital doctors and family doctor (GP) 46 % 22 %

Overall - would not recommend this Outpatients Department to family and friends 1 % 0 %

The Trust has worsened significantly on the following questions:

2009 2011

Patients unable to get suitable food or drink 5 % 11 %

Staff did not clearly explain test results 22 % 31 %


Compare results with others Picker Institute Europe ran the outpatient survey for 74 trusts nationwide in 2011. Your results are shown alongside the others to help you make comparisons against the average for all trusts where the Picker Institute implemented the survey. They will help you to focus on areas where your performance is poor compared to others and where there is plenty of scope for improvement, as well as highlighting your successes.


Your results were significantly better than the ‘Picker average’ for the following questions:

Trust Average

Appointment changed to later date by hospital 17 % 23 %

Not given name of person that appointment would be with 16 % 28 %

Appointment not with person told it would be with 14 % 21 %

Could not find a convenient place to park 8 % 35 %

Courtesy of receptionist was fair, poor or very poor 3 % 7 %

Patient waited for longer than they were told, or were not told how long the wait would be 58 % 69 %

Patient not told why they had to wait 57 % 67 %

Nobody apologised for the delay when waiting to be seen 38 % 47 %

No suitable magazines or newspapers provided in the waiting area 21 % 32 %

Toilets at the Outpatients Department not clean 2 % 5 %

No leaflets or posters about hand washing 4 % 6 %

Patients unable to get suitable food or drink 11 % 20 %

Staff did not clearly explain what would happen during test 18 % 24 %

Did not get clear answers to questions about test results 22 % 30 %

Not fully told before treatment what would happen 11 % 22 %

Risks and/or benefits not fully explained before treatment 13 % 26 %

Questions not fully answered before treatment 6 % 20 %

Not clearly told how treatment had gone 14 % 26 %

Did not have enough time to fully discuss health or medical problem with doctor 13 % 23 %

Doctor did not know enough about medical history 9 % 15 %

Doctor did not fully explain reasons for treatment/ action 11 % 21 %

Doctor did not fully listen to what patient had to say 12 % 18 %

Doctor did not always give clear answers to questions 17 % 26 %

Did not have full confidence and trust in doctor 8 % 17 %

Did not completely discuss worries or fears with doctor 19 % 31 %

Did not have enough time to discuss medical problem with other health professional 13 % 25 %

Other member of staff did not fully explain reasons for treatment/ action 15 % 21 %

Other member of staff did not listen fully to what patient had to say 14 % 18 %

Other member of staff did not always give clear answers to questions 14 % 23 %

Did not have full confidence and trust in other member of staff 12 % 16 %

Other member of staff did not know enough about medical history 11 % 15 %

Did not completely discuss worries or fears with other health professional 24 % 34 %

Do not always see the same doctor or member of staff 43 % 59 %

Staff talked in front of patient as if they weren't there 9 % 12 %

Not given complete privacy when discussing condition / treatment 8 % 13 %


Not given complete privacy when being examined or treated 3 % 9 %

Staff contradicted one another 6 % 12 %

Not fully involved in decisions about care or treatment 18 % 27 %

Staff did not ask patient what was important to them in managing their condition or illness 8 % 11 %

Patient not fully told purpose of new medications 7 % 17 %

Reason for change to existing medication not fully explained [8] % 17 %

Did not receive copies of all letters sent between hospital doctors and family doctor (GP) 22 % 41 %

Not given any written or printed information about condition/treatment but would have liked it

15 % 19 %

Not told fully about what danger signals to watch for 23 % 32 %

Reason for visit not dealt with completely to patients satisfaction 19 % 25 %

Overall - Outpatients Department not at all/fairly organised 30 % 38 %

Overall - not always treated with respect or dignity 7 % 12 %

Overall - care rated as fair or poor 2 % 5 %

Overall - would not recommend this Outpatients Department to family and friends 0 % 3 %

Your results were significantly worse than the ‘Picker average’ for the following questions:

Trust Average

Not given choice of appointment time 70 % 60 %

Unable to immediately find a place to sit in waiting area 7 % 4 %


Setting priorities for action Examining areas where your Trust’s performance is above average and you have demonstrated improvements since 2009 provides a valuable opportunity to share good practice.

The Trust has positive results on the following questions:

Average 2009 2011

Did not have enough time to discuss medical problem with other health professional

25 % 21 % 13 %

Did not receive copies of all letters sent between hospital doctors and family doctor (GP)

41 % 46 % 22 %

Overall - would not recommend this Outpatients Department to family and friends 3 % 1 % 0 %

In addition, focusing on the questions where your Trust’s score is lower than average and performance has slipped since 2009 should help you to identify key priorities for service improvement.

The Trust has poor results on the following questions:

Average 2009 2011

There were no questions where performance was both below average and had worsened since the last survey.


Areas where patients report most problems Questions where more than 50% of respondents reported room for improvement are listed below. Focusing on these areas could potentially improve the experience for a large proportion of your patients. N.B. Questions where less than 50 patients answered the question have been highlighted with [-]

Trust Average

Other patients could overhear discussions with receptionist 70 % 72 %

Not given choice of appointment time 70 % 60 %

Patient waited for longer than they were told, or were not told how long the wait would be

58 % 69 %

Patient not told why they had to wait 57 % 67 %

Not fully aware what would happen during appointment 56 % 54 %


Making the best use of your survey results: Moving beyond measurement We are dedicated to helping you make practical and effective use of your survey results and can provide the following support at no additional cost as part of your survey package:

• An on-site presentation of your survey data to staff or board members. Alternatively we can meet with you and your team to talk you through your results and answer any questions that you may have.

• Additional data analysis such as breakdown by ethnicity or specialty. This can help to target improvements in the areas where they are needed most.

• Regional workshops to practically support you in interpreting your results and prioritising areas for action. These sessions offer a valuable opportunity to network and share good practice with other organisations. To further support you in effectively using your patient experience data, our improvement team offer a range of tailored and practical approaches which include:

• A review of your current approaches to patient experience data collection, reporting and improvement work

• Staff training and development programmes

• Process improvement and implementation support

• Workshops and deliberative events for staff and patients If you need further assistance with understanding your results, or would like to discuss any of the above options, please contact Amy Tallett or another member of the survey team at Picker Institute Europe (Tel: 01865 208100), who will be happy to help you. Full contact details are listed overleaf.


Contacting Picker Institute Europe For more information about your survey report please contact the Project Manager, Amy Tallett, or another member of the Picker Institute Survey Team.

Picker Institute Survey Team: Amanda Attwood Stephen Bough Matt Cadby Bridget Hopwood Jenny King Tim Markham Nick Pothecary Amy Tallett





Executive Responsible John Grinnell, Director of Finance


Helen Ashcroft, Business Planning Manager Craig Macbeth, Deputy Director of Finance


Development



Link to National Policy �


�


Executive Summary

The Trust’s month 9 Performance Report is detailed in the attached paper.


Legal Implications None

Recommendation It is recommended that the Board note: • The performance at December 2011 (Month 9).

Subject/Title December (Month 9) Integrated Performance Report

Nature of Report For Information

For Discussion �

For Approval �

Paper 03

U:Drive\Trust Board & Committees\Public Trust Board\2011-2012\January 2012\Paper 3 Month 9 Integrated Performance Report

Balanced Scorecard Trust Board

2011 / 2012 Month - 09

VISION

To be the leading centre for high quality, sustainable Orthopaedic and related care, achieving excellence in both experience and outcomes for our

patients

Period Key Metric Actual Year to date Change Forecast

Dec-11 Infection Control Overall g a same a

Dec-11 Serious Incidents g g same g

Dec-11 Never Events g g same g

Dec-11 Deaths g a same g

Dec-11 Medicine Management g g same g

Dec-11 Patient Falls r a worse g

Dec-11 Pressure Ulcer Assessments g g same g

Dec-11 CQUIN Overall a a worse g

Nov-11 30 day Readmission Rates to RJAH for all specialties g g same g

Patient Safety

Overall Performance


Dec-11 Monitor Risk Rating - Finance g g same g

Dec-11 Monitor Risk Rating - Quality Governance g a better a

Overall Performance

External Perception


Dec-11 Patient Satisfaction g g same g

Dec-11 Number of Complaints g g same g

Dec-11 Access to Bone Tumour Services g g same g

Dec-11 Access to Services (RTT) - Welsh g g same g

Dec-11 Access to Services (RTT) - English g g same g

Dec-11 Reportable Cancellations g g same g

Dec-11 Delayed Discharges a g same g

Patient Experience

Overall Performance


Dec-11 Income and Expenditure g g same g

Dec-11 CIP Delivery a g worse g

Dec-11 Capital Expenditure a a worse g

Dec-11 PSPP g a better g

Dec-11 Liquidity Ratio g g same g

Dec-11 Sickness Absence r a worse a

Dec-11 Staff Turnover g g same g

Dec-11 Staff Appraisal r a same g

Resources

Overall Performance


Dec-11 Activity - Surgery g a worse g

Dec-11 Activity - Medicine r r same r

Dec-11 New to Follow Up Ratio (Consultant Led Activity) g g same g

Dec-11 Demand Against Contract r r same a

Dec-11 Daycase Rates g g same g

Dec-11 Admission on Day of Surgery g g same g

Dec-11 Theatre Efficiency a g worse g

Dec-11 Average Length of Stay - Overall g g same g

Dec-11 Average Length of Stay - Hips and Knees r r same a

Dec-11 Bed Occupancy - Adult Orthopaedic Wards r r worse g

Efficiency

Overall Performance

Paper 03


BOARD OF DIRECTORS

INTEGRATED PERFORMANCE REPORT

DECEMBER 2011

1. Introduction

1.1 This paper presents the Trust’s performance at the end of December 2011, the ninth

month of the 2011/12 financial year and the end of quarter 3.

1.2 The 2011/12 performance report details performance against the core standards set nationally by Monitor, the Department of Health and Care Quality Commission, locally

agreed CQUIN quality improvement targets and internally driven improvement

targets.

1.3 The scorecard and performance report format and metrics have been developed using the Trust’s electronic planning and performance system (interplan) and reflect

the format agreed by the Board in the May 2011 Trust Board paper ‘2011/12 Trust

Balanced Scorecard’.

1.4 Domain 5, of this report looks at the external perception of the Trust and includes further details of performance against Monitor’s compliance framework for quarter 3

which supports the Trust’s quarterly self declarations to Monitor.

2. Chief Executive’s overview

2.1 December was another strong month in terms of performance and the scorecard overall shows a positive position. Our activity levels reduced as planned over the

Christmas period however overall they remain on track with our revised trajectory as

we move into the final quarter of the financial year.

2.2 We continue to perform well across the scorecard particularly in the areas of patient safety, resource management and effectiveness whilst an improving picture is evident

within the efficiency domain. It should be noted that a number of indicators including

patient falls, theatre efficiency and delayed discharges have been adversely affected by the expected lower activity rates over Christmas however underlying performance

has not worsened.

2.3 Overall performance is reflecting positively in financial terms and we should note that the fourth quarter of the year will see a greater throughput in activity terms as part

of our overall planned profile.

3. November performance overview

3.1 Domain 1 – Patient safety

3.1.1 Patient safety: Directors assessment – Overall performance within this domain

during December was strong with all targets forecast to be achieved by the year end and reported as green with the exception of C. Difficile which is amber.

3.1.2 Infection control & screening - There were no cases of hospital acquired MRSA

bacterium in December and no cases of C. Difficile.

In year the Trust has had two cases of C. Difficile against a ceiling target of two. As

this is a Monitor key measure the infection control metric is therefore reported for the year to date and forecasted forward as ‘amber’ to reflect the risk associated with this

position.

Paper 03


3.1.3 Serious incidents – Two serious incidents occurred in December, one related to a

fracture which occurred as a result of a patient fall and the second to an incidence of physical and verbally abusive behaviour. Both incidents have been investigated

thoroughly and actions taken as appropriate.

3.1.4 Deaths – There were two patient deaths during December one medical and one

surgical. Both Deaths have been fully reviewed and no issues found.

The number of deaths in the ‘year to date’ KPI although marked as amber is not considered an overall concern as a majority of the deaths which have occurred in the

year to date have been expected following the patient’s admission to medical wards

for deteriorating long term conditions and co-morbidities.

3.1.5 Medicines management – There were 8 medication incidents in month which resulted in a change to Patient’s planned treatment but no patient harm. This

represented 0.63% of the total Trust inpatient activity. Each incident has been fully

investigated by the Medicines Management Co-ordinator.

3.1.6 Patient falls – The % of patient falls increased in December to 2.79% of inpatient activity against a target of 1.60% and its therefore reported as red ‘in month’ within

the scorecard. It should be noted that this % has been inflated by the lower activity rate in month. In total there were 17 falls in month compared to 15 in November

which is in line with historic levels. A number of patients (3) fell due to not following

the medical advice given to them.

Further emphasis will be placed on reducing the incidents of falls in the last quarter in order to bring performance back below the target ceiling. The impact of the recently

implemented additional patient information at preoperative assessment and revised

advice at the point of admission will also assist to deliver this metric by year end.

When benchmarked against other Hospitals across the Region the Trust is shown to be performing strongly against the falls metrics and has been asked to present at a

forthcoming West Midlands Quality Review Service, Good Practice Sharing Event.

3.1.7 Pressure ulcer assessment – The Trust continues to maintain its performance

with regards to pressure ulcer assessments undertaking 99.42% of pressure ulcer assessments against a target of 99%. In month there were no grade 3 or 4 pressure

ulcers which would require external reporting.

3.1.8 CQUINs – The Trust has now undertaken the quarter three audits of progress

towards delivering the 2011/12 CQUIN targets. Performance against the CQUIN metrics overall remains on track to deliver the year end improvements. There are

three areas of risk of non delivery that work is being focussed on:

The rescheduling of outpatient appointments

The introduction of a telephone reminder system for patient appointments

An area of medicines management improvement that is at risk due to low

numbers of patients skewing performance against the agreed KPI.

On this basis the ‘year to date’ performance is highlighted as amber however with

continued focus and commissioner engagement we are still optimistic that with that the CQUIN will be delivered by the year end.

Paper 03


3.1.9 30-Day readmission rates to RJAH for all specialties – The percentage of

readmissions decreased in December. 0.94% of patients treated in November were re admitted to the Trust within 30 days against a target of 1.3%. The outpatient

wound clinic continues to contribute towards this improving performance.

3.2 Domain 2 - Patient experience

3.2.1 Patient experience: Directors commentary – Performance within this domain is

excellent with all key metrics reported in the scorecard forecast to achieve by the year end including all key access targets.

3.2.2 Patient satisfaction – 96.23% of patients rated the Trust as excellent or good in December, exceeding the Trust’s 95% satisfaction target.

3.2.3 Complaints - There were 8 complaints in December against a target ceiling of 9

representing 0.07% of activity. Five of the complaints related to operational issues

including staff attitude, long waits in the outpatient department and a clinic cancelation. The remaining three complaints related to quality of care and included a

theatre cancellation, treatment in the Menzies Unit, and treatment received in Orthotics. There were no overall trends within departments noted between the

complaints received.

3.2.4 Access to services (waiting times) – All core English and Welsh waiting times

targets were achieved in December including the English 18 week referral to treatment targets, the 95th percentile, the Welsh 26 weeks waiting time targets and

cancer access targets.

Focus remains on improving performance against median waiting time targets. In

December median waits for admitted patients reduced for the second month in a row in line with planned activity levels.

3.2.5 Delayed discharges – Delayed discharges increased in November to 6.41%,

against a target ceiling of 4.23%. It should be noted that the overall percentage of

delayed discharges was adversely affected by the reduced activity during the Christmas period, in total there were 5 patients delayed which was a reduction from 6

in November 2011. The metric is reported as amber ‘in month’ however performance is expected to improve in January as activity levels increase.

3.3 Domain 3 - Efficiency

3.3.1 Efficiency: Directors Commentary – The delivery of efficiencies within the Trust

has improved through December, focus will remain on this domain to ensure this momentum is maintained in the final quarter of the year.

3.3.2 Activity - Surgery – Overall surgical inpatient activity exceeded that planned in month which is a continuation of our improved performance levels. The total

outpatient numbers, including new, follow up and preoperative assessments were below the revised plan but are expected to increase in January.

3.3.3 Activity Medicine – Medicine activity remained below that planned at the start of

the year against the Metabolic Service Line following the redesign of the service

model; it is therefore reported as red within the balanced scorecard.

Paper 03


3.3.4 Demand against contract – Additions to the outpatient waiting list reduced in

month to 1,903 in part due to the Christmas period. The outpatient waiting list increased due to the reduced in month plan of activity whilst the inpatient waiting list

remained stable.

Due to the size of the outpatient waiting list and in year high demand for our services

this metric is reported as red ‘in month’ and for the ‘year to date’ with an amber ‘forecast’ based on commissioner discussions and overall increasing capacity in the

final quarter of the year.

It should be noted that the additions to the outpatient waiting list data and RAG for

April to November has been updated following an internal data audit.

3.3.5 Daycase rate – During December the percentage of patients treated as a daycase increased to 52.96%.

3.3.6 Utilisation of available sessions – Theatre session utilisation rates decreased slightly in December to 93.13% against a target of 95% and are therefore reported

as amber ‘in month’ within the scorecard. Performance against this metric was expected to reduce in December and the sessions not utilised were used to undertake

a ‘deep clean’ over the Christmas period. It is expected performance will be back above target in January.

3.3.7 Cases per session – During December the Trust achieved an average of 2.48 cases per session against a target of 2.4 cases an increase on the previous month. This

improvement was assisted by the increased level of daycases.

3.3.8 Average length of stay hips and knees: – Overall average length of stay

(including daycases) remained within the target of 2.5 days at 2.22 days in December.

The average length of stay for both hip and knee patients decreased in month to 4.63

and 5.29 days respectively however remaining higher than the target ceiling of 4.5

days. It is therefore reported as ‘red’ within the scorecard for both the in month actual and year to date. During Quarter 4 focus will remain on increasing our use of

the estimated date of discharge tools and evaluating where patients do not achieve their estimated date of discharge.

3.3.9 Bed occupancy – The percentage bed occupancy decreased in December to

76.42% against a target occupancy of 87% which was as anticipated given the

planned lower activity levels.

3.4 Domain 4 – Resources

3.4.1 Resources: Directors Commentary - Performance within this domain remains strong as we continue to track ahead of our overall financial plans.

3.4.2 Finance overall – As expected, December generated a loss driven by lower activity

levels associated with the Christmas holiday period. EBITDA tracked to plan and the overall net loss for the month was £0.17m. Cumulatively both EBITDA and net

surplus remain ahead of plan; our overall net surplus now stands at £1.11m.

3.4.3 Income exceeded plan in month by £0.16m linked to the delivery of the additional

activity plan. We are now within reach of our original plan and will continue to increase activity in the remaining quarter of the year as we look to fulfil our

additional contractual commitments which remain outside of the financial plan.

Paper 03


3.4.4 Expenditure - Pay costs came in 2% ahead of plan linked to additional surgical capacity put in place to deliver the additional activity. Cumulatively we remain within

the planned pay budget although this is likely to face increasing pressure in the final quarter of the year.

Non pay over spent by 3% driven by high cost drugs (backed by income) and the profiling of reserves in month. Cumulatively we remain within the planned non pay

budget.

3.4.5 Cost improvements of £0.27m were made in month. This was beneath planned levels due to slippage of schemes relating to outpatient repatriation and increased

OJP worked in anaesthetics and outpatients. A number of new schemes are set to

commence in Quarter 4 and as activity also steps up we will look to identify further efficiencies linked to volume. We still anticipate the planned level of savings being

delivered in full.

3.4.6 Cash balances stayed static in month at £7.18m. A reduction had been expected

linked to the capital programme but the planned payments were not made until early January. As our activity levels increase further and the capital programme moves

towards conclusion we will see our cash balances return to planned levels by the end of the financial year.

3.4.7 Capital expenditure for the month was £0.44m and below the revised trajectory.

The programme is still however expected to be completed in full by the end of the

financial year.

3.4.8 Financial risk rating –The Trust's overall forecast risk rating remains unchanged at level 4 confirming that the Trust is performing at low financial risk.

3.4.9 Year end forecast - We have reached an agreement with our three main Commissioners regarding an end of year position; this will incorporate the

delivery of additional work in the final quarter of the year. Additionally we are finalising a technical adjustment in respect of the treatment of donated assets.

Both of these issues will be built into a revised forecast as part of next month’s

report.

3.4.10 Sickness rates – Sickness absence rates increased to 4.05% against the 2011/12 year end target of 3.00%. This is therefore reported as ‘red’ within the scorecard in

month and amber for the ‘year to date’ and ‘forecast’. Absence due to colds & flu, ENT and Musculo skeletal issues increased in month. Based on previous years trends

it is expected that sickness levels will decrease over coming months, however

achieving the year end target will be challenging.

