TRUST BOARD MEETING IN PUBLIC AGENDA · To receive N/A Chief Nurse Presentation ... GDC General Dental Council ... KPI Key Performance Indicator L

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TRUST BOARD MEETING IN PUBLIC

AGENDA

01 March 2018 at 9.30am – 12.00noon

Terrace Executive Meeting Room, Spice of Life Restaurant, Watford Hospital

Apologies should be conveyed to the Trust Secretary, Jean Hickman on [email protected] or call 01923 436 283

Item ref

Title Objective Previously presented

Lead Paper or verbal

01/57 Opening and welcome

To note N/A Chair Verbal

02/57 Presentation on respiratory medicine

To receive N/A Chief Nurse Presentation

OPENING

03/57 Apologies for absence


04/57 Declarations of interests To note N/A Chair Paper

05/57 Minutes of the meeting held on 01 February 2018

For approval

N/A Chair Paper

06/57 Board action log from 01 February 2018 and previous meetings and decision log

To note N/A Chair Paper

07/57 Chair’s report

For information

N/A Chair Paper

08/57 Chief Executive’s report For information

N/A Chief Executive

Paper

PERFORMANCE

09/57 Integrated performance report – month 10

For information

and assurance

Trust Executive Committee

Chief Operating Officer

Paper

SAFE EFFECTIVE CARE (BAF RISK 1)

10/57 Presentation by Mitie, facilities management company – This item has been deferred

For information

N/A Deputy Chief Executive/

Chief Nurse/ Director of

Environment

11/57 Quality Commitment For approval

Clinical Outcomes and Effectiveness Committee

Chief Nurse Paper

12/57 Quarterly learning from deaths report

For Approval

Clinical Outcomes and Effectiveness Committee

Medical Director Paper

AGENDA

1 of 121Trust Board Meeting in Public-01/03/18

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RECRUIT, RETAIN AND ENGAGE WORKFORCE (BAF RISK 2)

13/57 Gender pay gap report 2017 For approval

Patient and Staff Experience Committee

Director of Human

Resources

Paper

GOVERNANCE

14/57 Bi-monthly corporate risk register review

For information


Medical Director Paper

COMMITTEE REPORTS

15/57 Assurance report from Finance and Investment Committee

For information

and assurance

Finance and Investment Committee

Committee Chair/ Chief Financial

Officer

Paper

16/57 Assurance report from Clinical Outcomes and Effectiveness Committee

For noting Clinical outcomes and effectiveness

committee

Committee Chair/Chief Nurse

Paper

17/57 Assurance report from the Safety and Compliance Committee

For information

and assurance

Safety and Compliance Committee

Committee Chair/ Medical Director

Paper

18/57 Assurance report from the Patient and Staff Experience Committee

For information

and assurance


Committee Chair/Director of

Human Resources

Verbal

ANY OTHER BUSINESS

19/57 Any other business previously notified to the Chair

N/A N/A Chair Verbal

QUESTION TIME

20/57 Questions from Hertfordshire Healthwatch

To receive

N/A

Chair Verbal

21/57 Questions from our patients and members of the public

To receive N/A Chair Verbal

ADMINISTRATION

22/57 Draft agenda for next meeting To approve N/A Chair Paper

23/57 Date of the next board meeting in public: 12 April 2018, Terrace Executive Meeting Room, Watford Hospital


AGENDA

2 of 121 Trust Board Meeting in Public-01/03/18

Acronyms and abbreviations

AGENDA


A AAA Abdominal Aortic Aneurysm AAU Acute Admissions Unit A&E Accident and Emergency ABPI Association of the British Pharmaceutical Industry AC Audit Commission ACS Adult Care Services ADM Assistant Divisional Manger AGS Annual Governance Statement AHP Allied Health Professional

B BAF Board Assurance Framework BAMM British Association of Medical Managers BAU Business as usual BC Business Continuity BCP Business Continuity Plan BGAF Board Governance Assurance Framework B&H Bullying and Harassment BISE Business Integrated Standards Executive BMA British Medical Association BME Black and ethnic minorities BSI Bloodstream infection

C CAB/C&B Choose and Book Caldicott Guardian The named officer responsible for delivering and implementing the

Confidentiality and patient information systems CAMHS Child and adolescent mental health services CAS Central Alert System CCG Clinical Commissioning Groups

CCIO Chief Clinical Information Officer CCORT Clinical Care Outreach Team CCU Critical Care Unit CD Clinical Director C.Diff Clostridium Difficile CEO Chief Executive Officer CfH/CFH Connecting for Health CFO Chief Financial Officer CHD Coronary heart disease CIO Chief Information Officer CIP Cost improvement programme CIS Care Information Systems CMO Chief Medical Officer CNO Chief Nursing Officer CNS Clinical Nurse Specialist CNST Clinical Negligence Scheme for Trusts COI Central Office of Information COO Chief Operating Officer COPD Chronic Obstructive Pulmonary Disease COSHH Control of Substances Hazardous to Health CPA Clinical Pathology Accreditation

AGENDA


CPD Continuing Professional Development CPOP Clinical Policy and Operations CFPG Capital Finance Planning Group CPR Cardiopulmonary resuscitation CQC Care Quality Commission CQUIN Commissioning for Quality & Innovation CRS Care Records Service CSE Child sexual exploitation CSSD Central Sterile Service Department CSU Clinical Support Unit CT Computerised Tomography

D DCC Direct Clinical Care DD Divisional Director DGH District General Hospital DGM Divisional General Manager DM Divisional Manager DIPC Director of Infection Prevention and Control DH or DoH Department of Health DNA Did Not Attend DNR Do Not Resuscitate DO Developing our Organisation DoC Duty of Candor DoLS Deprivation of Liberty Safeguards DPH Director of Public Health DQ Data Quality DTA Decision to admit DTOC Delayed Transfers of Care DQ Data Quality

E EA Executive Assistant EADU Emergency Assessment and Discharge Unit ECG Echocardiogram ECIP Emergency Care Improvement Programme ED Emergency Department ED Executive Director EDD Expected Date of Discharge EDS Equality Delivery System EIA Equality Impact Assessment ENHT East & North Herts NHS Trust ENT ear, nose and throat EoE East of England EoL End of Life EPAU Early Pregnancy Assessment Unit EPRR Emergency Preparedness, Resilience and Response ERAS Enhanced Recovery Programme after Surgery ESR Electronic Staff Record EWTD European Working-Time Directive

AGENDA


F FBC Full Blood Count FBC Full Business Case FCE Finished Consultant Episode FFT Friends and Family Test FD Finance Director FGM Female genital mutilation FOI Freedom of Information FRR Financial Risk Rating FSA Food Standards Agency FT Foundation Trust FY Full Year

G GDC General Dental Council GGI Good Governance Institute GMC General Medical Council GP General Practitioner GUM Genito-urinary medicine GOO General other outcome

H H&S Health and Safety HAI Hospital Acquired Infection HAPU Hospital Acquired Pressure Ulcer HCAI Healthcare-Associated Infections HCC Hertfordshire County Council HCT Hertfordshire Community NHS Trust HDA Health Development Agency HDD Historical Due Diligence HDU High Dependency Unit HEE Health Education England HHH Hemel Hempstead Hospital HES Hospital Episode Statistics HIA Health Impact Assessment HITP Hertfordshire Integrated Transport Partnership HON Head of Nursing HPA Health Protection Agency HPFT Hertfordshire Partnership NHS Foundation Trust HR Human Resources HRG Health Related Group HSC Health Service Circular; (House of Commons) Health Select Committee HSC Health Scrutiny Committee, sub-committee of Overview and Scrutiny

Committee, Hertfordshire County Council HSE Health and Safety Executive HSMR Hospital Standardised Mortality Ratio (Rates) HSO Health Service Ombudsman HTM 00 Health Technical Memorandum HUC Herts Urgent Care HVCCG Herts Valley Clinical Commissioning Group

AGENDA


I IBP Integrated Business Plan IC Information Commissioner ICAS Independent Complaints Advocacy Service ICNs Infection Control Nurses ICO Information Commissioners Office ICT Information, Communications and Technology IDT Integrated Discharge Team IVF In Vitro Fertilisation ICU Intensive Care Unit IDVA Independent domestic violence advisors IG Information Governance IMAS Interim Management Service IM&T Information Management and Technology IP Inpatient IPR Integrated Performance Report IRGC Integrated Risk and Governance Committee ISE Integrated Standards Executive IST Intensive Support Team IT Information Technology ITFF Independent trust financial facility ITU Intensive Treatment Unit

J JSNA Joint Strategic Needs Assessment

K KLOE Key Line of Enquiry KPI Key Performance Indicator

L LAs Local authorities LABV Local Asset Backed Vehicle LAT Local Area Team (of NHS England) LCFS Local Counter Fraud Service L&D Learning and Development LDB Local delivery board LGBT Lesbian Gay Bisexual and Transgender LHCAI Local Health Care Associated Infections LHRP Local Health Resilience Partnerships LMC Local Medical Committee LSMS Local Security Management Specialist LSP Local Service Provider LTFM Long Term Financial Model

AGENDA


M MCA Mental Capacity Act MD Medical Director MDA Medical Device Agency MDT Multi-Disciplinary Team MEWS Modified Early Warning Score MHAC Mental Health Act Commission MHRA Medicines and Healthcare Products Regulatory Agency MIU Minor Injuries Unit MMC Modernising Medical Careers MMR Measles, mumps, rubella MRET Marginal rate emergency tariff MRI Magnetic resonance imaging MRSA Methicillin-resistant Staphylococcus aureus MSSA Methicillin-sensitive Staphylococcus aureus

N NE Never Event NED Non Executive Director NHS National Health Service NHS CFH NHS Connecting for Health NHSE NHS England NHSLA NHS Litigation Authority NHSTDA NHS Trust Development Agency NHSP NHS Professionals NHSP Newborn Hearing Screening Programme NICE National Institute for Health and Clinical Excellence NIHR National Institute for Health Research NMC Nursing and Midwifery Council #NoF Fractured Neck of Femur NPSA National Patient Safety Agency NSF National Service Framework NTDA NHS Trust Development Agency

O OBC Outline Business Case OD Organisational Development OJEU Official Journal of the European Union OLM Oracle Learning Management OMG Operational Management Group ONS Office for National Statistics OOH Out of Hours Service OP Outpatient OSC (local authority) Overview and Scrutiny Committee OT Occupational Therapist/Therapy

AGENDA


P PA Programmed Activities PAC Public Accounts Committee PACS Picture Archiving and Communications System PALS Patient Advice and Liaison Service PAM Premises Assurance Model PAS Patient Administration System PAS 5748 Publicly Available Specification 5748 - provides a framework for the

planning, application and measurement of cleanliness in hospitals PbR Payment by Results PCC Primary Care Centre PCT Primary Care trust PEG Patient Experience Group PFI Private Finance Initiative PHO Public Health Observatory PID Project Initiation Document PLACE Patient Led Assessment of the Care Environment PMO Programme Management Office PMR Provider Management Regime PPI Proton Pump Inhibitors PPI Patient and Public Involvement PR Public Relations PSED Public Sector Equality Duty PSQR Patient Safety, Quality and Risk Committee PTL Patient Tracker List

Q QA Quality Assurance Q&A Questions and Answers QG Quality Governance QGAF Quality Governance Assurance Framework QIA Quality Impact Assessment QIP Quality Improvement Plan QIPP Quality, Improvement, Prevention and Promotion QRP Quality Risk Profile QSG Quality and Safety Group

R R&D Research and Development RA Registration Authority RAG Risk and Governance/Red Amber Green RCA Root Cause Analysis RCN Royal College of Nursing RCP Royal College of Physicians RCS Royal College of Surgeons RES Race Equality Scheme RFH Royal Free Hospitals NHS Foundation Trust RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations RSRC Risk Summit Response Committee RTT Referral to Treatment RTTC Releasing Time to Care

AGENDA


S SACH St Albans City Hospital SCBU Special Care Baby Unit SES Single Equality Scheme SFI Standing Financial Instructions SHMI Standardised Hospital Mortality Index SHO Senior House Officer SI Serious Incident SIC Statement of Internal Control SIRG Serious Incident Review Group SIRI Serious Incident Requiring Investigation SIRO Serious Incident Risk Officer SLA Service Level Agreement SLR Service Line Reporting SLM Service Line Management SMG Strategic Management Group SMS Security Management Service SOC Strategic Outline Case SQ Safety and Quality SPA Supporting Professional Activity SRG System Resilience Group STEIS Strategic Executive Information System ST & M Statutory and Mandatory STP Sustainability and Transformation Programme SUI Serious Untoward Incident (same as Serious Incident, more commonly

used).

T T&D Training and Development TDA Trust Development Authority (also known as NTDA) TEC Trust Executive Committee TLEC Trust Leadership Executive Committee T&O Trauma and Orthopaedic TOP Termination of Pregnancy TOR Terms of Reference TPC Transformation Programme Committee

T TSSU Theatre Sterile Service Unit TUPE Transfer of Undertakings (Protection of Employment) Regulations TVT Tissue Viability Team

U UCC Urgent Care Centre

V VFM Value For Money VTE Venous Thromboembolism

AGENDA


W WACS Women’s and Children’s Services WBC Watford Borough Council WFC Workforce Committee WGH Watford General Hospital WHHT West Hertfordshire Hospitals NHS Trust WHO World Health Organisation WRVS Women’s Royal Voluntary Service WTD Working-time directive WTE Whole Time Equivalent (staffing)

Y YTD Year to date YCYF Your care, your future

AGENDA


Last updated : 20 February 2018

Declaration of board members and attendees interests 01 March 2018

Agenda item: 04

Name Role Description of interest Relevant dates

From To

Professor Steve Barnett Trust Chair Chair and Client Partner of SSG Health Ltd

Non-Executive Chairman of Finegreen Associates

Trustee and Director of the Institute of Employment Studies

Wife is CEO of Rotherham NHS Foundation Trust

Visiting Professor University of West London Business School

Honorary Visiting Professor Cranfield University School of Management

Member of the East Midlands Regional Committee for Clinical Excellence Awards

Present Present Present Present Present Present Present

Andy Barlow Divisional Director, Women’s and Children’s Services Barlow Medical Services Ltd Present

John Brougham Non-Executive Director Non-Executive Director and Chair of the Audit Committee of Technetix Ltd

2010

Present

4

Tab 4 C

onflict of interest

1 of 121T

rust Board M

eeting in Public-01/03/18


Helen Brown Deputy Chief Executive None

Professor Tracey Carter Chief Nurse and Director of Infection Prevention and

Control None

Paul Cartwright Non-Executive Director Treasurer for St Peter’s Church

Trustee and Chair of Finance and Audit Committee for The Church Lands, St Albans.

Charitable Funds for West Hertfordshire Hospitals NHS Trust

Nov 2015 Nov 2015 Nov 2015

Present Present Present

Virginia Edwards Non-Executive Director Trustee Peace Hospice Care

Global Action Plan; providing support to their programme called Operation TLC

Director Edwards Consulting Ltd

Husband is CEO of Nuffield Trust

Husband is a non-remunerated member of the Strategy Committee of Guys and St. Thomas’s Charitable Trust

Husband is Director of Edwards Consulting Ltd

Charitable Funds for West Hertfordshire Hospitals NHS Trust

2011 2016 2011 2011 2011 2011 2014


Katie Fisher Chief Executive None

Jeremy Livingstone Divisional Director of Surgery , Anaesthetics and

Cancer Jeremy Livingstone Ltd Present

4

Tab 4 C

onflict of interest

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Arla Ogilvie Divisional Director for Medicine Private practice Present

Jonathan Rennison Non-Executive Director Change Management and strategy support with Kings College London

Trustee Rising Tides Ltd

Director of The Yellow Chair Ltd

Edgecumbe Consulting

Association of NHS Charities

The Teapot Trust - coaching

BNET (Britain-Nigeria Education Trust)

March 2017 May 2015 August 2012 April 2015 Sept 2015 June 2016 Oct 2016


Don Richards Chief Financial Officer None

Phil Townsend Non-Executive Director None

Sally Tucker Chief Operating Officer None

Dr Mike van der Watt Medical Director

Owner and Director Heart Consultants Ltd

Private Practice

Wife is Director of Hearts Consultants Ltd

Present

4

Tab 4 C

onflict of interest

3 of 121T

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Minutes of the trust board meeting

on 01 February 2018 at 9.30am - 12.00noon

Terrace Executive Meeting Room, Watford General Hospital

Agenda item: 05/57

Chair Title Attendance

Professor Steve Barnett Chair Yes

Voting members

John Brougham Non-Executive Director Yes

Helen Brown Deputy Chief Executive Yes

Tracey Carter Chief Nurse and Director of Infection Prevention and Control Yes

Paul Cartwright Non-Executive Director Yes

Ginny Edwards Non-Executive Director Yes

Katie Fisher Chief Executive Yes

Jonathan Rennison Non-Executive Director Yes

Don Richards Chief Financial Officer Yes

Phil Townsend Non-Executive Director No

Dr Mike van der Watt Medical Director Yes

Non voting members

Dr Andy Barlow Divisional Director, Women's and children's service Yes

Paul da Gama Director of Human Resources Yes

Lisa Emery Chief Information Officer Yes

Mr Jeremy Livingstone Divisional Director, Surgery, Anaesthetics and Cancer Yes

Dr Arla Ogilvie Divisional Director, Medicine No

Sally Tucker Chief Operating Officer Yes

Attending

Jean Hickman Trust Secretary (notes) Yes

Louise Halfpenny Director of Communications Yes

Stephen Palmer Representative for Healthwatch Yes

2 members of public N/A

5

Tab 5 Minutes of the meeting held on 01 February 2018


Page 2 of 8

MEETING NOTES

Agenda item

Discussion Lead Dead-line


01.01 The chair opened the meeting and welcomed the board and members of the public.

02/56 Presentation on end of life care

02.01 The chair welcomed Michelle Sorley, Liz Sumner and Charlotte Calder to the meeting and invited them to update the board on the work of the end of life care (EoLC) team. The board was informed that the service was rated as ‘requires improvement’ by the Care Quality Commission (CQC) at an inspection in April 2015 and was invited to be part of NHS Improvement’s (NHSI) EoLC rapid improvement programme. The team embraced this opportunity to fully consider key areas which would have the most impact on the patient experience and on areas where long term improvements could be made. These included providing enhanced staff training, ward information boards and improving the environment for patients and their relatives. The team highlighted that maintaining staffing levels, monitoring improvements and engagement with other health professionals continued to be a challenge. The board was encouraged that the actions taken had resulted in the service receiving a rating by the CQC of ‘good’ in 2016, which had been maintained in an inspection in 2017 and the team had received a certificate of achievement from NHSI for developing the most innovative idea.

02.02 In response to a question by non-executive directors on EoLC for children, the team explained that the trust worked closely with external colleagues to offer the best possible care across the healthcare system.

02.03 The chief nurse thanked the team for the outstanding service it provided and advised the board that a key priority for a newly appointed EoLC nurse educator would be to offer the same level of EoLC across all wards.

02.04 The chair thanked the team for attending the meeting and for the excellent work.

02.05 Resolution: The board noted the presentation.

OPENING


03.01 Apologies were received from Phil Townsend, non-executive director and the divisional director of medicine.

04/56 Declarations of interests

04.01 No further declarations of interests were noted than those previously circulated.

05/56 Minutes of the meeting held on 11 January 2018

05.01 Resolution: The minutes were approved as a true record of the meeting.

06/56 Decision log from previous meetings

06.01 The board noted the decision log.


07.01 The chair presented his report and asked the board to acknowledge the outstanding achievements of the staff noted in the report.

07.02 Resolution: The board received the chair’s report for information.

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Agenda item


08/56 Chief Executive’s report

08.01 The chief executive presented her report, which was self-explanatory.

08.02 Resolution: The board received the report for information.

PERFORMANCE

09/56 Integrated performance report- month 9

09.01 The chief operating officer introduced the latest integrated performance report (IPR) to the board and highlighted areas of note.

09.02 John Brougham asked for assurance that the upward trend in the mortality rate was an area of focus for the trust. The medical director advised that the increase could be a consequence of a coding issue which was being investigated and would be reported back to the board when confirmed. He reminded the board that HSMR benchmarking had been reset and assured it that the mortality rate remained below the target of 100 and the trust continued to be placed in the top quartile in the UK.

09.03 Ginny Edwards acknowledged that the trust was working hard to improve the quality of complaint responses and enquired when the board could expect to see an improvement in the response rate. The chief nurse responded that communication had improved between the complaints team and complainants and advised that a new complaints manager had been employed and some changes made to divisional complaint support. She assured the board that complaints were a regular topic of discussion at divisional performance review meetings and she expected to see an improvement in performance data from February 2018.

09.04 Jonathan Rennison noted that there had been more never events reported than in the previous year and asked for clarification on how the trust was learning from incidents. The medical director advised that, in line with new guidance on never events, the trust had requested that four reported cases in 2017/18 be de-escalated. He assured the board that all never events were thoroughly investigated and discussed at clinical governance meetings.

09.05 The chair asked for an update on the impact of Brexit on the recruitment and retention of staff. The director of human resources advised that the trust’s previous recruitment strategy around band 5 nurse recruitment was to have an on-going programme to recruit from the EU as there was a ready supply of good quality nurses, albeit that it was recognised that they were only likely to stay for a relatively short period of time. Unfortunately the introduction of national English language testing, and longer term the impact of Brexit, meant that this supply chain had massively reduced. The director of human resources advised that the recruitment and retention of band 5 nurses was a national issue with an estimated 42,000 nursing vacancies within the UK. He assured the board that if data relating specifically to band 5 nurses was excluded, the trust’s turnover rata benchmarked as broadly similar to trusts. The director of human resources confirmed that the trust was working with NHSI on a project to address band 5 turnover issues, which included a local advertising campaign and significant non-EU recruitment with the aim of reducing the rate from 23% to 16%.

09.06 In response to a question by the chair regarding the position of mixed sex breaches, the chief nurse advised that in January 2018 clinical commissioning groups had been instructed to temporarily suspend sanctions for mixed sex accommodation breaches to ensure patient safety. The trust had agreed to only consider breaching mixed sex

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Agenda item


principles in cases where patients would breach the twelve hour standard or where patient safety would be compromised. The chief nurse advised that the majority of breaches had been in the intensive treatment unit and, to effectively manage an increase in cases of patients with flu, it had been necessary to mix some sexes in order to cohort patients with flu and protect surrounding patients.

09.07 The director of workforce reported that, although it was disappointing the trust’s flu vaccination compliance rate was not higher (56%), he highlighted that it was better than the previously year. He assured the board that the rate was expected to reach 60% over the forthcoming week and advised that all staff who were reported on the system to have not had the vaccination had been contacted directly. The director of workforce advised that the trust was reviewing all the data to ensure that it had been accurately recorded and was continuing the high profile internal communications campaign. The chair enquired on the particularly low compliance rate in the women’s and children’s division and the divisional director assured the board that every action was being taken to encourage staff to have the vaccination.

09.08 Paul Cartwright brought the board’s attention to a decreasing rate of delayed transfers of care (DTOC) and asked what impact this was having on performance. The chief executive officer acknowledged the improved DTOC position and advised the board that the agreed target was to have no more than 3.5% social care related DTOC and no more than 1% health related DTOC. She reminded the board of ongoing capacity challenges and that patients in the trust’s catchment area continued to wait longer for packages of care than in other parts of the country.

09.09 The chief financial officer presented an overview of the latest financial position and reported that a deficit of £5.8m in December 2017 was £1m worse than forecast for the month. He advised that this was due to lower than expected income from elective activity and an increase in pay costs to manage the higher than expected demand of unscheduled care. Pay costs were £7.6m adverse year to date and, although agency costs had reduced, they were £1.1m behind the year to date plan. The chief financial officer informed the board that, following a review of forecast activity, deficit reduction plans and risks for the final quarter of the year, the trust was unlikely to achieve the £35m deficit agreed with NHSI. He advised that the board would be discussing this in detail in the private session of the meeting. It was reported that the capital expenditure funding application had not been confirmed. The chief financial officer said he expected this to be received by the end of February 2018, at which time the trust would discuss with NHSI regarding carrying the funding forward into the next financial year.

09.10 John Brougham advised the board that the trust had always maintained a policy of paying smaller creditors first; however this was becoming more of a challenge. He confirmed that the trust was liaising on a month by month basis with NHSI regarding this issue.

09.11 Resolution: The board received the report for information and assurance.

DELIVER SAFE EFFECTIVE CARE (BAF RISK 1)

10/56 Quality improvement plan update

10.01 The chief nurse introduced a progress report on the quality improvement plan (QIP). She advised that all the ‘musts’ and ‘shoulds’ from the latest CQC inspection report had been included; with18 projects now closed. The chief nurse informed the board that this would be the last board

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Agenda item


report as from 01 April 2018 any outstanding QIP deliverables would be tracked by the project management office and monitored by the strategy delivery board and safety and compliance committee.

10.02 The chair enquired why the trust was expecting a visit by the CQC relationship manager and the chief nurse confirmed that this was a regular supportive interaction by the CQC.

10.03 Resolution: The board received the report for information and assurance.

GOVERNANCE

11/56 General data protection regulations update

11.01 The chief information officer presented a paper which updated the board on the implementation of the general data protection regulations (GDPR). She reported that good progress had been made on the delivery of the plan and the trust had built a good relationship with NHS Digital. The chief information officer advised that the safety and compliance committee would discuss a recommendation in February 2018 to appoint a data protection officer and that the information team would be expanded slightly to take on additional subject access requests. It was noted that the outcome of an internal audit, which had reviewed the trust’s preparedness of GDPR, would be reviewed by the safety and compliance committee.

11.02 Ginny Edwards thanked the information team for supporting Peace Hospice Care with the preparations for the new GDPR guidance.

11.03 Resolution: The board received the report for information.

12/56 Strategy update

12.01 The board received an update from the deputy chief executive on the position of a range of long-term service changes and strategic developments. She advised that the trust had reached an agreement with Herts Valley clinical Commissioning Group (HVCCG) regarding a diabetes contract. It was recognised that this was a positive move forward and would help progress in a number of other areas with HVCCG. The deputy chief executive advised the board that further challenging discussions would be required for contractual arrangements relating to other clinical models of pathway redesign.

