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1 REPORT TO THE TRUST BOARD MEETING IN PUBLIC August 2013 Title Lead Director Author(s) Purpose Previously considered by Executive Summary Integrated Performance Report Agenda Item: Paul Scott - Director of Finance & Performance Lynne Wigens Director of Nursing & Quality Julie Fryatt Director of HR Neill Moloney - Chief Operating Officer Chief Information Officer Mike Meers Deputy Director of Nursing Catherine Morgan Dave Mountford Interim Director of Finance To receive for information The board is being asked to note the contents of the integrated performance report (Appendix A) on: Quality Finance National & Contractual Standards Organisational Development Organisational Efficiency Trust summary performance management framework scorecard. The report also includes performance against the SHA Single Operating Model (SOM) for self-certification (Appendix B). Related Trust Objectives Sub-objectives 1. To provide safe, reliable, personal & Underlying Strategy: Effective Financial responsive emergency care, planned Management care, maternity & children s care; 2. To provide nationally recognised care for older people in the hospital; 3. To provide a number of more specialised services where they meet defined accreditation standards. N/A Risk and Assurance Related Board Assurance Framework N/A Entries Legal Implications/Regulatory None Noted Requirements Action Required by the Board The Trust Board is asked to receive the report. 1

2 BACKGROUND 1. This report has been revised to provide a new quality section and narrative with Appendix A. 2. The Trust SOM self-certification is Appendix B and shows Governance Risk Rating Green 0 for governance risk rating, with the trust achieving all targets Finance Year to Date Financial Risk rating is 1. (The financial risk rating is scored from 1 to 5 (1 indicates High risk, 5 indicates Low risk). Quality The Trust VTE data achievement remained above contractual target at 97.70% in July The Trust had 8 new SIRI s in June. Contractual The Contractual Risk Rating remained the same with contractual notices open around Emergency department timeliness indicators, General Surgery & T&O 18 Weeks and Breast Feeding initiation. 3. The National Trust Quality Dashboard is showing 2 (1 positive, 1 negative) alerts compared to the 3 reported in June. The Trust is showing 1 Positive Alerts in relation to: 30 Day Readmissions based on an improvement in Feb 2013 and 1 Negative Alert In relation to the Trust 18 Week Admitted performance latest data published Mar 2013 The Trust achieved the 19 Week admitted target at a Trust level in June. QUALITY Falls Although the performance for falls shows an improvement when compared to last year and a slight improvement in month the overall the rate of falls has reached a steady state over recent months, this is a particular area of focus for IHT & Ipswich and East CCG. The falls prevention group continue to lead on a number of key actions to prevent patients from falling; for example medical assessment, medicines management and compliance with post falls assessment. There is also recognition that further detailed work needs to be 2

3 undertaken to better understand causative factors in particular patient groups. A deep dive analysis of causative factors and trends will inform and direct future actions. It is anticipated that results and feedback from this work will be available to report ant Trust Board in October. Pressure ulcers Overall there is a sustained reducing trend for developed pressure ulcers across the Trust demonstrating that actions implemented earlier in the year are more consistently applied and embedded at ward level. The tissue viability team report improved documentary evidence of preventative measures and heightened awareness with clinical staff. There is assurance that reporting remains high through the number of contacts with the TVS for advice and support for minor skin integrity issues which demonstrates transparency and honesty from frontline staff and a desire to continue to improve practice. Despite this improved performance overall it is recognised that practice remains inconsistent in some clinical areas and the TVS will ensure additional visibility focus and educational support is available to these wards. VTE The compliance with VTE risk assessment remains above contractual standard but has not achieved the CQUIN target year to date (currently at 97.7%; CQUIN stretch target is 98%). To support achievement of this the VTE auditors are providing real time data by ward, patient and consultant level to the clinical teams to drive improvements and this will remain and area of focus within divisional senior leadership. Patient Experience Surveys The inpatient net promoter score reduced slightly in July (72.0) form June (81.7). There was a more marked drop for division 3 which on initial review appears to be related to Stour ward which received a higher proportion of likely responses rather than extremely likely. Overall there were also a slightly higher number of detractor responses (averages at 2.91% of total responses when compared with 1.58% in June). Further analysis will need to be undertaken to fully understand this variance. The net promoter score for the emergency department (ED) has reduced slightly (73.28 in July and 76.9 in June). The response rate has increased month on month since April and benchmarks higher than the national average. Comments on some of the patient surveys indicate communication of expected waiting times to have been an issue. The ED now ensure the triage Nurse, who see patients immediately on arrival, is informing patients of approximate waiting times. Comments in relation to delays will continue to be monitored in future months. The out patients net promoter score also decreased a little in June (70.89 form 76.93) however the response rate has increased significantly from 5.1% to 9%. The department have implemented buddies in clinics A/B and C/D; it is anticipated that this initiative will resolve any confusion or anxiety for patients/carers visiting this area. 3