3.4.11 Staff Appraisal - Performance decreased in December to 68.12% of staff having received an appraisal within a 12 month rolling period. Performance therefore

remains below target and as such is reported as ‘red’ in month and ‘amber’ for the

year to date within the balanced scorecard. A number of appraisals are just missing the 12 month deadline, as highlighted by a review of appraisals undertaken within a

14 month period which showed 82% of staff having had an appraisal in that timeframe. An escalation process is in place to senior management to address staff

who have not undertaken an appraisal within the required timeframe and with a concerted focus it is forecast the target will be met by year end.

Paper 03


3.5 Domain 5 – External perception

3.5.1 The Trust continues to maintain all external targets. The Quality Governance forecast

is highlighted as ‘amber’ to reflect the ongoing risk of delivering the C. Difficile target

as detailed within section 3.1.2.

3.5.2 Appendix 1 of this paper details the Compliance Framework service targets for the third quarter which will be reported to Monitor at the end of January 2012.

3.5.3 The submission will highlight that the Trust was fully compliant with all of Monitor’s

‘targets and indicators’ including C. Difficile, MRSA, Cancer waiting times, RTT 95th

percentile waiting times and Learning Difficulties during quarter 3. The submission will however highlight the ongoing risk to the Trust of the low C. Difficile target in

quarter four.

3.5.4 Further details regarding this submission are included within the Trust Board paper

“Quarter 3 Monitor Return”.

4 Recommendation

4.1 It is recommended that the Board:

Note the performance for December (Month 9)

John Grinnell Director of Finance, Contracting and Performance

Paper 03


2011/12 Month - 09

Balanced Scorecard - Trust Board

Patient Safety

Infection Control Overall

Hospital Acquired MRSA

0

1

2

3

4

5

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er

Period Target Actual Performance

gApr-11 0.00 0.00

gMay-11 0.00 0.00

gJun-11 0.00 0.00

gJul-11 0.00 0.00

gAug-11 0.00 0.00

gSep-11 0.00 0.00

gOct-11 0.00 0.00

gNov-11 0.00 0.00

gDec-11 0.00 0.00

Jan-12 0.00

Feb-12 0.00

Mar-12 0.00

Patient Safety

Infection Control Overall

Hospital Acquired C Difficile

0

1

2

3

4

5

6

7

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 1.00 0.00

gMay-11 1.00 0.00

gJun-11 1.00 1.00

gJul-11 2.00 1.00

gAug-11 2.00 1.00

gSep-11 2.00 1.00

gOct-11 2.00 1.00

gNov-11 2.00 2.00

gDec-11 2.00 2.00

Jan-12 2.00

Feb-12 2.00

Mar-12 2.00

Patient Safety

Serious Incidents

0.0

0.4

0.8

1.2

1.6

2.0

2.4

2.8

3.2

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 1.00 0.00

gMay-11 1.00 1.00

gJun-11 1.00 0.00

gJul-11 1.00 1.00

gAug-11 1.00 1.00

gSep-11 1.00 1.00

aOct-11 1.00 3.00

gNov-11 1.00 0.00

aDec-11 1.00 2.00

Jan-12 1.00

Feb-12 1.00

Mar-12 1.00

Paper 03


2011/12 Month - 09


Patient Safety

Never Events

0.0

0.2

0.4

0.6

0.8

1.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 0.00 1.00

gMay-11 0.00 0.00

gJun-11 0.00 0.00

gJul-11 0.00 0.00

gAug-11 0.00 0.00

gSep-11 0.00 0.00

gOct-11 0.00 0.00

gNov-11 0.00 0.00

gDec-11 0.00 0.00

Jan-12 0.00

Feb-12 0.00

Mar-12 0.00

Patient Safety

Deaths

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 1.00 0.00

gMay-11 1.00 0.00

aJun-11 1.00 4.00

gJul-11 1.00 1.00

gAug-11 1.00 0.00

aSep-11 1.00 4.00

gOct-11 1.00 1.00

gNov-11 1.00 0.00

aDec-11 1.00 2.00

Jan-12 1.00

Feb-12 1.00

Mar-12 1.00

Patient Safety

Medicine Management

Medication Errors - Total Numbers

4

8

12

16

20

24

28

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 15.00 12.00

gMay-11 15.00 15.00

gJun-11 15.00 12.00

aJul-11 15.00 18.00

gAug-11 15.00 7.00

gSep-11 15.00 8.00

gOct-11 15.00 12.00

gNov-11 15.00 9.00

gDec-11 15.00 8.00

Jan-12 15.00

Feb-12 15.00

Mar-12 15.00

Paper 03


2011/12 Month - 09


Patient Safety

Medicine Management

Medication Errors as % of activity

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 1.25 1.02

gMay-11 1.25 1.19

gJun-11 1.25 1.02

aJul-11 1.25 1.49

gAug-11 1.25 0.62

gSep-11 1.25 0.61

gOct-11 1.25 0.89

gNov-11 1.25 0.63

gDec-11 1.25 0.63

Jan-12 1.25

Feb-12 1.25

Mar-12 1.25

Patient Safety

Patient Falls

0.8

1.2

1.6

2.0

2.4

2.8

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%Period Target Actual Performance

aApr-11 1.60 1.75

rMay-11 1.60 2.07

aJun-11 1.60 1.76

aJul-11 1.60 1.62

gAug-11 1.60 1.40

gSep-11 1.60 1.55

rOct-11 1.60 2.35

aNov-11 1.60 1.86

rDec-11 1.60 2.79

Jan-12 1.60

Feb-12 1.60

Mar-12 1.60

Patient Safety

Pressure Ulcer Assessments

86

88

90

92

94

96

98

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 99.00 99.30

gMay-11 99.00 99.52

gJun-11 99.00 99.83

gJul-11 99.00 100.00

gAug-11 99.00 100.00

gSep-11 99.00 99.40

gOct-11 99.00 100.00

gNov-11 99.00 99.86

gDec-11 99.00 99.42

Jan-12 99.00

Feb-12 99.00

Mar-12 99.00

Paper 03


2011/12 Month - 09


Patient Safety

CQUIN Overall

VTE Risk Assessments

55

60

65

70

75

80

85

90

95

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 90.00 98.56

gMay-11 90.00 98.09

gJun-11 90.00 98.12

gJul-11 90.00 99.77

gAug-11 90.00 99.88

gSep-11 90.00 99.79

gOct-11 90.00 99.69

gNov-11 90.00 99.91

gDec-11 90.00 99.06

Jan-12 90.00

Feb-12 90.00

Mar-12 90.00

Patient Safety

30 Days Readmission Rates to RJAH for all specialties

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


rApr-11 1.30 1.54

gMay-11 1.30 1.02

gJun-11 1.30 0.96

rJul-11 1.30 1.83

gAug-11 1.30 1.16

gSep-11 1.30 1.17

gOct-11 1.30 1.18

gNov-11 1.30 0.94

Dec-11 1.30 no data

Jan-12 1.30

Feb-12 1.30

Mar-12 1.30

Paper 03


2011/12 Month - 09


Patient Experience

Patient Satisfaction

95.0

95.5

96.0

96.5

97.0

97.5

98.0

98.5

99.0

99.5

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 95.00 99.48

gMay-11 95.00 98.03

gJun-11 95.00 99.19

gJul-11 95.00 98.01

gAug-11 95.00 99.09

gSep-11 95.00 98.76

gOct-11 95.00 96.12

gNov-11 95.00 97.82

gDec-11 95.00 96.23

Jan-12 95.00

Feb-12 95.00

Mar-12 95.00

Patient Experience

Number of Complaints

2

4

6

8

10

12

14

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 9.00 3.00

gMay-11 9.00 8.00

gJun-11 9.00 6.00

gJul-11 9.00 7.00

gAug-11 9.00 6.00

aSep-11 9.00 14.00

aOct-11 9.00 10.00

gNov-11 9.00 2.00

gDec-11 9.00 8.00

Jan-12 9.00

Feb-12 9.00

Mar-12 9.00

Patient Experience

Access to Bone Tumour Services

2 week cancer referral target

82

84

86

88

90

92

94

96

98

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 93.00 100.00

gMay-11 93.00 100.00

gJun-11 93.00 100.00

gJul-11 93.00 100.00

gAug-11 93.00 100.00

gSep-11 93.00 100.00

gOct-11 93.00 100.00

gNov-11 93.00 100.00

gDec-11 93.00 100.00

Jan-12 93.00

Feb-12 93.00

Mar-12 93.00

Paper 03


2011/12 Month - 09


Patient Experience


Cancer 1 month wait

65

70

75

80

85

90

95

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 96.00 100.00

gMay-11 96.00 100.00

gJun-11 96.00 100.00

gJul-11 96.00 100.00

gAug-11 96.00 100.00

gSep-11 96.00 100.00

gOct-11 96.00 100.00

gNov-11 96.00 100.00

gDec-11 96.00 100.00

Jan-12 96.00

Feb-12 96.00

Mar-12 96.00

Patient Experience


Cancer 2 month wait

0

20

40

60

80

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


gApr-11 85.00 100.00

gMay-11 85.00 100.00

gJun-11 85.00 100.00

gJul-11 85.00 100.00

gAug-11 85.00 100.00

gSep-11 85.00 100.00

gOct-11 85.00 100.00

gNov-11 85.00 100.00

gDec-11 85.00 100.00

Jan-12 85.00

Feb-12 85.00

Mar-12 85.00

Patient Experience

Access to Services (RTT) - Welsh

26 week RTT (Admitted)

86

88

90

92

94

96

98

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


aApr-11 95.00 94.27

gMay-11 95.00 99.22

gJun-11 95.00 97.17

gJul-11 95.00 97.78

gAug-11 95.00 96.79

gSep-11 95.00 97.98

gOct-11 95.00 96.36

gNov-11 95.00 99.64

gDec-11 95.00 97.99

Jan-12 95.00

Feb-12 95.00

Mar-12 95.00

Paper 03


2011/12 Month - 09


Patient Experience

Access to Services (RTT) - Welsh

26 week RTT (Non-Admitted)

96.0

96.5

97.0

97.5

98.0

98.5

99.0

99.5

100.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


aApr-11 98.00 96.40

gMay-11 98.00 98.85

gJun-11 98.00 99.76

gJul-11 98.00 99.05

gAug-11 98.00 99.50

gSep-11 98.00 99.33

gOct-11 98.00 99.51

gNov-11 98.00 99.34

gDec-11 98.00 100.00

Jan-12 98.00

Feb-12 98.00

Mar-12 98.00

Patient Experience

Access to Services (RTT) - English

18 weeks RTT Admitted

90

91

92

93

94

95

96

97

98

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


gApr-11 90.00 92.21

gMay-11 90.00 95.64

gJun-11 90.00 93.60

gJul-11 90.00 93.25

gAug-11 90.00 93.03

gSep-11 90.00 93.99

gOct-11 90.00 93.77

gNov-11 90.00 95.51

gDec-11 90.00 94.30

Jan-12 90.00

Feb-12 90.00

Mar-12 90.00

Patient Experience


18 weeks RTT Admitted 95th percentile

17

18

19

20

21

22

23

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 23.00 21.30

gMay-11 23.00 17.98

gJun-11 23.00 19.75

gJul-11 23.00 19.81

gAug-11 23.00 21.85

gSep-11 23.00 20.88

gOct-11 23.00 19.85

gNov-11 23.00 17.99

gDec-11 23.00 19.63

Jan-12 23.00

Feb-12 23.00

Mar-12 23.00

Paper 03


2011/12 Month - 09


Patient Experience


18 weeks RTT Admitted Median

11

12

13

14

15

16

17

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 11.10 16.28

rMay-11 11.10 15.31

rJun-11 11.10 16.14

rJul-11 11.10 15.92

rAug-11 11.10 16.07

rSep-11 11.10 16.50

rOct-11 11.10 16.50

rNov-11 11.10 15.57

rDec-11 11.10 14.60

Jan-12 11.10

Feb-12 11.10

Mar-12 11.10

Patient Experience


18 weeks RTT Non-Admitted

95.0

95.5

96.0

96.5

97.0

97.5

98.0

98.5

99.0

99.5

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


gApr-11 95.00 98.63

gMay-11 95.00 97.22

gJun-11 95.00 98.12

gJul-11 95.00 97.87

gAug-11 95.00 97.56

gSep-11 95.00 96.84

gOct-11 95.00 98.42

gNov-11 95.00 98.02

gDec-11 95.00 98.21

Jan-12 95.00

Feb-12 95.00

Mar-12 95.00

Patient Experience


18 weeks RTT Non-Admitted 95th percentile

15.2

15.6

16.0

16.4

16.8

17.2

17.6

18.0

18.4

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 18.30 17.08

gMay-11 18.30 17.33

gJun-11 18.30 17.46

gJul-11 18.30 17.61

gAug-11 18.30 17.59

gSep-11 18.30 17.74

gOct-11 18.30 17.49

gNov-11 18.30 17.63

gDec-11 18.30 17.47

Jan-12 18.30

Feb-12 18.30

Mar-12 18.30

Paper 03


2011/12 Month - 09


Patient Experience


18 weeks RTT Non-Admitted Median

4.4

4.8

5.2

5.6

6.0

6.4

6.8

7.2

7.6

8.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 6.60 7.04

rMay-11 6.60 7.35

rJun-11 6.60 7.24

rJul-11 6.60 7.40

rAug-11 6.60 7.23

rSep-11 6.60 7.21

rOct-11 6.60 7.13

rNov-11 6.60 7.40

rDec-11 6.60 7.40

Jan-12 6.60

Feb-12 6.60

Mar-12 6.60

Patient Experience


18 weeks RTT Incomplete 95th percentile

16

18

20

22

24

26

28

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 28.00 23.78

gMay-11 28.00 20.70

gJun-11 28.00 21.27

gJul-11 28.00 22.58

gAug-11 28.00 23.78

gSep-11 28.00 22.62

gOct-11 28.00 22.35

gNov-11 28.00 24.88

gDec-11 28.00 26.65

Jan-12 28.00

Feb-12 28.00

Mar-12 28.00

Patient Experience


18 weeks RTT Incomplete Median

7

8

9

10

11

12

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 7.20 8.62

rMay-11 7.20 9.10

rJun-11 7.20 8.38

rJul-11 7.20 9.17

rAug-11 7.20 10.55

rSep-11 7.20 10.10

rOct-11 7.20 9.75

rNov-11 7.20 9.61

rDec-11 7.20 10.11

Jan-12 7.20

Feb-12 7.20

Mar-12 7.20

Paper 03


2011/12 Month - 09


Patient Experience

Reportable Cancellations

0.4

0.6

0.8

1.0

1.2

1.4

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 0.80 0.79

gMay-11 0.80 0.57

gJun-11 0.80 0.49

gJul-11 0.80 0.54

gAug-11 0.80 0.50

gSep-11 0.80 0.54

gOct-11 0.80 0.61

gNov-11 0.80 0.60

gDec-11 0.80 0.67

Jan-12 0.80

Feb-12 0.80

Mar-12 0.80

Patient Experience

Delayed Discharges

0

1

2

3

4

5

6

7

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


aApr-11 3.50 3.90

gMay-11 3.50 3.40

aJun-11 3.50 3.60

gJul-11 3.50 0.80

gAug-11 3.50 1.50

gSep-11 3.50 2.10

gOct-11 3.50 3.25

aNov-11 3.50 4.23

aDec-11 3.50 6.41

Jan-12 3.50

Feb-12 3.50

Mar-12 3.50

Paper 03


2011/12 Month - 09


Resources

Sickness Absence

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

4.2

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 3.00 2.93

gMay-11 3.00 2.75

gJun-11 3.00 2.70

aJul-11 3.00 3.39

aAug-11 3.00 3.08

gSep-11 3.50 3.42

aOct-11 3.50 3.68

aNov-11 3.50 3.82

rDec-11 3.50 4.05

Jan-12 3.50

Feb-12 3.50

Mar-12 3.00

Resources

Staff Turnover

6.5

7.0

7.5

8.0

8.5

9.0

9.5

10.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


gApr-11 10.00 8.78

gMay-11 10.00 8.69

gJun-11 10.00 8.10

gJul-11 10.00 7.50

gAug-11 10.00 7.53

gSep-11 10.00 7.72

gOct-11 10.00 7.69

gNov-11 10.00 7.51

gDec-11 10.00 7.57

Jan-12 10.00

Feb-12 10.00

Mar-12 10.00

Resources

Staff Appraisal

60

64

68

72

76

80

84

88

92

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


aApr-11 90.00 78.20

aMay-11 90.00 78.34

aJun-11 90.00 82.94

aJul-11 90.00 84.32

aAug-11 90.00 84.55

aSep-11 90.00 78.72

aOct-11 90.00 76.20

aNov-11 90.00 74.75

rDec-11 90.00 68.12

Jan-12 90.00

Feb-12 90.00

Mar-12 90.00

Paper 03


2011/12 Month - 09


Efficiency

Activity - Surgery

Surgical Division Activity - Inpatient Contract

850

900

950

1000

1050

1100

1150

1200

1250

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 994.00 966.00

gMay-11 1,007.00 1,014.00

aJun-11 1,081.00 916.00

rJul-11 1,094.00 912.00

rAug-11 969.00 915.00

gSep-11 1,031.00 1,033.00

gOct-11 1,056.00 1,058.00

gNov-11 1,109.00 1,121.00

gDec-11 1,028.00 1,055.00

Jan-12 1,095.00

Feb-12 1,096.00

Mar-12 1,122.00

Efficiency

Activity - Surgery

Surgical Division Activity - Outpatient Contract

4400

4800

5200

5600

6000

6400

6800

7200

7600

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 5,306.00 5,544.00

gMay-11 5,372.00 6,295.00

gJun-11 5,770.00 6,254.00

aJul-11 5,837.00 5,491.00

gAug-11 5,580.00 6,319.00

gSep-11 5,912.00 6,740.00

gOct-11 6,045.00 6,372.00

gNov-11 6,045.00 6,798.00

aDec-11 5,647.00 5,274.00

Jan-12 5,978.00

Feb-12 5,978.00

Mar-12 6,111.00

Efficiency

Activity - Medicine

Medicine Division Activity - Inpatient Contract

100

120

140

160

180

200

220

240

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 210.00 128.00

rMay-11 212.00 149.00

rJun-11 228.00 156.00

rJul-11 231.00 177.00

rAug-11 204.00 127.00

rSep-11 218.00 162.00

rOct-11 223.00 154.00

rNov-11 223.00 185.00

rDec-11 207.00 121.00

Jan-12 220.00

Feb-12 220.00

Mar-12 225.00

Paper 03


2011/12 Month - 09


Efficiency

Activity - Medicine

Medicine Division Activity - Outpatient Contract

600

700

800

900

1000

1100

1200

1300

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


aApr-11 912.00 901.00

gMay-11 924.00 997.00

gJun-11 992.00 1,241.00

gJul-11 1,004.00 1,080.00

gAug-11 890.00 1,100.00

gSep-11 947.00 1,129.00

aOct-11 969.00 967.00

gNov-11 969.00 1,074.00

aDec-11 901.00 811.00

Jan-12 958.00

Feb-12 958.00

Mar-12 981.00

Efficiency

New to Follow Up Ratio (Consultant Led Activity)

1.6

1.8

2.0

2.2

2.4

2.6

2.8

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 2.30 2.13

gMay-11 2.30 2.18

rJun-11 2.30 2.61

aJul-11 2.30 2.34

gAug-11 2.30 1.93

gSep-11 2.30 1.98

gOct-11 2.30 2.17

gNov-11 2.30 2.02

gDec-11 2.30 2.26

Jan-12 2.30

Feb-12 2.30

Mar-12 2.30

Efficiency

Demand Against Contract

Additions to Outpatient Waiting List

0

500

1000

1500

2000

2500

3000

3500

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 2,000.00 2,151.00

aMay-11 2,000.00 2,319.00

aJun-11 2,000.00 2,523.00

rJul-11 2,000.00 3,190.00

aAug-11 2,000.00 2,384.00

rSep-11 2,000.00 2,714.00

aOct-11 2,000.00 2,359.00

aNov-11 2,000.00 2,322.00

gDec-11 2,000.00 1,903.00

Jan-12 2,000.00

Feb-12 2,000.00

Mar-12 2,000.00

Paper 03


2011/12 Month - 09


Efficiency


Outpatient Waiting List (Consultant Led Activity Only)