12.02 The board was advised that the acute transformation/redevelopment strategic outline case (SOC) had been raised at a recent performance review meeting with NHSI and the trust had been given assurance that the SOC was a high priority. It was highlighted that the collapse of Carrillon could add further delay to the approval process of the SOC. The board was informed that the majority of local MPs were in support of the SOC and had agreed to give it their backing. The deputy chief executive confirmed that work was continuing with the Hemel Hempstead SOC; however the target timeline had slipped and the SOC was now expected to be completed for review by the finance and investment committee in March or April 2018, followed by presentation to the board in April or May 2018.

12.03 The deputy chief executive advised that the trust had received informal notification that the car parking SOC had been approved. Formal notification was expected shortly. The outline business case would be presented to the board in March 2018 for approval.

12.04 Paul Cartwright enquired on the number of pathway redesign initiatives that the trust would be bidding for in 2018/19. The deputy chief executive advised that this would be discussed in the private session of the

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Agenda item


meeting.

12.05 The board noted the Hertfordshire and west Essex Sustainability and Transformation newsletter.

12.06 The deputy chief executive was thanked for an excellent, clear report and the board acknowledged the improved quality of all the board reports.

12.07 Resolution: The board received the paper for information.

13/56 Review of corporate governance structure

13.01 The deputy chief executive introduced a report on the outcome of a review into the corporate governance structure. She reminded the board that the review had concluded that 70-80% of board and committee members believed that the overall governance structure was working well. The outcome of the review had been discussed in detail at a board development session on 18 January 2018 and the recommendations had been updated in line with the discussion. The board welcomed the confirmation that the governance structure was working effectively and reviewed ten recommendations to improve the structure further.

13.02 The deputy chief executive confirmed that, following discussion at a board development session in January, she had developed a set of strategic objectives for 2018/19, which would be presented to the board for approval in March 2018. She advised that the objectives would be mapped against the committee structure and would be used to drive the board agenda.

13.03 John Brougham enquired when chairs of the assurance committees would be advised of any changes to the committee responsibilities which had come out of the review. It was reported that agreed minor refinements to the responsibilities of the committees would be circulated to chairs within the next month and the terms of reference and work plans would be presented to the board in May for approval.

JH

04/18

13.04 The trust secretary was thanked for conducting the review and it was agreed that it had been a useful process.

13.05 Resolution: The board approved the current corporate governance structure to continue for 2018/19, subject to the proposed refinements.

COMMITTEE REPORTS

14/56 Assurance report from finance and investment committee

14.01 John Brougham presented a report on the work of the finance and investment committee. He advised that the committee had recommended board approval of an NHS revenue support loan to cover funding requirements for January 2018. It was also noted that the board would receive an update on plans and actions to minimise the risk of achieving the 2017/18 £35m deficit and the financial plan for 2018/19.

14.02 Resolution: The board received the report for assurance and approved an NHS revenue support loan for £209,000.

15/56 Assurance report from the patient and staff experience committee

15.01 The board noted a report on the work of the patient and staff experience committee from Ginny Edwards, which had been received verbally at the January board meeting. She noted that the committee had recommended an annual medical revalidation organisational audit for 2016/17 to the board for approval.

15.02 Resolution: The board received the report for assurance and approved the annual medical revalidation organisation audit.

16/56 Assurance report from the clinical outcomes and effectiveness committee

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Page 7 of 8

Agenda item


16.01 The board received a verbal report from Jonathan Rennison on the work of the clinical outcomes and effectiveness committee. He advised that it had been a full and detailed meeting. The IPR had been reviewed and assurance provided that there was appropriate focus on areas of under- performance. A number of GIRFT reports had been reviewed in details and it had been noted that many actions were either completed or on track. Jonathan Rennison confirmed that the committee had received a clinical audit and effectiveness report which had provided good assurance that learning had been taken on board. The final version of the trust’s quality commitment had been reviewed by the committee and it was noted that this would be presented to the board for approval in March 2018.

16.02 Resolution: The board received the report for assurance.

17/56 Assurance report from the audit committee

17.01 Paul Cartwright presented a report on the work of the audit committee. He advised that the committee had reviewed and approved the audit timetable for the production of mandatory annual documents. It had been assured on the process of a corporate governance review and looked in detail at the work of the trust executive committee over the past year. The committee had also considered, and been assured, by an internal audit annual plan for 2018/19.

17.02 Resolution: The board received the report for assurance.

ANY OTHER BUSINESS

18/56 Any other business

18.01 The chair thanked the non-executive directors for the informative, assurance reports.

18.02 No other business was reported.

QUESTION TIME

19/56 Questions from Hertfordshire healthwatch

19.01 Q1. Does the trust have any contracts with Carillon? A1. The chief financial officer confirmed that the trust did not currently have any contracts with Carillon.

19.02 Q2. How are patients informed when their elective procedures are cancelled and does it have a knock on impact to other patients? A2. The chief executive responded that the trust had started to defer some surgical procedures before the national directive was announced to allow an appropriate balance of emergency and elective services. She recognised that having a procedure delayed was upsetting for patients and advised that patients were contacted directly and all actions were being taken to minimise the impact. The chief executive confirmed that the trust was continuing to provide elective services at St Albans and was working with a number of independent providers to reduce the number of procedures that were cancelled. She reported that some services which didn’t require an inpatient procedure or surgery were starting to be increased, such as endoscopy and cardiology. The divisional director of surgery, anaesthetics and cancer commented that the trust was in a slightly better position that some trusts as it had an elective site, however the trust was acutely aware that some patients had been waiting a long time for surgery.

19.03 Q3. Would the approval of a new hospital at Princess Alexandra NHS Trust impact on the trust’s acute redevelopment SOC? A3. The deputy chief executive confirmed that the trust was working

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Page 8 of 8

Agenda item


closely with the Princess Alexander Trust and it was on the same level regarding its bid. She noted that both trusts were trying to get the very best solution for patients.

20/56 Questions from patients and members of the public

20.01 Q1. What is being done to improve outreach services? A1. The chief executive responded that there was a well-established programme of transformation works aimed at offering a range of outreach services. A clinical transformation summit would be held on 22 February 2018 when the trust and HVCCG would agree the plan of works for 2018/19.

ADMINISTRATION

21/56 Draft agenda for the next board meeting

21.01 The draft agenda was approved.

22/56 Date of the next board meeting in public

22.01 The next board meeting would be held on 01 March 2018 in the terrace executive meeting room, Watford hospital.

5



Page 1 of 1

Agenda item 06a/57

Action log Part 1 – 01 March 2018

Ref No.

Action from agenda item

Action Lead for completing the

action

Date to be completed

Update

1 13.03/57 Minor refinements from a corporate governance review to be circulated to committee chairs to ensure they are incorporated into the annual update of committee terms of references and work plans

JH 04/18 This action is on track to be completed. It will be picked up as part of the overall annual update of the committee terms of reference and work plans, for board review and approval in May 2018.

6

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oard action log from 01 F

ebruary 2018 and previous meetings and decision log

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Agenda item: 06/57

Board

meeting/decision date

Decision reference

(from minutes)

Item presented to Board for action Comments/outcome

01/02/2018 15.02/57 Assurance report from the patient and staff experience committeeApproval of the annual medical

revalidation organisation audit.

01/02/2018 14.02/57 Assurance report from Finance and Investment CommitteeApproval of an NHS revenue support

loan for £209,000.

01/02/2018 13.05/57 Review of corporate governance structure

Approval of the current corporate

governance structure to continue for

2018/19, subject to the proposed

refinements

07/12/2017 17.01/54 Corporate governance meeting schedule Approval of 2018/19 corporate

governance meeting schedule.

07/12/2017 18.03/54 Assurance report from the Charitable Funds Committee

The corporate trustee approved a

recommendation to appoint Kingston

Smith to undertake a review.

02/11/2017 13.03/53 The Board approved the Hertfordshire health concordat Approved

02/11/2017 15.04/53 Board assurance framework Approved

05/10/2017 13.03/52 Assurance report from Finance and Investment CommitteeRatified a £1.4 interim revenue support

loan

05/10/2017 13.03/52 Assurance report from Finance and Investment Committee

Approved £1m capital expenditure

funding for the redevelopment of the

A&E department

07/09/2017 10.02/51The board aproved the NHS England emergency preparedness, resilience and response

annual assurance. Approved

07/09/2017 13.02/51The board approved the infection prevention and control annual report 2016/17 for

publication on the Trust website Approved

06/07/2017 16.04/50 The terms of reference and work plans for the board and committees Approved

06/07/2017 22.05/50The corporate trustee approved the recommended way forward to the future management

of the charity Approved

06/07/2017 18.02/50The board approved the annual accounts, annual report, governance statement and

quality account 2016/17. Approved

01/06/2017 15.03/49 Proposed monitoring arrangements for aims and objectives Approved the approach

01/06/2017 14.04/49 Outline business case for theatre reconfiguration Approved option E

01/06/2017 17.01/49 NHS self-certification 2017/18 Approved condition G6 (3)

BOARD AND CORPORATE TRUSTEE

DECISION LOG PART 1

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01/06/2017 18.02/49 Assurance report from Finance and Investment CommitteeRatified the terms and conditions of a

£42m interim revenue support loan

04/05/2017 20a.03/48 West Herts charity strategy Approved

04/05/2017 20b.02/48 Discretionary resources policy Approved

04/05/2017 15.02/48 An interim revenue support loan of £1.964k Approved

06/04/2017 16.02/47 Interim capital support facility agreement £7.5m Rattified

06/04/2017 11.04/47 Hospital Pharmacy Transformation PlanApproved as direction of travel for

pharmacy service.

06/04/2017 16.02/47 Deficit control totals for 2017/18 of £15.4m Approved

06/04/2017 14.02/47 Aims, objectives and principle risks. Approved

06/03/2017 15.02/46 The conversion of an IRWCF loan of £26.8m to an ISLF loan. Approved

06/03/2017 18.02/46 The 2017/18 Board and Committee structure and meeting schedule Approved

06/03/2017 17.02/46Recommendation to delegate responsibility to the Audit Committee to sign off the Annual

Accounts, Annual Report and Annual Governance Statement.Approved

06/03/201715.02/46

An interim loan of £4m to cover cash flow requirements in February and March 2017

ApprovedApproved

06/03/2017 13.07/46 A graded approach to workforce metrics for future reporting. Approved

02/02/201712.01/45

The transfer of 0.29 hectares (0.72 of an acre), to Watford Borough Council in line with

the Trust's obligations under the Health Campus agreement

Approved

02/02/2017

02.13/45

Recommendation that the Watford site continue to be the location for emergency and

specialised care and the St Albans site continue to be the location for planned care as

recommeded in the SOC

Approved

02/02/201712.01/45

An interim revenue support loan of £2.3m to cover February 2017 revenue cash

requirements

Approved

12/01/201715.2/44 counter fraud policy

Approved

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Board

meeting/decision date

Decision reference

(from minutes)

Item presented to Board for action Comments/outcome

01/12/2016 10/43 Nursing, midwifery and allied health professions strategy Approved

03/11/2016 19/42c Update to terms of reference for the Board Approved

03/11/2016 18/42 The gifts, hospitality and sponsorship policy Approved

03/11/2016 13/42 Statutory annual public sector equality duty report 2015 Approved

03/11/201619/42a

Recommendation to reduce the frequency of Integrated Risk and Governance Committee

meetings

Approved

03/11/2016 12/42 Patient experience and carer strategy Approved

03/11/2016 19/42b Draft Board and Committee meeting schedule 2017/18 Approved

07/10/2016 14/41 Recommended changes to the BAF 2016/17. Approved

07/10/2016 07/41Recommendation to increase the number of scheduled Board meetings to eleven per

annum.

Approved

01/09/2016 23/40 Terms of reference for the Trust Executive Committee Approved

01/09/2016 21/40Charitable Funds annual report and annual accounts 2015/16 , £12,000 of funds of funds

to support a holistic service for patients and their carers

Approved

07/07/2016 21/39 Updated Board Assurance Framework Approved

07/07/2016 .09/39 The quality account 2015/16 Approved

07/07/2016 18/39 The end of life care strategy Approved

07/07/2016 19/39

The Board received the updated terms of reference and work plans for the Safety and

Quality Committee and the Trust Board

Approved

07/07/2016 17/39Infection prevention and control annual report 2015/16 Approved for publication

07/07/2016 16/39Funding for external advisory support to develop a strategy outline case (SOC) for the

configuration of acute hospital service

Approved

05/05/2016 17/37The Board received the updated terms of reference and work plans for 2016/17 for the

Audit, Remuneration, Workforce, Finance and Performance, Charitable Funds and

Integrated Risk and Governance Committees

Approved

07/04/2016 16/36

The Board received corporate aims and objectives for 2016/17 Approved, subject to inclusion of

comments from Board

07/04/2016 17/36

The Board received a refreshed Board Assurance Framework for 2016/17 Approved

BOARD AND CORPORATE TRUSTEE

DECISION LOG PART 1 2016/17

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Trust Board Meeting 01 March 2018

Title of the paper Chair’s report

Agenda item 07/57

Lead Executive Professor Steve Barnett, Chair

Author Jean Hickman, Trust Secretary

Executive summary (including resource implications)

The aim of this paper is to provide an update on items of national and local interest/relevance to the Board.

Where the report has been previously discussed, i.e. Committee/Group

N/A

Action required:

The Board is asked to receive the report for information.

Link to Board Assurance Framework (BAF)

[Please indicate which Principal Risk this paper relates to by double clicking on the corresponding box]

PR1 Failure to provide safe, effective, high quality care

PR2 Failure to recruit to full establishments, retain and engage workforce

PR3 Current estate and infrastructure compromises the ability to deliver safe, responsive and efficient patient care

PR4a

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance

PR5a

Inability to deliver and maintain performance standards for Emergency Care

PR5b

Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)

PR7a

Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes

PR7b

Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure

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PR8 Failure to engage effectively with our patients, their families, local residents and partner organisations compromises the organisation’s strategic position and reputation.

PR9 Failure to deliver a long term strategy for the delivery of high quality, sustainable care

PR10

System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)

Trust objectives [Double click on the box to mark as appropriate]

To deliver the best quality care for our patients

To be a great place to work and learn

To improve our finances

To develop a strategy for the future

Benefits to patients/staff from this project/initiatives

Risks attached to this project/initiatives and how these will be managed 7

Tab 7 Chairs report


Agenda Item: 07/57

Trust Board Meeting – 01 March 2018 Chair’s report Presented by: Professor Steve Barnett, Chair 1. Purpose

1.1. The aim of this paper is to provide an update on items of national and local

interest/relevance to the Board.

2. NATIONAL NEWS AND DEVELOPMENTS

Government’s response to Naylor review

2.1. The government’s response to Sir Robert Naylor’s review of NHS property and estates, was published on 30 January 2018. The review highlighted the challenge of making sure the NHS has the buildings and equipment it needs and also the scale of the opportunity that the NHS estate offers to generate money to reinvest in patient care.

2.2. The Naylor review made 17 recommendations for the government; the vast majority of

which the Department of Health and Social Care (DHSC) has accepted in full, while two recommendations have been accepted in principle and two have been accepted in part. The Department has rejected a 2 for 1 incentive offer in which public funds would have matched disposal receipts.

2.3. A new NHS Property board has been established, which incorporates rather than

merges existing NHS property organisations. The NHS Property board will be chaired by the Parliamentary Under Secretary of State for Health and will receive significant support from NHS Improvement (NHSI).

2.4. NHS trusts (not Foundation Trusts) will be allowed to apply to bank land sales receipts

with DHSC and draw these back with interest when they are needed to fund agreed sustainability and transformation partnership health priorities. New national chief information officer

2.5. Dr Simon Eccles, emergency medicine consultant has been appointed as the national chief clinical information officer. He will replace Keith McNeil in the role which is shared across NHS England (NHSE) and NHS Improvement (NHSI).

2.6. Dr Eccles is the second person to hold the position which was established in 2016 in response to Professor Bob Wachter’s review of NHS IT. He is expected to oversee the implementation of Personalised Health and Care 2020 on behalf of the health and care system, including direct oversight of the £4bn NHS technology investment allocated for the next three years.

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https://www.gov.uk/government/publications/nhs-property-and-estates-naylor-review

National planning guidance and financial allocations for 2018/19

2.7. NHSE has published national planning guidance and financial allocations for 2018/19. It has been framed in terms of the improved funding outlook, the already agreed 2018/19 ‘deliverables’ set out in the Next Steps document, the priorities set by Government in the November budget and the expected mandate, insight from public engagement as well as the five “considerations to guide decision”.

2.8. NHSE confirmed that the extra money now provides funding growth of 2.4% in real terms compared to 2017/18. Factoring in England’s growing and ageing population, age-weighted revenue growth per person becomes 1.4% in 2018/19.

2.9. Clinical commissioning group (CCG) running cost allocations have not changed and the

£600m core allocations will be distributed to all CCGs in proportion to a CCG’s overall fair share of funding according to the target allocation formula. A higher level of funding will be allocated to specialised services as the latest assessment has concluded there will be higher than expected costs.

Lessons learned review of the WannaCry Ransomware Cyber-attack

2.10. A report of a review into the WannaCry Ransomware Cyber-attack has been published. This draws on the NHS’s internal assessments, as well as on two national reviews that have been assessed: the National Audit Office as well as the National Cyber Security 2017 Annual Review. The report accepts the next cyber-attack is a question of “when” not “if” and consequently there are 22 recommendations which the review team would like NHSE to take forward.

2.11. Negotiations are ongoing between DHSC and HM Treasury on funding for cyber security spending. Implementing the first recommendation of NHSE’s WannaCry review would cost £1bn. It has been suggested that funding allocated to the Paperless 2020 programme should be used for this purpose.

2.12. The board will receive a briefing on cyber security assessments in the private session of the meeting.

NHS paperless 2020 programme

2.13. NHSI has informed DHSC that there is insufficient funding for the Paperless 2020 programme. This situation has been exacerbated by the requirement to fund cyber security investment from the programme’s budget, as described above. Care Quality Commission update

2.14. The CQC has reported that hospital inspections undertaken against its published

commitments are on track.

2.15. At the beginning of January 2018, in response to increased pressure on the health and care system over winter, the CQC paused some routine inspections of urgent care services. CQC monitored NHS acute services but went ahead with all planned inspections.

2.16. CQC plans to publish its annual Mental Health Act review later in February 2018, the

final report into Child and Adolescent Mental Health Services on 08 March 2018, and a report on mental health rehabilitation inpatient services shortly.

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2.17. The CQC’s third consultation on the next phase of its regulation is underway; with the

aim of developing a comprehensive overview of the quality of care that is currently being delivered by providers in the independent healthcare sector. Independent healthcare is playing an increasingly significant role in England with many of its services being partly or wholly funded by the NHS. The CQC’s proposals cover services that are offered by independent healthcare providers such as hospices, mental health care, substance misuse services, and diagnostic imaging. The CQC is seeking views on its proposals on how to introduce quality ratings to more types of services and to develop how they monitor, inspect and rate services. Report on the Kirkup review

2.18. A report into an independent review, commissioned by NHSI following concerns raised about care delivered at Liverpool Community Health NHS Trust (LCHT) during November 2010 to December 2014, was published in February 2018.

2.19. The review found that LCHT experienced failings in care quality, including an inexperienced management and director team. The review found that LCHT was focused on its pursuit of foundation trust status and achieving very significant cost saving required by its commissioners and, as a result of drastic cost improvement measures, the trust reduced staff numbers and the management lead for clinical quality was unclear.

2.20. The review also examined the role for the external bodies responsible for overseeing the

trust and highlighted that during the period covered by the review, organisational structures changed radically and responsibilities moved to new organisations. While the review examined LCH specifically, these recommendations are likely to impact on the sector as a whole, including the role of the national bodies. These recommendations include:

In approving trust board appointments, NHSI should take note of the level of experience of appointees and level of risk in the trust, and should ensure a system of support and mentorship for board members where indicated;

Regulators and oversight organisations should review how they work together jointly at regional and national level, and implement mechanisms to improve the use of information and soft intelligence more effectively;

Regulators and oversight organisations should ensure that, during both local and national reorganisations and reconfigurations, performance and other service information is properly recorded and communicated to successor organisations;

The DHSC should review the working of the CQC fit and proper person’s test, to ensure that concerns over the capability and conduct of NHS executive and non-executive directors are definitively resolved.

New guidance on off-shoring and cloud computing

2.21. National guidance has been published setting clear expectations for health and care

organisations who want to use cloud services or data offshoring to store patient information. The guidance states

NHS and social care providers may use cloud computing services for NHS data. Data must only be hosted within the UK - European Economic Area (EEA), a country deemed adequate by the European Commission, or in the US where covered by Privacy Shield;

Senior Information Risk Owners (SIROs) locally should be satisfied about appropriate security arrangements (using National cyber security essentials as a guide) in conjunction with Data Protection Officers and Caldicott Guardians;

Help and advice from the Information Commissioner's Office (ICO) is available and regularly updated;

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https://www.cyberessentials.ncsc.gov.uk/advice/

https://ico.org.uk/for-organisations/health/

https://ico.org.uk/for-organisations/health/

Changes to data protection legislation, including the General Data Protection Regulation (GDPR) from 25 May 2018, puts strict restrictions on the transfer of personal data, particularly when this transfer is outside the European Union. The ICO also regularly updates its GDPR guidance;

NHS Digital has provided some detailed guidance documents to support health and social care organisations.

3. LOCAL NEWS AND DEVELOPMENTS

Nascot Lawn - outcome of judicial review

3.1. Following a decision by Herts Valleys Clinical Commissioning Group (HVCCG) in November 2017 to discontinue full funding of a respite service at Nascot Lawn, three of the parents who use the Nascot Lawn service pursued their case for continued CCG funding of the service and took this to a judicial review. The outcome of this review was published in February 2018.

3.2. The judicial review was presented on six grounds and the judge’s ruling agreed with the families on one of those grounds and rejected the remaining five. The ground that the judge supported relates to the CCG’s requirement in law to formally consult with Hertfordshire County Council (HCC), in a specific way as the respite service was deemed by the judge to be a health service.

3.3. The CCG will now follow the process outlined in Regulation 23 and formally consult HCC before making a decision on the future funding of respite services at Nascot Lawn. Following a six- week consultation period, HCC will consider its response and also make this available to the families of children receiving respite services at Nascot Lawn.

3.4. A decision is expected to be made in early May 2018 and the service will be funded on the current basis until at least August 2018. Urgent Treatment Centre in Hemel

3.5. HVCCG’s consultation regarding the urgent treatment centre (UTC) in Hemel Hempstead is open until 28 March 2018.

3.6. In particular, HVCCG is focusing on the opening hours for the UTC, which has been operating on reduced hours since December 2016, as well as on the contract for West Herts Medical Centre.

3.7. Further information about the consultation can be found on the HVCCG’s website.

Watford Riverwell 3.8. Watford Riverwell marked the beginning of the work on its first residential developments

with a ‘spade in ground’ event on 20 February 2018. I was joined at the ceremony by the elected mayor of Watford, Dorothy Thornhill; Watford Borough Council’s Managing Director, Manny Lewis and Andrew Storey, senior development director for the construction company Kier, as well as senior representatives from Watford Riverwell’s other project partners.

3.9. The residential development will comprise 95 new homes that will offer well-designed,

modern apartment living in landscaped grounds. This includes 29 affordable homes, which will be purchased and managed by Watford Community Housing.

Thank you

3.10. Thank you to the following people for their kind donations of time and effort to improve

the experience for our patients

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https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/international-transfers/

http://hertsvalleysccg.nhs.uk/get-involved/surveys-and-consultations/urgent-care-consultation

Samuel Van Emden, aged seven, and his family for kindly donating an ‘end of treatment bell’ to Starfish ward to say thank you to the nurses where Samuel spent four years receiving treatment;

The staff from Baldwin’s Lane surgery in Croxley Green for their donations of homemade twiddle muffs to Winyard ward;

Students from Watford Boys school who visited care of the elderly wards to keep patients company during visiting times.

Recognising and celebrating our staff

3.11. Well done to the following staff and teams for their outstanding work since the last board

meeting:

Sian Edwards, nurse practitioner, children’s emergency department, Watford, who won staff member of the month for December 2017. Sian was nominated by a number of her colleagues for being very supportive to patients and being a real inspiration to her colleagues;

Rosalind Webb, lead echo physiologist, cardiology department, Watford, who won staff member of the month for January 2018. Rosalind was nominated by her colleagues for transforming the stress echo service to enable patients to be seen within a shorter time scale, which resulted in the trust meeting national diagnostic compliance standards.

4. KEY MEETINGS

Met with Ellen Schroder, chair of the East and North Hertfordshire NHS Trust

Attended Chair and CEO meeting with Herts Community Trust

Met with representatives from the Michael Green Charity

Visited various patient areas with a member of the patient panel

Chaired consultant interviews panels

Attended the ‘spade in the ground’ event with Watford Council

Met with the chair and vice-chair of the League of Friends

5. RECOMMENDATION

5.1. The Board is asked to receive the report for information. Professor Steve Barnett Chair March 2018

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Page 1 of 8

Trust Board Meeting

01 March 2018

Title of the paper Chief Executive’s report

Agenda item 08/57

Lead Executive Katie Fisher, Chief Executive Officer

Author Jean Hickman, Trust Secretary


The aim of this paper is to provide an overview of the work and key decisions taken by the trust executive committee since the previous board meeting.


N/A

Action required: The Board is asked to receive the report for assurance that the trust executive is effectively managing the business of the trust.

Risk to Board Assurance Framework (BAF)





PR4a

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b

Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance

PR5a

Inability to deliver and maintain performance standards for Emergency Care

PR5b

Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)

8

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Page 2 of 8

PR7a

Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes

PR7b

Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure



PR10

System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)

Trust objectives [Double click on the box to mark as appropriate]





Benefits to patients/staff from this project/initiatives

Risks attached to this project/initiatives and how these will be managed 8



Page 3 of 8

Agenda Item: 08/57

Trust Board Meeting – 01 March 2018 Chief Executive’s report Presented by: Katie Fisher, Chief Executive 1. PURPOSE

1.1. The aim of this paper is to provide an overview of the work and key decisions taken by

the Trust Executive Committee since the previous board meeting.

2. LOCAL NEWS AND DEVELOPMENTS

Emergency pressures 2.1 The National Emergency Pressures Panel (NEPP met on 21 December 2017 and on 02

January 2018 and issued a number of recommendations to help trusts to take decisions on patient safety during the heightened winter pressures. At a meeting of NEPP on 26 January 2018, it was decided not to renew the national recommendation for suspension of elective activity beyond 31 January 2018. NEPP concluded that increases in bed capacity were beginning to increase in line with the additional funding allocated in the November budget and early indications suggested that the flu position was stabilising. Whilst demand remains high and there will be further challenges, NEPP recognised that nationally the pressures on the NHS had eased in January compared to December. In this context, trusts were asked to work with regional directors to plan a timely and appropriate return to a full elective care programme, based on local clinical and operational pressures.