4 Complaints In early July there were a number of complaints/pals concerns raised for patients being cared for in additional beds linked to high activity. This has been addressed through development of a shadow roster with identification of additional senior support. There is a plan to appoint to a senior nurse post for the additional beds to ensure consistent leadership for the winter period and to ensure temporary staff are adequately supervised and trained.. The overall number of complaints received has remained static since the beginning of the year with similar trends in terms of the type of complaints received. It is recognised that there needs to be further work at divisional level to monitor and ensure that actions and practice changes identified through complaints are being effectively implemented and sustained and therefore positively impacting patient experience. It is also proposed that in future reporting there is a move from reporting complaints separately to a full patient experience summary which will include survey data, compliments and complaints. This will support a drive to better understand what patients and carers are telling us about their care and therefore drive future improvements. Ward staffing data and quality metrics Staffing Recruitment to vacant posts is progressing for the inpatient areas reported and it is anticipated that by the end of September the majority of posts will be recruited to in line with the current plan. The number of vacancies (taking into account staff recruited and due to start in September) is WTE Registered Nurse posts. The majority of these posts are at band 6 or are on wards requiring experienced nurses in order to maintain an appropriate skill mix of newly qualified and experienced. The Health Care Assistant vacancy is 2.64 WTE; these posts have recently become vacant and will be appointed to commence in training in September. Plans are also in place to recruit to the central bank and into a number of fixed term contracts to support additional beds that will be required during the winter. Quality Metrics Individual wards receive the data reported and the Heads of nursing along with associated matrons for the clinical area monitor actions and progress against these. Wards with new leadership (Sproughton and Woodbridge wards) are receiving additional support from the corporate nursing team and from within the division. Mortality SHIMI this is for the calendar year This is within the expected range of values. 4

5 Amenable mortality this has not been reported for July as there is no further update available HSMR this is for July which is below expected levels. FINANCE 1. Introduction This report summarises the current (Month 4) and forecast financial position 2013/14. The year to date position is a deficit of 3.4m, which is significantly adverse from the Trust s plan ( 200k surplus YTD). The deficit is driven by costs of providing activity being higher than planned, overactivity in NEL reating increased premium costs for 30% income, CIP shortfall and provisions for fines and other penalties in the Trusts main contract with Commissioners. At Month 4 YTD Elective income was behind plan by 0.2m corresponding with lower activity than planned. NEL income was favourable for the YTD and was driven by relatively higher than planned activity which was paid for at 30% marginal rate (this activity is impacting on the cost base). The CIP plan is behind plan by 0.2m at Month 4 The YTD position and the ongoing risks identified clearly place the Trusts forecast outturn at risk. Unmitigated risk to the forecast is standing at c 9m. The Executive Team continues to work with Divisions to prepare recovery plans and mitigate this risk. This work is expected to be complete in October. Whilst there are areas of uncertainty with income that may partially mitigate the risks Trust Board are advised that the extent of the deficit means there is a continued and immediate requirement to reduce costs, in particular pay costs, in operational delivery if the Trust is to meet its financial plans. Trust Board are asked to note that achievement of the Trusts financial plan is not secure and there are significant risks to delivery. Failure to deliver plans will place the Trusts strategic objectives at risk and could result in a cash shortfall. At this stage of the year the position is able to be recovered and the forecast remains that the Trusts planned outturn will be achieved subject to appropriate recovery plans being prepared. This forecast will be reviewed in Month 6 on the basis of the recovery work that is being undertaken. The Trust Board are advised that the Trust has sufficient cash reserves for the immediate future. Without an improvement in the trading position, however, this position will deteriorate. The TDA have been approached with a view to agreeing a temporary borrowing to ensure the Trust can continue to pay its bills. 2. YTD and Forecast Key Variations Financial Risk Rating (FRR) At this stage of the financial year the Trust s financial plan generated an FRR of 3 and the full year plan also generates an FRR of 3. Due to the actual financial deficit position at the end of July 2013, the Trust continues to have an FRR of 1. 5