0

1000

2000

3000

4000

5000

6000

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 3,250.00 3,943.00

rMay-11 3,250.00 4,101.00

rJun-11 3,250.00 4,645.00

rJul-11 3,250.00 4,939.00

rAug-11 3,250.00 5,216.00

rSep-11 3,250.00 5,224.00

rOct-11 3,250.00 5,642.00

rNov-11 3,250.00 5,208.00

rDec-11 3,250.00 5,730.00

Jan-12 3,250.00

Feb-12 3,250.00

Mar-12 3,250.00

Efficiency


Inpatient Waiting List Total

0

500

1000

1500

2000

2500

3000

3500

4000

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 3,250.00 3,490.00

gMay-11 3,250.00 3,470.00

aJun-11 3,250.00 3,582.00

aJul-11 3,250.00 3,582.00

aAug-11 3,250.00 3,581.00

rSep-11 3,250.00 3,780.00

aOct-11 3,250.00 3,730.00

aNov-11 3,250.00 3,732.00

aDec-11 3,250.00 3,544.00

Jan-12 3,250.00

Feb-12 3,250.00

Mar-12 3,250.00

Efficiency

Daycase Rates

38

40

42

44

46

48

50

52

54

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 44.00 46.19

gMay-11 44.00 48.13

gJun-11 44.00 49.94

gJul-11 45.00 46.84

gAug-11 45.00 48.84

gSep-11 45.00 50.52

gOct-11 46.00 51.93

gNov-11 48.00 50.05

gDec-11 48.00 52.96

Jan-12 50.00

Feb-12 52.00

Mar-12 53.00

Paper 03


2011/12 Month - 09


Efficiency

Admission on Day of Surgery

66

68

70

72

74

76

78

80

82

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 72.00 73.67

gMay-11 72.00 74.04

gJun-11 72.00 72.81

gJul-11 72.00 74.40

gAug-11 72.00 74.65

gSep-11 72.00 75.56

gOct-11 72.00 76.16

gNov-11 74.00 80.25

gDec-11 74.00 79.60

Jan-12 76.00

Feb-12 78.00

Mar-12 80.00

Efficiency

Theatre Efficiency

Theatre Efficiency

84

86

88

90

92

94

96

98

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


aApr-11 95.00 92.21

gMay-11 95.00 95.54

aJun-11 95.00 85.74

aJul-11 95.00 90.22

aAug-11 95.00 85.86

gSep-11 95.00 97.12

gOct-11 95.00 95.95

gNov-11 95.00 95.55

aDec-11 95.00 93.13

Jan-12 95.00

Feb-12 95.00

Mar-12 95.00

Efficiency

Theatre Efficiency

Cases Per Session

2.10

2.15

2.20

2.25

2.30

2.35

2.40

2.45

2.50

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


Apr-11 2.40 no data

May-11 2.40 no data

Jun-11 2.40 no data

aJul-11 2.40 2.14

aAug-11 2.40 2.17

aSep-11 2.40 2.21

aOct-11 2.40 2.27

aNov-11 2.40 2.31

gDec-11 2.40 2.48

Jan-12 2.40

Feb-12 2.40

Mar-12 2.40

Paper 03


2011/12 Month - 09


Efficiency

Average Length Of Stay - Overall

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 2.60 2.60

gMay-11 2.60 2.54

gJun-11 2.60 2.23

gJul-11 2.60 2.41

gAug-11 2.60 2.53

gSep-11 2.60 2.26

gOct-11 2.60 2.49

gNov-11 2.56 2.31

gDec-11 2.52 2.22

Jan-12 2.48

Feb-12 2.44

Mar-12 2.40

Efficiency

Average Length of Stay - Hips and Knees

Average Length of Stay Hips

4.0

4.4

4.8

5.2

5.6

6.0

6.4

6.8

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


aApr-11 4.50 4.79

rMay-11 4.50 4.70

rJun-11 4.50 4.63

rJul-11 4.50 4.55

rAug-11 4.50 5.40

rSep-11 4.50 5.53

rOct-11 4.50 4.92

rNov-11 4.45 4.71

rDec-11 4.40 4.63

Jan-12 4.35

Feb-12 4.30

Mar-12 4.25

Efficiency

Average Length of Stay - Hips and Knees

Average Length of Stay Knees

4.0

4.4

4.8

5.2

5.6

6.0

6.4

6.8

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 4.50 5.19

rMay-11 4.50 5.35

rJun-11 4.50 5.65

rJul-11 4.50 4.80

rAug-11 4.50 4.86

rSep-11 4.50 5.72

rOct-11 4.50 5.72

rNov-11 4.45 5.32

rDec-11 4.40 5.29

Jan-12 4.35

Feb-12 4.30

Mar-12 4.25

Paper 03


2011/12 Month - 09


Efficiency

Bed Occupancy - Adult Orthopaedic Wards

0

20

40

60

80

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


rApr-11 87.00 76.65

rMay-11 87.00 74.50

rJun-11 87.00 77.99

rJul-11 87.00 76.02

rAug-11 87.00 80.45

rSep-11 87.00 80.00

rOct-11 87.00 81.00

aNov-11 87.00 84.54

rDec-11 87.00 76.42

Jan-12 87.00

Feb-12 87.00

Mar-12 87.00

Paper 03


A) Key Facts 2011-12

B) Executive Summary

C) Monitor Risk Assessment/Ratio's D) Recommendations

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust Finance Report for period ending 31st December 2011

Recommendations:

The Board is asked to NOTE:

The Month 9 Financial Position.

As expected , December generated a loss driven by lower activity levels associated with the Christmas holiday period. EBITDA tracked to plan and the overall net loss for the month was £0.17m. Cumulatively both EBITDA and net surplus remain ahead of plan; our overall net surplus now stands at £1.11m.

We have reached an agreement with our three main Commissioners regarding an end of year position; this will incorporate the delivery of additional work in the final quarter of the year. Additionally we are finalising a technical adjustment in respect of the treatment of donated assets. Both of these issues will be built into a revised forecast as part of next months report.

Income exceeded plan in month by £0.16m linked to the delivery of the additional activity plan. We are now within reach of our original plan and will continue to increase activity in the remaining quarter of the year as we look to fulfil our additional contractual commitments which remain outside of the financial plan.

Pay costs came in 2% ahead of plan linked to additional surgical capacity put in place to deliver the additional activity. Cumulatively we remain within the planned pay budget although this is likely to face increasing pressure in the final quarter of the year. Non pay over spent by 3% driven by high cost drugs (backed by income) and the profiling of reserves in month. Cumulatively we remain within the planned non pay budget.

Cost improvements of £0.27m were made in month. This was beneath planned levels due to slippage of schemes relating to outpatient repatriation and increased OJP worked in anaesthetics and outpatients. A number of new schemes are set to commence in Quarter 4 and as activity also steps up we will look to identify further efficiencies linked to volume. We still anticipate the planned level of savings being delivered in full.

Cash balances stayed static in month at £7.18m. A reduction had been expected linked to the capital programme but the planned payments were not made until early January. As our activity levels increase further and the capital programme moves towards conclusion we will see our cash balances return to planned levels by the end of the financial year.

Performance against our 30 day creditor payment target was 96% in month and 94% on a cumulative basis demonstrating recent operational improvements.

Capital expenditure for the month was £0.44m and below the revised trajectory. The programme is still however expected to be completed in full by the end of the financial year.

Our overall forecast risk rating remains unchanged at level 4 confirming that the Trust is performing at low financial risk.

UnitAnnual

Plan

Month

Plan

Month

Actual

Month

Variance

Month

% Var

YTD

Plan

YTD

Actual

YTD

Variance% Var YTD Risk

Annual

Forecast

Annual

Forecast

Risk

Income £m 81.81 6.47 6.63 0.15 2% 61.07 61.05 -0.02 0% 81.81

Expenditure - Pay £m -45.55 -3.82 -3.89 -0.07 -2% -34.12 -34.09 0.03 0% -45.55

Expenditure - Non-pay £m -30.65 -2.48 -2.56 -0.08 -3% -22.74 -22.68 0.06 0% -30.65

EBITDA £m 5.62 0.18 0.18 0.00 2% 4.21 4.29 0.07 2% 5.62

Finance Costs £m -4.32 -0.36 -0.35 0.01 -3% -3.24 -3.17 0.07 -2% -4.32

Net Surplus £m 1.30 -0.18 -0.17 0.02 -8% 0.97 1.11 0.14 14% 1.30

CIP delivered £m 3.07 0.31 0.27 -0.05 -15% 2.17 2.16 -0.01 -1% 3.07

Capital Expenditure £m 5.58 0.52 0.44 -0.08 -15% 3.15 2.75 -0.40 -13% 5.58

Cash £m 3.02 4.50 7.18 2.68 59% 4.50 7.18 2.68 59% 3.02

BPPC % 95% 95% 96% 1% 1% 95% 94% -1% -1% 95%

Annual

PlanYTD Plan

Annual

ForecastRisk Rating

EBITDA Margin 6.9% 6.9% 6.9% 3

EBITDA Achieved 100% 100.0% 100.0% 5

Return on Assets (ROA) 5.0% 5.2% 5.0% 4

I&E Surplus Margin 1.6% 1.6% 1.6% 3

Liquidity Ratio (Days) 28 40 28 4

Overall risk rating 4 4 4 4

101.7%

7.0%

YTD Actual

4

39

1.8%

5.6%

Paper 03


OU

TP

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IEN

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PR

IVA

TE

PA

TIE

NT

S &

OT

HE

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NC

OM

E


E) Income and activity analysis

Inp

ati

en

tsO

utp

ati

en

ts

The surgical activity recovery plan was successful in

delivering an additional 73 cases during the month

with an average case mix. This earned the Trust an

additional £228k

The above was however dampened by a further

reduction in Metabolic Medicine inpatient activity

with a loss of 95 episodes from plan. Overall

Medicine division income fell short of plan by £62k.

Outpatient activity for the month was the lowest recorded so far this

year although this was in line with the original plan.

Activity is expected to increase in the final quarter of the year in line

with the increased activity plan.

Private Patient income exceeded plan by £21k in month and has

now generated an additional £168k for the Trust on a cumulative

basis.

Other income was also above plan as a result of high RTA claim

notifications.

Private Patients Income

0

0.1

0.2

0.3

0.4

0.5

Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar

£m

This Year P lan Last Year Actual This year Actual

Other Income

0.0

0.2

0.4

0.6

0.8

1.0


£m

This Year Plan Last Year Actual This year Actual

Outpatients - Activity

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000


Attendances


Outpatients - Income

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4


£m


Inpatients - Activity

0

200

400

600

800

1000

1200

1400

1600


Sp

ells


Inpatients - Income

0.0

0.5

1 .0

1 .5

2 .0

2 .5

3 .0

3 .5

4 .0

4 .5

A p r M a y Ju n e Ju ly A u g S e p O c t N o v D e c Ja n F e b M a r

£m


Inpatients - Income per Spell

2.6

2.7

2.8

2.9

3.0

3.1

3.2

3.3


£000s


Paper 03



F) Commissioner Performance G) Cost Improvement Programme

December was a good month for contract delivery with further recoveries of under performance made across our commissioner base.

Following discussion with our main Commissioner, Shropshire, we have agreed an out-turn position of around £26.8m which is £0.5m under the original plan. This reduction is to meet revised Commissioner requirements and will support an increased activity plan in 2012/13.

Both BCU (North Wales) and Powys continued to over achieve against base contract but both are covered by supplementary agreements to perform additional activity.

Whilst the above table shows a net cumulative under performance across all commissioners of £0.1m against the original plan, the activity plan for the final quarter of the year is expected to deliver an over performance of around £1m above the original plan.

Additional cost improvements of £266k were made in month to bring our cumulative total for the year to £2,158k which is marginally beneath plan. The most significant variances from plan are detailed below:

Operational Efficiency - slippage of the SaTH outpatient and bed closure schemes continued in month although they are set to deliver some savings in the final quarter. It is anticipated that the shortfall from this slippage will be more than compensated by the contribution earned from the additional activity planned for Quarter 4. An additional scheme to recognise the contribution from increased Private Patient activity has been added this month.

Tactical/Miscellaneous - Additional schemes relating to diagnostics maintenance agreements have been recognised in month.

A contingency for slippage was factored into the original plan. This allows for the non delivery of identified schemes up to a value of £204k (6%). £130k of this has been offset from plan so far year to date.

CommissionerAnnual

Plan £m

YTD

Plan £m

Actual

£m

Variance

£m

Risk

Rating

Shropshire County 27.3 20.4 19.5 -0.9

Betsi Cadwaladr 13.1 9.8 11.0 1.2

Powys 5.5 4.1 4.5 0.4

Telford & Wrekin 5.1 3.8 3.8 0.0

Specialised Commissioners 7.2 5.5 5.5 0.0

Other England Contracted 10.1 7.5 7.3 -0.2

Other Wales Contracted 0.8 0.6 0.5 -0.1

Non Contracted Activity 2.5 1.8 1.7 -0.1

Exclusions and other 0.7 0.4 0.0 -0.4

Grand Total 72.3 53.9 53.8 -0.1

Annual Plan

SchemesPlan Actual Variance Plan Actual Variance

£000s £000s £000s £000s £000s £000s £000s

Improving Operational Efficiency 964 132 53 -79 570 444 -126

Workforce Productivity 970 83 71 -12 719 730 11

Realising the benefits of technology 156 23 7 -16 107 73 -34

Improved Contributions 70 6 8 3 53 54 2

Back office function productivity 414 42 43 1 295 265 -29

Estates rationalisation/sustainability 141 12 12 0 106 106 0

Tactical/Miscellaneous 562 36 72 35 453 487 34

Contingency against slippage -204 -20 20 -130 130

Total 3,073 314 266 -48 2,171 2,158 -13

In Month Year to Date

Paper 03


Ma

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BA

NK

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NC

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XP

EN

DIT

UR

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UT

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JO

B P

LA

N

Ov

ert

ime

KEY PAY METRICS


PA

Y E

XP

EN

DIT

UR

E

H) Pay Expenditure related Key Drivers/Financial Assumptions

Pay costs came in £0.07m over plan primarily due to the surgery extended working arrangements that are set to continue for the remainder of the year. Whilst there was an increase in overtime worked, bank and agency spend continued to be well controlled.

Budget reserves of £38k were allocated in month to fund cost pressures; £14k was allocated to Medicine division to fund an additional enhanced recovery post in Physio. Additionally unexpected costs associated with paediatric cover have also been funded at £16k. Surgery had one additional post funded at £14k linked to service redesign in Theatres. Additional surgery posts are likely to be funded in the final quarter linked to the delivery of additional activity.

Pay Expenditure - Plan vs Actual

3.00

3.20

3.40

3.60

3.80

4.00

4.20


£m

This Year P lan Last Year Actual This Year Actual

Pay Expenditure/Spell - Plan vs Actual

2.0

2.4

2.8

3.2

3.6

4.0


£m


Out of Job Plan Expenditure - Plan vs Actual

0.00

0.05

0.10

0.15

0.20

0.25


£m


Out of Job plan Expenditure/spell - Plan vs Actual

0

20

40

60

80

100

120

140

160

180


£0

00s


Overtime Expenditure - 2010/11 vs 2011/12

0

10

20

30

40

50

60


£000

s

This Year Plan Last Year Actual This Year Actual

Clinical agency and bank spend

0

20

40

60

80

100

120


£000s


Non-Clinical Agency/Bank Expenditure

0

20

40

60

80

100


£000s


Monthly Average

Pay Expenditure per WTE - Plan vs Actual

2.00

2.50

3.00

3.50

4.00

4.50


£0

00


WTE - Plan vs Actual

0

250

500

750

1,000

1,250

1,500

1,750

Apr May June July Aug Sep Oct Nov Dec Jan Feb MarThis Year P lan Last Year Actual This Year Actual

Paper 03



I) Non-Pay Expenditure related Key Drivers/Financial Assumptions

KEY NON-PAY METRICS

DR

UG

SIM

PL

AN

TS

NO

N-P

AY

EX

PE

ND

ITU

RE

Non pay over spent by £0.08m in month but is still £0.06m underspent year to

date.

The main drivers for the in month position are high cost drugs (backed by

income) and the profiling of reserves (utilisation of under spend from earlier

periods.)

Reserves of £198k were allocated in month for:

Price inflationary pressures

Patient transport contract alignment

IT investments

Training and recruitment

Implants underspent against budget in month by £93k driven by the case mix of surgical operations completed.

Cumulatively implant spend is now £331k under plan which is supporting the delivery of the Cost Improvement Programme.

Drug costs were also above plan in month by £7k and have cumulatively exceeded budget by £80k.

This position has been driven by an increase in the use of high cost antibiotic drugs the costs of which are recoverable from Commissioner contracts.

Non-pay Expenditure - Plan vs Actual

1.00

1.50

2.00

2.50

3.00

3.50

4.00


£m

This Year P lan £m Last Year Actual £m

This Year Actual £m

Non-pay Expenditure per Spell - Plan vs Actual

1000.00

1500.00

2000.00

2500.00

3000.00


£

This Year P lan (£/Spells) Last Year Actual (£/Spells)

This Year Actual (£/Spells)

Implants Expenditure - Plan vs Actual

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00


£m

This Year P lan £m Last Year Actual £m

This Year Actual £m

Implants Expenditure per Orthopaedic Spell - Plan

vs Actual

400

600

800

Apr M ay June July Aug Sep Oct Nov Dec Jan Feb M ar

£

This Year P lan (£/Spells) Last Year Actual (£/Spells)


Drugs Expenditure - Plan vs Actual

0.06

0.07

0.08

0.09

0.10

0.11

0.12

0.13

0.14

0.15

0.16


£m

This Year Plan £m Last Year Actual £m This Year Actual £m

Drugs Expenditure per Spell - Plan vs Actual

70

80

90

100

110

120

130

Apr June Aug Oct Dec Feb

£

This Year Plan (£/Spells) Last Year Actual (£/Spells)


Paper 03



J) Balance Sheet Items Analysis

Cash balances stayed static in month at £7.18m. A

reduction had been expected linked to the capital

programme but the expected payments were not made

until early January.

Our cash balances are now £2.68m ahead of plan. The

drivers for this can be summarised as follows:

a) Commissioner payment profile - we continue to receive

a favourable payment profile of contract income compared

to activity delivery. As at the end of December this has

provided a cash benefit of £1.7m.

b) Capital payments slippage £0.7m.

c) Debtors have reduced from planned levels. This is

because the plan had been set on last years trajectory

that included over performance against contracts that has

not been a feature of this year.

As our activity levels increase further and the capital

programme moves towards conclusion we are expecting

our cash to return to planned levels by the end of the

financial year.

Surplus cash continues to be invested in line with the

parameters of our Treasury Management policy.

Performance against our target to pay bills within 30 days

was 96% during the month. Cumulatively performance

remains at 94% compliance which is marginally beneath

the 95% target.

Additional resources have been allocated to our payments

team to support the achievement of the required 95% by

the end of the financial year.

The overall age profile of our creditors decreased during

the month with the percentage of creditors older than 90

days reducing to 4.29%.

Debtors older than 90 days remain above the 5% threshold used by Monitor

as part of their forecast financial risk metrics. Performance has been measured

to include sums owing from CRU (Compensation Recovery Unit) and without;

the Trust is unable to influence the collection timeline of income owing from

the CRU.

Debtor days reduced across all categories in the month.

Current year cash - Plan vs Actual

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00


£m

Plan This Year Actual £m

Creditor Days - Plan vs Actual

5

10

15

20

25

30

35


Days

Plan Last Year Actual This Year Actual

Percentage of Creditors > 90 days

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

Apr May June July Aug Sep Oct Nov Dec

%

% value of trade & other payable over 90 days

Percentage of Debtors > 90 Days

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

Month

Perc

en

tag

e

Total receivables Total Less CRU

DebtorDays Dec 10 - Dec 11

0

10

20

30

40

50

60

70

Dec Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec

Month

Days

non clinical nhs clinical recharges

Paper 03


K) Capital Programme

L) Service Line Performance M) Key Financial Risks


The Service Line Reporting for Quarter 2 is shown in the table above. Whilst this shows an overall deterioration to the bottom line, it should be noted that this is mostly driven by a technical accounting change relating to donated asset depreciation as shown under the technical

adjustments line. From an operational perspective, key points to note are as follows:

Joint Surgery

An increase in Lower Limb activity has driven an increased surplus for the Joint Surgery service lines although this has been tempered by a decline in performance of both Sports Injury & Upper Limb both linked to reduced activity.

Spinal Services

Spinal Surgery continued to benefit from improved locally negotiated tariffs but Spinal injuries generated further losses linked to a re-base of overhead distribution.

Paediatric Services

The improved performance resulted from a refinement to the methodology for apportioning Therapy costs across service lines. The ORLAU service line also continues to perform well.