2.2 The trust executive committee welcomed the announcement to lift the suspension on elective activity; however it acknowledged that the trust continued to have significant emergency pressures. The reasons for this are multi-factorial and mirror the national picture with increases in the number of patients presenting with acute and respiratory conditions including influenza and an increase in the number of patients and staff with norovirus.

2.3 To alleviate pressure at Watford hospital, the trust executive committee approved a

temporary change to the use of 18 beds on De La Mare Ward at St Albans to be used for the reablement of patients. This means the promotion of independence and encouraging patients to engage in everyday activities with the aim of supporting a safe and appropriate discharge from hospital.

2.4 Due to increased incidences of flu in the local community and hot spots of flu being

identified nationally, a level 3 ‘moderate’ alert was triggered at Watford hospital in line with the pandemic flu plan. This means that some important changes were made to wards, such as one ward in the acute admissions unit being utilised as a dedicated flu ward and patients remaining in the emergency department until a flu result was known.

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2.5 As ever, our amazing staff have risen to the challenge and patients have received safe care, albeit with some extended waits. I have spent time, with other executive colleagues, in emergency and urgent care services and have seen for myself the efforts of staff and the quality of care delivered, despite the operational challenges. Flu vaccination campaign

2.6 All NHS trusts have been asked to show that every member of staff has been offered the flu vaccine. The trust has sought to make it as easy as possible for all staff to receive the flu vaccination, with staff flu clinics at the three hospitals, plus trained peer vaccinators on wards and in departments.

2.7 The trust has achieved 60% of front line staff being vaccinated, which is an improvement

on the previous year, but still short of the target. The trust continues to see patients being admitted to hospital wards and intensive care units with flu and therefore staff are still being encouraged to have their vaccination if they have not already done so and the communications campaign continues.

Oversight meeting

2.8 On 15 February 2018, myself, the chair and other executives took part in the monthly

regulatory oversight meeting with colleagues from NHS Improvement (NHSI) and other external stakeholders. The meeting was fairly positive and focused on celebrating the trust exiting quality special measures and the actions being taken by the trust to continue its improvement journey.

Car parking 2.9 The trust’s strategic outline case recommending the development of a new multi-storey

car park at Watford hospital has been approved by NHSI. The next phase is for the trust to invest in the development of an outline business case, with the aim pf presenting this to NHSI in March 2018 and for construction to start next spring.

2.10 Changes to current staff car parking will take effect from 01 April 2018. There will be

two types of permits, ‘essential’ for staff that have to travel across sites at least twice a week and a ‘standard’ permit for those who only use their vehicle to get to and from work or occasional cross site working. There will be no change in the current charge but a cap will be introduced.

Improving theatre efficiency

2.11 The trust executive committee approved funding for an external supplier to implement a

theatre scheduling tool. The aim of this tool is to improve the efficiency and effectiveness of theatres, including increasing the number of patients that can be treated and reducing the number of cancelled operations.

2.12 The first phase of this work will focus on general surgery; ear, nose and throat, and

orthopaedics. Following an evaluation process of the impact of the tool, it could be rolled out to other specialties.

Cyber security update

2.13 As early adopters of NHS Digital’s Care Computer Emergency Response Team (CareCERT) Assure programme, the trust has been identified by NHS Digital as a priority organisation for a free on-site, cyber-security assessment. Such assessments

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have now been conducted in approximately 200 NHS trusts, resulting in recommendations and actions for these organisations in each case.

2.14 The trust’s information security manager presented a report to the safety and compliance committee in February 2018, in response to areas of action identified within the report. In addition, the trust has been invited to submit a bid against a national cyber security fund, aimed specifically at addressing key issues raised in its assessment. This has been submitted and the trust is awaiting the outcome.

CQC maternity service survey 2.15 The CQC published its maternity survey results in February 2018. The survey was

conducted on women who gave birth in February 2017 and the trust’s result mirrored the national picture, which showed marked improvements in women’s experiences of maternity services across safety, personalisation and choice.

Smokefree campaign 2.16 To continue to reinforce the decision taken in October 2017 for the hospital to be a

smokefree environment, additional photographic posters have been displayed across the Watford hospital site. Nurse retention programme

2.17 To improve recruitment and retention of band 5 nurses, the trust has introduced a new

flexible working option. Nurses who join the flexible pool will be able to receive the same pay rates, annual leave allowance and other benefits as all band 5 nurses, as well as training and development opportunities.

Underground link still a trust priority

2.18 The Mayor of London has announced that the Metropolitan Line extension is not

prioritised in his immediate funding plan. This is disappointing; however the trust continues to support Watford Borough Council in its aim to bring this important development to completion as soon as possible. Opening a new Underground station close to the hospital will significantly improve access for those dependent on public transport and help reduce the current high dependence on car use by staff, patients and visitors. Facilities Management

2.19 Following a 12 month tendering process, the trust is coming to the end of negotiations with Mitie facilities management company to provide services across the three hospitals. These services include portering, catering, cleaning and switchboard services.

2.20 Mitie has been invited to present to the board on the services it would provide in the

public session of today’s meeting and the board will consider a recommendation by the finance and investment committee to approve the contract with Mitie in the private session of the meeting.

3. LEADERSHIP CHANGES 3.1 A new emergency medicine department has been established with Dr Rachel Hoey as

director of emergency medicine, Debbie Foster as director of operations, Sarah Cato as lead nurse and Dr Nida Suri as clinical director for emergency care.

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3.2 David Thorpe will be joining the trust on 02 April 2018 as the deputy chief nurse. David is currently head of nursing and clinical services at Colchester Hospital University NHS Foundation Trust.

3.3 Annesha Archyangelio has been appointed as the new deputy director of infection

prevention and control. Annestha joins the trust from Epsom and St Helier University NHS Trust and will be taking up the position on 19 March 2018.

4. COMMUNICATIONS REPORT

Media

4.1. Recent coverage has centred around the CQC inspection results, and scrutiny around winter pressures and performance. The Watford Observer reported on its front page that major improvements have seen the trust move out of special measures. The Watford Observer also included quotes from Watford MP Richard Harrington, Major Dorothy Thornhill and Watford mayoral candidate George Jabbour. They were full of praise for the staff and leadership teams at the trust.

4.2. BBC Three Counties Radion interviewed both Mike Penning MP and Katie Fisher. Mike

Penning said that “I must congratulate frontline staff for the improvements that we have seen but the report does say there’s a heck of a lot to be done and a lot of criticism is around the management which I must say I hear all the time.” In her interview, Katie praised staff for their hard work, said that there had been many improvements in our emergency department since the inspection, and noted the positive feedback we receive from patients.

4.3. The Gazette and Express reported in their print edition that every one of the trust’s 658 beds were occupied on New Year’s Eve, Edie Glatter, of the New Hospital Campaign, said this underlines once again why A&E at Hemel Hempstead should not have been closed in 2008 and why West Herts needs a new hospital. Jane Shentall, director of performance at West Herts, said “We had the highest number of attendances on record for the month of December with 8,234 people arriving at Watford General Hospital.” She added: “There are other services available to local people […] In addition, GPs are operating extended hours and the NHS 111 service can help people access out of hour’s appointments.”

4.4. The Herts Advertiser reported that we had not met monthly targets for A&E admissions and planned operations. “West Herts has not hit the target for A&E since May 2015”. We said: “Winter is always a challenge for hospitals and this year is no different. If anything, it’s even busier. We had the highest number of attendances on record for the month of December with 8,234 people arriving at Watford General Hospital’s A&E department.”

4.5. The Watford Observer reported that Transport for London (TfL) will not deliver a Metropolitan line extension. Richard Harrington, the MP for Watford, offered the £73 million shortfall needed to make the project work but Mayor of London Sadiq Khan has said “no” and offered a bus route instead.

8



Page 7 of 8

Communications data

Website

Total Quarter 1

Total Quarter 2

Total Quarter 3

Running Quarter

4 (to date)

Running annual total 17/18

Total 16/17

Total Page Views

1,364,707 1,414,842 1,321,512 519,807 4,620,868 4,901,513

Number of unique visitors

106,195 107,937 110,278 43,933 446,649 370,658

Top five pages visited on internet site (excluding home page and vacancy pages):

1. Watford wards and departments

2. parking

3. About/contact 4. Services/pathology 5. About/Watford General Hospital (our hospitals page)

Internal Communications

January 2018

Total Quarter

1

Total Quarter 2

Total Quarter 3

Quarter 4 (to date)

Running total 17/18

Number of e-newsletters (e-update)

8 15 26 23 8 72

Number of CEO briefings

5 12 19 16 5 52

Number of Herts & minds newsletters

0 1 1 1 0 3

January 2018 Positive coverage Neutral coverage Negative coverage

National coverage 3 0 1

Coverage (Watford) 11 5 10

Coverage (Dacorum) 0 0 0

Coverage (St Albans) 3 2 2

Other local 0 0 0

Letters coverage 0 6 3

8



Page 8 of 8

Freedom of Information

January 2018

Total Quarter

1

Total Quarter

2

Total Quarter

3

Quarter 4

(to date)

Running total 17/18

Total 16/17

Number of FoIs received

58 153 169 154 58 534 662

Compliance within 20 day deadline

92% 95.0% 88.6 88.6%

92% 88% 94.3%

No of FoIs received from media outlets

9 24 24 12 9 69 100

Social Media

Twitter

Followers Posts Likes Retweets

December 2017 6078 58 1,003 599

Our most popular Tweet was: “We’re thrilled to announce that we’re no longer in special

measures! #CQCreport #teamwestherts #improvements” with 158 likes, 42 retweets and 12

comments.

Facebook

Followers Posts Likes Reach Shares Comments

January 2018 1438 60 860 44,002 349 20

Like Twitter, our most popular Facebook post was: “We’re thrilled to announce that we’re no longer in special measures! #CQCreport #teamwestherts #improvements” with 151 likes, 78 shares and it reached 10, 772 people. 5. RECOMMENDATION

5.1. The Board is asked to receive the report for assurance that the trust executive

committee is effectively managing the business of the trust. Katie Fisher Chief Executive March 2018

8



Trust Board Meeting

01 March 2018

Title of the paper Integrated Performance Report (January activity)

Agenda item 09/57

Lead Executive Sally Tucker, Chief Operating Officer

Author Jane Shentall, Director of Performance


The Integrated Performance Report covers the December reporting period (November data). For this reporting period, the Board is asked to particularly note the following performance changes since the last reporting period: Safe, Effective, Caring:

HSMR has moved from “lower than expected” to “as expected”

Increase in of patient safety incidents that were harmful, from 8.6% to 12.3%

Mixed sex accommodation breaches up from 10 to 164 – some ITU breaches but mostly flu admissions necessitating the cohorting of strains

6 cases of Clostridium difficile reported - the year to date total of 21 remains below the ceiling target of 23

A&E (93.5%) and inpatient (94.7%) positive scores are just below target (95%)

Good improvement in complaints performance, now 76.3% (from 52%)

100% of complainants received verbal communication (up from 88.5%) at the beginning of the process

Combined C-section rates (elective & non-elective) were within the ceiling target (28%) at 24.8%

Some improvement in performance against stroke indicators – 48%(target 90%) admitted to Stroke unit within 4 hours, and 80% of patients spent 90% of their time there (target 80%)

Responsive:

RTT (incomplete) performance worsened, to 85.7% (86.4% last month)

20 x 52 week breaches were reported

28 day rebooking breaches increased from 12 to 20

Diagnostic waiting time performance was 100% and achieved in all areas

ED 4 hour wait performance deteriorated to 72.3% (77.4% previously)

Ambulance turnaround delays improved by 6% between 30-60 minutes but delays over 60 minutes fell by 8.5%

2ww breast symptomatic standard not achieved at 92.1% (target 93%) due to patient choice cancellations

62 day cancer screening at 72.7% was below the standard (90%) with 1 breach

Formal delayed transfers of care increased to 4.3% Well Led:

Staff turnover (rolling 3 months) increased to 17.1% (from 16.6%)

Band 5 nursing turnover rate unchanged at 25.6%

Vacancy rate fell from 11.7% to 10.9%

% Bank and agency pay are within target

Appraisal (83.7%) & Mandatory (86.1%) rates have fallen

FFT response rates for inpatients, day case and A&E were below target but improved on previous month with the exception of Maternity which deteriorated

Further detail is provided in the executive summary and relevant exception reports,

9

Tab 9 Integrated performance report - month 10


including performance trends.

Where the report has been previously discussed

Trust Executive Committee (Performance) 21.2.2018

Action required:

The report is provided for information and assurance.




PR5a Inability to deliver and maintain performance standards for Emergency Care

PR5b Inability to delivery and maintain performance standards for Planned Care(including RTT, diagnostics and cancer)

PR7a Failure to achieve financial targets, maintain financial control and realise and sustain benefits from CIP and Efficiency programmes

PR7b Failure to secure sufficient capital, delaying needed improvements in the patient environment, securing a healthy and safe infrastructure


PR10 System pressures adversely impact on the delivery of the Trust's aims and objectives PR6 – business continuity has been closed (incorporated into PR1)

Trust objectives To deliver the best quality care for our patients To be a great place to work and learn To improve our finances

Benefits to patients/staff from this project/initiatives The Integrated Performance Report provides a view of performance across all key metrics in the areas of Safe, Effective, Caring, Responsive and Well Led

Risks attached to this project/initiatives and how these will be managed The Integrated Performance Report is reviewed monthly at the Trust Executive Committee prior to submission to the Board. Individual performance indicators are also reviewed at divisional level at monthly Performance meetings, where associated risks and issues are discussed and documented, and relevant actions tracked. Data quality is regularly reviewed both internally and by the Trust’s auditors.

9

Tab 9 Integrated performance report - month 10


Integrated Performance

Report

February 2017

(January data)

1

9

Tab 9 Integrated perform

ance report - month 10

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Well ledReporting sub committee – PSE

ResponsiveReporting sub committee – TEC

Safe Effective CaringReporting sub committees – COE and S&C

2

Areas requiring performance improvement• VTE risk assessment was below threshold (pages 4 & 18) • Admissions to stroke ward within 4 hours was below the performance standard and worse than the national average (pages 4 & 14) • There were 164 mixed sex accommodation breaches (pages 3 & 24)• Harm free care (new and all harms), as measured through the Safety Thermometer was worse than the performance standard and the national average (pages 4 & 20) • Complaints responded to within agreed timescales was worse than the 85% external performance threshold but is now better than the internal improvement trajectory (pages 3 & 15)

New to category this month:• HSMR mortality indicator fell below the performance target (pages 3 & 13)• Inpatient FFT % positive indicator was worse than the standard (pages 3 & 35)• Clostridium difficile was worse than the monthly threshold (6 cases) but equal to the year to date threshold (21 vs 21) (pages 3 & 16)

Areas requiring performance improvement• A&E 4 hour wait performance was below standard (pages 5 & 30) • Ambulance turnaround times' performance was worse than standard (pages 5 & 30)• The RTT incomplete indicator was worse than the standard (pages 5 & 25)• Patients not treated within 28 days of their last minute cancellation was below standard (pages 6 & 26)

New to category this month:• The 2WW breast symptomatic cancer indicator did not achieve the performance standard (provisional) (pages 5 & 27)• The 62 day screening indicator did not achieve the performance standard (provisional) (pages 5 & 29)• The Trust recorded twenty 52 week RTT breaches (page 5)• Formal DToCs were below standard (pages 6 & 31)

Areas requiring performance improvement• The staff turnover rate (rolling 12 months) was below the performance standard (pages 7 & 32)• Staff turnover (rolling 3 months) was worse than target (pages 7 & 32)• The vacancy rate was worse than the performance standard (pages 7 & 32)• Appraisals were worse than target(pages 7 & 33) • Mandatory training was worse than target (pages 7 & 33)• Friends and Family response rate for A&E was below threshold (pages 7 & 35)• Inpatient FFT response rate was worse than the target (pages 7 & 35)• Maternity Friends and Family response rate was worse than target (pages 7 & 36)

New to category this month:

Areas of good performance • There were no cases of MRSA bacteraemia (pages 3 & 16)• Day case FFT % positive indicator was better than the standard (pages 3 & 36)• There were no medication errors causing serious harm (pages 4 & 18)• Maternity FFT % positive indicator was in line with the standard (pages 3 & 36)

New to category this month:• No never events were reported (pages 4 & 16)• The percentage of patients receiving a caesarean section was better than the performance threshold (pages 4 & 24)• Patients spending 90% of their time on the stroke unit was equal to the performance standard (pages 4 & 14)

Areas of good performance • The 2WW cancer indicator achieved the performance standard (provisional) (pages 5 & 27)• Cancer 62 GP, 31 subsequent drug and surgery indicators are delivering to the performance standard (provisional) (pages 5 & 28 - 29)• Hospital initiated outpatient cancellations under 6 weeks performed better than the performance standard(pages 6 & 26) • Diagnostic wait times achieved the performance standard (pages 5 & 26)• The cancer 31 first indicator is provisionally better than the performance standard (pages 5 & 28)• The Trust provisionally met the 62 day standard (pages 5 & 29)


Areas of good performance • The sickness rate was in line with target (pages 7 & 32)• Temporary costs and overtime as % of total pay bill was better than target (pages 7 & 32), including and excluding unfunded beds (two indicators)• Bank pay was within the new target range of 8 %– 12% (pages 7 & 32)• Agency pay was better than target (pages 7 & 32)


Executive Summary

Jan-18 11

Dec-17 11

Nov-17 10

Achieving

Jan-18 10

Dec-17 10

Nov-17 11

Not achieving

Better than

national

average

Jan-18 7

Dec-17 11

Nov-17 10

Worse than

national

average

Jan-18 10

Dec-17 5

Nov-17 6

NB. Indicators achieving relate only to where targets have been set - as seen on the indicator summary. Ratings showing the number of indicators better or worse than the national average relate to only those indicators where the national average

was available. Indicators which are identified in the main pack as provisional may lead to changes to achieving/not achieving counts previous months in Executive Summary.

Jan-18 9

Dec-17 12

Nov-17 10

Achieving

Better than

national

average

Jan-18 7

Dec-17 8

Nov-17 9

Worse than

national

average

Jan-18 7

Dec-17 6

Nov-17 5

Jan-18 5

Dec-17 5

Nov-17 5

Achieving

Better than

national

average

Jan-18 5

Dec-17 5

Nov-17 6

Worse than

national

average

Jan-18 5

Dec-17 5

Nov-17 4

Jan-18 11

Dec-17 11

Nov-17 11

Not achieving

Jan-18 12

Dec-17 9

Nov-17 11

Not achieving

NB. The sum of indicators achieving and not achieving may not be equal between months due to some indicators being reported with a lower frequency than monthly

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Indicator Summary

3

Data Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent with relevant standardsAmber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queriesGreen – Data is complete, accurate and consistent with the standards set for the specific indicator

Exception indicators keyRed for a minimum of two data points and amber for one, out of the latest three data pointsRed for the latest data point

l

u

Domain a Indicator Target a Nov-17 Dec-17 Jan-18 a YTD Actual YTD Target aExecutive

LeadMonth

Included

in

Detailed

Reports

National

/ Locala

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

SHMI (Rolling 12 months) 100 89.5 91.9 92.2 MD Aug-17 Y National 100 Aug-17G

u HSMR - Total (Rolling three months) 100 88.4 96.2 101.4 MD Oct-17 Y National 100 Oct-17G

Crude Mortality Rate (Non elective

ordinary)**3.5% 2.6% 3.4% 3.5% 2.8% 3.5% MD Jan-18 Y National 2.77% (East

of Eng.)Oct-17

G

l 30 Day Emergency Readmissions - Combined * 4.0% 7.2% 8.0% 6.8% 7.3% 4.0% MD Jan-18 Y National 11.4% 2011-12G £

Marginal tariff reimbursement, possible

penalties

30 Day Emergency Readmissions - Elective * n/a 2.9% 3.7% 2.3% 3.0% n/a MD Jan-18 Y National n/aG £


penalties

30 Day Emergency Readmissions - Emerg * n/a 11.2% 11.1% 10.8% 11.0% n/a MD Jan-18 Y National n/aG £


penalties^

Number of patients with a length of stay > 14

days *tbc 325 350 352 3399 tbc MD Jan-18 Local n/a

G £Reduction in reimbursement vs largely

fixed costs. No penalty levied.

Staff FFT % recommended care tbd NHSI^ 61.5% 59.0% 64.5% 62.4% tbd NHSI^ DoW Sep-17 Y National n/aG

Inpatient Scores FFT % positive 95% 95.8% 96.5% 94.7% 93.6% 95% CN Jan-18 Y National 95.6% Dec-17G

A&E FFT % positive 95% 88.9% 89.1% 93.5% 91.6% 95% CN Jan-18 Y National 85.5% Dec-17G

Daycase FFT % positive 95% 99.2% 97.8% 98.6% 98.6% 95% CN Jan-18 Y National n/aG

Maternity FFT % positive 95% 94.1% 100.0% 95.0% 94.8% 95% CN Jan-18 N National 96.7% Dec-17G

l

% Complaints responded to within one month

or agreed timescales with complainant85% 55.1% 52.0% 76.3% 55.3% 85% CN Jan-18 N Local n/a

R

Complaints - rate per 10,000 bed days tbd NHSI^ 40.7 25.9 36.8 35.0 tbd NHSI^ CN Jan-18 N National n/aR

Reactivated complaints 7 3 8 72 n/a CN Jan-18 N Local n/aR

Proportion of complaints with verbal

communication at the beginning of the

process

80.5% 88.5% 100.0% 75.7% CN Jan-18 N LocalR

l Mixed sex accommodation breaches 0 2 10 164 232 0 CN Jan-18 N National57 Trusts

breachingJan-18

G £Penalties from CCG. £250 per day per

service user.

l Clostridium Difficile 1 5 1 6 21 21 CN Jan-18 Y National 2.3 average Dec-17G £

Penalties from CCG, fines from other

statutory authorities. £10,000 per case

above threshold.

MRSA bacteraemias 0 0 0 0 1 0 CN Jan-18 Y National n/aG £


statutory authorities. £10,000 in respect of

each incidence in the relevant month.

E. Coli Bacteraemia tbc 4 2 2 30 tbc CN Jan-18 Y National n/aG

Safe

, Eff

ecti

ve, C

arin

g

* Performance may change for the current month due to data entered after the production of this report

** Crude mortality threshold UCL upper control limit (2 standard deviations from mean)

tbd NHSI^ - threshold/target to be determined by Trust Development Agency guidance when available

NB. Where national avg. blank - information not currently available

Financial impact

^Calculation of emergency re-admissions penalty – Re-admission rate is applied to the value of all admitted activity. 25% of this is

then applied on the basis that this proportion is avoidable.

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Indicator Summary

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l

u

Domain Indicator Target Nov-17 Dec-17 Jan-18 YTD Actual YTD TargetExecutive

LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

l Never events 0 1 1 0 4 0 MD Jan-18 Y National n/aG £


statutory authorities, prosecution^

Serious incidents - number* tbd NHSI^ 4 3 5 34 tbd NHSI^ MD Jan-18 Y National n/aG

% of patients safety incidents which are

harmful*n/a 10.2% 8.6% 12.3% 11.1% n/a MD Jan-18 Y National n/a

G

Medication errors causing serious harm * 0 0 0 0 1 0 MD Jan-18 Y National n/aG

l CAS Alerts: Number issued each month n/a 6 10 12 12 n/a CN Jan-18 Y National n/aG

CAS alerts not acknowledged within 48 hours 0 0 0 0 0 0 CN Jan-18 National n/aG

Number of falls* 103 96 119 1042 CN Jan-18 Y LocalG

Number of falls with harm* 23 14 36 218 CN Jan-18 Y LocalG

Number of G3 pressure ulcers (Hospital

acquired)0 2 4 9 28 0 CN Jan-18 Y Local

G

Number of G4 pressure ulcers (Hospital

acquired)0 0 0 0 1 0 CN Jan-18 Y Local

G

l

Safety Thermometer Harm Free Care (acquired

within and outside of Trust)*/**95.0% 92.9% 93.0% 91.3% 91.6% 95.0% CN Jan-18 Y National 94.2% Jan-18

G

Safety Thermometer % New Harm Free Care

(acquired within Trust)*/**tbd NHSI^ 97.6% 97.7% 97.5% 98.2% tbd NHSI^ CN Jan-18 Y National 98.0% Jan-18

G

Safety Thermometer New Harm Free Care:

Catheter & UTI New Harms*/**tbd NHSI^ 2 2 1 20 tbd NHSI^ CN Jan-18 Y National

WHHT 0.18

vs 0.27Jan-18

G

l VTE risk assessment* 95.0% 91.1% 88.7% 91.1% 91.1% 95.0% MD Jan-18 Y National 95.3% Q2 2017A

l Caesarean Section rate - Combined* 28.0% 28.4% 28.3% 24.87% 27.7% 28.0% MD Jan-18 Y Local 26.7%Apr15-

Aug15 A

Caesarean Section rate - Emergency* 15.0% 16.5% 18.3% 14.1% 16.3% 15.0% MD Jan-18 Y Local 15.3%Apr15-

Aug15 A

Caesarean Section rate - Elective* 11.0% 11.9% 10.0% 10.8% 11.4% 11.0% MD Jan-18 Y Local 11.4%Apr15-

Aug15 A

Maternal deaths 0 0 0 0 0 0 MD Jan-18 N National n/aG

lPatients admitted directly to stroke unit

within 4 hours of hospital arrival *90.0% 75.0% 46.5% 48.0% 62.3% 90.0% COO Jan-18 Y National 60.2% Jul-17

G

Stroke patients spending 90% of their time on

stroke unit *80.0% 85.0% 69.8% 80.0% 82.4% 80.0% COO Jan-18 Y National 85.7% Jul-17

A

* Performance may change for the current month due to data entered after the production of this report


** Indicators reported from NHS Safety Thermometer

Safe

, Eff

ecti

ve, C

arin

g

NB Exception reports not provided for FFT scores


Financial impact

^Recovery of cost of procedure or episode plus any additional charge incurred for

corrective procedure or care in consequence to the event.