6 Divisional Performance Divisional YTD and forecast variances are shown in Table 1 below. The new Divisions have put together their first forecasts of the year. The Divisions are new and a number of managers and clinicians are also new to the role - forecasts should be seen in this context. Improvements to the current run rate can be seen to be assumed in Division 2 and Division 3. YTD Forecast Comments m m Division Driven by pay controls, costs of escalation and CIPs Division Driven by cost of capacity and CIPs Division Driven by CIP delivery contingency being developed Division Driven by fines and penalties /TPP risk Total The key themes for each Division are as follows: Division 1 Prudent forecast based upon non-delivery of CIP ( 3m), escalation wards and pay controls ( 3m). Further work being undertaken to understand the driver of escalation wards and pay controls have been strengthened by the new management team resulting in a fall in pay costs in Month 4 of c 0.3m. Significant pressure on income due to emergency threshold adjustments (NEL activity is higher but income on plan) and direct access diagnostic imaging (the reasons are under investigation). Further review and challenge underway Division 2 Overspend risk of 1.4m. The key drivers are a shortfall in CIPs of 1m and premium payments for capacity. Penalties now in the position. Key actions by clinicians in improving capacity could improve the forecast by improving income, delivering CIPs. Downside risk not included of mobile endoscopy unit impacting on capacity. Division 3 Balanced forecast based upon full CIP delivery. Risks are being managed via non recurrent means. Division 4 Overspending risk of 2m- TPP and some remaining general penalty provisions under assessment. Other opportunities have been identified both within Divisions and corporately and these are included in the risks and opportunities schedule. These are areas for the Trust leadership teams to develop but do not currently have enough substance to alter the unmitigated risk to the Trust which remains at 9.2m. The Executive Team is working with Divisions to prepare recovery plans and mitigate this risk. Trust Board are advised that the extent of the deficit means there is an urgent and immediate requirement to reduce costs in operational delivery if the Trust is to meet its financial plans. Key areas for Board to anticipate for Month 5: Month 5 position, improved pay and income position Month 5 forecast improved forecast outturn for Divisions, greater crystallisation of opportunities. 6

7 The Executive Team have commissioned a number of reviews on cost improvement plans and the underlying financial position which will be presented to Finance and Performance Committee. The intention of these plans is to guide the Trust on its areas of focus and help judge the Trusts sustainability. A number of other workstreams are under way. These were described in m3 report. Trust Board are asked to note that achievement of the Trusts financial plan is not secure and there are continued significant risks to delivery. Failure to deliver plans will place the Trusts strategic objectives at risk. Whilst the position poses a considerable challenge the Executive Team considered tha, at this stage of the year, the position remains recoverable and the forecast remains that the Trusts planned outturn will be achieved subject to appropriate recovery plans being prepared. 4. Cost Improvement Plans At the end of Month 4 the Trust has seen a deficit of 0.3m against the planned delivery of CIPs. The profile of CIPs is predominantly due to impact from Month 5 (August). Whilst the majority of CIP targets have plans associated with them there is variation as to the development of the plans and only about 1/3can be considered to have robust plans underpinning them. A separate report has been presented to understand the full extent of the risk with current plans. 5. Other Issues Budgets have been set according to the Trust Board papers. Trust Board will be aware that there is limited contingency within these budgets and all uncommitted reserves have been devolved to Divisions. 6. Statement of Financial Position (Balance Sheet) The Trust s liquidity position is stretched with 9 days working capital available. Ongoing deficit trading will quickly lead to a cash problem. The bank balance of c 6.0m is adverse from plan by 5m which is predominantly driven by the I&E deficit. Capital expenditure for the year to date at 2.5m is behind the planned level of 4m. The cash flow forecast is under review and will be developed further. Without recovery plans to the I&E the Trust will need to develop mitigating cash plans during the summer. 8. Work Instigated to Address Financial Challenges IHT has instigated a series of work streams, contained within the table below, which enable the Trust to understand financial position earlier and more easily in addition to providing a basis for timely and effective identification of opportunities and management of delivery: Term Work Stream Impact Lead Short Baseline of underlying financial position Clarity of current financial position and understand strategic options. Understand cash position. DoFP 7

8 Short Data capture Targeted review to ensure appropriate income is being collected Short Communications clearly explain the implications of current position to all stakeholders and seek support, action and ideas Generate ideas and energy for improving cost from all staff and patients. Potential for improving patient experience and safety as well. Short Best practice tariff work A number of clinical areas are operating at best practice and could secure top up payments. DoFP DoHR DoFP Short Divisional recovery plans Return to surplus run rate COO/DoFP Short Review of CIP governance and reporting of CYE and FYE delivery Understanding of CIP position and impact of delivery upon current and COO/DoFP Short Productivity opportunities work commenced (benchmark, SLR, PLICs, Medeanalytics) future years Develop key strategic themes for effective patient care delivery over 5 years DoFP This workstream approach will continue to be developed to support the financial recovery. OPERATIONAL PERFORMANCE ED Performance 95.14% The hospital continues to deliver this standard with support to the ED department from all specialties. Cancer The Trust achieved all targets in July. 18 Weeks Non Admitted The Trust achieved the non-admitted with 98.4% in July Admitted The Trust achieved the admitted target at a Trust level 91.6%. This is the culmination of the plan to address the long standing backlog problem in General Surgery and the access policy problem in T&O. T&O is now sustainable for all sub-specialties with the exception of spinal which has an agreed plan which is on target to deliver. CONCLUSION 8

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