Medicine

Increased activity through the Care of the Elderly Service line following the opening of two additional beds on Sheldon Ward has increased income and reduced losses for this service line. The refined Therapy cost allocation has also benefitted the Medicine service lines.

Trading Directorate

An increase in Private Patient activity has driven the improved performance.

Our in month capital spend was £0.44m and lower than the planned value of £0.51m. This was due to lower than expected backlog and theatre cooling upgrade expenditure in month.

The table above details the status of our main capital schemes. It shows £2.8m of schemes have been completed to date against the revised plan of £3.2m. This equates to 87% of our year to date plan and so is above the Monitor risk metric threshold of 75%.

Our top financial risks are routinely reviewed and updated each month. The most significant ones that may effect the delivery of our financial plan are detailed below:

1) Failure to deliver the CIP in full although this is mitigated by schemes being identified for the year in excess of the target required.

2) Non achievement of contracted levels of activity leading to loss of income and contribution to establishment overheads. This is currently an area of attention and a recovery plan has been implemented.

Current year Cap Ex - Plan vs Actual

0.00

1.00

2.00

3.00

4.00

5.00

6.00


£m

Cumulative Revised P lan This Year Actual £m

ProjectAnnual Plan £000s

Year to date Plan £000s

Completed £000s

Forecast Outturn £000s

Progress

Hospital redesign scheme 3,503 2,033 1709 3507 Construction underway.Estates Backlog 907 639 610 907 OT & Rehab rewire completedMedical Equipment 180 72 72 180 Remaining spend to be agreedIT Replacement 200 123 146 200 Awaiting final agreed scheme X-Ray Refurbishment 200 0 0 200 Awaiting final agreed scheme Orthotics Manufacturing upgrade200 17 12 2 Expected to slip into 2012Theatre Cooling System 0 80 2 250 Brought forward from 2012/13 backlogOther Capital 300 187 199 337 Movement Centre relocation completeNHS Capital

Expenditure5,490 3,151 2,750 5,583

Capital Projects 2011/12

SLR Quarter 2 2011/12

2011-12 Q1 2011-12 Q2

£000s £000s

Surplus/(Loss) Surplus/(Loss)

Joint Surgery / Bone Tumour 404 570

Spinal Services -319 -284

Paediatric Services 152 218

Medicine -123 -82

Trading Directorate 57 82

Technical adjustment 244 -175

Total 415 329

Paper 03



N) Income and Expenditure Statement

ANNUAL

PLAN PLAN ACTUAL VAR % VAR PLAN ACTUAL VAR % VAR

NHS Clinical Income 72,300 5,717 5,800 83 1% 53,952 53,822 -130 0%

Non NHS Clinical Income 3,757 278 396 119 43% 2,802 3,286 484 17%

Research & Development 699 58 83 25 42% 524 545 21 4%

Education & Training 1,524 124 126 3 2% 1,155 1,155 0 0%

Other Income 3,533 297 221 -76 -26% 2,640 2,247 -394 -15%

Operating Income, Total 81,814 6,474 6,626 152 2% 61,073 61,055 -18 0%

Pay Costs -45,545 -3,818 -3,886 -69 2% -34,121 -34,092 29 0%

Drugs -5,060 -417 -493 -76 18% -3,780 -3,957 -176 5%

Clinical Supplies -15,910 -1,208 -1,228 -20 2% -11,982 -11,723 259 -2%

Non Clinical Supplies -2,133 -175 -182 -7 4% -1,653 -1,701 -49 3%

Other Operating expenses -7,547 -678 -655 23 -3% -5,323 -5,296 28 -1%

Non pay costs, Total -30,651 -2,478 -2,557 -79 3% -22,739 -22,676 62 0%

EBITDA 5,618 178 182 4 2% 4,213 4,286 73 2%

Interest Receivable 14 1 4 3 231% 11 19 9 84%

Interest Expense on loans and leases -37 -3 -3 0 -2% -28 -27 1 -2%

Depreciation and Amortisation -3,049 -254 -246 9 -3% -2,287 -2,230 57 -2%

PDC Dividend -1,246 -104 -104 0 0% -934 -934 0 0%

Non-Operating Expenses, Total -4,318 -360 -348 11 -3% -3,238 -3,172 66 -2%

Surplus/deficit before impairment 1,300 -182 -166 16 -9% 974 1,114 139 14%

Impairment of assets 0 0 0 0 0% 0 -50 -50 100%

Net Surplus/deficit 1,300 -182 -166 16 -9% 974 1,064 90 9%

IN MONTH YEAR TO DATE

Paper 03


O) Balance Sheet


April 2011

November

2011

December

2011

In month

movement

£'000 £'000 £'000 £'000

Non Current Assets (life of more than one year)

Fixed Assets 46,043 46,318 46,531 213

Non Current Receivables 231 358 281 (77)

Total Non Current Assets 46,274 46,676 46,812 136

Inventories (Stocks) 1,535 1,515 1,509 (6)

Receivables 4,110 2,381 1,986 (395) Reduction in Partially Completed spells accrual

Cash at bank and in hand 3,859 7,193 7,176 (17)

Total Current Assets 9,504 11,089 10,671 (418)

Payables (Creditors) (6,456) (7,262) (7,149) 113

Borrowings (DH Loans & accrued

interest + finance lease commitments)(75) (73) (73) 0

Current Provisions for liabilities and

charges(262) (289) (289) 0

Total Current Liabilities (6,793) (7,624) (7,511) 113

NET CURRENT ASSETS

(LIABILITIES)2,711 3,465 3,160 (305)

TOTAL ASSETS LESS CURRENT

LIABILITIES48,985 50,141 49,972 (169)

Non Current Borrowings (DH Loans +

finance lease commitment)(402) (363) (360) 3

Non Current Provisions for liabilities and

charges(426) (391) (391) 0

Total Creditors due after more than

one year(828) (754) (751) 3

TOTAL ASSETS EMPLOYED 48,157 49,387 49,221 (166)

Public dividend capital 31,220 31,220 31,220 0

Income and expenditure reserve (2,910) (1,678) (1,844) (166) In month surplus

Capital Grant Reserve 326 326 326 0

Donated asset reserve 10,345 10,345 10,345 0

Revaluation Reserve 9,176 9,176 9,176 0

TOTAL TAX PAYER'S EQUITY 48,157 49,389 49,223 (166)

Taxpayers Equity

Current Assets

Current Liabilities

Non Current Liablities

Paper 03


P) Cash Flow Statement

``


Rolling Cashflow Forecast Dec-11

INCOME

Jan Feb March April May June July August Sept Oct Nov Dec Jan Feb Mar Apr May June July August Sept Oct Nov Dec

2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012

Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan

Clinical SLA Income 5,615 5,435 5,493 5,394 5,498 5,638 6,014 6,332 6,239 5,907 5,908 5,744 5,902 5,902 5,905 5,850 5,850 5,850 5,850 5,850 5,850 5,850 5,850 5,850

Clinical SLA Overperformance 234 567 1,068 60 215 320 262 203 -19

Clinical SLA Underperformance refunds -434 -39 -700

Other NHS Income 869 669 924 561 693 751 954 580 767 642 678 725 600 600 600 650 650 650 650 650 650 650 650 650

Non NHS Income 866 678 680 504 544 375 694 469 673 474 644 550 400 400 400 450 450 450 450 450 450 450 450 450

Recharges 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125

Donated Capital 600

Total Cash receipts 7,584 7,349 7,731 6,605 7,075 7,209 8,049 7,709 7,785 7,148 7,355 7,144 7,027 7,027 6,930 7,075 7,075 7,075 7,075 7,075 7,075 7,075 7,075 7,075

EXPENDITURE

Payroll 2,219 2,197 2,098 2,195 2,229 2,250 2,179 2,144 2,170 2,172 2,246 2,221 2,225 2,225 2,225 2,200 2,200 2,200 2,200 2,200 2,200 2,200 2,200 2,200

Tax,NI,SPN 1,551 1,547 1,489 1,561 1,539 1,549 1,596 1,514 1,468 1,521 1,492 1,556 1,531 1,530 1,530 1,520 1,550 1,550 1,550 1,550 1,550 1,550 1,550 1,550

Theatre rental 816

Non-Pay via Accs Payable (Trade) 1,662 2,330 2,712 2,677 2,000 2,175 2,259 2,325 2,101 1,748 2,552 2,927 2,650 2,650 2,650 2,500 2,500 2,500 2,500 2,500 2,500 2,500 2,500 2,500

Non-Pay via Accs Payable (NHS) 542 411 1,125 629 487 718 481 654 521 554 513 423 650 650 650 650 650 650 650 650 650 650 650 650

Capital (NHS) 274 312 863 175 284 188 62 271 378 136 427 24 913 500 1,315 213 213 213 213 213 213 213 213 213

Capital (Donated) 9 0 45 200 200 200

Investments 1,000 1,000 -500 -500 0 -2,000 4,500 -500 0 0 0 -3,500 -500

Loan Repayment 25 25 25 25

Loan Interest 8 8 8 8

PDC Dividend 582 623 623 623

Total Cash Payments 7,257 7,797 8,447 7,237 6,039 6,880 4,577 11,408 7,610 6,131 7,230 7,151 8,169 4,255 8,726 7,083 7,113 7,113 7,113 7,113 7,769 7,113 7,113 7,113

CASH BALANCE

Opening Balance 2,193 2,520 2,072 1,356 724 1,760 2,089 5,561 1,862 2,037 3,054 3,179 3,172 2,030 4,802 3,006 2,998 2,960 2,922 2,884 2,846 2,152 2,114 2,076

Cash Movement 327 -448 -716 -632 1,036 329 3,472 -3,699 175 1,017 125 -7 -1,142 2,772 -1,796 -8 -38 -38 -38 -38 -694 -38 -38 -38

Closing Balance 2,520 2,072 1,356 724 1,760 2,089 5,561 1,862 2,037 3,054 3,179 3,172 2,030 4,802 3,006 2,998 2,960 2,922 2,884 2,846 2,152 2,114 2,076 2,038

Total cash including investments

Add short term investments 2,000 3,000 2,500 2,500 2,000 2,000 0 4,500 4,000 4,000 4,000 4,000 4,000 500 0

Total Cash Holding 4,520 5,072 3,856 3,224 3,760 4,089 5,561 6,362 6,037 7,054 7,179 7,172 6,030 5,302 3,006 2,998 2,960 2,922 2,884 2,846 2,152 2,114 2,076 2,038

Previous month forecast cash holding 3,480 3,703 3,200 4,185 4,384 4,499 4,584 6,317 5,463 5,650 6,350 6,321 5,678 5,035 3,058 3,050 3,012 2,974 2,936 2,898 2,204 2,166 2,128

Variance 1,040 1,369 656 -961 -624 -410 977 45 574 1,404 829 851 352 267 -52 -52 -52 -52 -52 -52 -52 -52 -52

Drivers for Variance from previous

months forecast

Capital expenditure -700k

ForecastActual

Paper 03


Appendix 1 - Declaration of performance against healthcare targets and indicators

These targets and indicators are set out in the 2011-12 Compliance Framework

Definitions can be found in the "2011/12 Compliance Framework"

Month 9 Year to

dateThreshold/

agreed target

YTD Weighting

Achieved /

Not Met explanation

Clostridium Difficile -meeting the C.Diff objective 2 1.0 Achieved

MRSA - meeting the MRSA objective 0 1.0 Achieved

Cancer 62 Day Waits for first treatment (from urgent GP referral) >85% 1.0 AchievedReferral to treatment time, 95th percentile, admitted patients <23Wks 1.0 AchievedReferral to treatment time, 95th percentile, non-admitted patients <18.3Wks 1.0 AchievedCancer 31 day wait from diagnosis to first treatment >96% 0.5 AchievedCancer 2 week (all cancers) >93% 0.5 AchievedCompliance with requirements regarding access to healthcare for people with a learning disability N/A 0.5 Achieved

Risk of, or actual, failure to deliver mandatory services Yes/No 4.0 No

CQC compliance action outstanding Yes/No 2.0 No

CQC enforcement notice currently in effect Yes/No 4.0 No

Moderate CQC concerns regarding the safety of healthcare provision Yes/No 1.0 No

Major CQC concerns regarding the safety of healthcare provision Yes/No 2.0 No

Yes/No 2.0 No

Results left to complete 0Total Score 0.0

Override

RatingAMBER-GREEN Amended to reflect low C.Diff target

Indicative Governance risk rating AMBER-GREEN

Target or Indicator (per 2011-12 Compliance Framework)

Unable to maintain, or certify, a minimum published CNST level of 1.0 or have in place appropriate alternative arrangements

Paper 03


Paper 04

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 04 Quarter 3 Infection Control Report.doc

1

BBOOAARRDD OOFF DDIIRREECCTTOORRSS 2266TTHH JJAANNUUAARRYY 22001122

Russell Hardy 4358 Chairman

Executive Responsible Nicki Bellinger, Interim Director of Nursing Paper prepared by (if different from above)


Development

Performance and Governance Context Previous Board discussion Link to National Policy National Requirement Link to Trust’s Strategic

Objectives

Risk if no action taken Executive Summary

Quarter 3 infection prevention and control and cleanliness report outlines the performance of the Trust against the registration requirements. Activity to support these requirements is outlined in the report, and is on trajectory against the annual work programme.

Subject/Title Quarterly Infection Prevention, Control and Cleanliness Report – Quarter 3

Nature of Report For Information For Discussion For Approval


Legal Implications

Recommendation The Board of Directors approve the attached report


Paper 04


2

BBOOAARRDD OOFF DDIIRREECCTTOORRSS 1111TTHH JJAANNUUAARRYY 22001122

QQUUAARRTTEERR 33 RREEPPOORRTT FFOORR IINNFFEECCTTIIOONN PPRREEVVEENNTTIIOONN AANNDD CCOONNTTRROOLL AANNDD

CCLLEEAANNLLIINNEESSSS

EEXXEECCUUTTIIVVEE SSUUMMMMAARRYY 1.0 Introduction Through the monthly Board performance report, the Board are briefed on the mandatory bacteraemia results and any key issues emerging from those results. Over and above the mandatory reporting, the Board are required to receive a quarterly Board report from the Director of Infection Prevention and Control (Director of Nursing and Governance), to ensure that the Board are briefed at a high level on any trends or issues that identify best practice or any gaps in assurance from which further work or actions are required. This report includes a high level summary of the key issues in Infection prevention and control as well as cleanliness. 2.0 Key Issues for Quarter 3 MRSA

Bacteraemia MSSA

Bacteraemia C Difficile E- coli

Bacteraemia Commenced June

2011

Month No. of Cases No. of Cases No. of Cases No. of Cases October 0 0 0 0 November 0 0 1 4 December 0 0 0 1 Through the balanced score card approach the Board receive the monthly performance against the reportable mandatory bacteraemia.

Rationale for commencing E- coli reporting June 2011

The Department of Health (DH) has asked NHS acute Trusts to report episodes of Escherichia coli bacteraemia to the HPA through the established enhanced mandatory surveillance Data Capture System (DCS); with effect from 1 June 2011. This is following a year-on-year increase in Gram-negative bacteraemia as reported by the HPA via the voluntary surveillance system and an ARHAI recommendation to commence E. coli bacteraemia surveillance.

The purpose of the enhanced surveillance is to gather information on the phenomenon of increasing reports of Gram-negative bacteraemia and particularly E. coli bacteraemia. This information will allow more accurate determination of possible interventions to prevent avoidable bacteraemias.

There were four cases of E- coli bacteraemia during November, these rates are in line with national figures.

Paper 04


3

There was one case of C- difficle reported in November on Ludlow Ward. A Root Cause Analysis (RCA) highlighted that the patient received two post operative doses of prophylactic antibiotics, which could have contributed to the cause. The ward followed the C-difficle policy and the patient responded to treatment. 3.0 Annual Infection prevention and Control work plan

The Infection Control Committee reviewed the programme of work on 17th October

2011 and considerable progress continues to be made and remains on target to be completed within the timeframe.

A summary in the main report outlines the performance in Infection Control.

4.0 Recommendation The Trust Board are asked to approve the quarterly progress reports against the annual plan for:

Infection prevention and Control Report Nicki Bellinger Interim Director of Nursing

Paper 04


4

QQUUAARRTTEERR 33 IINNFFEECCTTIIOONN PPRREEVVEENNTTIIOONN CCOONNTTRROOLL AANNDD CCLLEEAANNLLIINNEESSSS RREEPPOORRTT

1.0 Introduction The Board are required to receive a quarterly Board report from the Director of Infection Prevention and Control (Director of Nursing and Governance), to ensure that the Board are briefed at a high level on any trends or issues that identify best practice or any gaps in assurance from which further work or actions are required. 2.0 Infection Control Committee 2.1 The Board agreed an annual Infection prevention and Control programme of work for

2011/2012. The activities outlined in that plan up to Quarter 3 have been undertaken and the plan is therefore on target.

3 Cleanliness 3.1 Measured cleanliness has been maintained above the National calculated target (86.4%)

and Trust target (94.0%) over the second quarter period, achieving an overall average for the quarter of 97.4%, this score is within 0.1% of the previous quarters score.

Trust Audit Scores

78

80

82

84

86

88

90

92

94

96

98

100

28/0

3/20

11

04/0

4/20

11

11/0

4/20

11

18/0

4/20

11

25/0

4/20

11

02/0

5/20

11

09/0

5/20

11

16/0

5/20

11

23/0

5/20

11

30/0

5/20

11

06/0

6/20

11

13/0

6/20

11

20/0

6/20

11

27/0

6/20

11

04/0

7/20

11

11/0

7/20

11

18/0

7/20

11

25/0

7/20

11

01/0

8/20

11

08/0

8/20

11

15/0

8/20

11

29/0

8/20

11

05/0

9/20

11

12/0

9/20

11

19/0

9/20

11

26/0

9/20

11

03/1

0/20

11

10/1

0/20

11

17/1

0/20

11

24/1

0/20

11

31/1

0/20

11

07/1

1/20

11

14/1

1/20

11

21/1

1/20

11

28/1

1/20

11

05/1

2/20

11

12/1

2/20

11

19/1

2/20

11

Audit Week (Monday)

Per

cen

tag

e S

core

National Target Trust Target RJAH Score

Paper 04


5

3.2 Measured standards in Theatres have continued to be maintained above the National

Target of 98%:

Month Average Score April 11 99.33%May 11 99.29%June 11 98.99%July 11 98.65%August 11 98.58%September 11 98.72%October 11 99.12%November 11 98.85%December 12 99.10%

4.0 Infection Prevention and Control Training

General Statutory Training Course

October 49

November 32 General Statutory Training Course on

E Learning for non clinical staff December 37

Total 194

October 32

November 22 General Statutory Training Course on

E learning for clinical staff December 22

Total 76

October -

November - General Statutory Training Course

for Consultants December 14

Total 14

4.1 The feedback from training delivery in Quarter 3 has continued to remain positive as

reported in the previous reports. The training has raised an awareness for consultants of the local targets set for the Trust.

4.2 Infection Control & Cleanliness Link Nurse/Working group Meetings Link Nurse AttendanceOctober 19November 18 December 16 The infection control link meetings have amalgamated with the infection control and cleanliness working group. This has proved successful as the ward/departmental links can discuss any issues/concerns with key personnel from both facilities and estates.

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6

5.0 Audit In Quarter 3, the identified planned clinical audits have been undertaken. These include audit tools from the ICNA (Infection control nursing association) which include:

Departmental waste handling and disposal, Safe handling and disposal of sharps, Environment, Ward/departmental kitchens, Management of patient equipment Isolation precautions High Impact Intervention audit tool kit Hand hygiene audits

5.1 Audit results Quarter 3 Saving Lives Ownership has been transferred to clinical areas via the saving lives initiative and results are displayed on the ward. The ward managers have received training to enable them to be able to support their teams and to produce action plans of the key areas when compliance is less than 90%. The infection control nurse continues to support clinical staff in undertaking audits. 5.2 Year to date compliance on High Impact Interventions

High Impact Intervention – Quarter 3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ludlo

w

Clwyd

Powys

HDU

Theat

re/A

naes

thet

ics

Recov

ery

POAU

Gladsto

ne

Wre

kin

SIU o

p's

Kenyo

n

Ercall

Sheldo

nAlic

e

ORLAU

MENZIE

SOP'S

AVERAGE

October

November

December

The audit results demonstrate that in Quarter 3 the average for all areas was maintained at 95% and above. Although Menzies and Theatres/Anaesthetics have lower scores than the other areas, they have raised their scores considerably over the past months and continue to improve. Nil returns were received from Gladstone and Wrekin ward during November and December. This has been raised with the Ward Manager and the Matron for Spinal Injuries.