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Indicator Summary

5



l

u


LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

l Referral to Treatment - Admitted* 90.0% 65.4% 69.2% 66.9% 70.6% 90.0% COO Jan-18 Y Local 77.2% Dec-17G

l Referral to Treatment - Non Admitted* 95.0% 88.6% 88.3% 87.5% 88.8% 95.0% COO Jan-18 Y Local 89.8% Dec-17G

l Referral to Treatment - Incomplete* 92.0% 88.3% 86.4% 85.7% 88.7% 92.0% COO Jan-18 Y National 88.2% Dec-17G £

CCG penalty of £100 in respect of each

excess breach above the threshold

uReferral to Treatment - 52 week waits -

Incompletes0 1 0 20 21 0 COO Jan-18 National

1750 (all

Trusts)Dec-17

G

Diagnostic wait times 99.0% 99.4% 99.8% 100.0% 99.2% 99.0% COO Jan-18 Y National 97.8% Dec-17G £


excess breach above the threshold

l ED 4hr waits (Type 1, 2 & 3) 95.0% 81.9% 77.4% 72.3% 81.2% 95.0% COO Jan-18 Y National 85.3% Jan-18G £


excess breach above the threshold (cap off

8% of attendances)

ED 12hr trolley waits 0 0 0 0 0 0 COO Jan-18 Y National1043 (all

Trusts)Jan-18

G £ CCG penalty £1,000 per incidence

l

Ambulance turnaround time between 30 and

60 mins0 406 435 409 3,992 0 COO Jan-18 Y Local n/a

R £CCG penalty £200 per service user waiting

over 30 mins

l Ambulance turnaround time > 60 mins 0 106 153 166 1,654 0 COO Jan-18 Y Local n/aR £

CCG penalty £1,000 per service user

waiting over 60 mins

Cancer - Two week wait * 93.0% 96.9% 94.7% 95.8% 95.3% 93.0% COO Jan-18 Y National 94.9% Q3 17/18G £

CCG penalty breaches per qtr in excess of

tolerance is £200 for each breach.

u Cancer - Breast Symptomatic two week wait * 93.0% 99.3% 95.8% 92.1% 93.7% 93.0% COO Jan-18 Y National 95.1% Q3 17/18G £


tolerance is £200 for each breach.

Cancer - 31 day * 96.0% 98.6% 96.7% 98.5% 98.5% 96.0% COO Jan-18 Y National 97.7% Q3 17/18G £


tolerance is £1,000 for each breach.

Cancer - 31 day subsequent drug * 98.0% 100.0% 100.0% 100.0% 100.0% 98.0% COO Jan-18 Y National 99.5% Q3 17/18G £



Cancer - 31 day subsequent surgery * 94.0% 100.0% 100.0% 100.0% 99.4% 94.0% COO Jan-18 Y National 95.6% Q3 17/18G £



Cancer - 62 day * 85.0% 86.5% 89.0% 85.9% 87.5% 85.0% COO Jan-18 Y National 83.0% Q3 17/18G £



l Cancer - 62 day screening * 90.0% 81.0% 83.3% 72.7% 87.7% 90.0% COO Jan-18 Y National 90.7% Q3 17/18G £



*RTT and cancer performance for latest month is provisional and subject to validation


Res

po

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Indicator Summary

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l

u


LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

Urgent operations cancelled for a second time 0 0 0 0 0 0 COO Jan-18 Y National n/aG

lNumber of patients not treated within 28 days

of last minute cancellation0 6 12 20 78 0 COO Jan-18 Y National

10 (avg. all

Trusts)Q3 17/18

G

u Delayed Transfers of Care (DToC)* 3.5% 4.4% 2.1% 4.3% 5.3% 3.5% COO Jan-18 Y National 6.0% Feb-16G

Delayed Tranfers of Care (DToC) beddays used

in month988 735 866 11,822 COO Jan-18 Y National n/a

G

l Outpatient cancellation rate 8.0% 10.1% 10.6% 11.6% 11.2% 8.0% COO Jan-18 Y Local n/aG

Outpatient cancellation rate within 6 weeks^ 5.0% 3.9% 3.7% 4.6% 4.1% 5.0% COO Jan-18 Y Local n/aG

l Patient initiated cancellations (all) 12.5% 14.3% 11.5% 12.8% COO Jan-18 Y LocalG

Hospital + Patient initiated cancellations (all) 22.6% 24.9% 23.1% 23.9% COO Jan-18 Y Local n/aG

^ Excluding valid cancellations (cancellations to provide earlier appointments or where appointment no longer required, cancellations due to where patients have died, cancellations to appointments made in

error and cancellations where there was a change to a clinic template without a change to a patient's appointment date, time or site)


*DToC benchmark estimated by total delayed patients nationaly as percentage of occupied general and accute beds

Res

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Indicator Summary

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l

u


LeadMonth

Included

in

Detailed

Reports

National

/ Local

National

avg.

National

avg.

Period

Trend

Data

Quality

RAG

l Staff turnover rate (rolling 12 months) 12.0% 16.1% 16.4% 16.9% 16.3% 12.0% DoW Jan-18 Y National 13.5% (Beds

and Herts orgs)Dec-15

G

Staff turnover rate (rolling 3 months) 12.0% 15.7% 16.6% 17.1% 15.5% 12.0% DoW Jan-18 Y National 13.5% (Beds

and Herts orgs)Dec-15

G

Nurse Band 5 Turnover Rate 25.2% 25.6% 25.6% 26.0% DoW Jan-18 Y Local n/aG

% staffleaving within first year (excluding

medics and fixed term contracts)19.0% 19.6% 20.3% 19.0% DoW Jan-18 Y National n/a

G

Sickness rate 3.5% 3.4% 3.5% 3.5% 3.2% 3.5% DoW Jan-18 Y National 3.8% (EoE

orgs)Dec-15

A

l Vacancy rate 9.0% 10.6% 11.7% 10.9% 12.0% 9.0% DoW Jan-18 Y National 11% (local

survey)Dec-15

G

l Appraisal rate (non-medical staff only) 90.0% 85.9% 85.4% 83.78% 83.8% 90.0% DoW Jan-18 Y National 85% (local

survey)Dec-15

G

l Mandatory Training 90.0% 89.1% 86.9% 86.1% 89.1% 90.0% DoW Jan-18 Y Local 86% (local

survey)Dec-15

A

% Bank Pay** 8% - 12% 10.4% 9.8% 10.8% 9.8% 8% - 12% DoW Jan-18 Y Local n/aG

% Agency Pay** 8.0% 8.7% 7.3% 6.44% 8.1% 8.0% DoW Jan-18 Y Local 11.4% (local

survey)Dec-15

G

Temporary costs and overtime as % of total

paybill** (Inc. unfunded beds)22.6% 19.5% 17.6% 17.7% 18.3% 22.6% DoW Jan-18 Y National n/a

G

Temporary costs and overtime as % of total

paybill** (Excl. unfunded beds)8.2% 7.0% 5.5% 7.4% DoW Jan-18 Y National n/a

G

l Inpatient FFT response rate 50.0% 21.6% 15.9% 19.0% 21.9% 50.0% CN Jan-18 Y National 22.1% Dec-17G

l A&E FFT response rate 15% 4.2% 2.7% 3.4% 4.3% 15.0% CN Jan-18 Y National 11.6% Dec-17G

Daycases FFT response rate tbd NHSI^ 28.8% 25.7% 27.5% 29.8% tbd NHSI^ CN Jan-18 Y National n/aG

l Staff FFT response rate+ 50% 15.7% 11.8% 19.4% 15.6% 50% DoW Sep-17 Y National n/a

G

Staff FFT % recommended work 66% 58.5% 51.1% 53.8% 52.8% 66% DoW Sep-17 Y National n/aG

u Maternity FFT response rate 35% 53.4% 32.3% 25.4% 37.5% 35% CN Jan-18 N National 19.2% Dec-17G

*Perfomance for current month may change due to data entry post production of this report

*Medication errors causing serious harm data for latest month is provisional and subject to validation. Temporary costs and overtime performance is provisional for the current month

NB. Exception reports not provided for FFT scores ** Trajectory set as target


+ Staff FFT reports latest quarterly positions in monthly columns (eg. Q1, Q2 and Q3 = month 1, 2, and 3)

Wel

l Led


9



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Finance (Overview)

8

Operational performanceCurrent deficit of £39.34m is £23.77m adverse to plan as at M10 YTD. Unallocated CIP accounts for £9.03 of this, £5.90m due to NHS revenue, £4.15m to other revenue (mostly STF foregone), and £3.63m of pay costs (after above CIP element removed).

Recovery plans have been identified to maximise the chances of the Trust achieving its revised target of a £35.00m deficit, allowing for the effects of certain central decisions which have impacted on the Trust’s operational capacity.

Savings and outlook for FY18Savings achieved at £8.32m up to M10, in line with plan, i.e. projects costed vs actual delivery), and behind target by £7.63m (where we wanted to be at this point in the year). 2017/18 Trust savings target is £21.9m, of which £13.7m has been assigned to divisions and £10.30m identified.

Achievement of the £13.7m will be challenging, with focus naturally falling to 2018/19 but also ensuring that anything which could possibly be brought forward into 2017/18 will do so.

Operational performanceRevised forecast of £35m accepted by NHSI, compared to agreed 2017/18 control total of £15m. Change driven by challenges re CIP achievement, commissioner challenges, and consequent STF loss. (Base fcst position of £47.7m after taking into account M10 results, less recovery actions)

£m Plan Actual Var

Surplus / (Deficit) 1.1 (3.1) (4.2)

£m

Surplus / (Deficit) (15.6) (39.3) (23.8)

Breakeven

£m % Budget

Medicine 0.0 0

Unscheduled Care (4.5) (32)

Surgery (8.3) (73)

Women's (1.0) (5)

BPPC Clinical Support 0.2 3

Estates & Facilities 0.4 2

Corporate 0.1 0

Other (10.6)

Total (23.8)

FY18 YTD Variance by Division

Financial Overview as at 31 January 2018

Statutory / Regulatory Duties

The Trust has a deficit plan of £15m

for FY18.

CRL The Trust has not exceeded its Capital

Resource Limit.

Month 10 Income & Expenditure

Year to Date

EFL The Trust has managed spend w ithin its

External Financing Limit.

10 Days' Cash Cash at 31/1/18 equated to 5 days'

spend

Month 10 performance - 18% on number,

18% on value (95% target)

Financial Risk Rating FY18

0

5

10

15

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

Forecast Cash £m

F'cast cash

10 days' cash

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Fe b Mar

Savings £'000

Actuals

Target

0

20

40

60

80

100

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

Rolling BPPC Payment Performance

Target

No.

Value

-50

-45

-40

-35

-30

-25

-20

-15

-10

-5

0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Income & Expenditure FY18 £m

Actuals

Plan

BaseForecastRecoveryForecast

3

GG

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Finance (I&E)

9

Statement of Comprehensive Income (I&E)

Engagement with Commissioners• Contractual HVCCG activity continues to form the bulk of all income. Final FY17 income still under discussion, subject to mediation alongside 17/18.• CQUIN management involves formal monitoring and regular operational controls, assuming 90% achievement at this stage less PY adjustment.• FY19 QIPP discussed regularly and is the main subject of a summit on 22 February.

Operational performanceNHS income was £5.9m below plan YTD (£2.5m below in month), with a favourable variance in Non-Elective (£3.0m) offset by Elective (£4.1m, primarily Surgery), Outpatients (£2.2m) and Other (£2.1m).Other income was £4.2m adverse YTD (£0.8m in month) primarily due to STF income assumptions offset by favourable car parking income.

Outlook for FY18The current income forecast reflects all known and anticipated pressures (e.g. elective directive, tender outcomes), any STF income forgone as a result of missing the original control total of £15m, and winter pressures.Other service pressures clearly impact the Trust and are quantified where possible.

Budget Actual Var Budget Actual Var

Volumes

3,783 3,518 (265) Elective 42,806 36,198 36,306 108 34,857

4,315 4,059 (256) Non elective 49,525 41,361 41,996 635 41,969

40,658 38,499 (2,159) Outpatient 433,803 387,299 370,199 (17,100) 357,198

10,263 9,653 (610) A&E 117,791 98,375 98,316 (59) 98,102

4,861 3,966 (895) Elective 55,461 46,249 42,191 (4,058) 44,441

8,798 9,042 244 Non elective 100,978 84,333 87,290 2,957 80,412

6,137 5,486 (651) Outpatient 70,191 58,566 56,402 (2,164) 58,693

1,397 1,238 (158) A&E 16,032 13,389 13,243 (146) 12,275

1,201 1,193 (8) Critical care 13,781 11,509 11,081 (428) 11,480

3,745 3,503 (242) Other NHS revenue 42,978 35,894 33,836 (2,058) 34,273

26,138 24,428 (1,710) TOTAL NHS REVENUES 299,421 249,940 244,043 (5,897) 241,573

22 42 21 Private Patients 259 216 212 (3) 233

1,314 520 (793) Other non-NHS clinical income 11,306 8,678 3,892 (4,787) 11,552

1,335 563 (773) TOTAL Non NHS Clinical 11,565 8,894 4,104 (4,790) 11,785

804 791 (13) Education & Training 9,644 8,036 8,023 (14) 7,828

1,247 1,277 30 Other Revenue 15,315 12,753 13,408 655 14,050

2,050 2,068 18 TOTAL OTHER REVENUE 24,958 20,789 21,430 641 21,879

29,523 27,058 (2,465) NET HOSPITAL REVENUE 335,943 279,623 269,577 (10,046) 275,237

£000's

Month 10 (Jan)Prior Year

Actual

YTD FY18

Budget

£000's£000's £000's £000's £000'sNHS REVENUE£000's £000's

9



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Finance (I&E)

10

Statement of Comprehensive Income (I&E)

CIP schemesCIP schemes are a combination of expenditure, income, and transformational schemes.All cross-cutting CIP themes are closely monitored through formal meetings and operational actions.

Targeted assistance from SD & PMO colleagues is helping to generate a wide range of CIP ideas alongside the means and expertise to implement them in the best possible way.

Operational performance Pay costs were £9.4m adverse YTD (Medical £3.7m adv, Other Clinical £1.4m adv, Sci / Tech / Prof £0.6m adv, Nursing £0.5m adv & Unidentified CIP £5.8m, offset by Non-Clinical £2.5m fav). Focus on agency management continues agency cost trend established in FY17, £1.0m behind plan YTD (see following slide).

Non-pay costs were £4.3m adverse YTD – Increased outsourcing and drugs overspends were offset by favourable depreciation and clinical services.[Further detail is given in the main Finance Report.]

Outlook for FY18Current and recovery actions are continually assessed as part of general good practice alongside a formal process with NHSI. Mitigating actions, incluse of the Model Hospital and internal SDO are at various stages of progress.

Budget Actual Var Budget Actual Var

18,369 18,456 (87) Permanent / Bank Staff 223,267 186,195 179,194 7,001 163,818

507 1,272 (765) Agency 6,257 5,183 15,812 (10,628) 23,881

(1,065) (1,065) Unidentified pay savings (8,497) (5,809) (5,809)

17,811 19,728 (1,917) TOTAL PAY 221,027 185,570 195,006 (9,436) 187,699

1,798 1,907 (109) Drugs 21,075 17,477 18,898 (1,421) 18,191

2,661 2,257 404 Clinical services 32,069 26,734 24,612 2,122 26,017

5,735 5,444 291 Non-clinical services 70,829 59,419 62,190 (2,771) 56,831

(529) (529) Unidentified non-pay savings (5,084) (3,226) (3,226)

9,665 9,608 57 TOTAL NON-PAY 118,889 100,404 105,700 (5,296) 101,039

2,048 (2,277) (4,325) EBITDA (3,973) (6,351) (31,129) (24,778) (13,501)

721 622 99 Depreciation & Amortisation 8,650 7,211 6,202 1,009 6,021

128 156 (28) Interest 1,545 1,288 1,502 (213) 1,492

72 41 32 Dividends Payable 872 728 511 217 1,476

1,127 (3,096) (4,223) Surplus / (Deficit) (15,040) (15,578) (39,344) (23,766) (22,491)

Month 10 (Jan)Prior Year

Actual

YTD FY18

Budget

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11

Finance (Agency)Agency spend trajectory

Green – 2015/16 £36.8m, large

proportion of pay costs on

agency spend; agency caps

and other measures

implemented in-year

Red - This year, where we

needed to be in order to

achieve target expenditure of

£17.0m. YTD results M10

were £1.0m behind plan with

plans being implemented to

maximise the chances of

achieving FY18 targets. The

Purple line shows what may

happen if M10 spend persists.

.

Blue – 2016/17 £26.5m, a

>£10m decrease on 2015/16

but still a high proportion of pay

spend compared to peers.

Month 1A Month 2A Month 3A Month 4A Month 5A Month 6A Month 7A Month 8A Month 9A Month 10A Month 11F Month 12F

Required trajectory 17/18 1,860 3,438 4,996 6,741 8,163 9,772 11,354 12,586 13,817 14,877 15,938 17,000

Trajectory based M10 1,860 3,438 4,996 6,741 8,163 9,772 11,355 13,090 14,541 15,813 17,151 18,489

Cumulative plan 17/18 1,701 3,571 5,102 6,462 7,823 9,183 10,713 12,074 13,434 14,625 15,815 17,000

Cumulative actual 16/17 2,605 5,416 7,655 9,846 11,932 14,004 16,635 18,938 21,560 23,847 24,973 26,501

Cumulative actual 15/16 2,772 5,712 8,744 11,930 15,236 18,418 21,978 25,157 28,255 31,149 34,046 36,827

Required trajectory 17/18 1,860 1,578 1,558 1,745 1,422 1,609 1,583 1,232 1,230 1,060 1,060 1,060

Trajectory based M10 1,860 1,578 1,558 1,745 1,422 1,609 1,583 1,735 1,451 1,272 1,338 1,338

Months plan 17/18 1,701 1,871 1,530 1,360 1,360 1,360 1,530 1,360 1,360 1,190 1,190 1,190

Months actual 16/17 2,605 2,811 2,239 2,191 2,086 2,072 2,631 2,303 2,621 2,288 1,126 1,528

Months actual 15/16 2,772 2,940 3,032 3,186 3,306 3,182 3,561 3,179 3,098 2,894 2,898 2,780

9



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Detailed reports

12

9



14 of 121T

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Performance relative to targets/ thresholds

Executive lead Clinical lead Operational lead

Jan-18 4 4

Dec-17 3 5

Nov-17 4 4

Hospital

Standardised

Mortality

Ratio

(HSMR)*

Summary

Hospital

Mortality

Indicator*

Not achieving

Reporting sub committee - S&C &

COEC

Safe,

effective,

caring Achieving

Crude

mortality rate

(non-

elective)*

*Dr Mike Van der Watt

Tracey Carter

0

30

60

90

120

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

HSMR (overall) HSMR (weekend) Threshold (HSMR overall)

0

30

60

90

120

Apr 2012 to

Mar 2013

Jul 2012 to

Jun 2013

Oct 2012 to

Sep 2013

Jan 2013 to

Dec 2013

April 2013

to Mar 2014

July 2013 to

June 2014

Oct 2013 to

Sept 2014

Jan 2014 to

Dec 2014

Apr 2014 to

Mar 2015

Jul 2014 to

Jun 2015

Oct 2014 to

Sep 2016

Jan 2015 to

Dec 2015

Apr 2015 to

Mar 2016

Jul 2015 to

Jun 2016

Oct 2015 to

Sep 2016

Jan 2016 to

Dec 2016

Apr 2016 to

Mar 2017

Jul 2016 to

Jun 2017

SHMI (Rolling 12 months) Actual SHMI (Rolling 12 months) 100

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Crude Mortality Non-Elective Actual Mean UPL 2 standard devs LPL 2 standard devs

13

Hospital mortality

For the 12 month period (November 2016 to October 2017), theTrust’s HSMR of 95.7 was in the ‘as expected’ range having movedbanding from ‘lower than expected’. The Trust is reviewing the clinicalcoding of outlier groups to identify if the appropriate diagnosis andrelative risk has been applied.

The Trust is 1 of 7 within the Shelford peer group of 11 that sit withinthe ‘as expected’ range.

WHHT had the 54th lowest HSMR out of 136 non specialist trusts inEngland. The Trust has the 5th lowest HSMR within the East of Englandregion.

The Summary Hospital Mortality Indicator’s (SHMI) latestperformance (for Jul 16 to Jun 17) was 92.16 and ‘as expected’ (band2), placing the Trust 23rd nationally.

The Trust continues to hold monthly specialty/departmental MortalityReview meetings, cases from which are then discussed at a bi-monthlyTrust wide Mortality Review, chaired by the Medical Director. The casenote review process is currently being reviewed in order to align withthe recent publication, ‘National Guidance on Learning from Deaths’.

9



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Stroke 60 mins , s troke care and STeMI 150 mins* (to fol low)

% Emergency

re-admissions

within 30

days

following an

elective or

emergency

spell*

Patients

admitted

directly to

stroke unit

within 4

hours of

hospital

arrival*

Stroke

patients

spending 90%

of their time

on stroke

unit*

0%

2%

4%

6%

8%

10%

12%

14%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

30 Day Emergency Readmissions - Elective % 30 Day Emergency Readmissions - Emergency %

Combined Performance Combined Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)

0%

20%

40%

60%

80%

100%

120%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Performance Target Mean Upper control limit (3 sd) Lower control limit (3 sd)

14

Emergency ReadmissionsCombined readmission rates, including both emergency and electiveadmissions, includes all patients with more than one admission to thehospital within a period of 30 days, regardless of whether the secondadmission was related.

Both elective and emergency re-admission rates have risen but thecombined rate remains lower than the national average

StrokePerformance against the 4 hour admission to the stroke unit target is 48% . An improvement from 46.5% previous month performance . The YTD figure of 62.3% remains above the national average of 58 .2 % for August –November for admissions to the stroke unit within 4 hours. The Trust continue to experience high attendance activity resulting in capacity constraints . The Trust has been operating on business continuity, restricting timely access to the stroke beds.The stroke patients who arrive via a pre-alert ambulances are immediately seen by the stroke team on arrival. Other potential stroke patients are not always admitted to the stroke unit within 4 hours, they experience longer waits in ED especially during times of increased capacity pressure. When the waiting time to be assessed in ED is long the resultant is a delay in timely referral to the stroke team for specialist assessment.

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Number of

reactivated

complaints

% Complaints

responded to

within one

month or

agreed

timescales

with

complainant

Safe,

effective,

caring (continued)

Complaints -

rate per

10,000 bed

days

0

10

20

30

40

50

60

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Complaints - rate per 10,000 bed days Complaints - rate per 10,000 bed days

Mean Upper control limit (3 sd)

Lower control limit (3 sd)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Compliants timely response Target Mean

Upper control limit (3 sd) Lower control limit (3 sd) Trajectory

-30

-20

-10

0

10

20

30

40

50

60

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Reactivated complaints Threshold Mean

Upper control limit (3 sd) Lower control limit (3 sd)

15

Complaints rate per 10,000 bed days74 new complaints were received in January, of which 34% (25) relate to Surgery, Anaesthetics and Cancer (SAC), 28% (21) relate to Emergency Medicine (USC), 16% (12) relate to Women’s and Children’s Services (WACS), 14% (10) relate to Medicine, 4% (3) relate to environment, 3% (2) relate to CSS, 2% (1) relate to corporate. In 27% of complaints the patient was unhappy with their treatment. General Surgery and midwifery were the most complained about. Nearly 7% of all complaints related to the delay in appointments being arranged/received (cardiology being the highest). Staff attitude was the concern in 10% of complaints.

% Complaints responded to within one month or agreed timescales with complainant In January 76% (29) of complaints were responded to on time. 41 responses were sent in total. There is a target to respond to 85% of complaints on time.

Complaints responded to on time, by division, are as follows:

There were eight complaints reactivated in January.

Every division had a reopened complaint. Half of the responses to the original complaints were sent late and half did not wish to be telephoned.

There are currently 12 complaints over 4 months old, 9 relate to one division.

N/A denotes – no complaints valid for reply to this month.

9



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*Dr Mike Van der Watt

Tracey Carter

Safe,

effective,

caring

MRSA

bactaraemias

and E. Coli

Bacteraemia

Clostridium

Difficile

Never

events*

Reporting sub committee - S&C &

COEC

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

2015/16 2016/17 2017/18

MRSA bacteraemias Actual 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0

MRSA bacteraemias Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

E. Coli Bacteraemia 3 3 2 3 2 1 1 2 5 0 3 7 1 1 1 4 2 2 5 1 4 4 2 2 1 1 3 8 3 2 4 4 2 2

0

1

2

3

4

5

6

7

8

9

0

5

10

15

20

25

30

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Clostridium Difficile Actual Clostridium Difficile Target

Clostridium Difficile Actual YTD Clostridium Difficile Target YTD

Actual YTD (Excl. cases with no lapses in care)

0

1

2

3

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Never events Actual Never events Trajectory Never events Target

16


Jan-18 2 4

Dec-17 4 2

Nov-17 3 3

Achieving Not achieving

Clostridium difficile Infection (CDI)6 cases were reported in January. The full year target ceiling for WHHT apportioned CDI is23 – the year to date actual is 21.

2 cases were reported in Medicine, and unusually, the remaining 4 cases were identifiedin Surgery. 2 cases in surgery were coincidently linked by ‘time/date/place’ to one ward.However, rybotype results support no association and thus transmission on that wardwas not of concern. RCA’s have been undertaken and rybotypes received for 5 of the 6cases. The rybotypes are all different and support no evidence of transmission at thistime, suggesting cases are sporadic in nature. Key learning from RCA’s relates toinappropriate sampling.

The IPC team continue with antimicrobial rounds, weekly Clostridium difficile rounds.There is also increased targeted IPC support, audit, power training to key clinical areas.To date there has been agreement with Herts Valleys CCG that there was no identifiedlapse of care in 1 case of CDI. A further 4 cases were submitted to Herts Valley CCG forconsideration in January and the outcome is awaited.

MRSA bacteraemia (MRSAb)The full year target ceiling for MRSAb is 0 avoidable cases. A pre-48hr MRSAb wasreported in January. A CCG lead Post Infection Review (PIR) has been completed withWHHT support and as anticipated, the MRSAb has been assigned to ‘Third Party’.

E. Coli bacteraemia (E colib)2 cases of post 48hrs E colib were reported in January. The target set for the CCG thisyear is a 10% reduction equating to 36 cases. There is no target for WHHT. The IPCTintend to increase the organisations focus on E.Coli bacteraemias, deploying a similarstrategy/process and focus to this as that of C.diff and MRSAb. The IPCT is represented onthe WHHT continence group & supports the review of post 48hrs E colib RCAs.

