Delivering for Quality Integrated Performance Report. September Page 1 of 63

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1 Delivering for Quality Integrated Performance Report September Page 1 of 63

2 Contents Page(s) Executive Summary 3-4 Section A LDP Standards Performance Summary 5-7 Targets on Track Short Report 8 Chief Executive s Performance Escalation Cancer 62-Day RTT Weeks RTT 11 Patient TTG 12 Outpatient Waiting Times 13 A&E 4-Hour Waits 14 Diagnostics Waiting Times HAI Sabs 17 Sickness Absence / Workforce Dementia Delayed Discharge Smoking Cessation 27 CAMHS Waiting Times Psychological Therapies Waiting Times Section B - Capital Programme Section C - Financial Position Section D- Scottish Patient Safety Programme Section E - Healthcare Associated Infection (HAI) Section F - FOI 61 Section G - Complaints Page 2 of 63

3 EXECUTIVE SUMMARY OBJECTIVE OF THE REPORT The object of the Integrated Performance Report (IPR) is to provide assurance to the Board on the overall performance of NHS Fife against the corporate aims relating to National Standards (as described in the Local Delivery Plan), local priorities and significant risks. OVERVIEW A new style report was introduced to the Board for the first time in June as part of a series of changes to improve the Board s Integrated Performance Management arrangements. Within section A, LDP standards performance, the report format and content were modified to focus on those areas where improved performance was required (i.e. those areas with an AMBER or RED RAG status). Our traditional Action Plan has changed, to focus on identification of recovery actions with clear accountabilities and timescales which correlate to improvement trajectories and accurate forecasting of achievement of the performance level required. The rigour of monitoring progress against plans has increased through frequent, focused meetings of a group tasked specifically to concentrate on delivery of the required levels of performance. The Executive Directors established a platform to review Finance and Performance on a weekly and monthly basis. The structure is detailed below. The above structure supports delivery on the ground and provides assurance to the Finance & Resources (F&R) Committee and to the Board that systems and processes are being rigorously reviewed. In parallel, the Acute Services Division (ASD) has established a revised method of performance reporting and has introduced monthly Directorate Performance Reviews to improve the rigour of performance management across its Directorates. Performance Packs within Health & Social Care Services have also now been developed, in a similar format to those of ASD. Page 3 of 63

4 RECENT CHANGES AND CHANGE PROPOSALS Three changes have been implemented from September: Individual Recovery Plan Tasks have been assessed, as indicated by the shading of boxes in either GREEN (COMPLETE / STARTED), AMBER or RED (LATE); where an action has not been completed on schedule, is forecast to overrun or now has an extended scope, a Situational Analysis has been provided The sub-section reports have been re-named, going from Section B through to Section G. Section A is now the LDP Performance report. More detailed information is now included in relation to Sickness Absence / Workforce performance, in Section A Going forward, we are aiming to develop a sub-section report for the Programme Management Initiatives We are also considering the need for Section F (FOI). Page 4 of 63

5 SECTION A: LDP STANDARDS PERFORMANCE SUMMARY The NHS Fife Board receives performance data in the IPR. The source of data varies and can be derived from validated published sources, official government returns and databases, and local management information from a variety of internal sources. It is important to note that whilst local management information provides a more up to date position, data validation processes may not have been completed and this information may therefore be subject to change. Page 5 of 63