Paper 04


7

5.3 Hand Hygiene Audit A key objective of the Trust is to promote a clean culture and to ensure that hand hygiene and infection prevention and control is embedded in the management agenda and the accountability of all staff. The importance of hand hygiene is considered a priority and the need for its emphasis in the health care setting is recognised.

Of the 952 audits carried out in quarter 3 the overall score was 95%. The average score each month continues to rise with October demonstrating a score of 94% with an increase to 97% for November and 99.7% for December. The overall score for the Doctors was 92% for the Quarter, which is a continued improvement from previous scores.

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8

5.4 ICNA

• Carried out on a monthly, rolling programme basis

The monthly ICNA environmental audits continue to achieve above 93%. A report is generated and distributed to ward/departmental managers highlighting outstanding issues that require action. 6.0 Surgical Site Surveillance (SSI) and Wound Clinic Providing data to the national SSI process enables the Trust to benchmark on a national basis with other Trusts and promote the low Infection rates within the Trust. The process uses nationally agreed criteria from which the definition of a Surgical Site Infection is formed. The national requirement for the auditing of SSI in arthroplasty patients is one quarter per calendar year. In recent years audits had been carried out to meet the minimum national standard but the Trust has the resources to compile a full complement of quarterly audits. During Quarter 3 spinal surgery was included as a surveillance category.

Paper 04


9

The Infection Control Nurse liaises with Consultants concerning any wound infections. The data for Quarter 2 has been verified and these results have been published.

Total Knee replacement surgical site Infections

Quarter 2 National Average

Activity of 4 infections from 352 Procedures 1.1% 0.9%

Total Hip replacement surgical site infections

Quarter 2 National Average

Activity of 3 infections from 346 Procedures 0.86% 1.0%

Spinal surgical site infections Quarter 2 National Average

Activity of 1 infection from 155 procedures 0.6% 1.3%

There were 7 reported cases of surgical site infections in hip and knee replacements. This shows an increase from previous quarters with total knee replacements slightly above the national average for Quarter 2. Following a root cause analysis there was no correlation between:-

o Surgeons o Organisms isolated o Theatres o Wards

However over the year, RJAH infection rates remain below the national average. 6.1 Wound Clinic The wound clinic continues to prove successful from a patient and consultant prospective in preventing patient readmissions and delayed discharges with a total of 130 visits since opening in August. Of the 130 visits, 21 patients required further treatment and 10 patients required re-admission. 7.0 MRSA Swabbing process & New Isolates MRSA swabbing for all admissions continues and is monitored internally to ensure that the Trust remains compliant to the national requirement for reducing preventable Hospital acquired Infections. Quarter 3 % screening compliance October 100% November 99.83% December 99.90% The MRSA screening compliance continues during quarter 3. This has been achieved by a more robust reporting system from the wards to the information department. 8.0 Outbreaks There have been no recorded outbreaks during quarter 3 9.0 Conclusion RJAH is constantly striving for low infection rates. Currently the Trust is below the national average for Healthcare associated Infections. 10.0 Recommendations The Trust Board are asked to note the progress outlined in the Quarter 3 report and approve the report. Nicki Bellinger

Paper 04


10

Interim Director of Nursing (DIPC)

Paper 05

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 05 Q3 Monitor Return.doc

Russell Hardy �� 4358

Chairman



Executive Responsible Wendy Farrington Chadd, Chief Executive


Helen Ashcroft, Business Planning Manager Craig Macbeth, Deputy Director of Finance


Development



Link to National Policy �


�


Executive Summary

This paper provides assurance to the Trust Board in relation to

the key targets and declarations required by Monitor for the

Quarter 3 performance return.



Recommendation It is recommended that the Board approve: • The content of the Quarter 3 (Month 9) submission to

Monitor.

Subject/Title Quarter 3 Monitor Return


For Discussion �

For Approval �

Paper 05


TRUST BOARD

MONITOR QUARTERLY RETURN

QUARTER 3 - JANUARY 2012

1. Introduction

1.1 As a Foundation Trust the organisation is required to provide Monitor with quarterly

returns detailing the Trust’s performance against the national targets and core

standards as outlined in Monitor’s Compliance Framework.

1.2 The return for the third quarter is due on the 31st of January 2012 and will detail performance to the end of December 2011, the ninth month of the 2011/12 financial

year.

1.3 This paper presents the Board with the details of the targets against which the Trust

is measured and provides assurance of the Trust’s position in relation to these targets as to the end of December 2011.

1.4 The content of the quarterly return is drawn from the Board’s monthly performance

scorecard which covers the majority of the Compliance Framework requirements.

2. Monitor quarterly return format and targets

2.1 The Monitor Quarterly return is split into four sections:

• Overarching declarations of achievement

• Compliance Framework targets and indicators (service performance)

• Details of Governor elections

• Financial position indicators

2.2 Overarching declarations

2.2.1 There are three overarching declarations against which the Trust must confirm its compliance. These are:

• In year Finance declaration:

“The Board anticipates that the Trust will continue to maintain a financial risk

rating of at least 3 over the next 12 months”

• In year Quality Board statement:

“The Board is satisfied that, to the best of its knowledge and using its own

processes and having had regard to Monitor’s Quality Governance Framework (supported by Care Quality Commission information, its own information on

serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), its NHS Foundation Trust has, and will keep in place,

effective arrangements for the purpose of monitoring and continually

improving the quality of healthcare provided to its patients”

Paper 05


• In year governance declaration:

“The Board confirms that all targets and indicators have been met (after

application of thresholds) over the period and that sufficient plans are in place to ensure that all known targets and indicators which will come into

force during 2011-12 will also be met” and “Details of any elections held

(including turnout rates) and any changes in the Board or Board of Governors are included in that quarter’s return”.

2.3 Compliance Framework targets and indicators

2.3.1 Monitor’s return requires the Trust to confirm its service performance against the

main Compliance Framework targets relevant to the Trust as set out below.

• Clostridium Difficile – requirement to have no more than 2 C. Difficile cases during the financial year 2011/12

• MRSA - requirement to maintain a zero MRSA rate

• Maintenance of all national cancer targets including:

� Maximum one month wait from diagnosis to treatment

� Maximum waiting time of 31 days for second or subsequent treatments for

all cancers

� Maximum waiting time of 31 days from diagnostic to first treatment for all

cancers

� Maximum 62 day wait for first treatment either from urgent GP referral to

treatment or from Consultant screening to treatment

� All cancers 31 day wait from diagnosis to first treatment

� Maximum waiting time of 2 weeks from urgent GP referral to first

outpatient appointment for all urgent suspected cancer referrals

• Referral to treatment times for admitted patients of 23 weeks (95th percentile) –

18 weeks

• Referral to treatment times for non-admitted patients of 18.3 weeks (95th

percentile) – 18 weeks

• Learning Difficulties – achievement of the 6 criteria for meeting the needs of people with learning difficulties

2.4 Details of any Governor elections 2.4.1 The Trust must confirm details of any Governor’s elections which have taken place in

the reporting quarter alongside turnout rates. Details of any changes to the Board are not reported in the return instead uploaded on an ‘as and when’ basis through the

year.

2.5 Financial position indicators 2.5.1 The Trust must report on a series of indicators Monitor have developed as early

warning indicators of financial risk. There are 10 indicators in total focusing predominantly on liquidity performance of the Trust.

Paper 05


3. RJAH assurance processes

3.1 The Trust Board is assured of compliance with the quarterly submissions via the

existing reporting structures in place, supporting the sign off of the Trust

declarations. These include the integrated balanced scorecard, reports made directly to the Board and those reviewed by delegated sub committees of the Board.

3.2 Details of the Trust’s financial and compliance framework targets are reported

monthly via the integrated balanced scorecard whilst quality governance assurance is provided via the monthly performance report, the work of the Quality and Safety

Committee and through the Board Assurance Framework. In addition regular

feedback is received via Directors reports and from non executive patient safety walkabouts.

3.3 Any exceptions to the targets would be formally reported via normal reporting routes

and in addition highlighted in a quarterly submission preview paper such as this

provided to the board in advance of the Quarterly submission deadline.

3.4 Further assurance can be gained from the recent Board self assessment process which concluded that the board and its processes were fit for purpose. A Board

development programme is being signed off by the Board under a separate agenda item.

4. The quarter 3 submission

4.1 The Quarter 3 submission will detail performance to the end of December 2011 and

will be uploaded to Monitor on the 31st of January 2012.

4.2 The Board declarations will be signed off by the Chief Executive Officer following

approval by the Trust Board via this paper.

4.3 Main points to note within the quarter 3 submission are:

4.4 Financial position declaration & indicators

4.4.1 Evidence to assure the Board that the Trust has met its financial targets for quarter 3

is contained within the Trust’s integrated performance paper.

4.4.2 The Trust is continuing to achieve an overall financial risk rating level of 4 as per its

plan and forecasts to do so to the year end.

4.4.3 No change from the Q2 position for the ‘early warning’ financial indicators with us continuing to flag as an exception against two of the ten tests applied. As last quarter

these are the percentage of Capex spend vs. plan and the percentage debtors over

90 days. Neither of these metrics represents any underlying issues and both have been discussed directly with Monitor who have confirmed they are satisfied with the

Trust’s position. Following the quarter 2 return the Trust were required to submit a revised capital plan trajectory.

4.5 Compliance Framework targets and quality indicators

4.5.1 Aligned with the monitoring of the financial position indicators the compliance framework targets are reported to the Trust Board on a monthly basis via the

integrated performance paper.

4.5.2 All compliance framework targets including infection control, cancer and referral to

treatment (RTT) 95th percentile waiting times and learning difficulties targets have been met for Quarter 3.

Paper 05


4.5.3 Whilst the Trust has met its predicted C. Difficile target for the quarter it has now

reached its target ceiling of 2 for the whole financial year. As such it is proposed that we continue to highlight with Monitor a risk of the indicator not being achieved by the

year end. This is consistent with the Board corporate risks and aligned to Monitor’s

annual assessment of the Trust. Assuming all other indicators continue to perform to plan this would trigger a score of 1.0 against the compliance framework

(Amber/Green).

4.5.4 The Trust has maintained a level 2 performance for all Monitor key requirements included in the Information Governance Statement of Compliance in the Department

of Health’s Information Governance Toolkit.

4.5.5 The Trust has not received any Care Quality Commission (CQC) reviews and has no

CQC actions outstanding.

4.6 Details of Governor elections & Board changes 4.6.1 The Trust has a full complement of Executive Directors in place and through the

recent Board self assessment is assured that it has the required management capacity, capability and experience in place necessary to deliver the Annual Plan and

that the management structure can deliver the forward plan.

4.6.2 As previously reported there will be two Executive Director appointments over the

coming quarter; the permanent appointment of a Director of Nursing and Director of Operations, both of which have been reported to Monitor by the Chief Executive

Officer.

4.6.3 There have been no Governor elections or changes during the last quarter.

4.6.4 The register of conflicts of interest is maintained by the Head of Financial Governance

for both the Board and Members’ Council which is updated on an annual basis and no material conflicts of interest exist at this time.

5 Recommendations

5.1 On the basis of the information supplied to the Trust Board via routine monitoring

processes and the information within this paper it is recommended that the Board agree:

• The Quarter 3 submission to Monitor and in particular highlighting the

potential risk to the achievement of the C. Difficile target indicator.

• That the Chief Executive signs the relevant declarations within the return on

behalf of the Trust Board.

Wendy Farrington Chadd

Chief Executive

Paper 06

BBooaarrdd ooff DDiirreeccttoorrss

2266tthh JJaannuuaarryy 22001122 Russell Hardy �� 4358

Chairman


Category of Item Strategic Direction and Development


Context Previous Board discussion The Q2 BAF was discussed at the October Board




Executive Summary

The BAF addresses the high level risks to the Trusts objectives. One new risk has been added, which concerned

the NHS Restructuring. The CIP risks have also been clarified to differentiate the current year risk from the future year’s

risk.

Subject/Title Board Assurance Framework


For Discussion �

For Approval �


Legal Implications

Recommendation That the Board notes the Board Assurance Framework.

Acronyms and

Abbreviations

BAF: Board Assurance Framework BRIC: Business Risk and Investment Committee CIP: Cost Improvement Programme

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 06 Board Assurance Framework

Paper 06



RREEVVIIEEWW OOFF TTHHEE BBOOAARRDD AASSSSUURRAANNCCEE FFRRAAMMEEWWOORRKK

Since the Board Assurance Framework (BAF) was discussed at the October Board all of the

risks included in it have been discussed at the nominated Sub Committees.

There has been one new risk added to the BAF. At the request of the BRIC, a new risk has been included which concerns the impact which the restructuring of the NHS will have on the

Trust’s commissioning arrangements. This will be kept under continual review and the Chief

Executive will report developments to the Board as the new arrangements evolve.

The Risks posed by the CIP programme have been clarified and the in year and future year risks are shown separately. Whilst there remains a risk to the in year delivery of the CIP, the

residual risk has been reduced to 9 to reflect current performance and the plans in place for the remaining quarter.

The risk posed by the challenging C-Difficile target remains the highest risk facing the Trust. There have now been two cases of C-Difficile, which is the number which the Trust may not

exceed. The Trust will remain extremely vigilant for the rest of the year and considers that a residual risk of 16 remains appropriate.

Recommendation

That the Board notes the risks which are included in the BAF, the steps taken to mitigate them and the sources of assurance

Wendy Farrington Chadd Chief Executive


Board Assurance Framework Quarter 3

Version: 1.0 Last updated:

Link to IBP

Delivery of services as

demand for our services

increases

Increased referrals due

to failure of demand

management schemes

by commissioners

Director of

Operations

Demand for service exceeds contractual expectations

Cause: Increased referrals through patient choice

Effect: Breach of access targets. Failure to meet contractual

obligations.

I = 4 L = 4

16

40 Implementation of Hip & Knee scores

Implementation of new spinal pathway

Triaging of referralsImproved use of Locums

Out of Job plan sessions with surgeons and anaesthetists have been secured

Improved use of Saturday lists

Capacity has been increased by locum appointments

BRIC / Executive Team Monthly performance report to Trust Board Activity delivery in 2010/11 I = 4 L = 3

12

Delivery of services as

demand for our services

increases

Director of

Operations

Failure to optimise capacity, which could lead to a shortfall in meeting

contractual and RTT obligations

Cause: Delay in the introduction of consultant job plans covering 6 day

operating, with appropriate staff support

Effect: Breach of access targets.

Failure to meet contractual obligations

I = 4 L = 4

16

1189 Improved use of Locums

Out of Job plan sessions with surgeons and anaesthetists have been secured

Improved use of Saturday lists

Capacity has been increased by locum appointments

BRIC / Executive Team Monthly performance report to Trust Board Activity delivery in 2010/11 I = 4 L = 3

12

Maintain C-Difficile

target

Key Monitor

performance indicatorDirector of

Nursing &

Governance

Target set for C-Difficile in 2011/12.

Cause: The DoH have set extremely challenging targets of less than or

equal to 2 cases for this year (2011/12). As at December 2011 two

cases have been reported.

Effect: Due to the nature of patients admitted, potentially this is

unachievable. New testing is much more sensitive, which may result in

a higher level of positive results.

I = 4 L = 5

20

1,161 Policies and Procedures are in place.

Staff are reminded of the Policies and procedures around Infection Control and to contact

the Infection Control Sister if clarification is needed.

Continual monitoring takes place

Additional staff Infection Control training provided by the Infection Control Team.

Increased infection control processes at pre-op.

Introduction of a new pre-op questionnaire.

Surgeons have received additional notice around C-Difficile procedures.

Quality & Safety Committee/

Executive Team

Monthly performance report to Trust Board Target met in 2010/11. (ceiling 7 cases, actual 2 cases) I = 4 L = 4

16

To redesign the patient pathway to facilitate improved patient outcomes and increased productivity

Continue to develop

and improve the patient

pathway, and flow

through the hospital

Revised patient

pathways / length of

stay reduction

Director of

Operations &

Director of

Nursing /

Director of

Nursing and

Governance

Implementation of new patient pathways could result in disruption to

patient services or adversely impact on quality or safety.

Cause: Failure of internal governance or change management

processes.. Failure to recruit appropriately skilled staff.

Effect: Potential quality and safety breaches. Risk to business

continuity including the delivery of some key services. Inability to

deliver demand requirements. Risk to CIP delivery

I = 4 L = 4

16

1,127 Process for incident reporting;

Formal process for introducing new procedures;

HR Strategy and succession plans;

Training and development strategy;

Internal key principles to pathway improvements agreed and project group formed;

Steering group to lead implementation;

Working operational group.

Governance processes to manage identification of guidance.

Monitoring of patient safety measures.

Principle agreements in place for change.


Executive Team

QIPP Work Plans.

Monthly performance report to the Board.

Quarterly divisional reviews.

Steering Group to monitor progress.

Patient Experience KPI's, as reported to the Trust Board,

continue to be rated "green".

I = 4 L = 2

8

Monitor the national

economic climate and

the impact this may

have on local

commissioners

Economic Climate

pressures/ local

commissioner financial

pressures.

Director of

Finance

Financial challenges of the Economic Climate.

Cause: Reduction in Public Sector expenditure. Financial pressure on

the Trusts key commissioners. Financial problems experienced by other

providers in the Local Health Economy.

Effect: Inability of PCT/LHB to afford underlying growth in activity,

which could result in difficulties recovering payment for over

performance. Loss of income through increased demand management

measures. Requirement for increased cost reduction or higher

efficiency gains if income is reduced in any year.

I = 4 L = 4

16

858 The Trust, in collaboration with the SOA, is in communication with the DoH re PBR/

Operating Framework issues.

Plan assumes a reduction in funding over the next 5 years.

The Operating Framework key requirements are within the parameters of the IBP.

North Wales commissioners have confirmed the Trusts position as a strategic partner in

their review of Orthopaedic Services. 2 year financial agreement in place with BCU

(2011/12 to 2012/13)

BRIC / Executive Team Monthly performance report to the Board.

Robust contract monitoring procedures in place.

Monthly contract meetings with Commissioners.

Impact of financial climate built into baseline.

Debt position reported to the Board and in detail every

quarter at Audit Committee.

CIP assumes reduced funding reported monthly to Board.

Financial surpluses delivered.

Planned CIP over achieved.

Positive contractual negotiations and financial

agreements in place.

Long term sustainability model agreed with key English

commissioners aligned to Trust plans.

Downside scenarios as part of IBP demonstrate Trusts

financial viability.

Positive positioning from BCUHB seeing RJAH as

strategic partner.

FT authorisation demonstrates that Monitor have

assessed the Trust as being able to withstand the current

economic climate 2 year financial agreement in place

with BCU (2011/12 to 2012/13)

I = 4 L = 3

12

Emerging Risk Area. Emerging Risk Area. Chief Executive Impact of NHS restructuring on commissioning arrangements

Cause: "Liberating the NHS" reforms will restructure NHS

commissioning. The establishment of clusters and CCGs will cause

instability during transition

Effect: Need to rebuild commissioning relationships. ore complex

commissioning relationships.

I = 4 L = 4

16

1100 Transitional organisations are now in place for local, specialist and SHA clusters. New

relationships are being developed and this is seen as a key area of focus

BRIC / Executive Team Monthly Chief Executive updates to Trust Board. New risk area I = 4 L = 3

12

Principal Risks (and Cause & Effect) Risk RatingRisk Reg

RefMitigating Actions/Controls

Sub-Committee/ reporting

committeePositive Assurance in last 18 monthsSources of Assurance

To develop a vibrant and viable

organisation where people achieve their full potential and success leads to investment in

services for patients

Residual Risk

Score

17/01/2012

Lead DirectorStrategic Aim Principal Objectives

To be the provider of choice for patients

through the provision of safe, effective and high quality orthopaedic and related care.


Board Assurance Framework Quarter 3

Version: 1.0 Last updated:

Link to IBP Principal Risks (and Cause & Effect) Risk RatingRisk Reg

RefMitigating Actions/Controls

Sub-Committee/ reporting

committeePositive Assurance in last 18 monthsSources of Assurance

Residual Risk

Score

17/01/2012

Lead DirectorStrategic Aim Principal Objectives

Continue to work with

colleagues at the

Strategic Orthopaedic

Alliance on the national

tariff, to ensure it

reflects true costs

National tariff volatility Director of

Finance

The risk of instability arising from fluctuations in the annual tariff.

Cause: Associated risk of instability arising from annual tariff

fluctuations. The impact could be compounded given the specialist

nature of the Trust.

Effect: The Trust would not be fully reimbursed for its activity, which

would result in a financial deficit.