Never eventNo never events were recorded in January.

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Medication

errors causing

serious harm*

% of reported

patient safety

incidents that

are harmful

Serious

incidents

0%

5%

10%

15%

20%

25%

30%

35%

40%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Actual Target

Upper control and lower control limit to be added

-5

0

5

10

15

20

25

30

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2014/15 2015/16 2016/17

Actual Target to follow UPL will be used Upper control limit (3 sd)

Lower control limit (3 sd) Mean

0

1

2

3

4

5

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Actual Target

17

Serious Incidents

5 Serious Incidents (SIs) were declared in January 2018, 2 more than in December 2017. • 3 in the Women’s and children’s services division – one complications following surgery,

and two obstetric incidents;• 2 in the Medicine division – one fall and one safeguarding incident.

At the end of January 2018 the Trust had 26 open SIs. Fourteen of these had been completed and were with commissioners pending formal closure on StEIS. At the end of January 2018 there were 12 ongoing SI investigations, 11 of which were within the deadline and 1 which was overdue with the estimated date of completion in February 2018.

Learning from SIs

The following actions and processes are in place to ensure learning from SIs and provide assurance that learning has taken place and changes have been implemented:

45 day review meetings allow the SI draft report to be discussed and challenged by the relevant clinical and management teams prior to the action plan being completed. There was 1 45-day meeting held in January 2018.

Each action plan is developed, signed off and monitored by the division leading the investigation into the incident.

The SI review group (SIRG), chaired by the Medical Director, review all closed SI action plans where senior divisional representation provides assurance and evidence that actions have been implemented before the SI is formally closed internally. The last SIRG meeting took place in November 2017 and was reported on in December’s report. The next SIRG meeting was scheduled to take place on 1 February, however it was cancelled last minute due to unforeseen circumstances and has been re-scheduled for 26 February.

% of patient safety incidents which are harmful

12.3% of incidents reported in January 2018 were recorded as harmful, which has increased from 8.56% in December 2017.

There has been a slight increase in the number of incidents reported scored as moderate or above from 19 being reported in December 2017 to 33 being reported in January 2018. Out of those 33 incidents 24 still require harm validation and are therefore subject to change.

Medication incidents causing serious harm

No medication errors were reported as causing serious harm in January 2018.

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Executive lead Clinical lead Operational lead*Dr Mike Van der Watt

Tracey Carter

Safe, effective,

caring

VTE risk

assessment*

Reporting sub committee - S&C & COEC

CAS alerts:a) number issued per month

(not target)

b) number where

acknowledgement overdue* (target = 0)

(Class 4: for information only and

class 2: Action within 48 hours) AprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMar

2015/16 2016/17 2017/18

a) CAS alerts issued 7 4 4 8 19 8 12 8 12 6 5 4 1 22 24 14 11 11 10 7 5 7 4 1 6 11 16 5 16 5 6 6 10 12

b) CAS alerts target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

b) CAS alerts overdue 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0

5

10

15

20

25

30

80%

85%

90%

95%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

VTE risk assessment Actual VTE risk assessment Target Mean

Upper control limit (3 sd) Lower control limit (3 sd)

18


Jan-18 1 4

Dec-17 1 4

Nov-17 1 4


CAS alertsAll alerts issued by CAS in January 2018 were acknowledged within the 48hr deadline.

There were 12 alerts issued in January 2018. 7 Estate & Facilities alert, 3 Medical Device Alerts and 2 Patient Safety Alerts.

1 of the Medical Device alert actions is underway and 2 are now closed .

4 of the Estate & Facilities alerts have been closed and actions complete and 3 have been sent to the relevant division and actions are underway.

The 2 patient safety alerts are underway and within deadline.

There were no breaches during January 2018 and all alerts with deadlines were closed on time.

VTE There has been some improvement in VTE risk assessment compliancebut more work is required to target non-compliant areas.

Issued by CAS 12

Breached in month 0

Currently overdue 0

CAS alerts not acknowledged within

48hrs 0

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Hospital

acquired

pressure ulcers

Falls and falls

with harm

0

5

10

15

20

25

30

35

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Hospital acquired pressure ulcers Hospital acquired pressure ulcers (G3) avoidable

Hospital acquired pressure ulcers (G4) avoidable

0

20

40

60

80

100

120

140

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Nu

mb

er

of

falls

Number of falls Number of falls with harm

19

Hospital acquired pressure ulcersIn January 31 new pressure ulcers were recorded affecting 23 patients:twenty two grade 2 and nine grade 3 pressure ulcers.7 of the 9 occurred in SurgeryThe avoidability has not yet been confirmed due to RCA’s underway.

The grade 2 pressure ulcers are validated by the Matrons for the clinical areas but not differentiated between avoidable and unavoidable.

A Trust wide improvement plan is in place to ensure continuing focus onreducing pressure damage as part of harm free care. A revised BestShot care plan is in place. Harm Free Care team are linking with Divisionsto refocus support. Skin Champion training days have been organised.High Risk prompt posters being trialled in surgery. Education team tosupport key areas with Tissue viability competencies for staff. Enhancedsupport and focus with the surgical division is underway.

Some significant improvements have been made, with over 36%reduction in grade 3 pressure ulcers between April and December 2017.

Falls and falls with harmIn January there were 119 inpatient falls with 34 resulting in low harm across 21 clinical areas, two resulting in severe harm an increase from December . Falls with harm remains low in comparison to numbers of falls.

The campaign to address falls continues with the creation of Fall Champions, and with the multidisciplinary falls group.

There is also joint working with Community teams, reviewing falls and common themes.

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NB. Indicator reported at WHHT from April 2017

Children's

Safety

Thermometer:

Harm Free Care

Adult Safety

Thermometer:

Harm Free Care

and New Harms

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Harm Free Care (acquired within and outside of Trust)

Harm Free Care (acquired within and outside of Trust) Target

New Harm Free Care (acquired within Trust)

New Harm Free Care (acquired within Trust) national average

0%

20%

40%

60%

80%

100%

120%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Harm Free Care Actual Harm Free Care national average

20

Adult Safety ThermometerThe Adult Safety Thermometer is a measurement tool for improvement thatfocuses on the four most commonly occurring harms in healthcare: pressureulcers, falls, UTI in patients with a catheter and VTEs. Data is collected through apoint of care survey on a single day each month on all patients. ‘Harm free’ care isdefined by the absence of harm in these four areas. In January , Harm Free Carewas 91.3%, below the national target of 95%. This includes harms acquired bothinside and outside of the Trust. New Harm Free care (harms acquired in the Trust)for January 2018 was 97.5%, slightly below the national average for January at98%.Nine Month Review of Harms.Since August no patient has experienced more than 1 harm. There was an increase in the January safety thermometer numbers of new pressure ulcers increasing to 7 from 5. Old pressure ulcers also increased from 25 to 34. A reduction has been seen in Falls and falls with harm and catheters with new UTIThere was a slight rise in catheters (89) but significantly lower that October 2017 (114)

The safety thermometer data reflects the increases seen with hospital acquired pressure ulcers but the same is not seen with the falls data.

Children and Young People's Services Safety ThermometerHarm includes patients with a PEWS completed: triggered but not escalated,extravasation (leakage of a fluid out of its container), patients in pain at time ofsurvey and any pressure ulcer or any moisture lesion. Harm free care was 100%in January for Acute Children’s Services, compared to 85.7% nationally. An analysisof the January 2018 survey demonstrated that all patients had a set ofobservations and had been assessed for an Early Warning Score in the last 12hours. Of those patients with an intravenous (IV) device, extravasation was notobserved in any patient . There were no reports of pressure ulcers or moisturelesions and no patient reported pain at the time of survey.

Harm Free Actions• Urology Steering group monitoring E-coli in conjunction with Infection

Prevention and control with continued monitoring of cathethers• Focus on the Pressure Ulcer improvement plan with Divisions.• Collaborative working with community on harms.• Falls collaboration with community teams• Falls Lanyard cards being brought re lying and standing blood pressure• Harm free Care tweets with key messaging• Targeted ward teaching• Implemented pain assessment recording on PEWs charts.

Indicator May17 Jun17 Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18

Number of patients with two

harms - 1 1 2 - - - - -

New pressure ulcers 3 3 4 5 5 8 6 5 7

Old pressure ulcers 46 34 51 56 50 27 26 25 34

Number of falls 3 3 9 13 14 10 12 13 9

Number of falls with harm 1 1 2 3 4 1 - 3 1

Catheters 103 74 117 86 99 114 107 80 89

Catheter & New UTI 1 1 5 4 3 - 2 2 1

New VTE 4 2 3 3 4 2 7 3 5

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21

Ward scorecard – key themesWhat is causing the variance in Trust performance

Safety Alerts – There has been an increase in January ( 56 ) from December (34). Safety alerts are mainly due to numbers of falls, and pressure ulcers , and thepercentage of extremely likely Friends and Family response rates in clinical areas. The areas with a high numbers of falls are Bluebell, Heronsgate/Gade,Sarratt, Tudor, Stroke and Letchmore. Heronsgate/Gade, Sarratt and Letchmore have seen an increase in the number of pressure ulcers. Surgery has had anincrease in c-diff isolates for January. Targeted work on raising awareness of high risk patients with clinical staff is being trialled.Process Alerts –January saw an increase (131) from December (127). The majority of the alerts are due to the overall Test Your Care results, twelve out ofthirty five clinical areas’ results are 90% or below. There appears to be a direct link between process – risk assessment and care planning and an increase insafety outcomes in relation to pressure ulcers demonstrated by the Safety thermometer data.Summary:• Paediatrics - one safety alert in CED.• Maternity - no safety alerts.• Nine clinical areas are demonstrating a higher trend of alerts for January compared to December.•The staffing slide outlines the impacts across ward areas rated to vacancies and lower fill rates and the opening of surge areas.

What actions have been taken to improve performance

• Trial of text messaging for patients attending ED for feedback for FFT. Awareness of FFT raised across the Trust through leadership academy programme• Introduction of speciality specific FFT forms in Outpatients .• Reviewing support mechanisms for staff such as care certificates, Band 6 and Band 7 development courses.• Targeted ward teaching on Falls prevention and management• Bed rail audit to be shared for learning• Falls lanyard cards for lying/ standing BP – being purchased• Multi disciplinary teams reviews in clinical areas with high numbers of falls• Targeted training in relation to Pressure ulcers with wards – purchased a body map that highlights pressure points• Pressure Ulcer focus with Surgery identifying support and actions• Harm Free Care promotion such as Newsletters, Mr B Harmfree – key messages, and Trolley dashes and use of simulation.• Targeted monitoring on practice and cleaning by infection control around C- Diff• Safer Care tool being implemented.• Ward Accreditation being undertaken by all ward areas

Changes in outcomes

• Improvements have been made with a >36% reduction in grade 3 pressure ulcers during April – December 17 compared to 2016.• Falls with harm has remained low• No increase in incidents around patient deterioration• Reductions in Thromboembolisms with preventable cases and deaths in the Trust

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C-section rate

Mixed sex

accommodation

13%

9% 11%

11%

9% 11%

11%

11% 15

%11

%11

%11

%8% 11

%11

%10

%9%

16%

11%

8%13

%10

% 14%

15%

13%

12%

11%

10%

11%

11% 14

%12

%10

%11

%

18%

21%

17%

19%

19%

16% 21

%20

%22

%20

%20

%20

%21

% 21%

19%

18%

20%

18%

22%

24% 16

%18

% 16%

14%

17%

18%

13%

17%

13% 17%

19%

17%

18%

14%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Ma

r

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Ma

r

2015/16 2016/17 2017/18

Caesarean Section rate - Elective Actual Caesarean Section rate - Emergency Actual

Caesarean Section rate - Combined Target

0

20

40

60

80

100

120

140

160

180

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

MSA breaches Actual MSA breaches Target

24

C-section rateThe caesarean section rate for January has remained within the required parameters.

Guidance is to be drafted explaining Trust policy relating to elective sections due to the number of women who feel they are entitled to sections regardless of the clinical situation (according to NICE guidance.)

The service are benchmarking this type of request and how it is managed in other neighbouring hospitals. A decision and process/SOP will then be agreed and written to demonstrate how the service will manage this cohort of women.

A paper will then be presented in TEC with an update on the agreed process, how it fits with RCOG and NICE guidance .

Mixed sex accommodation (MSA)The number of reported breaches increased in January as a result of winter pressures and cohorting for flu.

All patients who are bedded where there is mixed sex are recorded as a breach. For example a male patient bedded in a bay of 5 female patients would constitute 6 breaches.

The monitoring and management of patients requiring step down from ITUis reviewed daily as part of the regular operational management meetings,with the intention of reducing where possible, the number of mixed sexaccommodation breaches that occur. Advance planning for complex patientsrequiring side-room capacity is reviewed as part of these meetings.

The Trust policy on mixed sex accommodation has been reviewed and ratified.

The completion of the RCA template provided by HVCCG is being undertaken inITU.

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Responsive

Reporting sub committee - TEC


Sally Tucker Jeremy Livingstone Divisional Managers

Access indicators - RTT, diagnostics, cancelled operations

and outpatient appointments

Incomplete

pathways

within 18

weeks

Completed

pathways

within 18

weeks

Incomplete

pathways WL

profile

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Admitted performance Non admitted performance

Non admitted target Admitted target

Apr M ay Jun Jul Aug Sep O ct Nov Dec Jan Feb M ar Apr M ay Jun Jul Aug Sep O ct Nov Dec Jan Feb M ar Apr M ay Jun Jul Aug Sep O ct Nov Dec Jan Feb M ar

2015/16 2016/17 2017/18

52+ 3 1 - - - - - - - - - - 2 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 20

26 < 52 701 657 528 358 349 358 347 347 455 550 492 636 649 761 892 984 1,03 987 990 892 964 884 782 659 661 647 625 748 892 993 921 935 1231 1405

18 - <26 1,62 1,35 1,48 1,29 1,23 1,15 1,10 1,10 1,38 1,34 1,24 1,62 1,83 1,68 2,07 2,21 2,17 2,26 1,96 1,83 1,96 1,65 1,53 1,43 1570 1522 1638 1757 1971 2082 2026 2017 2157 2115

<18 20, 7 21, 1 21, 4 19, 6 18, 9 17, 8 17, 4 17, 4 17, 3 17, 2 18, 8 19, 6 19, 2 20, 0 22, 9 21, 7 21, 8 21, 0 20, 5 19, 9 19, 3 19, 1 19, 2 20, 7 20780 21218 22178 22550 22629 22749 22580 22243 21506 21131

% of PTL wi thin 18 weeks 89. 9% 91. 3% 91. 4% 92. 2% 92. 3% 92. 2% 92. 3% 92. 3% 90. 4% 90. 1% 91. 6% 89. 7% 88. 6% 89. 1% 88. 5% 87. 2% 87. 2% 86. 6% 87. 4% 88. 0% 86. 9% 88. 3% 89. 2% 90. 9% 90. 3% 90. 7% 90. 7% 90. 0% 88. 8% 88. 1% 88. 5% 88. 3% 86. 4% 85. 7%

82%

84%

86%

88%

90%

92%

94%

0

5,000

10,000

15,000

20,000

25,000

30,000

% p

atie

nts

wit

hin

18

we

eks

Nu

mb

er

of

pat

ien

ts

80%

82%

84%

86%

88%

90%

92%

94%

Apr

May Jun

Jul

Aug Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Performance Mean Upper control limit (3 sd)

Lower control limit (3 sd) Target Trajectory

25


Jan-18 5 2

Dec-17 5 2

Nov-17 5 2


RTTJanuary’s performance, at 85.7%, shows a decrease on the previous month’sperformance of 86.4%. The most recent national data available (December) showsthat the Trust’s performance that month was below the national average (88.2%).Performance at the L&D (90.9%) and RFH (86.7%) was also below the nationalstandard of 92%. The median waiting time at WHHT (ie the weeks half the patients onan RTT pathway were waiting) was worse than the national position (8.0 vs 7.4 weeks)and worse than the 92nd percentile wait time (22.5 vs 21.3 weeks).

Urgent care demand has continued to have a significant impact on performance as aresult of limited bed capacity for routine elective procedures. Although he nationaldirective to defer elective activity has been lifted, restoration of elective bed capacityis not yet possible as a result of sustained emergency care pressures.

As a direct result of the loss of elective bed capacity at WGH, there have been 20 x 52week breaches, the majority in Orthopaeics.

Service18 Weeks

Plus

% Under 18

WeeksService

18

Weeks

Plus

% Under 18

Weeks

GENERAL MEDICINE 0 100.00% PAED EPILEPSY 2 96.23%

OTHER 0 100.00% ORTHOTICS 8 95.90%

ANAESTHETICS 0 100.00% CARDIOLOGY 68 95.82%

CRITICAL CARE MEDICINE 0 100.00% PAED OPHTHALMOLOGY 7 95.24%

PAED CLINICAL HAEMATOLOGY 0 100.00% GYNAECOLOGY 41 95.18%

PAED DERMATOLOGY 0 100.00% CLINICAL HAEMATOLOGY 12 94.83%

STROKE MEDICINE 0 100.00% DERMATOLOGY 105 94.55%

TRANSIENT ISCHAEMIC ATTACK 0 100.00% PAEDIATRICS 43 94.07%

MEDICAL ONCOLOGY 0 100.00% UPPER GI 4 93.85%

NEONATOLOGY 0 100.00% RESPIRATORY MEDICINE 33 93.04%

GYNAE ONCOLOGY 0 100.00% HEPATOLOGY 5 92.19%

ORTHOPTICS 0 100.00% RHEUMATOLOGY 46 90.87%

CLINICAL ONCOLOGY 0 100.00% COLORECTAL SURGERY 43 90.23%

GERIATRIC MEDICINE 1 99.12% ORAL SURGERY 146 86.56%

PAED GASTROENTEROLOGY 1 99.08% NEUROLOGY 141 86.18%

PAED ENDOCRINOLOGY 1 97.78% ENT 312 83.97%

PAED CARDIOLOGY 1 97.67% UROLOGY 228 81.79%

BREAST SURGERY 11 97.32% VASCULAR SURGERY 31 80.63%

DIABETIC MEDICINE 2 97.14% TRAUMA & ORTHOPAEDICS 806 79.27%

PAED UROLOGY 4 96.99% GENERAL SURGERY 506 73.77%

ENDOCRINOLOGY 8 96.95% OPHTHALMOLOGY 664 73.00%

NEPHROLOGY 1 96.67% PAIN MANAGEMENT 213 72.41%

ORTHODONTICS 3 96.63% Total 3540 85.65%

GASTROENTEROLOGY 43 96.46%

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Diagnostics

Patients not

treated within

28 days of last

minute

cancellation

and urgent

operations

cancelled for

2nd time

Hospital

outpatient

cancellations

all and %

cancelled*

within 6 weeks * Ex c l udi ng v a l i d c a nc e l l a t i ons

( c a nc e l l a t i ons t o pr ov i de e a r l i e r

a ppoi nt me nt s or whe r e a ppoi nt me nt no

l onge r r e qui r e d, c a nc e l l a t i ons due t o

whe r e pa t i e nt s ha v e di e d, c a nc e l l a t i ons

t o a ppoi nt me nt s ma de i n e r r or a nd

c a nc e l l a t i ons whe r e t he r e wa s a c ha nge

t o a c l i ni c t e mpl a t e wi t hout a c ha nge t o

a pa t i e nt ' s a ppoi nt me nt da t e , t i me or

si t e )

0

5

10

15

20

25

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Patients not treated within 28 days of last minute cancellation

Trajectory (28 day standard)

Target (28 day standard)

Mean

0%

2%

4%

6%

8%

10%

12%

14%

16%

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Outpatient cancellation rate Actual Outpatient cancellation rateTarget

Mean Upper control limit (3 sd)

Lower control limit (3 sd) Outpatient cancellation rate within 6 weeks

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

100.5%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2014/15 2015/16 2016/17

Performance Trajectory Target

Mean Upper control limit (3 sd) Lower control limit (3 sd)

26

Hospital cancellations – patients not treated within 28 days of last minute cancellation

There were 20 breaches of the 28 day rebooking requirement. These were in GeneralSurgery, Orthopaedics, ENT, Ophthalmology, Urology and Pain. Breaches were theresult of capacity (bed) pressures, equipment availability and patient choice.

The Increased numbers of breaches is expected to continue until an elective bed base can be restored at WGH, as it is not possible to make alternative arrangements for the majority of patients cancelled.

Hospital cancellations – patients cancelled within 6 weeks and overall

Short notice, hospital initiated cancellation remains below the Trust tolerance (5%) at4.7% (excluding valid cancellations and patient initiated cancellations).

NB: Total cancellation rate does not equate to unfilled capacity.

Diagnostic wait times

Performance against the 6 week waiting time standard has been maintained, with all services achieving the target, delivering 100% compliance.

All cancellations Under 6 weeks All cancellations Under 6 weeks

11.6% 4.7% 11.5% 9.2%

Total cancellations: 23.1%

Hospital initiated Patient initiated

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28 of 121T

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Responsive



Sally Tucker Jeremy Livingstone Divisional managers

Recovery plan/ existing actions and update

Breast

symptom two

week

standard

CWTs

Two week

standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Two week wait performance Two week wait target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Breast Symptomatic performance Breast Symptomatic target

27

2wwThe provisional position for January is compliant at 95.8%.

Breast symptomaticThe provisional position for January is non- compliant at 92.2%. There were 152 cases and 12 breaches.

The main reasons for non-compliance are increasing numbers of referrals via both Breast Symptomatic and 2ww GP urgent for breast. Eight extra clinics were supplied in January but demand and capacity work is being revised in order to meet demand.


Jan-18 6 1

Dec-17 6 1

Nov-17 6 1


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29 of 121T

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31 day

subsequent

surgery

standard

31 day

subsequent

drug standard

31 day

standard

93%

94%

95%

96%

97%

98%

99%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 31 day Performance Cancer - 31 day Target

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

102%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 31 day subsequent surgery Performance Cancer - 31 day subsequent surgery Target

80%

85%

90%

95%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 31 day subsequent drug Performance Cancer - 31 day subsequent drug Target

28

31 day first

The position for January is currently compliant at 98.5%.

31 Day subsequent – Drug

The position is provisionally compliant at 100%

31 day subsequent –Surgery

The position is provisionally compliant at 100%

9



30 of 121T

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62 day

screening

standard

62 day

standard

number of

104+ day

waiters

62 day

standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 62 day Performance Cancer - 62 day Trajectory Cancer - 62 day Target

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Cancer - 62 day screening Performance Cancer - 62 day screening Target

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

Cancer 62 day patients waiting 104 days+ 24 3 3 4 4 2 3 3 2 0 1 1 2

Cancer 62 day PTL (total) 1466 1338 1284 1331 1312 1456 1521 1720 1392 1251 1254 1475 1425

0

5

10

15

20

25

30

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Nu

mb

er

of

pat

ien

ts w

aiti

ng

10

4+

day

s

Nu

mb

er

of

pat

ien

ts o

n P

TL

29

62 day GP – urgentThe provisional position for January was compliant at 85.9% Update on 21.2.18 - There are 68.5 treatments and 9.5 breaches. More treatments are expected to be added and some breaches still to be validated. The final position is expected to be compliant.General themes that cause delays: a) patient tracking is not yet optimal due to new staff training and some capacity problems, b) not seeing enough patients in the first 7 days instead of 14 c) If a patient does not have the right discussion or decision at an MDT, this causes delays d) some long waits for information from our tertiary centres.Actions: Focus on PTL tracking continues with training and structured PTL meetings and checklists.

104 day waitsActive – in the January submission, we had 2 H&N patient pathways >104 days.Closed – 3 pathways >104 were closed in January - 2 lung and 1 urology .

62 day screening Performance is provisionally non-compliant at 72.7%Update on 21.2.18 - The position has slightly changed but still non-compliant. There were 5.5 cases and 1 breach. It was in LGI. Action: Patients on the screening PTL will have daily tracking to avoid breaches. A weekly MRI slot has been ring-fenced for colorectal patients since 24th January 2018

Tumour site Jan

Breast 91.7

Gynaecological 100

Haematological 100

Head and Neck 33.3

Lower Gastrointestinal 64.7

Lung 40

Sarcoma 100

Skin 100

Upper Gastrointestinal 83.3

Urological 75

Total 85.9

9



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30

Responsive


Executive lead Clinical lead Operational lead Performance relative to targets/ thresholds

Sally Tucker Dr David Gaunt Divisional managers

Jan-18 1 4

Dec-17 1 4

Nov-17 1 4

A&E

* Please note that the A&E trajectory is a working trajectory and awaiting final approval

Ambulance

turnaround

time

Unscheduled care

indicators - A&E,

ambulance turnaround

and DToCAchieving Not achieving

70%

75%

80%

85%

90%

95%

100%A

pr

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Performance Trajectory Target


0

100

200

300

400

500

600

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Ambulance turnaround 60 mins+ Ambulance turnaround between 30 and 60 mins Target

A&E performance fell in January to 72.3% compared with 77.4% the previous month.Minors performance fell to 89.7%. CED performance also fell to 90.8% from 94.1%.January saw attendances with high acuity and an increase in respiratory illness.

There were a number of days when the Trust was in Business Continuity due tocapacity issues.

A new Directorate of Emergency Medicine has been established with a newlyappointed Director of Emergency Medicine, who will focus on the delivery of EDperformance. Work has been ongoing to clarify pathways and to improve compliancewith the 30 minute response time target for Internal Professional Standards (reviewof A&E patients by specialty teams). Streaming of patients is occurring much earlier inthe patient pathway although activity is limited when assessment areas are used forbedded patients at peak times.

Focus continues on ensuring full use of the Emergency Surgical Assessment Unit(ESAU), Medical Assessment Area (MAU), Ambulatory Care (ACU) and Frailty,although at times of increased pressure and capacity issues these are used as beddedareas which significantly limits streaming opportunities.

The new programme of work to improve ambulance handover times commenced inDecember which includes ambulance crews recording NEWS (National Early WarningScores) to ensure a consistent approach in measuring acuity. A trial is underway ofambulance crews presenting to the streaming nurse for patients with a NEWS scoreless than 1 with the aim of speeding up the handover process. Ambulance crews arealso trialling taking pre-hospital bloods. Trust paramedics and additional queuenurses have been approved, in order to improve handover times.