I = 4 L = 4

16

1063 Working with colleagues in the Strategic Orthopaedic Alliance (SOA), the trust has agreed

prospective working arrangements with the DoH PBR Team, including a review of the Trusts

PLICs data. The

Trust participates in the National Sense check exercise to highlight any anomalies in the

tariff prior to it being issues. This had a positive impact on the 2011/12 tariff setting

exercise.

SLR/ PLICs allows detailed understanding of cost and income interrelationships.

Approaches to the DoH have been successful on previous occasions. Trust participating in

National Spinal Taskforce review including focus on appropriate specialist tariffs. 2012/13

tariff roadtest has now been released & is currently being assessed.

BRIC / Executive Team Previous successful discussions with SOA/PbR Team.

Meeting with D Flory to discuss future input SOA can have

with PbR team.

Input into tariff setting assumptions.

Downside risk of unstable tariff modelled in IBP.

Participation in the National Sense checking exercise,

resulting in a positive impact on the 2011/12 tariff setting

exercise.

Continual review of the position.

I = 4 L = 3

12

Maintain business

continuity

Business Continuity -

Local Health Economy

incident planning

Director of

Nursing &

Governance

Risk of failure of key Trust systems due to a major incident.

Cause: Catastrophic failure of key Trust systems due to major incident

or acute business continuity issues.

Effect: Potential impact on direct patient care delivery and safety of

staff. Trust systems (IT) fail leading to Trust key processes being

unable to support service delivery. Loss of activity for

a period of time and decreased through put and subsequent loss of

income and increased costs. Impact on Local Health Economy/ key

corporate objectives.

I = 5 L = 4

20

853 Major incident plan includes business continuity and pandemic flu plans developed with LHE.

Major incident and business continuity plans tested on an annual basis.

Department level plans and operational plans in place.

Systems and controls in place to manage a variety of scenarios.

IT disaster recovery plans in place to support electronic systems failure.

Identified Trust lead for major incident and pandemic emergency planning.

Major incident policy has been updated and presented to the December 2011Trust Board.


Executive Team

Regular testing of Trust level business continuity plans.

Departmental and operational plan in place.

Review of Trust plans to ensure remain up to date in light

of any new guidance received.

Updated plan taken to December 2011 Trust Board.

Presentation on the Business Continuity Plans in

preparation for winter pressures given to the Board

(December 2011). Desk

top major incident exercise carried out March 2011.

Significant assurance from an Internal Audit review of

Business Continuity and Disaster recovery (March 2011).

I = 5 L = 2

10

Maintain financial

stability in line with

the Annual Plan,

including the delivery

of CIPs

Undershoot on CIP

beyond 2011/12

Director of

Finance

Risk that the Trust fails to deliver the CIP programme in future years

Cause: Inability to deliver the CIP in future years as the efficiencies

required from the tariff become more challenging.

Effect: Failure to meet financial plan. Deterioration in risk rating.

Possible deferral of capital programme due to cash flow issues.

Potential impact on the quality of service provision.

I = 4 L = 4

16

979 There are detailed plans in place for 2012/13 & 2013/14. Realistic thenmes have been

identified for the subsequent two years.

The Trust has a strong track record of challenging CIP delivery.

The Trust has robust processes embedded for the sign off of CIPs by the relevant

managers.

The service line reporting and PLICs systems are providing more detailed information which

is enhancing the CIP/ QIPP programmes.

BRIC / Executive Team Monthly integrated performance report to the Board.

Regular updates to Executive Team.

Quarterly divisional reviews.

Audit Committee.

External audit.

Business Risk & Investment Committee.

SHA Financial Monitoring.

CIP Track record.

Divisional Performance Framework review meetings.

Divisional meetings minutes.

2009/10 CIP fully met.

Positive Internal and External Audits / Annual Accounts /

Annual Audit Letter.

Audit report providing significant assurance on Financial

Reporting.

FT authoristaion demonstrates that Monitor consider the

Trust to be financially stable

SLR reports.

Efficiency Strategy approved by the Board.

I = 4 L = 3

12

Maintain financial

stability in line with

the Annual Plan,

including the delivery

of CIPs

Undershoot on

2011/12 CIP

Director of

Finance

Undershoot on 2011/12 CIP.

Cause: Slippage in CIP schemes

Effect: Potential impact on outturn Potential impact on cash balance -

both of which could adversely affect the Monitor risk rating

I = 4 L = 4

16

1193 Alternative schemes have been identified to cover known slippage

Monthly & Quarterly divisional reviews include CIP progress. All

CIPs are agreed & signed off by managers Current CIP is being delivered in line with the

plan and forecast to be achieved at the year end. Trust Board is focussing on the key

productivity metrics which will achieve this.

BRIC / Executive Team CIP is reported to the Board on a monthly basis, with more

deytailed deep dives undertaken on request.

2011/12 CIP schemes agreed.

Positive Internal and External Audits / Annual Accounts /

Annual Audit Letter.

Audit report providing significant assurance on Financial

Reporting.

FT authoristaion demonstrates that Monitor consider the

Trust to be financially stable

SLR reports.

Efficiency Strategy approved by the Board.

I = 3 L = 3

9

Maintain business

continuity

NHS wide industrial

action was not

envisaged when IBP

was produced

Associate

Director of

Human Resources

Risk that the Trust will fail to maintain services to its patients

Cause: Inability to agree changes to NHS pensions at a national level.

Effect: Potential ongoing disruption to services, including targeted

action with key groups in the public sector.

Possible failure to meet targets or contractual obligations

I = 4 L = 4

16

1188 Existing contingency and Business Continuity plans are in place

SHA coordination of Business Continuity plans

National guidance has been issued

Associate Director of HR attendance at "Desktop" contingency planning exercise

Local industrial action protocol has been agreed.

Updated information on union membership has been agreed.

BRIC / Executive Team Monthly monitoring report to SHA

Exception reporting to Board of Directors

Activity delivered on 30th November Day of Action I = 3 L = 4

12

Reduce staff sickness

to 2% by 2015

Staff sickness absence Associate

Director of

Human Resources

Failure to manage absence and avoid causes of absence.

Cause:Sickness absence resulting in paid time off

Effect: Increased pressure on colleagues; cost of paid leave; potential

litigation and personal injury.

I = 4 L = 4

16

1004 Sickness Absence Management Strategy

Sickness Trigger points set and monitored monthly

HR performance management and support to Trust

OH service provision Health and Wellbeing Strategy

Constant monitoring and application of the Sickness Absence Management Strategy

Addressing main causes of absence (MSDs/ Stress/ Anxiety) through targeted action

BRIC / Executive Team Monthly performance report to Trust Board.

Quarterly detailed reports to BRIC.

Seeing reduction in overall sickness percentage and long

term issues eg: MSDs.

Launch of the Health and Wellbeing Strategy (Jan 2011).

Improvements in the Staff Survey 2010.

3.5% sickness target is on track to be acheived for

2011/12. Internal Audit review of sickness abscence

(June 2011) gave significant assurance

I = 4 L = 2

8

Acronyms and abbreviations

ALE IM&T Information Management and Technology QIPP Quality Improvement Programme

BAF Board Assurance Framework KPI Key Performance Indicators RJAH Robert Jones and Agnes Hunt Orthopaedic and District NHS Trust

BRIC Business Risk and Investment Committee KSF Knowledge Skills Framework RTT Referral to Treatment

CHC LHB Local Health Board SCPCT Shropshire County Primary Care Trust

CEO Chief Executive Officer LHE Local Health Economy SHA

CINCH LTFM Long Term Financial Model SLR

CIP MPET Multi Professional Education and Training levy SoS

CQC NHSLA NHS Litigation Authority OH

CQUIN OOH Out Of Hours

DIPC PALS Patient Advice and Liaison Service

ESR PEAT Patient Environment Action Teams

FT Foundation Trust PCT Primary Care Trust

HCAI Healthcare Acquired Infections PDR Personal Development Review

HDD Historic Due Diligence PPI Patient and Public Involvement

IIP Investors In People PROMS Patient Reported Outcome Measures

Community Health Council

Community Involvement in Care and Health

Auditors Local Evaluation

Director of Infection Prevention and Control

Strategic Health Authority

Service Line Reporting

Occupational Health

Secretary of State

Care Quality Commission

Commissioning for Quality and Innovation

Cost Improvement Plan


Paper 07

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 07 Consultation on amendments to the Compliance Framework for 2012.doc

Page 1 of 6





Paper prepared by (if

different from above)

Margaret Surrage, Head of Board Governance (Trust

Secretary)


Performance and Governance



Link to Trust’s Strategic

Objectives


Executive Summary

The paper highlights the key changes which Monitor plan to

make to the compliance framework for 2012 and sets out the Boards proposed response to the consultation

Subject/Title Monitor Consultation on the Compliance Framework for 2012


For Discussion

For Approval


Legal Implications

Recommendation That the Board approves the responses as set out in the paper to be submitted to the FTN to be included in their

collective response.


FTN: Foundation Trust Network FRR: Financial Risk Rating CQC: Care Quality Commission

Paper 07


Page 2 of 6



MMOONNIITTOORR CCOONNSSUULLTTAATTIIOONN OONN TTHHEE CCOOMMPPLLIIAANNCCEE FFRRAAMMEEWWOORRKK FFOORR

22001122 Monitor have issued the latest update to their Compliance Framework for 2012/13 for consultation. Until the new licensing regime is introduced, the Compliance Framework remains at the core of Monitor’s regulatory framework. It is proposed that the Trust should respond via the Foundation Trust Network (FTN). 1.0 Summary of key changes The key changes are in the following areas

• changes to Monitor’s board statements;

• adjustments to the FRRs (Financial Risk Ratings) with regard to the treatment

of the cost of capital, income from donated assets and material one-off

income;

• a revision of how Monitor will incorporate the Care Quality Commission’s

(CQC) judgements in its governance scores; and

• the inclusion, as in previous years, of relevant priorities from the Operating

Framework.

2.0 Board Statements Monitor aims to “to streamline and simplify the board statements focusing on the areas of quality, finance and governance. This will reduce the overall number by eight, aiming to address any ambiguity or overlap and ensure greater consistency with the Authorisation”. This will result in the number of statements reducing from 24 to 16. The key points are

• Quality: Clarifies that boards must assess against the Quality Governance

Framework, not merely have regard to it

• Finance: 2 new statements, one of which used to be in the annual monitoring

template. They are that the organisation will maintain

o a Financial Risk Rating (FRR) of at least 3 and

o that the trust shall at all times remain a going concern.

• Governance: 3 amended statements and the merging of 14 statements into

7. (See Appendix 1)

Paper 07


Page 3 of 6

• Each statement is to be certified on an annual basis, with in year statements

on maintaining an FRR of 3 and on compliance with existing targets (as

already happens)

NB The Trusts Quality Strategy links to the Monitor Quality Governance Framework,

so the Trust already uses the key Monitor fields and this will be demonstrated in the

Annual Quality Report.

Proposed Response

The Trust welcomes the move to streamline the number of statements.

The Trust considers that the new finance statements will not prove to be

burdensome as they are in line with current reporting arrangements.

3.0 Adjustments to the FRRs This will introduce a flexibility to recognise the range of financing options to NHS Foundation Trusts. Technical guidance on the classification of the Income from donated assets. Proposal to exclude any “one off” advance or exceptional payment which could skew the FRR. Proposed Response

The Trust considers that the proposed changes represent a pragmatic solution to these technical issues. The Trust has identified a potential problem whereby the calculation of the ROCE (Return on Assets Employed) could be skewed by a large impairment. Further clarification of how this should be treated should be included in the guidance. 4.0 Care Quality Commission’s (CQC) judgements Monitor have set out two options on how CQC’s regulatory actions could be reflected in the Governance risk ratings (GRR).

Impact on governance rating CQC action

Option A Option B

Compliance action with minor impact

+0 (no impact) +0 (no impact)

Compliance action with moderate impact

+0 (no impact) +1.0 (minimum Amber-green)

Compliance action with major impact

+2.0 (minimum Amber-red) +2.0 (minimum Amber-red)

Enforcement action Red-rated and consideration for escalation for potential significant breach of the terms of Authorisation

Red-rated and consideration for escalation for potential significant breach of the terms of Authorisation

Paper 07


Page 4 of 6

Proposed Response

The Trust supports the view expressed by the FTN. (i.e. “The FTN agrees with Monitor that Option A is preferable. This is largely based on the need for the CQC to change its culture sufficiently to ensure a proportionate regulatory response, which it has not always achieved in the past. Therefore until we can be sure there is appropriate discrimination by CQC between minor and moderate impact it will be better for Monitor to be cautious”)

5.0 Operating Framework Priorities

These reflect the priorities as set out in the Operating framework. The most significant change being the “Referral to Treatment” measures. The metric has reverted back to measuring the percentage of patients, both admitted and non admitted seen in 18 week from referral to treatment and a new metric had been added for patients waiting on an incomplete pathway. The new metrics are shown in the table below.

Maximum 18 week waiting time

Score Monitoring frequency

Admitted patients 90% 1.0 Quarterly

Non-admitted patients

95% 1.0 Quarterly

Patients on an incomplete pathway

92% 1.0 Quarterly

The Trust will amend its performance report to reflect these metrics. The new metric on the incomplete pathway will present a risk to the Trust, as it is currently performing at slightly under this target. At December the performance was 88%. This is currently being monitored on a weekly basis. Proposed Response

The Trust is in agreement with the principle that the Compliance

Framework should reflect the Operating Framework.

6.0 Other Issue –Clostridium Difficile metric

The Trust would like to express its disappointment that there has been no

change to this metric, and would ask Monitor to consider a de minimis

limit similar to that adopted for MRSA. The current situation penalises

high performing Trust’s, who are set targets with no threshold for

variations.

7.0 Recommendation

That the Trust should forward the responses as listed above to the FTN for inclusion

in their collective response.

John Grinnell

Director of Finance

Paper 07


Page 5 of 6

Appendix 1

Paper 07


Page 6 of 6

Paper 08

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 08 FT Annual Reporting Requirements.doc






Margaret Surrage, Head of Board Governance (Trust Secretary)


Development



Link to National Policy Monitor Requirements



Executive Summary

This reports sets out the key changes in the Annual

Reporting requirements the Trust faces as a Foundation

Trust. It notes that the Annual report contains both the full

Financial and the Quality Accounts and all of these elements must be submitted to Monitor by May 31st

Subject/Title Foundation Trust Annual Reporting Requirements


For Discussion

For Approval


Legal Implications

Recommendation That the Board note the FT reporting requirements and

approve the revised approach to the Annual Report.


Paper 08





FFTT AANNNNUUAALL RREEPPOORRTTIINNGG RREEQQUUIIRREEMMEENNTTSS As a foundation trust, the Trust faces a number of changes to its Annual reporting regime.

The key changes are:

• The Quality Accounts, Annual Report and the Annual Accounts (in Full) will all be

combined into one document

• This has resulted in a significantly shortened timescale for the production of the

quality accounts and the annual report, as these will be required to be submitted to Monitor, along with the Accounts on May 31st

• The Annual report and accounts must be “laid before parliament”, they may not be

published before this has been done (end of June)

• There are a number of additional disclosures as laid out in the Governance

Framework

These changes will impact on the style and nature of the document; it will inevitably be a lot

longer than in previous years. (A review of an FT’s 2010/11 Annual report found that it ran to 144 pages, as opposed to the Trust's report which was 27 pages). It will also contain a lot

more detail about the Governors and Directors (see Appendix 2)

It is proposed that future Annual Reports will be more focussed on business matters and the mandatory reporting areas, rather than including photographs and additional interesting

items about the Trust.

There are two areas where reporting is voluntary, but encouraged as best practice;

• Sustainability

• Equality

It is proposed to include a brief report on sustainability and an overview of the Trusts actions

on equality, which will include a reference to the detailed equality report which will be

published on the Trust website.

A summary of the items which must be included in the Annual report is shown at Appendix 1, along with the two voluntary disclosures. A more detailed list of the items which are required

as part of the Foundation Trust Code of Governance is shown at Appendix 2.

Recommendation

That the Board note the FT reporting requirements and approve the revised approach to the Annual Report.

John Grinnell

Director of Finance

Paper 08


Appendix 1

FT Annual Reporting Requirements

Minimum contents Notes Change from Trust

Requirements

Full set of Accounts As per accounting Manual Previously summary version

Directors report,

including management commentary

• Details of directors &

Trust’s principal

activities • Operating & Financial

review

• Enhanced Quality

governance reporting

• Directors statement

re disclosure to auditors

• Brief history of FT &

Statutory background • Directors interests

• Going Concern. (no

presumption of going

concern, director must “decide” &

declare)

No Change

No Change

New

No change

New

No change

New

Remuneration report • Details of Senior

persons remuneration

• Remuneration

policies etc

No Change

Disclosures as set out in code of governance

(See below for detail)

• Council of Governors

• Board of Directors

• Audit Committee

• Nominations

Committee • Membership

New

New No significant change

New

New

Quality report Full report to be included Separate guidance to be

issued

Previous report published separately

Assume similar to last year.

Staff Survey • Commentary –

approach to staff

engagement

• Focus on top &

bottom 4 scored answers

• Table of results

• Action plan

• Future priorities &

targets

New

New

New

New

Regulatory ratings • Monitor risk ratings

• Compare to planned

& actions in place to

rectify shortfalls

New

New

Paper 08


Other disclosures in the

public interest (Best practice)

Required

• Info to/consultation

with employees

• Disabled/equal ops

policies • Health & safety,

Occupational health

• Better payments

practice code • Consultations

• Consultation with

local groups, inc

overview & scrutiny committee

• Other public/patient

involvement activities

• Management Costs

• Ill health retirements

• Details of “other

income” if significant • Sickness absence

data

• Compliance with

charging requirements re

provision of

information • SI’s re data

governance

No significant change













Statement of accounting

officer responsibilities

Model Statement provided No significant change

Annual Governance

Statement (SIC)

• To be included in full

• Include quality

governance (this is a

significant

requirement – it includes

� Board assurance on compliance with CQC

registration

� Board Assurance on accuracy of quality

report • Board review of the

effectiveness of

internal controls

New

New


Voluntary Disclosures • Sustainability Report

• Equality Reporting

New

New

See overleaf for detail of the disclosures required by the Code of Governance.

Paper 08


Appendix 2

Disclosures set out in Code of Governance

Council of Governors

How relates to Board of Directors

New

Governor details & interests New

Meetings & attendance by governors &

Directors

New

Steps taken to understand the views of governors & members

New

Board of Directors

Names of chair/NEDs appointment date,

length of appointment, which NEDs

considered to be independent, how NEDs may be terminated

New

Number of meeting & attendance New

Background of board members inc areas of expertise & experience

New

Statement about balance of board

membership

New

Performance evaluation of board, committees

& Directors

New

Declaration of interests New

Other Significant commitments of chair New

Audit Committee

Names, number of meetings, attendance at

meetings

More detail

Role No significant change

Statement if Governors do not accept AC recommendation re external auditors

New

Auditor independence New

Directors responsibility for preparing accounts & auditors statement of their

reporting responsibilities

No Change

Nominations Committee

Membership, number of meetings

attendance, role. Extra info if recruitment of Chair or NED not open advert or search

consultancy

New

New

Membership

Eligibility, boundaries New

Members numbers New

Summary of strategy, inc progress to targets. New

Paper 09

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 09 Board Business Programme.doc




Executive Responsible Russell Hardy, Chairman


Margaret Surrage, Head of Board Governance (Trust Secretary)


Development

�





�


Executive Summary

This schedules the key business of the Board, including its

development sessions.

The dates of the Sub Committees are also included.

Subject/Title Board Business Programme


For Discussion �

For Approval �


Legal Implications

Recommendation That the Board approve the Board Business Programme.

Acronyms and

Abbreviations

Paper 09

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 09 Board Business Programme.doc




BBOOAARRDD BBUUSSIINNEESSSS PPRROOGGRRAAMMMMEE

The Board Business Programme has been updated and expanded to include the Board Development Sessions and the dates of the Sub Committees.

Board Dates It has been necessary to make one change to the scheduled Board dates. This was in

response to the timetable for the submission of the Annual Report and Accounts which was issued by Monitor after the Board dates had been agreed. The Annual Report has to be

submitted before 9:00am on 31st May 2012, which is the date at which the Board would have

been reviewing them, so the Board meeting has been brought forward to 29th May 2012.

Sub Committees The Sub Committees have been scheduled to meet in the month following the end of the

quarter. This will enable them to support the quarter Monitor sign off process. It has not been possible to schedule this for April owing to Easter.

Special meetings of the Quality & Safety Committee and the Audit Committee have been scheduled for the morning of 29th May 2012 to enable them to review the Quality and Annual

Accounts respectively and then feedback to the Board of Directors later that afternoon.

Board Development Programme

The topic areas which had previously been agreed at the October meeting have been prioritised and scheduled.