An activity comparison of the current financial period with the same period last year has shown:• Type 1 attendances are up by 1.1%.• Ambulance arrivals are down by 4.7%.• Admission rate from A&E (excluding ambulatory and frailty) is down by 0.1%.• Discharges (Trust wide) are up by 5.8%

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32 of 121T

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31

Delayed Transfers of CareDToC patients represented 4.3% of occupied beds in January, an increasefrom 2.1% in December, measured using the nationally reported method.This is based on a snapshot of the number of patients waiting at a point intime in the month, expressed as a percentage of beds.

The total beds occupied by DToC patients is a helpful measure to illustratethe impact of DToC because it includes all patients waiting in the month. InJanuary DToC patients consumed 866 bed days, the equivalent of 27.9 beds.

There are regular audits of both DToC and other stranded patients (over 7day length of stay) to identify issues and remove avoidable causes of delay.

Ongoing escalation to system partners via the A&E Delivery Board continues,with significant resource directed to generating additional capacity andimproving discharge processes.

An IDT improvement plan is underway. However its impact will be marginaluntil capacity matches demand for onward health and social care services.

Streamlined processes for data monitoring and reporting have beenintroduced, as well as daily “live” patient monitoring with board briefingswith the discharge planning nurses. Lead roles have been developed inrelation to self-funded patients, and continuing healthcare (CHC)assessments, and a number of staff have been re-allocated to different areasto tackle issues relating to a build up of referrals.

12 hour

trolley waits

Delayed

Transfers of

Care (DToC)

0

10

20

30

40

50

60

0%

2%

4%

6%

8%

10%

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep Oct

No

v

De

c

Jan

Feb

Ma

r

2015/16 2016/17 2017/18

Beds used by DToC patients in month DToCs DToC target

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

JulAug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

2015/16 2016/17 2017/18

Performance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0

1

2

Performance Target

0

10

20

30

40

50

60

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Jul-1

7

Aug

-17

Sep-

17

Oct

-17

Nov

-17

Dec

-17

Jan-

18

Nu

mb

er

of

be

ds

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Total number of beds used by DToC patients 27.135.132.540.535.738.738.641.232.731.843.245.041.335.135.242.747.352.851.647.947.644.037.538.335.332.923.727.9

NHS Days 12 21 25 31 24 29 23 23 17 20 25 26 25 21 19 21 24 25 24 19 20 26 18 17 15 17 12 11

DHSS Days 15 14 7 9 11 9 16 18 15 11 18 19 16 12 16 21 23 28 27 28 27 18 20 21 19 16 12 16

Days (BOTH) - - - - - 0 - - - - - - 0 2 0 1 - 0 0 1 0 - 0 0 0 - - 0

Beds used by DTOC patients: DHSS vs NHS

9



33 of 121T

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Well led

Reporting sub committee - PSE


Paul da Gama

Sickness rate

Staff turnover

and vacancy

rate

% bank,

agency and

temporary

pay

Workforce indicators - staff turnover, sickness, bank & agency,

vacancy, appraisal, and mandatory training

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Staff turnover Performance Staff turnover Trajectory Staff turnover target

Vacancy rate Performance Vacancy rate Trajectory Vacancy rate Target

0%

5%

10%

15%

20%

25%

30%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

% Bank Pay performance % Bank Pay Trajectory % Agency Pay performance

% Agency Pay Trajectory Temporary costs performance Temporary costs Trajectory

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Sickness rate performance Sickness rate target Sickness rate Trajectory


Jan sickness hard

32

Turnover and VacanciesThe overall Trust vacancy rate showed a decrease to 10.9% in January (from 11.7% inDecember). Whole time equivalent (wte) staff in post increased by 19wte overJanuary, to 4,301wte while the establishment remained constant. The vacancy ratefor qualified Nursing & Midwifery posts decreased in January, from 16.4% to14.5%. For Band 5 Nurses, the rate reduced from 22% to 17.7%. However, this rateincludes nurses who are awaiting their PIN numbers, once these staff are taken out ofthe staffing numbers, the rate is 27%. Recruitment activity has continued to build up alarge pipeline of new N&M. A further overseas recruitment trip is being consideredfor May. As stated, many staff in the pipeline are from overseas with long lead-intimes, and the Trust currently has 65 such nurses awaiting registration.WHHT is working with NHSI to reduce the turnover rate within Band 5 nursing, andrates have reduced over the last 5 months, from over 27% to 24.5% currently. The 12-month rolling turnover rate for registered nurses and midwives is 17.5% which hasincreased from 17.4% last month. The overall Trust turnover rate is 16.9%, anincrease from last month (16.4%). WHHT has the eighth highest turnover (of 11organisations) compared to Herts & Beds peers and is above the regional average of15.9%, although this is largely due to band 5 nurse turnover. Over the last 2 years,turnover has shown a modest downward trend, although Band 5 nursing as notedabove, is relatively high.

% Bank and Agency ExpenditureAgency spend in January decreased to £1.27m (£1.45m in December). This spendrepresented 6.4% of the overall pay-bill (target 8%). Agency spend has reducedconsiderably over the last couple of years, with spend in 2016/17 being £10m lessthan 2015/16. Renewed work continues to reduce agency costs via the AgencySteering Group, and through partnership working across Herts & Beds, with theshared staff bank being the latest initiative. YTD spend of £15.8m is above thetrajectory required to meet annual targets, with a M10 projected total agencyexpenditure of £18.6m compared to a required total (set by the Trust) of £17.0m. Thiscompares favourably to the cap set by NHSI in2017/18 of c£24m

Sickness rateThe sickness absence rate remains low at 3.49%, and is in line with the Trust target of 3.5%. The Trust is currently well below the Herts & Beds average of 3.9% at the end of Quarter 2. Over the last 2 years, sickness absence has fluctuated between 3.8% and 2.8%. Average sickness absence in 2015/16 was 3.4%, whereas in 2016/17 it was fractionally lower at 3.2%. It has averaged just over 3.0% in the current year to date.


Jan-18 3 4

Dec-17 3 4

Nov-17 2 5


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34 of 121T

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Number of

staff leaving

within first

year (excluding

medics and fixed term

contracts)

Mandatory

training

Appraisal rate (non medical staff only)

60%

65%

70%

75%

80%

85%

90%

95%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Mandatory Training Performance Mandatory Training Target Mandatory Training Trajectory


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Appraisal rate Performance Appraisal rate Target Appraisal rate Trajectory


0%

5%

10%

15%

20%

25%

0

50

100

150

200

250

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Number of staff % of new staff

33

Appraisal – non medical staffJanuary’s rate, at 83.7%, is below the 90% compliance rate for the third monthrunning. There continues to be a significant challenge in maintaining focus andensuring appraisal dates are aligned to staff increments. HRBPs continue their workwith Divisions to develop trajectories and monitor and achieve complianceconsistently above the 90% target, although Winter pressures mean it is difficult tospecifically focus on this. HR Business Partners are also working with managers,producing bi-weekly reports to support the transition to effective alignment ofappraisals to increments and to plan the completion of all outstanding appraisals.Currently 34% of staff incremental dates are aligned to appraisal dates

Mandatory training Mandatory training compliance is currently at 86%. TEC have been provided with an overview of issues related to the reporting of mandatory training data and the impact on the compliance figures. A working group has been set up to manage this work and has started to put in place actions that address the allocation of core training needs to job roles recorded in ESR and address compliance of new starter overseas Nurses, Junior doctors on rotation and Consultants. They have agreed in the short term to implement manual interventions within Acorn to address the shortfall of 550 active directory accounts which does not reflect the total workforce for the purposes of reporting. The working group is reviewing options to address this.

Number of staff leaving within first yearThe overall rate was 20.3% in January, an increase compared to last month. A year ago the figure was 18%.

The Trust is closely monitoring staff leaver information via the web-based exit leaver system, particularly regarding reasons for leaving. The latest summary has just been reported onto the Divisions as part of their workforce reports. The key reason for leaving remained unchanged, being career related. The reconnect sessions following corporate induction continue, bringing new starters back together and offering an opportunity to resolve any issues and gather information to further improve staff experience in the first year in post. Key work is also under way to support retention of Band 5 nurses, where there is the highest turnover, although as stated this has fallen over the last 6 months. This also forms a part of the Nursing retention project with NHSI, where Band 5 nursing leavers have been identified as a key workforce to seek to improve engagement with and reduce turnover.

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34

The Board Assurance Framework shows key workforce indicators in the context ofcurrent performance, performance 12 months and 3 months ago, Trust workforcetargets, the distance to these targets and a RAG rating based on 5 scales. It also hasbenchmarking data taken from NHS healthcare providers in the Hertfordshire andWest Essex and Bedford, Luton and Milton Keynes STPs.

The RAG rating is based on distance to targets – if current performance is within 0% to20% (or exceeds) its target then the RAG rating is green. If performance is within 60%– 80% of target then the rating is yellow. This is repeated at 20% intervals for amberand brown until performance is over 80% from the target when the RAG rating is red.If 2 indicators are rated red, then the overall rating is red. If all indicators are ratedgreen, or one is amber then the overall rating is green. Any other combination isamber.

The performance indicators were changed for November to reflect more relevant anddetailed areas of the workforce. The new indicators include Band 5 Nurse Vacancy,and Band 5 Nurse Turnover, reflecting the focus on recruitment and retention inconjunction with NHSI. Nursing Band 5 vacancy and turnover areas are identified asthe Trusts highest workforce risk factors. Nursing Vacancy rates have increased overthe last 3 months, increasing from 21.8% to 22.3%. Band 5 Nursing turnover hasimproved, reducing from 25.8% to 25.6%. The Band 4 vacancy indicator is rated Red,due to the percentage distance to target. Band 5 nursing turnover is rated amber.

Appraisals were just below target at 84% and mandatory training compliance is 86%.The confidence for data accuracy for training compliance is rated amber, work isongoing to ensure complete accuracy.

The Trust has achieved its target of a sickness rate less than 3.5%

The current agency pay bill percentage is 6.4%, below the 8% target.

The 12 month turnover rate is 16.9%, which has increased compared to 3 monthsago, and one year ago. It is also above the benchmark average.

The latest Q2 FFT score shows a slight increase compared to Q1, and the currentscore is within 20% of the target.

Benchmark averages are taken from Q3 17/18 data and are from 11 nearby NHSorganisations.

Trust targets reflect benchmarking of targets of other comparable acute Trusts,including those rated as ‘outstanding’ by the CQC. Appraisal and Core Trainingcompliance targets are now 90% rather than 95% previously. Agency costs as a % ofpay bill has changed from 10% to 8% as this reflects the Trust’s NHSI agency target

Workforce BAF scorecard

9



36 of 121T

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Well ledTracey Carter and Paul

Da Gama

Reporting sub committees - PSQ and PSE

Staff scores (%

reccommended

and not

recommended)

and response

rate

A&E scores (%

positive and

negative) and

response rate

Safe, effective,

caring

Friends and family

Inpatient scores

(% positive and

negative) and

response rate 0%

20%

40%

60%

80%

100%

120%

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Inpatient Scores FFT % positive performance Inpatient FFT response rate Inpatient FFT response rate Target

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

A&E FFT response rate performance A&E FFT % positive Performance A&E FFT response rate Target

0%

10%

20%

30%

40%

50%

60%

70%

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Staff FFT % recommended work Performance Staff FFT response rate Performance

Staff FFT response rate target

Positive performance targets to follow

35

InpatientsAn improvement has been seen in the response rate this month but with a slight drop in the recommended rate and a similar level of increase in the not recommended response.

A&EOverall the results have improved in all aspects, with a higher response rate and number of patients recommending us and a reduction in the number not recommending the service.

Staff The Trust has now received the national staff survey results and has started to communicate these across the organisation. Key findings from the survey show that whilst there has been a small decrease in this year’s results, scores have improved against comparator Trusts. Overall out of 89 questions, 43 worsened as compared to last year’s responses, 28 have improved and 18 stayed the same. However in comparison to the average of the comparator trusts, we performed better in 54 questions and had the same results in 18. The Trust did particularly well in questions relating to health and wellbeing, support from managers, reporting near misses and appraisals. The Trust did less well in relation to colleagues feeling that the organisation acted fairly in relation to career progression regardless of diversity issues. In addition there has been a slight decrease in the overall staff engagement score from 3.79 in 2016 to 3.77 in 2017. This is largely due to a reduction in the scores for the Friends and Family questions. The Trust has adopted a new approach to sharing and acting on the feedback from the staff attitude survey to ensure staff believe that we are listening and acting on staff feedback. This approach identifies 5 key corporate actions which will be taken to address staff feedback and mirrored in each division by 5 local actions. This will be supported with newly developed divisional workforce plans to address feedback from the survey.

Staff Friends and Family test for quarter 4 will be launched on 26th February 2018 – 5th March 2018.

Well led

Jan-18 0 3

Dec-17 0 3

Nov-17 0 3


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36

dupe

Daycases scores

(% positive and

negative) and

response rate

Maternity (Q2)

scores (%

positive and

negative) and

response rate

Outpatient

scores (%

positive and

negative) and

response rate

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Daycase FFT % positive Performance Daycases FFT response rate Performance

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

Ma

y

Jun

Jul

Aug Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Outpatient FFT % positive Performance Outpatient FFT response rate Performance

0%

20%

40%

60%

80%

100%

120%

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Jun

Jul

Au

g

Sep

Oct

Nov

Dec Ja

n

Feb

Mar

2015/16 2016/17 2017/18

Maternity FFT % positive Performance Maternity FFT response rate Performance

DaycaseThe Trust is now measuring both the main DSU at SACH and also the Surgicaladmission lounge at WGH.

OutpatientsSignificant increase in responses (circa 1000) but a small drop in therecommended rate.

Maternity Question 2Significant improvement in response rate but some reduction in therecommended rate and an increased rate in those who would not recommend.

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Safer staffingIndicator Performance (January) Threshold Trend Forecast next month

% Nursing hours versus planned 90.6% >95% Down >95%

Care hours per patient day 7.5 n/a Stable 7.2

Indicator by shift and skill mix Shift RN Care staff

% Nursing hours versus planned Day 81.6% 91.2%

Night 92.2% 100.3%

Care hours per patient day All 4.6 2.9

What actions have been taken to improve performance

Enhanced care needs team commenced 13 May 2017 – recruiting to theteam continues, continued use of temporary staff at night to support the team.

Local and international recruitment initiatives continue. Trust Recruitment Group formed

Shared bank approach across four Trusts commenced 31st July. Project plan to address the retention rate of band 5s External Visit requested by Chief Nurse looking at Safe Staffing now

rescheduled for April 2018. Safe Care Implemented in Adult inpatient wards

What is causing the variance

Overall the Trust % fill rate for January was 90.6%, a decrease of 0.3% from last month and below the national threshold of 95%. The fill rate within Medicine is 91.9%, adecrease of 0.2%. In Surgery the fill rate was 91%. Overall the fill rate in WACS was 86.3%, down 0.7%, with maternity fill rates at 95.4%, up 2.5% and paediatrics fill rate is71.8%, down 5.7%. The low fill rates in paediatrics are mainly nursery nurse shifts day and night due to recruitment and retention. This is currently being reviewed by theHead of Nursing as part of the establishment review, covering skill mix and role redesign. The number of shifts rag rated green were 67.5%, an increase of 1% from lastmonth. A total of 31.6% of shifts were rated amber, a decrease of 0.4%. 22 shifts were rag rated red (0.9%), one was a red flagged shift of less than 2 registered nurses. Noharm to patients was reported and mitigations were put in place, e.g. moving staff to the areas, supervisory band 7s working, specialist and corporate nursing supportingstaffing in order to maintain patient care and safety, and datix forms were completed. A total of 30.5% of shifts were red flagged for registered nurses more than 8 hours lessthan planned, an increase of 2.7% from last month. A number of areas have fill rates below 80% - De La Mare, Beckett, Starfish and NNU. The following areas were used assurge - MAU, COB, ESAU, Ambulatory Care, Elizabeth, Cath Lab, New CDU, Old CDU, Castle, Stroke gym and Oxhey had an additional patient bed open. Patients were caredfor in these areas through redeployment of substantive staff and temporary staff from NHSP (bank and agency). Enhanced care needs continue to be provided by theenhanced care team by day and bank/agency at night. Overall Trust Supervisory Hours lost in October was 44.4 %, an increase of 3.1% from last month. Safe care has nowbeen implemented in all the acute inpatient areas and patient acuity and staffing is now reported daily . Care Hours per patient day continue to be reported monthly as partof UNIFY.

97.2%

96.2%

96.9%

97.6%97.3%

94.3%

95.2% 95.0%

93.0%

90.9%

92.2%

90.9%90.6%

5.0

5.5

6.0

6.5

7.0

7.5

8.0

8.5

9.0

90%

91%

92%

93%

94%

95%

96%

97%

98%

Car

e H

ou

rs P

er

Pat

ien

t D

ay

Pe

rce

nta

ge o

vera

ll p

lan

ne

d v

s. a

ctu

al n

urs

ing

ho

urs

Percentage overall planned vs. actual nursing hours & CHPPD

Care Hours Per Patient Day (CHPPD) % Fill Rate Threshold - fill rate

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38

End of Life CareNumber of patients who are referred to the palliative care team and who have an identified preferred place of death

In 2008 the End of Life Care Strategy (Department of Health) was published and one ofthe insights from this was that people weren’t supported to die in their place of choice;and although progress has been made, this has been evidenced in many other reports.In July 2014 just over 50% of respondents to the National Survey of Bereaved People(VOICES-SF) felt that their relative had died in a place of their choice (Office of NationalStatistics, 2014).There is now a national focus on reducing the numbers of patientsdying in hospital and offering everyone who is approaching the end of their life theopportunity to express and share their preference for where they want to die as wellas any goals that are important to them (National Palliative and End of Life CarePartnership, 2015).

There were 94 referrals in total in January 2018.10 of these referrals were inappropriate.41 patients had no capacity to identify a PPD (Preferred Place of Death) and 4 patients declined to state a PPD.Of the remaining 39 patients all had a PPD identified.

Q1

2015/

16

(avg

per

mont

h)

Q2

2015/

16

(avg

per

mont

h)

Q3

2015/

16

(avg

per

mont

h)

Q4

2015/

16

(avg

per

mont

h)

Q1

2016/

17

(avg

per

mont

h)

Q2

2016/

17

(avg

per

mont

h)

Q3

2016/

17

(avg

per

mont

h)

Jan-

17

Feb-

17

Mar-

17

Apr-

17

May-

17

Jun-

17Jul-17

Aug-

17

Sep-

17

Oct-

17

Nov-

17

Dec-

17

Jan-

18

Total referrals 63 59 67 71 75 69 78 98 111 120 103 96 108 84 72 90 120 112 93 94

-

20

40

60

80

100

120

140

Nu

mb

er

of

refe

rral

s p

er

qu

arte

r

Referrals to Trust Specialist Palliative Care Team

Q1 201

5/16

(avg

per mo

nth)

Q2 201

5/16

(avg

per mo

nth)

Q3 201

5/16

(avg

per mo

nth)

Q4 201

5/16

(avg

per mo

nth)

Q1 201

6/17

(avg

per mo

nth)

Q2 201

6/17

(avg

per mo

nth)

Q3 201

6/17

(avg

per mo

nth)

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Nursing Home 0 3 5 6 5 6 2 3 11 9 6 6 5 4 5 2 5 4 5 8

Hospital 0 3 4 6 10 5 9 19 20 17 6 16 3 6 10 8 6 10 3 1

Hospice 0 11 15 12 10 13 1 15 7 8 12 10 10 9 8 6 16 14 23 14

Home 28 10 12 15 18 13 6 13 15 11 6 10 17 10 13 9 16 10 6 15

Impaired capacity to state a preference 12 14 13 22 17 12 23 35 28 27 23 29 29 23 21 20 26 18 47 42

% with identified preference 54.6% 58.8% 66.9% 82.0% 79.6% 73.0% 69.5% 94.3% 65.1% 51.1% 81.6% 100.0 79.5% 52% 71% 82% 88% 77% 100% 100%

0

10

20

30

40

50

60

70

80

90

0%

20%

40%

60%

80%

100%

120%

Nu

mb

er

of

refe

rral

s b

y id

en

tifi

ed

pre

fere

nce

Pe

rce

nta

ge o

f re

ferr

als

Number and percentage of referras with identified preference for preferred place of death, excluding patients unable to state preference, inappropriate referrals or deaths prior to being seen or transferred

back to other HCP’s

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Trust data quality, by exceptionData Quality RAG keyRed – Data accuracy is not known, it is incomplete and inconsistent

Amber – Data is assumed to be complete and accurate, although there may be limitations or unresolved queries

Green – Data is complete, accurate and consistent with the standards set for the specific indicator

39

Domain a Indicator a

Data

Quality

RAG

a Description of issues Improvement action plan Target date for 'Green' rating

Safe, Effective, CaringDischarges between 8am and 12pm*

(main adult wards excl AAU) A

Safe, Effective, Caring% Complaints responded to within one month or agreed

timescales with complainant

R

Operational and clinical pressures has meant it has been

challenging to find the time for clinical and operational staff to

respond to concerns on time.

The Unscheduled Care Division are recruiting a 0.5 WTE

position to assist clearing the backlog.

The team are recruiting a new complaints manager and have

approach NHSP and agencies to fill the vacancy.

The Surgery Division has held a complaints workshop to

address backlog. The same will be done in Unscheduled Care.

The Women and Children’s Division are recruiting a post to

deal with complaints. The Environment and Medicines Division

have improved their response times considerably.

Recruitment expected to be completed by end of Summer.

Improvements are hoped to be seen by end of 2017.

Safe, Effective, Caring Complaints - rate per 10,000 bed days

R Capturing complaints across the Trust.

All complaints are captured and triaged daily. All complaints

are logged daily and there are systems in place to capture all

complaints received through the CEO, executive assistants,

through NHS net and on social media. Reminders are sent to all

staff about forwarding complaints received in clinical areas.

There is a system for auditing all new complaints taken through

triage on the following day. This risk is being minimised as much as possible.

Safe, Effective, Caring Reactivated complaints

R Increase in reactivated complaints

We telephone every reactivated complaint to talk through

concerns. We consider if someone independent needs to

investigate. We send reactivated complaints to external

investigators in complex cases. We invite complainants to

meetings to discuss their concerns.

We now record the reason for reactivated complaints and will

audit this. We have asked Healthwath Hertfordshire to review

a pool of complaints and provide feedback. We will ask that

they include a small pool of reactivated complaints also. This risk is being minimised as much as possible.

Safe, Effective, Caring Hospital Acquired Pressure Ulcers - Grade 3A

Safe, Effective, Caring Number of Falls*A

Safe, Effective, Caring VTE risk assessment*A

Paper based VTE forms used for assessing compliance by clinical

coding team. Evidence elsewhere within notes demonstrating

compliance not on form not previously identified.

Clinical Advisory Group has approved new process for coding

team to assess VTE compliance. Electronic system required to

improve compliance to green.

July 2017 (Amber). Electronic system date of implementation TBC

(for Green)

Safe, Effective, Caring Caesarean Section rate - Combined*A

Perception that there is a difference between caesarean section

rate on CMiS compared to what has been clinically coded

Review of clinically coded notes and comparison to CMiS to

review discrepancies July 2017

Safe, Effective, Caring Caesarean Section rate - Emergency*A As above As above As above

Safe, Effective, Caring Caesarean Section rate - Elective*A As above As above As above

Safe, Effective, Caring Stroke patients spending 90% of their time on stroke unit *A

Responsive Ambulance turnaround time between 30 and 60 minsR Identified inaccuracies in timing of Ambulance Service data Ongoing work with ambulance service TBA

Responsive Ambulance turnaround time > 60 minsR As above Ongoing work with ambulance service TBA

Well Led Sickness rate

A

1. Potential for under reporting

2. There can be issues with data recorded on ESR but this will be

fixed with the implementation of the new ESR 2 system.

1. HR undertook a number of audits to look into areas who were

reporting 0% sickness throughout 2016 and have implemented

learning from those audits, including a new process for

capturing absences if medical staff.

2. implementation of the new ESR 2 system.

September 2017 (linked to the ESR implementation). There will

also be ongoing audits to ensure that absence data is still being

accurately recorded

Well Led Mandatory TrainingA

1. Potential for reporting inconsistencies on ESR in certain staff

groups A project group has been set up to investigate and correct

reporting issues Feb-18

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Title of the paper

Quality Commitment

Agenda Item 11/57

Lead Executive

Tracey Carter, Chief Nurse and Director of Infection, Prevention and Control

Author(s)

Cathy Shaw, Strategy Delivery Senior Programme Manager

Executive Summary

The purpose of this report is to ask the Board to formally approve the Trust’s Quality Commitment. The Commitment sets out the how the Trust will build and embed a culture of quality improvement across the organisation - engaging, empowering and supporting all staff to deliver the very best care for every patient every day. The Quality Commitment has been extensively discussed and approved at the Strategy Delivery Board Trust Executive Committee (SDB TEC) and endorsed by the Clinical Outcomes and Effectiveness Committee. The Commitment has been developed through a bottom-up engagement process with staff and it describes ‘The West Herts Way’; setting out how we will realise our organisational strategy and corporate aims and objectives through our culture, ways of working, and supportive organisational changes. It is a commitment between the Trust and staff to drive quality and the golden thread through everything we do to deliver our overall Trust strategy and vision. To help achieve a supportive organisational environment that will drive this commitment, we plan to create a central quality improvement (QI) team/hub, which will provide expertise, guidance and embedded support to facilitate service improvement across the organisation. The hub will use a consistent QI methodology, developed by the Institute of Healthcare Improvement (IHI). IHI are also supporting us to build quality improvement capability within the organisation and will be delivering a 2-day leadership workshop in April. We will be working with Gate One, who supported the engagement and development of the Quality Commitment, to launch the Quality Commitment and QI hub across the Trust in April/May. Our work with the Royal Free on reducing unwarranted variation in care is a core aspect of the overall quality improvement approach. As our partnership with the Royal Free London group continues to develop, we will explore opportunities for collaborating on quality improvement to ensure we make the best possible use of available capacity and expertise. On approval of this document, the Quality Commitment will provide the framework for setting the Trust Quality priorities for 2018/19, which will be set out in our Quality Account. This will enable us to monitor how we are meeting the Trust’s vision: To provide the best care for every patient, every day.

Where the report has been previously

Clinical Outcomes and Effectiveness Committee: 06/09/2017 28/09/2017 30/11/2017

11

Tab 11 Quality commitment


discussed, i.e. Committee/ group

25/01/2018

Strategy Delivery Board TEC: 06/09/2017 11/10/2017 15/11/2017 17/01/2018

Action required:

With endorsement from the Clinical Outcomes and Effectiveness Committee, the Board is asked to approve the Quality Commitment.