Two worksheets are attached, one summarising the dates of the Sub Committees and the

Board Development sessions, and one setting out the Board programme in detail.

Recommendation

That the Board approve the Board Business Programme.

Russell Hardy Chairman

BOARD DEVELOPMENT SESSIONS Date

Board Strategy Day Jan 31st

SLR/PLICS April 27th

Risk Management June 29th

Governors & Members Sept 28th

Research, Audit & Outcomes Nov 30th

Board Strategy Day 2013/14 Jan 25th 2013

Sub Committees dates Date Time

Audit Committee April 19th 2:00pm

July 12th 2:00pm

October 11th 2:00pm

January 10th 2:00pm

Audit Committee - special meeting to approve Accounts May 29th 10:00am-11:00am

BRIC March 21st 10:00am

July 11th 10:00am

October 10th 10:00am

January 9th 10:00am

Q&S March 22nd 2:00pm

July 19th 2:00pm

Oct 18th 2:00pm

Jan 16th 2:00pm

Q&S - special meeting to approve the Quality Accounts May 29th 11:00am - 12:00

Charitable Funds Committee (After Trust Board) March 29th

June 28th

(November meeting not after Trust Board due to Governors meeting) November 20th

BOARD BUSINESS PROGRAMME 2011/12 and 2012/13

Jan Feb

Mar (Feb

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

2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013 2013 2013

FORMAL TRUST BOARD (monthly) 26th 1st 29th 26th 29th pm 28th 26th 30th 27th 25th 29th - 24th 28th 28th

ANNUAL GENERAL MEETING (annual) 26th

Council of Governors meeting dates (quarterly) 23rd 31st 26th 29th 21st

BOARD DEVELOPMENT SESSIONS 31st 27th 29th 28th 30th 25th 29th

Sub Committees

Audit Committee - Regular 19th 12th 11th 10th

Audit Committee - Extraordinary (draft & final accounts) 19th

29th am

10:00: 11:00

Quality & Safety - Regular 22nd 19th 18th 16th

Quality & Safety - Extraordinary (quality accounts)

29th am

11:00to12:00

BRIC 21st 11th 10th 9th

Charitable Funds 29th 28th 20th

Nomination & Remuneration committee as & when required

BOARD DEVELOPMENT SESSIONS

Board Strategy Day

SLR/PLICS

Risk Management

Governors & Members

Research, Audit & Outcomes

FORMAL TRUST BOARD

External Reporting

Annual Plan (12/13)

Initial draft presented to Governors

Draft- (to include 12/13 budgets for Board approval)

Annual Plan (12/13) Board Approval

Annual Plan (12/13) Presentation to Governors

Annual Plan (12/13) Submission 31st May

Annual Accounts & Report (NB inc Quality Accounts)

Draft Annual Governance Statement (SIC)

Annual Accounts & Report & supporting documents - Board Approval

Annual Accounts Submission 9:00am May 31st

Monitor Returns

FT Q3 monitoring report (Submission date 31st Jan)

FT Q4 monitoring report (Submission date 30th April)

FT Q1 monitoring report (Submission date 31st July)

FT Q2 monitoring report (Submission date 31st Oct)

Strategic Direction & Development

Private Patients

Surgery- Divisional presentation

Strategic Direction Review

Diagnostics Divisional presentation

Medicine- Divisional presentation

Strategic Risk Review -

CIP/QIPP/SLR

Annual Operating/Compliance Framework

Supporting Strategies

Human Resources

Marketing

Strategy Updates

Marketing -

IM&T Strategy

Efficiency Strategy

Quality

Human Resources -

Review of Constitution -

Private Patients -

Standing Financial Instructions

Jan Feb

Mar (Feb

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

2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013 2013 2013

Performance & Governance

Performance Balanced Scorecard

Board Assurance Framework & Corporate Risk Register

Board Sub-Committee Reports (Dates To Be Confirmed)

Sustainability report

FT Q3 monitoring report (Submission date 31st Jan)

FT Q4 monitoring report (Submission date 30th April)

FT Q1 monitoring report (Submission date 31st July)

FT Q2 monitoring report (Submission date 31st Oct)

Council of Governors Report

Staff Opinion Survey Results

Board annual performance review

Board Business Programme

Trust Seal

Register of Interest

Trust Board Terms of Reference

Quality & Safety

Medical Director's Report

Nurse Director's Report

Quality Accounts

Infection Control Report

Infection Control Committee Annual Report

Complaints and Feedback Report

Quality Strategy

Clinical Audit Annual Report

Consultant Appraisal Report

Research Business Plan Strategy Update

Inpatients Survey Results

Update on Legal Claims

Paper 10

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 10 Quality and Safety Committee Chairman’s Report.doc

TTRRUUSSTT BBOOAARRDD

2266tthh JJaannuuaarryy 22001122

Peter Jones �� 4358 Chairman

Executive Responsible Peter Jones, Non Executive Director/Chairman of Quality and Safety Committee








Objectives


Executive Summary

The Quality and Safety Committee met on the 8th December 2011.

A summary of the key issues discussed is given in the Chairman’s

report.

Subject/Title Quality and Safety Committee Chairman’s Report


For Discussion

For Approval


Legal Implications

Recommendation That the Trust Board note the Chairman’s report.

Acronyms and Abbreviations TKR - Total Knee Replacement THR – Total Hip Replacement VTE – Venous Thromboembolism PROM’S – Patient Reported Outcome Measures

Paper 10

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 10 Quality and Safety Committee Chairman’s Report.doc



CCHHAAIIRRMMAANN’’SS RREEPPOORRTT FFRROOMM TTHHEE QQUUAALLIITTYY AANNDD SSAAFFEETTYY CCOOMMMMIITTTTEEEE MMEEEETTIINNGG

88TTHH DDEECCEEMMBBEERR 22001111

Patient Story

• The Interim Director of Nursing shared a written patient story from a recent inpatient on Alice

Ward. Comments, which were overwhelmingly positive, from the patient were shared with the

Committee. The Interim Director of Nursing and Director of Operations had undertaken a ward visit following the patient’s negative comments regarding toilet/shower facilities for

parents, which had highlighted areas for improvement and which would be addressed.

Quality & Safety

• The Committee had a full discussion on the three recent serious incidents. The Committee

discussed the preventative actions, particularly concerning the adherence of patients to the

advice on the prevention of falls, to be taken to ensure similar incidents did not re-occur in the future.

• The Committee received a presentation from the falls lead. The falls lead explained what

measures had been introduced to ensure that patient falls are kept to a minimum including

introduction of a flowchart. As part of a wide ranging discussion on falls prevention, the Committee reviewed the flowchart and suggested how it could be refined to ensure actions

are followed up.

Clinical Effectiveness

• Patient Reported Outcome Measures (PROMs)

The Committee discussed the Data collected by the Outcome Centre. It was noted that this

information will be shared with individual surgeons.

• Dr Foster Report The Committee noted the publication of the report. As a specialist hospital, data relating to hips and knees is not included. However, the patient experience website does show that the

hospital responds well to patient feedback.

Routine Matters

• The Work Plan was reviewed and it was agreed that the Interim Director of Nursing would

update the Work Plan.

• The Medical Director presented the Clinical Audit Quarterly Report. The Committee

recommended that the TKR/THR VTE Audit be repeated as the changing practice at the time

of the audit had affected data collection and a number of variables identified during the audit had made it difficult for conclusions to be reached.

Peter Jones Non Executive Director/Chair of the Quality and Safety Committee

Paper 11

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 11 BRIC Chairs Report.doc




Executive Responsible James Turner, Non Executive Director








Objectives


Executive Summary

This report highlights the key business undertaken by the BRIC at its meeting on 14th December 2011.

The Committee approved a revised Self Assessment for 2010/11,

which is attached for information at Appendix 1. The minutes of the meeting are included with the papers for the

private session of the Board.

Subject/Title Report from the Chair of the Business Risk & Investment

Committee (BRIC)


For Discussion

For Approval �


Legal Implications

Recommendation The Trust Board are asked to • note the Chairman’s Report and the Self Assessment.


Paper 11


James Turner Non-Executive Director



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Risk

The Committee reviewed all of the Corporate and Strategic risks which had been allocated to the

BRIC. They were updated on the risks caused by the NHS restructuring and the actions taken to mitigate the risk of failing to optimise capacity.

Governance

The Committee:

• Received an update on the new main entrance project which included both the progress and

risks concerning the building work and the supporting operational policies. • Received the Internal Audit Reports on “IT General Controls” and “Working Capital and

Treasury Management”, both of which gave significant assurance.

• Approved its Self Assessment, which had been revised following discussion at the September

meeting. A copy is attached for information.

Regular Reports

The Committee noted the following reports: • Capital Programme. This included a discussion relating to a number of future schemes.

• Health & Safety report.

• IM&T. The Committee was also updated on the work to test for Wi-Fi black spots in the

patients’ wireless system and discussed the safeguards in place to ensure that its use did not

compromise patient privacy and dignity.

• Human Resources, which included an update on the recent industrial action and the risks

associated with any further action. • Treasury Management ( Investment Register).

• Work Plan.

James Turner

Non-Executive Director

Paper 11


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ISSUE YES

/NO COMMENTS

RECOMMENDATION

AGREED ACTION

Committee Governance

Does the Committee have written terms of reference that

adequately and realistically define

the Committee’s role?

Yes The Terms of Reference are reviewed annually. They were last approved in June

2010 and will be reviewed at the June 2011

meeting.

Have the terms of reference been

adopted by the Board?

Yes Following the meeting mentioned above,

these were approved by the Trust Board in September 2010.

Are the terms of reference

reviewed annually to take into

account governance developments

Yes See above

Has the Committee established a

plan for the conduct of its own work across the year?

Yes The annual work plan is agreed at the

beginning of the year and is reviewed at subsequent meetings

Are changes to the Committee’s

current and future workload discussed and approved at Board

level?

Yes This was included in the discussions

surrounding the board self assessment – but formal approval not sought

Paper 11


ISSUE YES /NO

COMMENTS

RECOMMENDATION

AGREED ACTION

Does the Committee report

regularly to the Board?

Yes The Chairs provides a written report to the

Board meeting the following month and the minutes are also presented to the Board

once approved. The Board has agreed that committee minutes should be approved

“electronically” enabling the approved

minutes to be presented to the Board the following month

Are members, particularly those

new to the Committee, provided with training?

Yes Not specifically for this committee, but

there is a comprehensive Board development programme, much of which

has a direct relevance.

Does the Board ensure that members have sufficient

knowledge of the organization to

identify key risk areas

Yes As above. There have been specific Board development sessions on risk.

Does the Committee prepare an

annual report on its work and

performance in the preceding year for consideration by the Board?

Yes The first Annual report was prepared for

the June 2010 meeting, and the second for

the September 2011 meeting.

Paper 11


ISSUE YES /NO

COMMENTS

RECOMMENDATION

AGREED ACTION

Business Risk

Has the Committee fulfilled its

obligations to the Audit

Committee to ensure that Business Risk management is

comprehensive and effective?

Yes The Committee has approved a report for

the Audit Committee which demonstrated

that it had effective & comprehensive risk management processes. The chairman of

the audit committee attended the BRIC to receive this report.

The Committee agreed a programme of

risk review which included both a comprehensive review of all of the risks

allocated to it and “deep dives” into specific risk areas.

Has the committee raised new

strategic risks or confirmed the treatment of previously

recognized risks.

Yes The BRIC has requested that additional

risks relating to the NHS reorganization and tariff instability be added to the register.

They have reviewed the risk scores &

confirmed or amended them as appropriate

Has the Committee identified risk

areas where further assurance has been required?

Yes In depth presentations were requested on

Contract management , NHS restructuring and the CIP

Has the committee reviewed

relevant strategies/policies

Yes The committee reviewed a number of

policies including:

Treasury management policy Estates Strategy

Human Resources Data Protection

Information governance forensics

Partnership governance

Paper 11


Investment decision making

Has the Committee reviewed the

investment risks incurred by the Trust when investing its surplus

cash?

The Committee has reviewed the Treasury

management policy and receives regular reports on the Trusts’ investments

Business Investment

Has the Committee reviewed the Business cases for “significant”

investment proposals, & made

appropriate recommendations

Yes No significant investments were presented to the Committee during 2010/11. The

main project (the hospital redevelopment)

having been approved the previous year.

Has the Committee reviewed PPE’s of significant investments

within an appropriate timeframe?

Yes The new theatre was reviewed in October 2010, a year after the theatre became

operational in September 2009. The Torch Building was reviewed in June

2010; services were transferred to the building during November 2008 – January

2009.

Overview & Scrutiny .

Has the Committee received the

KPI’s it requires to perform this

role

Yes The Committee receives quarterly KPI’s

relating the Human Resources and Health

and safety; and Sustainability KPI’s every six months.

Have the reports from the

subcommittees and directors been received with sufficient detail &

timeliness for the Committee to perform this role.

Yes The reports have been received on a

quarterly basis.

Paper 12

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 12 Audit Chairs Report.docx




Executive Responsible Richard Clarke, Non Executive Director.




Development






Executive Summary

This report highlights the key business undertaken by the Audit Committee at its meeting on 15th December 2011.

A brief update is also given on the appointment of the External Auditors for 2012/13

The Minutes of the meeting are included with the papers for the

closed session of the Board.

Subject/Title Report from the Chair of the Audit Committee


For Discussion

For Approval


Legal Implications

Recommendation The Trust Board are asked to note the Chairman’s Report.


Paper 12


Richard Clarke Non-Executive Director



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Governance The Committee

• Reviewed the risk which had been allocated to it from the Corporate Risk Register • Received a report on the progress made against the audits programme which was

set out in the data quality framework. Internal Audit Matters The Committee received the Internal Audit progress report. They reviewed two internal Audit Reports

• Financial reporting • Data Quality

Both of which gave significant assurance. Counter fraud Matters The Committee

• Received the Counter Fraud progress report. • Approved the updated Counter Fraud Policy.

Annual Accounts The Committee

• Received an update on the key technical issues which would impact upon the accounts.

• Approved the draft sign off timetable, pending further clarification on the date of the May Board of Directors meeting.

• Approved the Accounting policies, pending a further review when the draft accounts were presented to the Audit Committee.

Routine Reports The Committee received reports on

• Debtors greater than 90 days, noting that the reporting criteria had changed from “greater than six months” to reflect Monitor reporting requirements.

• Waivers and Losses. • Registers of Interests and Hospitality, and noted that there was only one declaration

which was still outstanding, and that the 2012 exercise would start in January.

• The Committee reviewed its Work plan for 2011/12.

Paper 12


Confidential Session – Appointment of External Auditors Following the receipt of tender documents the list of tenders who would be asked to give a presentation to the panel was agreed. Private discussion with the Internal & External Auditors A meeting took place without any Trust management being present Update on the Selection of External Auditors Following the presentations, on 12th January 2012, to a panel, which comprised of the three audit committee members, the Director of Finance and Ron Pugh representing the governors, the panel reached a unanimous decision of which firm the Audit Committee should recommend that the Governors appoint at their meeting on February 23rd. Richard Clarke, Non Executive Director

Paper 13

Suzanne Marsden – Named Nurse for Safeguarding Children & Young people – Annual Report April 2011 U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 13 Annual Report for Safeguarding Children and Young People 2011.doc

1




Executive Responsible Nicki Bellinger, Interim Director of Nursing





Context Previous Board discussion �



Objectives


Executive Summary

The Trust has statutory responsibility to prepare an Annual Report

for Safeguarding Children and Young People for 2011. This report covers the time period from April 2010 until March 2011. The

purpose of this report is to review actions from last year’s report, and to highlight priorities for the coming year.

Subject/Title Annual Report for Safeguarding Children and Young People


For Discussion �

For Approval �


Legal Implications

Recommendation The Board of Directors are asked to note the report.


Paper 13


2

Annual Report for Safeguarding Children and Young People

1st April 2010 – 31st March 2011

Paper 13


3

1.0 Introduction

1.1 This is the statutory Annual Report for Safeguarding Children and Young People for 2011 as prepared by Suzanne Marsden, Named Nurse for Safeguarding children and Young

people. This report covers the time period from April 2010 until March 2011. The

purpose of this report is to review actions from last year’s report, and to highlight priorities for the coming year.

1.2 Safeguarding children and young people remains high on the national agenda and for all

departments within the Trust that come into contact with children.

The RJAH Trust Board has adopted the Shropshire Safeguarding Boards (SSCB) policy

and incorporates this into the Trusts own Safeguarding children and Young peoples policy.

This report will highlight the National context for safeguarding children and young people

whilst they are in hospital; The local context – including Update on the role of Named

Professionals working in the Trust, training, referrals made during this period with any trends, concerns, together with any recommendations for the coming year.

2.0 Background - National Context & Policy

2.1 The policy context for the statutory guidance is the overarching “Every Child Matters” framework for improving outcomes for children and young people, the “Working

Together to Safeguard children” – A guide to interagency working to safeguard and promote the welfare of children (DOH 2010), The Care Quality Commission (CQC)

standards regulation 11: outcome 7 and The Children’s NSF (2004).

2.2 National Institute for Health and Clinical excellence (NICE) and Social Care

Institute for Excellence (SCIE) have produced guidance regarding When to suspect child maltreatment (July 2009) and this document provides a summary of the clinical

features associated with maltreatment that may be observed when a child presents to healthcare professionals.

2.3 It is clearly evident that safeguarding children is everyone’s responsibility and as a Trust it is crucial that the appropriate procedures are put in place to improve outcomes for

children.

At an organisational level, these key features are having:

� senior managements commitment to the importance of safeguarding and

promoting children’s welfare;

� a clear statement of the Trust’s responsibilities towards children available for all staff;

� a clear line of accountability within the organisation for work on safeguarding and promoting the welfare of children;

� service development that takes account of the need to safeguard and promote

welfare and is informed, where appropriate, by the views of children and

families;

� staff training on safeguarding and promoting the welfare of children for all staff working with or in contact with children and families;

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4

� safe recruitment procedures in place;

� effective inter-agency working to safeguard and promote the welfare of children; and

� effective information sharing

� Updated statutory guidance on making arrangements to safeguard and promote

the welfare of children under Section 11 of the Children Act 2004.

3.0 Local Context

3.1 The role of the Named Doctor for Safeguarding Children

The Named Doctor post became vacant following the resignation of Dr Ros Quinlivan in

2010 and Mr Nigel Kiely Paediatric Orthopaedic Consultant has now undertaken this role with ½ PA protected time per week. The Named Doctor provides all staff groups across

the Trust with expert advice and support regarding safeguarding children issues.

The Role of the Named Nurse for Safeguarding Children The Named Nurse - Suzanne Marsden is the ward manager on Alice ward and she has 8

hrs per week protected time to undertake this role. The Named Nurse works closely with

the Named Doctor to ensure that the Trust meets its statutory responsibilities in safeguarding children as defined in Working Together to Safeguard Children, 2010 and

the Children Act (1989, 2004).

The Named Nurse represents the Trust at the Health governance Safeguarding

Committee in Shropshire on a quarterly basis and the County Named Nurse meetings bimonthly. The Designated nurse in Shropshire, Telford and Wrekin provides supervision

for the Named nurse and the aim is to make these meetings bimonthly to ensure effective support.

The Named nurse coordinates and delivers level one and two training for staff working in the Trust and provides all staff groups across the Trust with expert advice and support

regarding safeguarding children issues.

The role of the Executive Lead – Director of Nursing Vicky Morris was initially the Executive Lead for Safeguarding children and following her

resignation this role was taken over by Nicki Bellinger.

The Executive lead represents the Trust at the Shropshire Safeguarding Children Board

and Health Governance Safeguarding Committee in Shropshire on a quarterly basis and provides supervision for the named professionals. They also chair the Trust Safeguarding

Children and Vulnerable adults committee bimonthly.

3.2 Training During 2010/2011 80% of staff had been trained to level one and 98% to level two.

Following the new recommendations set out in the “Intercollegiate” document (2010), we now need to increase the number of clinical staff undertaking level two training. This

will be achieved by all clinical staff undertaking the NSPCC e-learning package. External

training provision continues to be provided for staff requiring levels three and four.

3.3 Referrals Thirteen children were highlighted as requiring Safeguarding support during 2010/2011.

These were dealt with in accordance with Trust Policy.

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5

3.4 Audit The Named nurse undertook an annual audit documentation audit in February 2010 and

this was shared with the Shropshire safeguarding Children Board (SSCB).

3.5 Service Review

In February 2011 the Care Quality Commission (CQC) and Ofsted inspected Safeguarding and Looked After Services in Shropshire and the RJAH Orthopaedic and District Hospital

were part of that review. The Trust did not have a site visit however, both the Named Doctor and Nurse attending a meeting with the review panel to present information

regarding safeguarding practice within this Trust. The final report was published on 25th

March and there were no significant concerns raised for the Hospital.