Links to the board assurance framework


Trust objectives




11



Agenda Item: 11/57

Trust Board meeting – 01 March 2018 Quality Commitment Presented by: Tracey Carter, Chief Nurse and Director of Infection, Prevention and Control

1. Purpose

1.1 The purpose of this report is to ask the Board to formally sign off the Trust’s Quality

Commitment. The Commitment sets out the how the Trust will build and embed a culture of

quality improvement across the organisation - engaging, empowering and supporting all staff to

deliver the very best care for every patient every day. The Quality Commitment has been

reviewed and endorsed by the Clinical Outcomes and Effectiveness Committee of the Board.

1.2 A copy of the full ‘Quality Commitment’ document can be found on the resources section of

Diligent.

2. Background

2.1 Staff engagement has been central to our approach to developing our ‘Quality Commitment’; a

bottom-up approach with staff driving and determining what quality looks like is key to

successfully building a culture of continuous quality improvement. As such, throughout the

development of the ‘quality commitment’ , we have tested and validated thinking with staff in

order to describe how we want WHHT to look and feel as an organisation delivering high quality

care, in a way that resonates with staff. Indeed, it was through this engagement process that the

concept of the ‘Quality Commitment’ was born.

3. Analysis/Discussion

3.1 The final ‘Quality Commitment’ was presented to SDB TEC on 17 January and to Clinical

Outcomes and Effectiveness Committee on 25 January 2018. The Commitment describes the

‘West Herts Way’: how we will realise our aims and priorities through our culture, ways of

working, and supportive organisational changes. It is a commitment between the Trust and staff

to drive quality.

3.2 The Quality Commitment summary, presented as part of this paper (appendix 1), is an

accessible summary of the full document designed for wide circulation. The full document

describes the commitment and recommended areas of focus and set out the steps we will take

as an organisation to continue to build a sustainable Quality Improvement culture. A short set

of slides has also been developed that staff can use to support discussion of the quality

commitment with their teams.

3.3 We are currently in the process of developing the Trust’s quality priorities for 2018/19, which will

be documented in our Quality Account. We are proposing to structure our 18/19 quality

priorities around the three themes identified in the Quality Commitment, which are:

11



Sharing a commitment to quality of care and service

Fostering a team working culture

Building an organisation that drives quality

The Quality Account will incorporate a range of specific process and outcome metrics that will

enable the Trust to track progress on quality on an annual basis.

3.4 The Quality Commitment summarises the range tools, methods, measures and assurance

processes that will enable the organisation to be confident that it is delivering high quality care

and demonstrate continuous quality improvement.

3.5 Next steps in our Quality journey

3.5.1 The West Herts Way will drive a culture of continuous improvement by sharing a commitment to

quality of care and service between staff & the Trust, fostering a team working culture, and

building an organisation that drives quality. To help achieve a supportive organisational

environment that will drive this commitment, we plan to create a central quality improvement

(QI) team/hub.

3.5.2 The quality hub will be tasked with providing expertise, guidance and embedded support to

facilitate service improvement across the organisation. The hub will use a consistent QI

methodology, developed by the Institute of Healthcare Improvement. To help build our expertise

in how to run a Quality Hub, site visits to St Mary’s Imperial College and Ashford & St Peter’s

NHS Trusts have been arranged, to learn from how they have set up their quality improvement

teams.

3.5.3 Our work with the Royal Free on reducing unwarranted variation in care is a core aspect of the

overall quality improvement approach. As our partnership with the Royal Free London group

continues to develop, we will explore opportunities for collaborating on quality improvement to

ensure we make the best possible use of available capacity and expertise.

3.5.4 Gate One has supported the development of a quality hub design and implementation plan,

which describes how the hub will work with the organisation and the actions needed to set it up.

This plan will be revised and implemented following the completion of a management of change

within corporate nursing and quality governance teams. Gate One will support the set-up of the

hub and launch of the quality commitment.

3.5.5 To support the implementation and delivery of the quality commitment, we have also engaged

with the Institute for Healthcare Improvement, to build capability and capacity around quality

improvement. The IHI diagnostic phase took place in November and consisted of a series of

workshops with a number of staff groups. Based on this work, a 2-day leadership workshop will

be delivered by IHI in April, in order to build quality improvement capability within the

organisation.

4. Recommendation

4.1 With endorsement from the Clinical Outcomes and Effectiveness Committee, the Board is

asked to approve the Quality Commitment.

Tracey Carter Chief Nurse and Director of Infection, Prevention and Control 01 March 2018 A copy of the full ‘Quality Commitment’ document can be found on the resources section of Diligent.

11



We will build a “team of teams” that work together innovatively to focus on quality

and safety: Teams with a common vision: where the duty and responsibility for quality is shared.

Teams with an understanding of the bigger picture, that recognise their colleagues’ great work.

Teams with staff-led ambitions, where empowered staff lead improvements supported by managers.

Teams with trust, where collaboration means learnings and successes are shared openly.

1. Sharing a commitment to quality of care and service

2. Fostering a team working culture

We will make it easier for our staff to drive quality by building an environment which

supports that:

A quality hub to champion improvement, own our quality methodology & build improvement

capabilities.

Staff-led learning and improvement – our people are listened to and supported to learn and improve.

Leadership which is visible & role-models best-practice behaviours, including a ‘thank you’ recognition

culture.

Communication and engagement which is open and honest throughout the organisation.

Workforce development and training that supports all staff in taking accountability for quality.

Clinical standards that enable on-going commitments to decreasing variation and increasing safety.

Estates, IT, systems and facilities which are supportive to staff.

3. Building an organisation that drives quality

We, the Trust, commit to make it

easier for staff to deliver the best

quality care for every patient, every

day

West Herefordshire Hospitals

NHS Trust

Our people commit to taking

ownership for quality in everything

they do, lead in their roles, and seek

to learn and improve

The West Herts Way makes this possible by:

1. Sharing a commitment to quality of care and service

2. Fostering a team working culture

3. Building an organisation that drives quality

Our vision: The very best care for every patient, every day

THE WEST HERTS WAY

Our Quality Commitment Jan 2018

11



Trust Board Meeting

01 March 2018 Title of the paper

Quarterly learning from deaths report

Agenda Item 12/57

Lead Executive

Mike Van Der Watt, Medical Director

Author(s)

Ian Stevens, Head of Litigation & Claims, SIs, Complaints and PALS

Executive Summary

In March 2017 NHS England published the first edition of the National Guidance on Learning from Deaths: A framework for NHS Trusts and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care. From April 2018, trusts will be required to collect and publish specified information on deaths on a quarterly basis. This should be an agenda item to a public Board meeting in each quarter to set out the trust’s policy and approach (by the end of Q2) and publication of the data and learning points (from Q3 onwards). This paper provides the data and learning points recorded to date.

Where the report has been previously discussed, i.e. Committee/ group

Due to time constraints this paper did follow the usual governance route for review by the clinical outcomes and effectiveness committee. It was reviewed by the Quality & Safety Group in February 2018. Future reports will be reviewed by the clinical outcomes and effectiveness committee prior to board.

Action required:

The board is asked to approve the report for publication in line with national guidance.






PR4a Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance


12

Tab 12 Learning from deaths report








Trust objectives

[Double click on the box to mark as appropriate]





12



Agenda Item: 12/57

Trust Board – 01 March 2018 Quarterly learning from deaths report Presented by: Mike Van Der Watt, Medical Director

1. Purpose

1.1 This paper is prepared to provide the data submission required by the March 2017 NHS England National Guidance on Learning from Deaths. The paper is also to provide details of the outcome of recently completed audits and patient surveys and recommendations.

2. Background

2.1 From April 2017, Trusts will be required to collect and publish specified information on

deaths on a quarterly basis. This data should include;

The total number of the Trust’s in-patient deaths (including Emergency Department deaths for acute Trusts);and

Those deaths that the Trust has subjected to case record review. Estimates of how many deaths were judged more likely than not to have been due

to problems in care.

2.2 The Trust has been introducing and implementing new systems and processes to ensure deaths requiring further review and learning are referred to a structured judgment review (SJR) process and a review is completed within 15 working days of the medical records being made available to the reviewer.

2.3 Data is being collected on the quality of care provided and scored using the Royal College of Physicians SJR data collection form. SJRs where the score of the overall care is scored as 2 (strong evidence of avoidability) or lower are further reviewed by a panel of Associate Medical Directors, Chief Nurses and Medical Directors at a fortnightly panel meeting. The outcome of those meetings feed into this paper.


The total number of the Trust’s in-patient deaths (including Emergency Department deaths for acute Trusts)

3.1 There were 446 inpatient deaths in quarter three.

Those deaths that the Trust has subjected to case record review.

3.2 In quarter three, 2 deaths were referred for an SJR. One was because it was declared a serious incident (SJR2). The other was for another reason identified to ensure learning (SJR1).

12



3.3 Neither patient had learning difficulties, mental health issues or was under 18 years old. In both reviews the reviewer felt that there were problems with the healthcare that contributed to harm during the assessment, investigation and diagnosis phase of the care and during the clinical monitoring of the patient. In SJR1 the reviewer felt that the treatment and management plan led to harm.

Estimates of how many deaths were judged more likely than not to have been due to problems in care.

3.4 In SJR2 the SJR panel felt that the death was possibly avoidable but not very likely (less than 50:50)(score 4).

3.5 In SJR1 the SJR panel felt that the death was probably avoidable (more than 50:50)(score 3).

In Summary

3.6 During Q3, new systems and processes were fully embedded into the Trust’s digital record keeping system and the Trust introduced a dedicated SJR internal email to make contact with the relevant teams. This has seen an increase in referrals at the time of writing and substantial evidence that the systems and processes are having the desired effect so that the team can move on to carrying out SJRs as routine business. In addition the quality governance lead has been giving talks at mortality and morbidity meetings and divisional governance meetings.

4. Risks 4.1 None

5. Recommendation

The Board is asked to approve this report for publication, in line with national guidance.

Mike Van Der Watt Medical Director 22 February 2018

12




Title of the paper

Gender pay gap report 2017

Agenda Item 13/57

Lead Executive

Paul Da Gama, Director of Human Resources and Organisational Development

Author(s)

Monika Kalyan, Equality & Diversity Manager

Executive Summary

In 2017 the government introduced legislation that made it statutory for organisations with 250 or more employees to report annually on their gender pay gap. These regulations require relevant organisations to publish their gender pay gap data by 29 March 2018 and then annually. Key headlines from the Trust’s report includes:

On average, female employees earn 14.9% less than male employees.

The difference in average bonus payments between males and females is 22.59%; male employees receive 22.59% higher bonus payments

The proportion of male employees receiving a bonus is 7% males and the proportion of female employees receiving a bonus is 1%.

We have a larger proportion of male employees in more senior grades. 78.30% of the organisation’s total workforce is female. Females make up 71.27% of the highest pay quartile. In contrast, males make up 21.70% of the total workforce and 28.73% of the highest pay quartile. There is a higher proportion of males in Agenda for Change (AfC) bands 8, 9 and VSM meaning they are the highest earners in the organisation.

Whilst the above headlines are worrying we have carried out additional analysis and which is detailed in this report, which suggests many of these differences in pay and bonuses are as a results of the type of roles held by men and women within the organisation. There is little evidence to suggest ‘equal pay for equal value’ type concerns. For example there are no significant differences between the genders in terms of Agenda for Change type analysis. We are seeing a clear growth in the number of women occupying senior roles within the organisation for example the proportion of our consultant body who are women has grown in the last years from 31% to 37%. Also female colleagues are more likely to be promoted within the trust; they are more likely to be appointed following shortlisting and are less likely to state that they have experienced discrimination in the last 12 months as reported in NHS staff survey. If you would like to see the full report, it is available in the Diligent resource centre. The Patient and Staff Experience Committee reviewed the report and recommend the board approve it for publication, in line with national reporting

13

Tab 13 Gender pay gap report 2017


requirements.

Where the report has been previously discussed, i.e. Committee/ group

Trust Executive Committee 07/02/18 Workforce Equality Forum 19/02/18 Patient and Staff Experience Committee 22/02/18

Action required:

The Committee is asked to approve the gender pay gap report 2017 for publication on the trust’s and government website for gender pay gap reporting on 30 March 2018.






PR4a Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – IM&T

PR4b Underdeveloped informatics infrastructure compromises ability to deliver safe, responsive and efficient patient care – Information and information governance








Trust objectives

[Double click on the box to mark as appropriate]





13



Agenda Item: 13/57

Trust Board Meeting – 01 March 2018

Gender pay gap report 2017 Presented by: Paul Da Gama, Director of Human Resources and Organisational Development

1. Purpose

1.1 The purpose of this paper is to ask the Committee to note the Trust’s first Gender Pay Gap Report 2017 produced to meet the new gender pay gap reporting regulations. The Report contains statutory gender pay gap data and additional areas of analysis with priority actions to address the pay gap.

1.2 If you would like to see the full report, it is available in the Diligent resource centre.

2. Background

2.1 A 2016 report from McKinsey Global Institute, The power of parity: Advancing women’s

equality in the UK found that bridging the gender pay gap could add as much as £150 billion to the UK economy by 2025. In a step to close the gap, the Gender Pay Gap reporting regulations were introduced in April 2017, with organisations with over 250 employees being required to publish their gender pay gap results on their website and upload them to a Government website by 30 March 2018.

2.2 There regulations require employers to publish six calculations showing;

Salary the mean (average) pay gap the median pay gap the proportion of male and female employees in each salary quartile band. Bonus the mean bonus pay gap the median bonus pay gap the proportion of male and female employees receiving a bonus payment.


3.1 The figures set out below have been calculated using the standard methodologies stated in

the Equality Act 2010 (Gender Pay Gap Information) Regulations 2017. The data is taken from a snapshot of earnings on 31 March 2017.

3.2 A positive percentage (e.g. 1.0%) indicates that female employees have lower ordinary pay or bonuses than male employees. A negative percentage (e.g. -1.0%) indicates that male employees have lower ordinary pay or bonuses than female employees.

13



Our statutory gender pay gap figures 2017

3.3 Mean and median pay gap The data tells us that on average, female employees earn 14.9% less than male employees. This mean gender pay gap of 14.9% percent is lower than the ONS figure of 17.4% for public sector employees, and the median figure is even lower at 8.02% for the Trust against the national ONS median of 18.4% (ONS, 2017). Figure 1

Gender Avg. Hourly Rate Median Hourly Rate

Male 17.6117 14.5534

Female 14.9869 13.3849

Difference 2.6248 1.1685

Pay Gap % 14.9% 8.02%

3.4 Salary quartile bands To understand how the grade balance impacts pay, hourly pay of all staff has been

arranged in order then divided into four equal parts. The table shows the proportion of males and females in each pay quartile; the Lower Quartile includes the lowest paid staff per hour and the Upper Quartile includes the highest paid staff per hour. There is larger proportion of male employees in the upper quartile.

Figure 2

Quartile Female Male Female% Male%

1 lower quartile 890.00 216.00 80.47% 19.53%

2 lower middle quartile 891.00 215.00 80.56% 19.44%

3 upper middle quartile

895.00 211.00 80.92% 19.08%

4 upper quartile 789.00 318.00 71.27% 28.73%

Overall gender split 78.30% 21.70%

3.5 Bonus payments The mean gender pay gap for bonuses paid is 22.59%. The median Gender Pay Gap for bonuses paid is 34.37%. Figure 3

Gender Avg. Pay Median Pay

Male 14,450.64 11,934.30

Female 11,186.80 7,831.92

Difference 3,263.84 4,102.39

Pay Gap % 22.59% 34.37%

During the reporting period of April 1 2016 to March 31 2017, 7% of male employees received a bonus payment, compared to 1% of female employees.

Figure 4

Gender Employees Paid Bonus

Total Relevant Employees

Bonus Gap %

Male 38.00 3,742.00 7.04%

13



Female 78.00 1,108.00 1.02%

3.6 Additional analysis (non-statutory)

To better understand the gender pay gap we have carried out additional data analysis. The

bonus pay gap calculation in the regulations is based on the number of female employees

paid bonus pay divided by the number of females in the workforce. This calculation runs the

risk of presenting a distorted picture as bonus payments are exclusively made up by the

Clinical Excellence Awards scheme which only consultants are eligible for.

If only the proportion of staff who are eligible to receive a bonus (consultants) is looked at,

this shows 42.2% of females and 51.3% males received a bonus.

Figure 5

We anticipate that the bonus pay gap will become smaller as the number of female consultants increases over time. The Trust employs 35 more female consultants than it did 10 years ago. In 2008, 31.6% of consultants were female this figure has increased to 37.2% in 2018.

Figure 6

Year Male Female Total Male% Female%

2008 119 55 174 68.4% 31.6%

2013 128 72 200 64.0% 36.0%

2018 152 90 242 62.8% 37.2%

When looking at data by staff group it shows that most differences are seen for staff in the administrative and clerical, medical & dental and estates staff group. This could be partly explained by a higher proportion of males being employed in higher bands in these staff groups. 7% of females in the administrative and clerical staff group are employed in bands 8a – 9 while 20% of males are.

Figure 7

Main Staff Group Avg. Hourly Rate

Overall gender split of workforce

Female Male

Add Prof Scientific and Technic (e.g Pharmacists Technicians)

-4.36%

72% 28%

Additional Clinical Services (HCA's, health support workers)

0.63%

79% 21%

Administrative and Clerical 22.29% 82% 18%

Allied Health Professionals (Occ Therapists, Physio's)

1.67%

82% 18%

Estates and Ancillary 22.91% 79% 21%

Healthcare Scientists (Pathology staff) 8.50%

74% 26%

Medical and Dental 28.61% 45% 55%

Nursing and Midwifery Registered -12.61% 89% 11%

Gender Headcount Consultants

% of Consultants with bonus

Female 90 42.22%

Male 152 51.32%

Grand Total

242 47.93%

13



Looking at AfC banding distribution, 5.7% of females are employed on bands 8a – 9, while

10.7% of males are. When looking at individual AfC bandings, there are only small gender

differences in pay earnings and this is to be expected as the AfC salary range is fixed. It will

vary slightly by e.g. point on the scale and salary sacrifice / child care voucher deductions.

Figure 8

AfC band

Female Male Difference

% Pay Gap

Female Male Female %

Male %

Band 1 £8.80 £10.08 £1.28 14.59% 5 3 0.2% 0.5%

*Band 1

£3.62 £3.41 £-5.21 -5.71% 10 2 0.3% 0.3%

Band 2 £9.73 £10.07 £0.34 3.50% 663 150 20.7% 23.7%

Band 3 £10.18 £10.21 £0.03 0.27% 358 81 11.2% 12.8%

Band 4 £11.63 £11.36 -£0.27 -2.35% 353 53 11% 8.4%

Band 5 £14.40 £14.22 -£0.18 -1.23% 686 124 21.5% 19.6%

Band 6 £17.52 £17.14 -£0.38 -2.20% 553 80 17.3% 12.6%

Band 7 £20.42 £20.48 £0.05 0.25% 382 68 11.9% 10.7%

Band 8a

£24.05 £23.13 -£0.92 -3.83% 113 37 3.5% 5.8%

Band 8b

£27.25 £27.13 -£0.12 -0.43% 38 13 1.2% 2.1%

Band 8c

£31.77 £34.15 £2.38 7.50% 16 10 0.5% 1.6%

Band 8d

£39.91 £40.03 £0.12 0.31%% 13 6 0.4% 0.9%

Band 9 £41.91 £46.85 -£1.05 -2.20% 3 2 0.1% 0.3%

VSM £57.80 £61.60 £3.79 6.56% 5 4 0.2% 0.6%

*local apprentice

3.7 Benchmarking our results: Currently there are very few trusts which have publish their gender pay gap data, for those who have the following was found:

Royal Orthopaedic Hospital mean salary – 34.8% lower for women top quartile - 52.4 % men v 47.6% women lower quartile – 31% men v 69% women mean bonus pay – 49.5% lower

Gloucestershire mean salary – 28.2% lower top quartile – 31% men v 68% women lower quartile – 21.2% men v 78.8% men mean bonus pay – 0%

Lincoln Partnership NHS Foundation Trust mean salary – 19% lower for women top quartile - 15% men v 85% women lower quartile – 30% men v 70% women mean bonus pay – 40% lower

3.8 More about women in the workforce

3.9 The Trust collects and publishes equality monitoring employment information on an annual

basis in order to assess how people with protected characteristics fare as job applicants and employees. On a number of measures, females fare the same or better than males. Females are more likely to be promoted within the trust; they are more likely to be

13



appointed following shortlisting and are less likely to state that they have experienced discrimination in the last 12 months as reported in NHS staff survey.

3.10 We continue to train our staff in recognising and mitigating unconscious bias in recruitment and selection; in 2017 we introduced a new policy requiring at least 1 interview panel member to be trained. Promoting flexible working is well embedded in our Workforce strategy.

3.11 Conclusion

3.12 The Trust has calculated the gender pay gap data in line with the government’s gender pay gap reporting regulations ahead of the submission deadline of 30 March 2018. We are encouraged that our gender pay gap (mean and median) is below the national average but acknowledge that ongoing commitment and focused actions are required to close the gap. We will continue to implement steps to build a more diverse and inclusive culture in order to ensure that our workforce represents the patient base we serve.

4. Risks

4.1 Failure to publish gender pay gap information is ‘an unlawful act’ and the Equality and Human Rights Commission (EHRC) can take enforcement action (s34 of the Equality Act). The EHRC may open an investigation if they suspect a considerable pay gap is being hidden by employers. Reputational risks associated with having a large pay gap. This report will fulfil the Trust’s reporting requirements, analyses the figures in more detail and sets out what we are doing to close the gender pay gap in the organisation.

5. Recommendation

5.1 The Patient and Staff Experience Committee reviewed the report and recommend the board approve it for publication, in line with national reporting requirements.

Paul da Gama Director Human Resources and Organisational Development March 2019

13



1

Trust Board Meeting

01 March 2018

Title of the paper Bi-monthly Corporate Risk Register Review

Agenda item 14/57

Lead Executive Mike van der Watt, Medical Director

Author Leigh Gibson, Deputy Head of Risk


The corporate risk register is reviewed on a regular basis by the Risk Review Group (RRG). The last RRG was held on 16 January 2018. In this report there is 1 escalated risk and 1 de-escalated risk approved by RRG. Data for this report was extracted from Datix on 12 February 2018.


Risk Review Group – 16 January 2018

Action required:

The Board is asked to receive the report for information.



Trust objectives To deliver the best quality care for our patients

Benefits to patients/staff from this project/initiatives Effective risk management frameworks and reporting provides a source of assurance that identified risks to patients are being identified, assessed and mitigated.

Risks attached to this project/initiatives and how these will be managed Nil identified

14

Tab 14 Bi-monthly corporate risk register review


2

Agenda Item: 14/57

Trust Board meeting – 01 March 2018

Corporate Risk Register review Presented by: Mike van der Watt, Medical Director

1. Purpose

1.1 The aim of this paper is to provide a summary update of the status of the corporate risk register and corporate risk profile of the organisation.

2. Background

2.1 The Safety and Compliance Committee leads on the development and monitoring of

risk and governance arrangements across the Trust to ensure that the organisation delivers key priorities and manages risk efficiently.

2.2 The Safety and Compliance Committee meets bi-monthly to review the overall corporate risk profile and seek assurance that risks are being appropriately identified and managed.

2.3 The Risk Review Group reviews all changes to risk scores for corporate risk entries including risks escalated to 15 or above and risks that are recommended for de-escalation due to effective mitigation or changes in circumstances.


3.1 The risk register is a live document recorded on Datix and risk leads regularly review

and update entries.

3.2 Data for this report was extracted from Datix on 12 February 2018. At this date 22 risks were recorded on the corporate risk register with a current score of 15 or more.

3.3 The chart below demonstrates the risk score movement on the corporate risk register from April 2016. From April 2016 to January 2018 there is an overall decrease of risks on the corporate risk register.

3.4 Work continues both at a corporate level with Board sub-committees and with

Divisions to improve the alignment, recording and management of individual risk

registers and the corporate risk register (CRR) which contains all risks with a current

score of 15 or more.

14



3

The chart below shows the risk score movement of all risks on the risk register from

April 2016.

There was a gradual decrease of the number of risks scored at 15 between July 2017

and October 2017; followed by small increases in November 2017 to date. The number

of risks scored at 16 has been increasing gradually since October 2017. The risks scored

20 have remained reasonably consistent over recent months.

There has been a gradual decrease with the number of risks scored 9 and a small

increase with the number of risks scored between 10-12.

Appendix 1 includes a summary of the current status of all risks on the corporate risk

register.

4. Risks 4.1 The corporate risk register is an integral part of Trust risk management

arrangements.

5. Recommendation

5.1 The Board is asked to note the report for information.

Mike van der Watt Medical Director 12 February 2018 14



4

Appendix 1

ID The Risk Update

Co

nse

qu

en

ce (

curr

en

t)

Like

liho

od

(cu

rre

nt)

Rat

ing

(cu

rre

nt)

Principal Risk

(Primary)

Board Assurance (Primary)

Lead

ESCALATED RISKS

1011

Watford Health

Campus – Summary

Risk

This risk has been escalated and accepted at RRG on 16 January 2018 due

to next phase in construction and has the potential to affect both

operational activity and strategic development of the WGH site.

Trust continues to work with LABV to develop long term car parking

solution for WGH.

Maj

or

Like

ly

12

→1

6

PR9 Trust Executive

Committee PH

CURRENT CORPORATE RISKS

3652

Lack of back up

mammography

facilities/existing

machine 9 years old

A full business case is due for completion by 28/02/2018 – options to

provide space at St Alban’s City Hospital to install a second machine are

currently being assessed.

Mo

der

ate

Cer

tain

12

→ 1

5

PR5

Safety and

Compliance

Committee

ST

3958

Risk of condensate

tank failing – WGH

boiler house

A site survey undertaken in December 2017 identified that the boiler on

WGH site has corroded and requires replacement. A business case was

written and submitted in January 2018 with aim for boiler to be replaced

March 2018. In the meantime weekly maintenance inspections are being

carried out.