4 Recommendations for 2011 /12 and Conclusion

4.1 • To introduce the Level two E learning package for all clinical staff, this will

dramatically reduce the number of face to face teaching sessions proved by the

Named Nurse and will be more cost effective. • To train the remaining 20% of staff requiring Level One Basic awareness training.

• To ensure staff working with children continue to access level three developing

practice modules provided by Shropshire County Council.

• To improve information sharing with Executive lead – to provide a monthly /

bimonthly record of safeguarding cases in the Trust. • To book regular bimonthly supervision sessions between the Named Nurse and

Designated Nurse (Telford).

4.2 In conclusion, the Named Nurse, Named Doctor and Executive lead continue to strive to

maintain high standards of practice, procedure and continued improvement in service

relating to Safeguarding Children and Young People, requiring treatment in this Trust. Training remains as always high on the Trust agenda.

Update April 2011 – October 2011

Referrals Fifteen children were highlighted as requiring Safeguarding support during the period April –Sept 2011.

This is more than the whole of last year and at times has been extremely difficult to manage. Several of these cases have been complex cases and have involved attendance to case conference and Team

around the Child meetings Telford and Wolverhampton.

Safeguarding Record keeping Audit – undertaking in Sept, results currently being populated.

Safeguarding supervision – supervision for the named nurse increased to monthly during July, Aug

& September due to high ratio of complex safeguarding cases. Supervision was provided by the Designated Nurse.

Group Supervision provided on Spinal injuries department and a debrief and training session has been planned for the 5th October.

Paper 14

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 14 FT Bulletin.doc






Margaret Surrage, Head of Board Governance (Trust Secretary) Monitor


Development

�





Objectives


Executive Summary

The December edition of the FT Bulletin published by Monitor is

attached for information.

A summary of progress of the key actions required by the Trust is detailed overleaf.

Subject/Title FT Bulletin


For Discussion

For Approval


Legal Implications

Recommendation The Trust Board are asked to note the FT Bulletin.


Paper 14

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 14 FT Bulletin.doc



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Responsibility

Progress

AANNNNUUAALL PPLLAANN RREEVVIIEEWW SSUUBBMMIISSSSIIOONN

• Submission date 31 May

• Early submission of templates requested where

possible

Director of Finance

Annual Planning

timetable has been developed with a view to

submission on that date

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This will now be updated using “on line forms” which can be

used throughout the year.

Head of Board

Governance

(Trust Secretary)

New process has been noted & will be used

when required

MMOONNIITTOORR AANNNNUUAALL SSTTAAKKEEHHOOLLDDEERR SSUURRVVEEYY To be completed by January 20th

Chief Executive

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AACCCCOOUUNNTTIINNGG IISSSSUUEESS

Some supplementary submission dates given

Details of key Accounts contact requested

Director of

Finance/Deputy Director of

Finance

Dates already in

accounting timetable

Details have been submitted

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Closing date 24th February

Head of Board Governance

(Trust Secretary)

On the agenda for the

January Board

Consultations

FT Bulletin

19 December 2011

Issue 52

For information For action Monitor

publications

Welcome to the Deceber edition of Monitor’s FT Bulletin.

This bulletin is sent to NHS foundation trust chief executives, chairs, finance, medical and nursing directors and the Foundation Trust Network. Click on the links below to jump straight to the relevant sections of the bulletin.

• Annual plan review

submissions process

2012/13

• Reminder of process for

governor and director

Board changes

• Monitor annual survey of

NHS stakeholders

• Implementation of the

Alignment Project

• Quality Assurance

Department review of the

2010/11 audits of NHS

foundation trust

• Lessons learned from

Monitor’s review of

significant Transforming

Community Services

transactions

• Q2 performance of NHS

foundation trusts to 30

September 2011

• Monitor’s proposed new role

– The Bill

• Recently authorised trust

• Regulatory approach for the

transfer of PCT estate to

NHS foundation trusts

• Southend University

Hospital NHS Foundation

Trust found in significant

breach

• Patients waiting on planned

waiting lists

• Annual Reporting Manual

2011/12

• Licensing conditions

• Compliance Framework

2012

Events & development

programmes External

news/updates • FT Chairs Academy –

second cohort launching

on 17 January 2012

• SLM webinar with the

HFMA

• Save the date: SLM

conference March 2012

• Department of Health

payment by results

2012/13 road test package

http://www.monitor-nhsft.gov.uk/home/our-publications/browse-category/guidance-foundation-trusts/monthly-nhs-foundation-trust-bullet

http://www.monitor-nhsft.gov.uk/

Jump straight to a section using the quick links above

For information Monitor’s proposed new role – The Bill

Parts 3 and 4 of the Health and Social Care Bill, concerning Monitor and the future of Foundation Trusts, were debated in the House of Lords committee on Tuesday 13 and Thursday 15 December 2011. As expected, some strong views regarding Monitor’s proposed future role were put forward, especially from the opposition. Key areas of debate included: the role for competition within the health sector; the way Monitor will be accountable to the Secretary of State and how Monitor may handle potential conflicts between its FT and sector regulator roles. We expect the committee debates on the final parts of the Bill to finish before Christmas. Following this, the House of Lords report stage should start early in the New Year, where further debate will take place on potential changes to the Bill. For all latest news on our proposed new role visit our website. Recently authorised trust

At Monitor’s November Board meeting West Suffolk NHS Trust became the 141st NHS foundation trust.

Regulatory approach for the transfer of PCT estate to NHS foundation trusts

The Department of Health has set out its intention to transfer “service critical clinical infrastructure”

from PCTs to NHS trusts and NHS foundation trusts in its document PCT Estate: future ownership

and management of estate in the ownership of PCTs in England. We have considered our regulatory role in any potential transfer and have set out our proposed approach below. Whilst we recognise that foundation trusts are unlikely, at this stage, to have agreed which sites, if any, will be transferring, we wanted to set out our intended approach for clarity. Appendix F of Monitor's Compliance Framework sets out the process that Monitor undertakes in relation to transactions and the related thresholds for each approach. Monitor has considered the implications of these for PCT estate transfers and has concluded that: • where the transfer of PCT estate meets the threshold for material transactions, the foundation

trust will be expected to provide a board statement in line with current expectations; (Cont’d)

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programmes External news/updates


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For information Regulatory approach for the transfer of PCT estate to NHS foundation trusts (cont.)

• where the transfer of PCT estate meets the threshold for significant transactions a more detailed review will be required. Monitor will tailor this review to focus primarily on the impact of the acquisition on the financial risk rating (recognising that it is unlikely to impact on the governance risk rating). It is not anticipated that foundation trusts will be required to attend a Board to Board meeting with Monitor, nor obtain an independent accountants’ report on financial reporting

procedures, post transaction integration plan or working capital, but Monitor will retain discretion to require these on a trust-by-trust basis (in particular if a cash consideration is required). It is anticipated that such a review by Monitor will take approximately one calendar month to complete; and

• Monitor will continue to require trusts to complete a three-year financial model for significant transactions but will require only summary information in some areas (such as income) to lessen the time burden on foundation trusts of completing this model.

No action is required by foundation trusts at this stage. However, we would be grateful if you can keep your relationship team informed if and when you intend to acquire assets from the PCTs. For further information please contact Toby Lambert ([email protected]). Southend University Hospital NHS Foundation Trust found in significant breach

We have found that Southend University Hospital NHS Foundation Trust is in significant breach of the terms of its authorisation due to its failure to comply with the following terms:

• Governance (NHS foundation trust boards must ensure appropriate arrangements are in place to provide effective leadership and governance).

• Healthcare and other standards. The decision was triggered by the Trust’s ongoing failure to meet cancer and C.difficile targets and by CQC concerns which resulted in the Trust being red rated for governance by Monitor in the first quarter of 2011/12. Patients waiting on ‘Planned’ waiting lists

A recent review by the Department of Health of patients who had been waiting for hospital appointments found examples of patients waiting inappropriately and clinical outcomes being affected as a result. There are strong clinical governance and safety reasons why patients’ planned care should not be deferred and all NHS foundation trusts should treat patients at the right time and in order of clinical priority. A service that allows planned activity to be deferred because of pressure on active waiting lists is not in control of its total demand. As part of the Quality Governance framework both applicant trusts and foundation trusts should be committed to delivering the best clinical outcomes for patients.

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For information Annual Reporting Manual 2011/12

The consultation on the 2011/12 Annual Reporting Manual closed on 16 December 2011. We expect to publish the final manual by the end of January 2012 at the latest.

In the meantime, the draft manual and guidance are available here on our website.

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publications

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For action Annual plan review submissions process 2012/13

Monitor can confirm that there will be no change in the submission date for the APR for 2012-13 with all submissions due to Monitor on 31 May 2012. Given the two-day bank holiday in June 2012, Monitor would find it extremely helpful if any foundation trusts that have completed their templates prior to this date do submit them at the earliest opportunity. As mentioned in November’s bulletin, we are in the process of reviewing the templates that trusts will

need to complete for APR. At this stage our intention is to release the strategy template (i.e. the Word document) at the end of February 2012. We intend to release the financial template at the end of March 2012 to coincide with the release of the 2012/13 Compliance Framework, thereby reducing the need for late model “fixers”. We do not anticipate there being major changes from last year’s

financial model. If you do want to make comments on either of last year’s templates please email

Katherine Cawley ([email protected]). Reminder of process for governor and director Board changes It is part of Monitor’s statutory duties to publish a directory of foundation trusts on our website. This

directory includes the members of each trust’s board and their governors. As part of our Compliance

Framework, all foundation trusts are required to provide Monitor with these details.

Foundation trusts used to inform Monitor of director and governor changes via the quarterly monitoring forms (and annual plan process). In an effort to make both the process easier for foundation trusts and to ensure the directory is as up to date as possible, we have removed the director and governor updates from the quarterly monitoring sheet and replaced it with two online forms on our website. These forms should be used throughout the year to update your director and governor details, not just on a quarterly basis. Monitor annual survey of NHS stakeholders This year’s online survey of foundation trusts, NHS trusts, SHAs and PCTs went out last month. If you

haven’t already completed the survey you can find the link here. Your input is very important to us and we welcome all of your views.




publications

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For action Implementation of the Alignment Project

The restatement of 2010/11 accounts is an exercise which foundation trusts are required to participate in as a result of the Alignment Project. All foundation trusts are reminded of the submission date for the restatement FTC: Friday 23 December 2011. The submission date for the agreement of balances and transactions date was Wednesday 14

December 2011. Any foundation trusts that have not yet made this submission will have been contacted by their relationship manager and are required to submit as a matter of urgency (in line with the requirements set out in Monitor’s letter to foundation trust finance directors dated Friday 2 December 2011). We are receiving feedback on the restatement FTC from foundation trusts over the course of the restatement exercise. Monitor considers it important to update the 2011/12 month 9 FTC as a result of this feedback and, has therefore made a decision to release this form to foundation trusts at a later date than the previously communicated 12 December 2011 deadline. It is anticipated that the month 9 FTC will be released before the end of December. We recently wrote to all foundation trust finance directors requesting them to provide contact names for the agreement of balances exercise and a key contact for the accounts preparation. The latter is being requested to enable more frequent and direct communication from Monitor to foundation trust finance teams over the course of 2011/12 accounts production to provide, for example, additional guidance or a response from us to foundation trusts’ feedback. We encourage all foundation trusts to provide appropriate contact details.




publications

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Monitor publications Quality Assurance Department review of the 2010/11 audits of NHS foundation trusts

The Audit Code for NHS Foundation Trusts (“the Code”) makes provision for the review of the work of

auditors of foundation trusts. We commissioned the Quality Assurance Department (“the QAD”) of the

Institute of Chartered Accountants in England and Wales to undertake reviews on our behalf of the work of auditors in respect of nine audits of trust accounts for the year or period to 31 March 2011. A document of key findings has now been published on our website. Lessons learned from Monitor’s review of significant Transforming Community

Services transactions

We have published a short report which sets out some of the lessons learned from our risk evaluation of recent Transforming Community Services transactions. The report also summarises our requirements and signposts you to useful guidance. Q2 performance of NHS foundation trusts to 30 September 2011

We have published sector performance results for the second quarter of 2011/12. Overall, foundation trusts are performing well financially and there have been significant improvements in the total number of target breaches, which are down from the previous quarter. However, C.difficile remains a challenging target as does the delivery of CIPs.




publications

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Licensing conditions engagement

The Health and Social Care Bill proposes that Monitor should license providers of NHS services. If the Bill is approved by Parliament, we will need to issue licences relatively quickly - in December 2012 for foundation trusts and April 2013 for other providers. Last month we published Developing the new NHS provider licence – a framework document which started initial engagement on the proposal for our provider licence once the Bill becomes law. The deadline for responses was 12 December 2011. We have now launched six documents that set out our early thoughts on proposed licence conditions and ask for your views on how they should be developed. The deadline for responses is Friday 23 January 2012. Our aim is to share our early working proposals for your scrutiny and review. We will listen to your responses and use them to inform our development work. There is no intention to anticipate or pre-empt Parliament’s role and authority in relation to the Bill. There is more information on our proposed new role here on the Monitor website.

Compliance Framework 2012

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FT Chairs Academy – second cohort launching on 17 January 2012

The second cohort of the FT Chairs Academy which Monitor and the Foundation Trust Network are co-sponsoring in conjunction with Cass Business School will launch on 17 January 2012 (a full day plus dinner). This will be a five-day programme over approximately eight months, hosted by a range of top speakers, including experienced leaders from the NHS and other sectors as well as leading academics. Topics to be covered include: • exploring the case for change; • influencing the changing landscape; • board effectiveness; • healthcare strategy and futures; and • partnerships in the local economy (including working effectively with governors).

The cost of the programme is £3,500. All chairs of NHS foundation trusts and NHS trusts are welcome and the programme is specifically tailored to meet the requirements of both new and very experienced chairs in leading foundation trusts through the challenges ahead. For more information or to enrol on the January programme, please contact Anika Bloomfield on [email protected] or visit the Cass website. Alternatively, for more information please contact Carolyn May at [email protected] or on 020 7340 2452. SLM webinar with HFMA: revised date The first webinar in our SLM series, scheduled for Wednesday 7 December on Lessons learned

from implementing Service-line Management, unfortunately experienced technical issues and was therefore not broadcast. Once again please accept our apologies for any inconvenience caused, as soon as we have a revised date for this session we will update our website. The first webinar will now be held on Wednesday 19 January between 4-5pm and will look at Robust SLR; ensuring a comprehensive finance and quality picture at service-line level

This session will focus on the importance of having timely and robust quality and financial information available at a service-line level. Dr David Rosser and Gus Heafield will highlight how robust information has supported both service efficiency and quality and safety improvements in their organisations, thus enabling improved performance at both service-line and trust level. Examples will be drawn from two trusts; one acute and one mental health. To register for the webinar click here. We will be sending information out about the next webinars in the series shortly.

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Save the date: SLM conference March 2012

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Department of Health payment by results 2012/13 road test package

The road test exercise provides an opportunity for the NHS to test out the new tariff, and supports the planning process. As in previous years the main focus of the road test is to gather comments on the draft 2012-13 PbR guidance and PbR Code of Conduct. Full details are available from the Department of Health website.

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Paper 15

U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Paper 15 Update on FT Membership.doc




Executive Responsible Ruth Tyrrell, Associate Director of Human Resources




Development


Context Previous Board discussion �



Objectives

�


Executive Summary

This report provides an update on Foundation Trust membership

and representation, and identifies sections of the population that need to be targeted to secure a more representative membership.

Subject/Title Foundation Trust Membership Update


For Discussion

For Approval



Recommendation The Trust Board are asked to note the information contained within this paper.


Paper 15



FFOOUUNNDDAATTIIOONN TTRRUUSSTT MMEEMMBBEERRSSHHIIPP UUPPDDAATTEE


1. Background 1.1 This paper provides an update on membership numbers using a baseline just prior to authorisation

as a Foundation Trust in July 2011, and highlights areas where representative membership is

currently low and targets for growth.

A detailed analysis of membership numbers is given in appendix 1.

2. Membership recruitment 2.1 The current membership total (at January 2012) is 4354 which can be broken down as follows:

Staff 1156

Public 3198 Total 4354

The membership target for the end of 2011/12 is 4,290.

3. Membership Growth

3.1 Staff membership numbers remain consistent, with very few staff ‘opting out’ of membership.

3.2 Public membership has grown by 46 since July, however there are twice as many female members as male meaning men are underrepresented compared to the local population.

FT Public Membership Male/Female

0

1,000

2,000

3,000

4,000

Total M embership

M ale

Female

Total M embership 3,152 3,163 3,198

M ale 1,081 1,092 1,107

Female 2,071 2,071 2,090

Jul-11 Oct-11 Jan-12

3.3 The breakdown of membership by public constituency, shows, as expected that Shropshire provides the largest membership base, however compared to the local populations, Cheshire & Merseyside

and West Midlands are under represented.

Paper 15


Jan-12

Cheshire & Merseyside 214

North Wales 599

Powys 362

Shropshire 1,512

West Midlands 330

Rest of England & Wales 117

Out of Trust Area 64

Total 3,198

Public constituency membership will be monitored from January 2012 on a quarterly basis.

3.4 Public membership by age shows a consistent pattern of membership, however compared to the local population, the 17-21 and 22-49 age groups are under represented.

FT Public Membership by Age

0

200

400

600

800

1,000

1,200

0-16

17-21

22-29

30-39

40-49

50-59

60-74

75+

Not stated

0-16 10 11 10

17-21 118 112 110

22-29 165 172 180

30-39 223 220 237

40-49 334 334 333

50-59 424 415 420

60-74 1,075 1,081 1,081

75+ 516 533 543

Not stated 287 285 284


3.5 Finally, although relatively small numbers of members are from Black and Minority Ethnic groups,

compared to the local population, these groups are representative of the population.

FT Public Membership by Ethnicity

0

500

1,000

1,500

2,000

2,500

3,000

White

BME

Not stated

White 2,517 2,534 2,543

BME 38 44 46

Not stated 597 585 609


Paper 15


4. Membership Activities & Communication

4.1 Following authorisation as a Foundation Trust, the regular ‘connect’ newsletter continues to be

issued, membership events have been organised and the first full meetings of the Council of Governors have taken place as follows:

• 16 June Members event with Sue Sayles, Infection Control Nurse

• June 2011 Connect newsletter

• 24 November Council of Governors

• November 2011 Connect Newsletter

• 7th December Council of Governors

• December League of Friends Balloon Race (including sign up of new members)

5. Membership Strategy

5.1 The Trust will continue to seek to grow membership across all categories but particular emphasis should be placed on growing membership from under represented groups as follows:

• Men

• Cheshire & Merseyside and West Midlands

• Aged 17-49

A revised membership target together with future membership events will be discussed with Governors at the next Council of Governors meeting in February 2012.

6. Recommendation

6.1 The Board are asked to note the information contained within this paper.

Ruth Tyrrell

Associate Director of Human Resources

Paper 15


Appendix 1

Key Index of 100 equivalent to ‘perfect match’

Index of < 100 equivalent to under represented Index of > 100 equivalent to over represented

RJAH FT Membership Analysis January 2012

Local area popn

% of Local area popn count Index Index Change

Age 8,596,387 100.00 3198

0-16 1,752,691 20.39 10 1 0

17-21 582,969 6.78 110 50 -2

22+ 6,260,727 72.83 2794 119 0

Not stated 0 0.00 284 0 0

Age 22+ 6,260,727 72.83 2794

22-29 876,503 10.20 180 55 2

30-39 1,076,529 12.52 237 59 4

40-49 1,250,969 14.55 333 71 -1

50-59 1,065,906 12.40 420 105 0

60-74 1,300,251 15.13 1081 223 -2

75+ 690,569 8.03 543 211 2

Gender 8,596,387 100.00 3198

Unspecified 0 0.00 1 0 0

Male 4,212,362 49.00 1107 70 0

Female 4,384,025 51.00 2090 128 0

Ethnicity 8,355,496 100.00 3198 0

White 7,745,862 92.70 2543 85 -1

Black or Black British 113,144 1.35 6 13 -1

Asian or Asian British 401,589 4.81 29 18 0

Mixed 94,901 1.14 5 13 0

Other Ethnic Groups 46,843 0.56 6 33 5

Not stated 0 0.00 609 0 0

A P NE UBLIC MEETING - RJAH · 2020-05-11 · U:\Trust Board & Committees\Public Trust Board\2011-12\January 2012\Agenda - January.doc Russell Hardy 4358 Chairman BOARD OF DIRECTORS

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