Maj

or

Like

ly

NEW

16

PR3 Safety and

Compliance PH

14

Tab 14 B

i-monthly corporate risk register review

4 of 121T

rust Board M


5

3894

ICT Applications

reduced availability,

poor reliability &

performance

41/53 applications have been migrated. A revised schedule for migration

of the remaining 12 applications has been agreed with CGI; the programme

is scheduled to complete by end June 2018. Maj

or

Cer

tain

20

PR4

Finance &

Investment

Committee

LE

3892

ICT Data Centres


poor reliability &

poor performance

Additional funding for further remedial works included in ITFF application -

outcome awaited

Meeting held with Estates on the 23rd Jan 2018 for re-evaluation of the

risk and an options appraisal to be produced.

Maj

or

Like

ly

16

PR4

Finance &

Investment

Committee

LE

3896

ICT Data Networks


poor reliability &

performance

Local area network issues persist with some areas using out of support

(end of life) end switches. CGI have not been able to identify the root-

cause. Maj

or

Cer

tain

20 PR4

Finance &

Investment

Committee

LE

3899

ICT Trust Bleep

System Business case to recruit a subject matter expert to look into Bleep

replacement options approved in Jan 2018. Recruitment to commence in

February 2018

Cat

astr

op

hic

Like

ly

20

PR4

Finance &

Investment

Committee

LE

3893

ICT Servers reduced

availability, poor

reliability &

performance

Progress is closely linked to the Applications migration work as servers are

upgraded as they are migrated to the CGI data centres. Migration activities

have slowed down while commercial discussions take place with CGI. The

availability of resources has impacted progress.

Maj

or

Cer

tain

20

PR4

Finance &

Investment

Committee

LE

3897

Internal, External

malicious or

unintentional breaches

of, or attacks on

information systems.

An external IT Health Check for Cybersecurity was completed in early

December. The full report received identified a number of

recommendations to strengthen the Trust’s cyber-security arrangements.

The Head of Information Security has developed an action plan with an

overall completion date before 30 June 2018.

Maj

or

Like

ly

16 PR4

Finance &

Investment

Committee

LE

14

Tab 14 B


5 of 121T

rust Board M


6

3890

Limited ability to

Dispose of Biological

Hazard Group 2 and

3 Organisms in the

Microbiology

Department

The implementation of both autoclaves has temporarily stopped due to an

unforeseen requirement for Trust insurance personnel to witness and

approve installation. This process is being managed by the Estates team.

Following implementation and period (four weeks) of monitoring

functionality the risk will be closed. Cat

astr

op

hic

Po

ssib

le

15

PR1

Safety &

Compliance

Committee

PH

3912

High turnover rate

within Band 5

nursing population

Comprehensive action plan in place to address. Delivery oversight via

fortnightly steering group. Regular updates provided to Patient and Staff

experience committee (PSEC) Maj

or

Cer

tain

20

PR2

Patient and

Staff

Experience

Committee

PdG

3825

Workforce and Finance

risks linked to the

introduction of the

Apprentice Levy

Apprentice Levy delivery group in place – meets fortnightly. Good progress

has been made in establishing approach and framework and action plan in

place. The Trust pays £70k per month levy (£840k per annum), current

commitments for apprenticeships total £800k over two years – ie 50% of

the ‘gap’ has been bridged. Hard launch of the programme planned for

national ‘Apprenticeship Week’ in early March.

Mo

der

ate

Cer

tain

15 PR2

Patient & Staff

Experience PdG

3845

CCG financial

situation and

consequent impact

on WHHT - 2017/18

Further CCG engagement underway at Trust level with the support /

involvement of STP, NHSI and NHSE colleagues. Mediation not fully

successful and specific actions not yet assigned beyond this higher-level

work.

Cat

astr

op

hic

Like

ly

20

PR7

Finance &

Investment

Committee

DR

3742

Failure to achieve

sufficient efficiencies

to support Annual and

longer term plans

Targeted Strategic Delivery Office (SDO) & Programme management (PMO)

support for CIP schemes into 2018/19. Interim resource to strengthen

2017/18 provision within Finance. Use of Model Hospital tool to derive

further schemes for use in current and future years' programmes.

Divisional opportunity packs developed and produced. Cat

astr

op

hic

Like

ly

20 PR7

Finance &

Investment

Committee

DR

14

Tab 14 B


6 of 121T

rust Board M


7

3744

Inability to secure

sufficient capital funds

to meet investment

plans in the Annual and

Strategic Plans.

Independent Trust Financing facility (ITFF) application for capital funding

completed in July 2017. NHS Improvement (NHS I) review has been

undertaken by the East of England team – the finance and estates teams

continue to liaise with NHS I to respond to queries and seek progress

updates.

Maj

or

Like

ly

16

PR7

Finance &

Investment

Committee

DR

3737

Risk of failing to

deliver the Annual

Plan due to

changing clinical

capacity in an

unplanned way

Trust Executive to continue enforcing time-limited approvals for

emergency changes and the need for recovery plans. This will ensure that

where unplanned changes are made there is a break clause to ensure

proper review and a sustainable plan put in place. A number of service

changes are in progress via the CCG QIPP programme and the outworking

of recent tender processes; in addition work around re-establishment of a

Trust-wide private patient function is underway.

Maj

or

Like

ly

16 PR7

Finance &

Investment

Committee

DR

3741

Risk of failure to

achieve financial

plan resulting from

failing to meet all

Sustainability and

Transformation

Fund (STF)

conditions.

Risk remains in place as work goes on to minimise future impacts in

2018/19 and beyond. Compliance with STF conditions are reported and

assessed at each Finance & Investment Committee. Current forecasts

indicate that 2017/18 will not be met but 2018/19 onwards is possible.

Maj

or

Maj

or

20

PR7

Finance &

Investment

Committee

DR

3930

Disruption to

Endoscopy &

Bronchoscopy Services

due to

decontamination

failure

Work underway at HHGH site due to complete and in use end Feb 2018.

Validation of dryers at WGH and HHGH sites now complete and machines

in use. Buildings work at Watford site due to commence during February

2018 with target completion date end April 2018.

Decontamination service continues to be outsourced to Chase Farm to

assure continuation of service.

Maj

or

Like

ly

16 PR1

Safety and

Compliance

Committee

PH

14

Tab 14 B


7 of 121T

rust Board M


8

3503

Hardware Support

for McKesson

Systems

(Cardiology)

McKesson and IT currently building environment for upgrade. Go live

target date revised and changed to March 2018. Service continues with

control measures in place.

Maj

or

Like

ly

16

PR4

Safety and

Compliance

Committee

LE

3120

Patient Medical Notes

missing, Delayed or

poor condition.

Business case for offsite medical records solution was approved at TEC on

8th November. The approved option is to start scanning records with the

ultimate aim to move to a full Electronic paper record.

A tender specification is being written for the scanning option which will

then go out to tender. Once costs have been received, a final case will be

presented to TEC to approve the finances to move forward with this

option. Target timeline for full business case – March 2018.

A working group has been set up to oversee implementation of scanning.

Maj

or

Cer

tain

20

PR4

Finance &

Investment

Committee

LE

3781

Unscheduled Care

medical workforce -

gaps in rota

Job role re-design being undertaken and proactive recruitment campaign

underway.

This risk to be disaggregated to reflect changes to operational structures –

potential for de-escalation within the next 2-3 months, to be reviewed via

risk review group.

Maj

or

Like

ly

16 PR2

Patient & Staff

Experience PdG

14

Tab 14 B


8 of 121T

rust Board M


9

3786

Risk of poor patient

experience & adverse

clinical outcomes due

to poor flow through

the emergency care

pathway

Monthly detailed updates provided to Trust Board on comprehensive

action plan to address emergency care pathway pressures and risks.

New CDU operational December 2017. Winter resilience funding confirmed

to WHHT and system partners to provide additional capacity through to

end March.

CAG / TEC are developing plans to respond to the National Emergency

Pressures Panel guidance issued on the 2nd January.

Maj

or

Cer

tain

20

PR5 Trust Executive

Committee ST

DE-ESCALATED RISKS

3957 Lack of anaesthetic

machines and monitors

The risk has been minimised by prioritising areas within the department

and have moved machines and monitors accordingly.

Cat

astr

op

hic

Po

ssib

le

15

→ 9

PR1 Safety and

Compliance MvdW

14

Tab 14 B


9 of 121T

rust Board M


1

Agenda Item: 15/57

Report to: Trust Board

Title of Report: Assurance report from Finance and Investment Committee

Date of meeting: 01 March 2018

Recommendation: For information and assurance

Chairperson: John Brougham, Non-Executive Director

Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Finance and Investment Committee at its meeting on 22 February 2018.

The duration of this meeting was shortened to allow executive attendance at a meeting with HVCCG, permitting only time-critical items to be discussed.

Background The Committee meets monthly and provides assurance on:

Scheduled reports from all Trust operational committees with a finance and information technology brief according to an established work programme.

Financial Performance

i. I&E deficit

The Committee reviewed the actual performance in the month and year to date, and focussed on the challenging action plans in place to deliver the forecast deficit for the year of £35m, which has been agreed with NHSI.

Following review of the forecast activity, deficit reduction plans, and risks for the final two months, the Committee was not assured that the full year deficit forecast could be achieved due to lower projections of elective activity, including the impact of the national directive, the £5m of previously reported recovery actions which are not underpinned, and the ongoing contractual issues on income with HVCCG.

The Committee recommends that the deficit recovery plans and associated risks to achieve the £35m full year deficit forecast are reviewed at the March Board.

ii. Productivity improvement plans

The Committee reviewed the status of plans to improve productivity in back office activities, in particular planned savings from improvements in financial systems. The Committee

15

Tab 15 Assurance report from Finance and investment committee


2

recognised that these plans were still to be formally approved by the Executive Committee, but gave its support to the direction of travel and the targeted improvements in cost and operational efficiency.

The Committee will continue to review these, and other back office productivity plans, on a regular basis and seek assurance that the financial savings are built into budgets and business plans.

iii. Capital Spend/Funding

Capital spend in January of £1.2m took year to date spend to £5.2m, and the Committee was assured that commitment and spend continues to be carefully prioritised and managed not to exceed the current NHSI authorisation limit of £7.8m.

The Committee reinforced its concern that there was still no confirmation that the ITFF application for £14.4m of planned capital spend in the year would be approved by NHSI, or that the subsequent underspend would be authorised in next year’s plan.

The Committee was not assured that there was compatibility between the restrictions in capital spend approval from NHSI and the operational and financial improvements that were being asked of the Trust.

iv. Revenue Funding

Funding of revenue spend by NHS is subject to monthly approval, and following review, the Committee recommends ratification by the March Board of a loan of £11.4m to meet the funding requirements in February.

Financial Plan 2018/19

The Committee received a verbal update on the status of the plan, and the challenge of achieving a deficit control total, pre STF funding of £21.6m. The Committee was informed that a number of meetings were scheduled later in the day, with HVCCG, and NHSI, relating to next year’s plan, and the Committee recommended that a paper on the outcome, and the latest status of the plan be presented to Part 2 of the March Board.

The proposed final plan is scheduled to be reviewed by the March Committee with approval by the Board in April.

Corporate risk register (CRR)

The Committee reviewed the 6 IM&T and 5 finance currently on the CRR.

The Committee was assured that the risks and ratings should remain as presented, and that appropriate mitigating actions were in place.

15



3

Information and Communications Technology (ICT)

The Committee received an update on the progress of the infrastructure improvement plan and noted that there were no changes to the current corporate level risks associated with the programme.

The Committee also noted that a bid for replacement devices was submitted in February, against a national cyber-security improvement fund.

Watford General Hospital Car Park Solution

The Committee received a verbal update on the milestones to deliver the planned multi-storey car park in line with the SOC approved by the Board in June 2017 and by NHSI in January. The Committee will review the OBC in March with a paper for approval submitted to the April Board.

Risks to refer to risk register

See corporate risk register above.

Issues to escalate The Committee recommends the following:

to Part 1 of the March Board for ratification:

i. the NHS revenue support loan of £11.4m to cover funding requirements in February.

to Part 2 of the March Board for assurance:

ii. the plans and risks in achieving the £35m deficit forecast.

iii. an update on the 2018/19 financial plan.

Attendance record

Attended

John Brougham, Non-Executive Director (Chair)

Don Richards, Chief Financial Officer

Ginny Edwards, Non-Executive Director

Jeremy Livingstone, Divisional Director, Surgery, Anaesthetics & Cancer

Katie Fisher, Chief Executive

Lisa Emery, Chief Information Officer

Mike van der Watt, Medical Director

Paddy Hennessy, Director of Environment (for item 15.3)

Paul da Gama, director of Human Resources (for item 15.2)

Sally Tucker, Chief Operating Officer

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Stephen Dunham, Assistant Director of Finance & Commercial Development

Prof. Steve Barnett, WHHT Chair

Tim Duggleby, Head of Strategic Development & Compliance (for item 15.1)

Tom Drabble, Patients’ representative

Apologies

Helen Brown, Deputy Chief Executive

Lesley Headland, Chair of Staffside

Phil Townsend, Non-Executive Director

Clerk

Clare Ransom, Executive Assistant

15



1

Agenda Item: 16/57


Title of Report: Assurance report from Clinical Outcomes and Effectiveness Committee

Date of meeting: 01 March 2018


Chairperson: Jonathan Rennison, Non-Executive Director

Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Clinical Outcomes and Effectiveness Committee at its meeting on 25 January 2018

Background The Committee meets bi monthly and provides assurance to the Board on:

Safe and effective patient care

Prevention, early intervention, recovery and rehabilitation

Ensure that the Trusts responsibility for infection control is effectively fulfilled

Promoting a culture of learning and continuous improvement.

Measure change using clinical outcome measures to monitor the impact of the services provided by the Trust.

Business undertaken

Integrated Performance Report (IPR) The Committee received and reviewed the IPR and was assured that appropriate actions were being taken to maintain and improve performance across a range of measures. Mortality sustained improvements in all three mortality measures over the last two months. VTE risk assessment is below the target but compliance was improving and the focus was now on the re-assessment of VTE risk after 24 hours of admission. The trust is piloting a band 3 role to support the review of completion and re-assessment. This would be monitored and evaluated to see if this was successful before permanently implementing. The committee noted that there has been a reduction in fill rate in N&M staffing with a further reduction in December from Nov of 1.3% . The SACH fill was very low at 36% but this was partially due to closure and occupancy. The Chief Nurse outlined that staffing is reviewed 5 times a day to ensure safety on all shifts. This

16Tab 16 Assurance report from the Clinical Outcomes and Effectiveness committee


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triangulated with the ward scorecard and an increase in process alerts and reduced supervisory time of the ward sister. The committee were assured that safety was being maintained and under careful review although the Chief Nurse was concerned that this may impact on harm free care. GIRFT (Getting it Right the First Time)

1. The committee received a report relating to Getting it Right First Time on obstetrics and gynaecology. The committee was assured that the outcomes from the GIRFT inspections had been reviewed; clear actions identified with time scales and these were on track. The committee were assured the learning had been embedded. Research and Development 2017/18 Mid-Year Update Report The Committee received the report and were assured that good management process were in place. There had been a reduction in funding from the NIHR Local Clinical Research Network however; there had been success in seeking and securing independent funding. The department was also linking with the Royal Free network for grant funding. Clinical Audit & Effectiveness and National Institute of Clinical Excellence (NICE) Report The committee received an update on this and were assured that the work being undertaken was going well and they were developing a more detailed KPI to track compliance clinical audit activity across divisions with this initiative is appropriate. The committee commended on the new format which was found to be clear and easy to follow. Improvement Plan aimed to reduce the Local Caesarean Section Rate The committee received the Improvement Plan which had been drawn up to address the rising trend in caesarean sections locally in response to CQC alert in June 2017. Key items to noted were:

o Service objective was to achieve incremental and sustainable reduction in the caesarean section rate during the course of 17/18 with a yearend target rate of 28% which the service is working to achieve.

o The specific actions for key areas for intervention and improvement in the action plan are mostly achieved or underway except for the Normal Birth Strategy however, there has been a recent appointment of a Consultant Midwife to lead on the Normality.

o Elective Caesarean section rate has declined to 11.5% YTD compared to national rate of 11%.

o Emergency Caesarean section rate is marginally on the decline 16.1% YTD compared to national 16%.



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o A successful end of year figure would be a caesarean section rate of 28 with an emergency rate of 16%

The committee were assured by the progress being made and sustained. National Hip Fracture Database Annual Report The committee received a presentation on the report which instigated a lively and thorough discussion. There were several questions around targets, performance and consultancy provision. The Committee noted that the proportion of general anaesthetic was better than the national average, however they were falling behind with nerve block hence the outliers in those parameters. The use of screws versus nails was challenged by the committee and it was noted it was being recognised nationally that the surgeon’s preference was to use nails. The committee questioned surgeons preference and sought assurance that this was appropriate – they were informed that the use of nails (instead of screws) resulted in better patient outcomes and reduced length of stay. The committee were assured of the actions implemented and how it would be maintained to ensure quality. Draft Quality Commitment (Strategy) Update The committee commended the work undertaken and the final document and agreed to submit the strategy to the March Board for approval. COE Committee risk register to include risks at 15 There was one risk with a score of 15 currently with this committee, relating to Emergency Care and Patient Flow. We were assured that the actions and mitigation in place are appropriate this was actively being managed at Clinical Advisory Group and the Trust Executive Committee. COE Committee risk register to include risks at 12 and below The committee noted the report and requested the older risks to be updated. It was agreed that a further column would be added to show when the risk was reviewed and comments updated. BAF Action Tracker 2017-18 The committee reviewed the Board Assurance Framework and all actions were appropriate and on track. End of Life Care – Six Monthly Update The committee received the bi-annual report for this area and reviewed the report and the evidence presented in it. The committee commented on the good measures of success and the progress that has been made.



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None

Issues to escalate to Board

Increased focus on the emergency standards and work underway to support this target. – on-going

Attendance In attendance for Specific Items

Ginny Edwards, Non-Executive Director Tracey Carter, Chief Nurse & DIPC Maxine McVey, Deputy Chief Nurse Angela White, Head of Nursing, Medicine and Emergency Medicine Jo Fearn, Head of Nursing, Children Services Anna Wood, Associate Medical Director of Clinical Standards and audit Jackie Birch, Head of Risk, Assurance and Compliance Jane Shentall, Director of Performance Linda Tarry, Executive Assistant to Chief Nurse (minutes) Mr Deierl, Consultant Orthopaedics Ms M Coker, Consultant, Obs& Gynae Michelle Sorley, Lead Nurse Palliative Care



1

Agenda item: 17/57


Title of Report: Safety and Compliance Committee Assurance Report to Trust Board

Date of board meeting:

01 March 2018


Chairperson: Jonathan Rennison, Non Executive Director Purpose

The report summarises the assurances received, approvals, recommendations and decisions made by the Safety and Compliance Committee at its meeting on 15 February 2017.

Background The Committee meets bi-monthly and provides assurance on:

CQC standards

Compliance with external bodies, eg. NHS Litigation Authority, Health and Safety Executive, Health Service Ombudsman

Actions taken and lessons learnt in response to adverse clinical incidents, complaints and litigation

Compliance with clinical and non-clinical governance, standards and guidance

Risk and governance strategy

Board Assurance Framework

Business undertaken

Annual Review of Terms of Reference The Committee reviewed the Terms of Reference for the Committee. It was noted that some divisions had not been represented at this meeting and agreed that the membership should be more explicit around divisional representation. It was agreed to add two divisional representatives to the membership. It was also agreed that the ToRs should include an explanation of non-quorate, indicating that the meeting could take place but that no decisions could be made. Performance Report The Committee reviewed the November and December data in the performance report and noted the areas of good performance and areas requiring performance improvement. We received an update from the Medical Director on our mortality rates performance, which overall is better than expected, placing us amongst the best performing Trusts in the country. We were informed that our results are carefully checked and reviewed internally and this has identified some areas in the Trust that are performing as expected (rather than better than expected) and the data for these areas are being carefully examined. Initial findings indicate that there are coding issues with the data. This is being fully investigated and a report will be brought back to the Committee.

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Tab 17 Assurance report from the Safety and Compliance Committee


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Corporate Risk Register report The Committee received a report on the risks scoring 15 or more on the corporate risk register and the risks aligned to the committee with progress against the action plan. It was noted that, as of this date, there had been one escalated, one de-escalated and one new risk added to the corporate risk register aligned to the Safety and Compliance Committee. Board Assurance Framework action tracker The Committee reviewed the status and progress of actions in the Board Assurance Framework, designated to the committee. Medical Devices Update The Committee received an update on the management of medical devices and were assured by the progress being made. Recommendations from NHS Breast Screening Programme QA Visit Sept 2017 Members received a presentation on the draft recommendations following the QA visit and noted the actions that had already taken place ahead of the final report. Risk Review Group Terms of Reference The Committee agreed the Risk Review Group Terms of Reference. Safeguarding Six Monthly Report for May – Oct 2017 The Safeguarding annual report was well received and members were assured that it showed strong levels of safeguarding. Quality Improvement Plan Progress Update The Committee reviewed the recommendations from SDB TEC and was assured of the monitoring of the progress of the QIP. Fire Safety Update The Committee received an update with regards to Fire Safety measures and management procedures throughout the Trust. Premises Assurance Model (PAM) The Committee was updated on the implementation of the Premises Assurance Model (PAM) and noted the progress to address the five areas currently graded ‘inadequate’. General Data Protection Regulation (GDPR) Update Members were updated on the progress made against the Trust’s

GDPR action plan and approved the recommended appointment of a

Data Protection Officer subject to confirmation that the guidance from

Working Group 29 had been complied with. In recommending the role,

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Information Governance Manager for appointment to the Trust’s Data

Protection Officer (DPO), we are putting forward a role that is

independent and impartial and without a conflict of interest. These

requirements are existing virtues of the role of Information Governance

Manager. The position does not have any responsibility for the direct

control or processing of information/data, but rather responsibility for the

governance regarding how and why data are processed and for

ensuring that the organisation adheres to data protection requirements.

The Committee was also made aware that there was a national

expectation that the role of DPO would likely be filled by staff

who oversee issues relating to data protection, such as Heads of

Information Governance, Information Governance Leads, Information

Governance Managers or Privacy Officers. These roles are most likely

to, and it is particularly the case at WHHT, have the necessary IG and

Data Protection knowledge and experience. Therefore, the

recommendation of the Trust to appoint the role of Information

Governance Manager as DPO is consistent with other acute trusts.

Cyber Security Assessment Update Members received an update on actions being taken to reduce the cyber security risks identified during a recent Cyber Security Assessment at the Trust. EPRR Core Standards Assurance meeting The Committee noted the letter from NHS England confirming that, following the assurance meeting and review of the Trust’s submission, they agreed with the assessment of fully compliant and members congratulated those involved.


The risks on the corporate risk register aligned to the Safety and Compliance Committee (scored at 15 and over).

Key decisions taken

Members approved 1. The work plan for 2018/19 2. The Terms of Reference for both S&CC and RRG 3. The appointment of a Data Protection Officer

Issues to escalate

1. IPR 2. Safeguarding six-monthly report 3. Fire Safety Update 4. Medical Devices Update

5. EPR

Challenges and exceptions

None

Future exceptional items

None

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Attendance record

Jonathan Rennison, Non-Executive Director Paul Cartwright, Non-Executive Director Katie Fisher, Chief Executive Sally Tucker, Chief Operating Officer Mike Van der Watt, Medical Director Tracey Carter, Chief Nurse Lisa Emery, Chief Information Officer Paddy Hennessey, Director of Environment Anna Wood, Associate Medical Director of Clinical Standards and Audit Paula King, Head of Nursing, Surgical Division Janette Leston, Matron, Women’s and Children’s division Lisa Morris, Executive Assistant (minute taker) For individual items: Simon Thomson, Consultant and Lead Clinician Breast Care Unit (Breast Screening Programme) Aleksandra Lukaszewicz, Information Security Manager (Cyber Security update)

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Page 1 of 2

TRUST BOARD MEETING IN PUBLIC

AGENDA Agenda item: 22/57

12 April 2018 at 9.30am – 12.00noon

Terrace Executive Meeting Room, Spice of Life Restaurant, Watford Hospital

Apologies should be conveyed to the Trust Secretary, Jean Hickman on [email protected] or call 01923 436 283

Item ref

Title Objective Previously presented

Lead Paper or verbal



02/58 Patient experience presentation

To receive N/A Chief Nurse Presentation

OPENING



04/58 Conflict of interests To note N/A Chair Paper

05/58 Minutes of the meeting held on 01 March 2018

For approval

N/A Chair Paper

06/58 Board action log from 01 March 2018 and previous meetings and decision log

To note N/A Chair Paper


For information

N/A Chair Paper

08/58 Chief Executive’s report For information

N/A Chief Executive

Paper

PERFORMANCE

09/58 Integrated performance report – month 11

For information

and assurance


Chief Operating Officer

Paper

DELIVER A LONG TERM STRATEGY (BAF RISK 9)

10/58 Strategy update For information

and assurance


Deputy Chief Executive

Paper

GOVERNANCE

13/58 2018/19 corporate aims and objectives

For approval


Deputy Chief Executive

Paper

14/58 Board assurance framework update

For approval

All Deputy Chief Executive

Paper

COMMITTEE REPORTS

22

Tab 22 Draft agenda for the next board meeting


Page 2 of 2

15/58 Assurance report from Finance and Investment Committee

For information

and assurance

Finance and Investment Committee

Committee Chair/ Chief Financial

Officer

Paper

16/58 Assurance report from Clinical Outcomes and Effectiveness Committee

For information

and assurance

Clinical outcomes and effectiveness

committee

Committee Chair/Chief Nurse

Verbal

17/58 Assurance report from the Patient and Staff Experience Committee

For information

and assurance


Committee Chair/Director of

Human Resources

Paper

REPORT TO CORPORATE TRUSTEE

18/58 Assurance report from the Charitable Funds Committee

For information

and assurance

Charitable Funds

Committee

Committee Chair/ Director of

Communications

Paper

ANY OTHER BUSINESS

19/58 Any other business previously notified to the chair

N/A N/A Chair Verbal

QUESTION TIME

20/58 Questions from Hertfordshire Healthwatch

To receive

N/A

Chair Verbal

21/58 Questions from our patients and members of the public

To receive N/A Chair Verbal

ADMINISTRATION

22/58 Draft agenda for next meeting

To approve N/A Chair Paper

23/58 Date of the next board meeting in public: 03 May 2018 Lecture Room, Postgraduate Centre, St Albans Hospital


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Tab 22 Draft agenda for the next board meeting


TRUST BOARD MEETING IN PUBLIC AGENDA · To receive N/A Chief Nurse Presentation ... GDC General Dental Council ... KPI Key Performance Indicator L

Documents