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8 TARGETS ON TRACK NHS Fife continues to meet or perform ahead of the following National Targets and Standards: Alcohol Brief Interventions: In FY -16, we will deliver a minimum of 4,187 interventions (4,505 in FY -15), at least 80% of which will be in priority settings ***Note that the target has been reduced as per Scottish Government guidance issued in April. The figures for the first quarter of -16 were available in late August, and they showed that Fife had delivered 878 interventions, some way behind the planned figure (1,047). This was largely due to there being no figures provided for interventions carried out in Wider Settings (e.g. Criminal Justice). There was also a drop in interventions carried out in Primary Care, in comparison to last year. Addictions Services are confident that the position at mid-year will have recovered. Antenatal Access: at least 80% of pregnant women in each SIMD quintile will book for antenatal care by the 12th week of gestation Local management information shows that NHS Fife has continued to record a performance level of over 80% in all SIMD quintiles. The lowest-performing quintile for the 3-month period ending June was Quintile 4 (Quintile 1 is most-deprived, Quintile 5 is least-deprived), with a figure of 87.7%. The highest-performing quintile was Quintile 5 (93.7%), while the overall NHS Fife figure was 89.7%. HAI: we will achieve a maximum rate of C diff infection in the over 15s of 0.32 Local management data for the 12-month period ending August indicates a C difficile rate of This is the lowest infection rate reported for more than a year. IVF: no eligible patient will wait longer than 12 months for screening following referral from Secondary Care Since mid, when the Key Performance Indicator was changed to consider screening times following referral, no NHS Fife patient (via the service run by NHS Tayside) has waited more than 12 months for screening. At the end of July, no patients currently waiting had exceeded this limit. Cancer Waiting Times - we will treat any cancer patient within 31 days of decision to treat Local management information shows that NHS Fife exceeded the 95% standard in both June and July (97.5% and 96.5%, respectively). Drug and Alcohol Waiting Times: at least 90% of clients will wait no longer than 3 weeks from referral to treatment Local management information shows continuing improvements regarding waiting times for patients with drug and/or alcohol problems. Between April and May, 98% of patients were seen within the 3 week referral to treatment period. Improvements have continued since introducing new processes and more robust management systems. This will continue to be monitored and any necessary amendments will be made. Detect Cancer Early: at least 29% of cancer patients will be diagnosed and treated in the first stage of breast, colorectal and lung cancer The measure for this target covers a rolling 2-year period, and the NHS Fife target of 29% covers and. Local management information for the 2-year period ending March shows that we were slightly behind plan, though continuing to improve in all 3 specialties. The Stage 1 Detection Rate for Lung Cancer has risen from 10.3% to 18% since the end of Page 8 of 63

9 CHIEF EXECUTIVE S PERFORMANCE ESCALATION ACUTE SERVICES PLANNED CARE CANCER 62 DAY REFERRAL TO TREATMENT At least 95% of patients urgently referred with a suspicion of cancer will start treatment within 62 days Key Concerns & Risks As described in previous reports there are a number of areas of risk in achieving this target, namely around Urology and Lung Cancer, including recruitment, liaison with tertiary providers and diagnostics and visiting oncology capacity Recovery Trajectory Situational Analysis In the recovery plan for this target there are 4 measures which are red-rag-rated. Challenges with vacancies continue to be difficult to resolve with primacy, rightly being given to on-call and ward cover. There is ongoing effort to recruit. Discussions are being progressed with Scottish Government regarding access to EBUS for Fife patients, including the potential efficiency benefits of an EBUS service in Fife. The Inter-Hospital Transfer Policy has been finished, but requires to be tabled at the Regional Cancer Action Group. NHS Lothian is leading this and completion of this action will move this action from red-rag to green-rag. The Standard Operating Procedure alluded to in measure 4.3 was tabled at a recent Acute Services Management Team meeting and some minor amendments will be made prior to roll-out, thus completing this action. Page 9 of 63

10 Recovery Plan Page 10 of 63

11 18 WEEKS REFERRAL TO TREATMENT At least 90% of planned/elective patients will commence treatment within 18 weeks of referral Performance has now been ahead of trajectory for three successive months. Key Concerns & Risks As described in previous reports, Gastroenterology, Urology, Oral Surgery and Vascular Surgery are key specialties at risk of not meeting 18 weeks RTT. This is driven by vacancies, increasing demand and a demand-capacity gap as described at the recent Board development session. NHS Fife continues to meet with Scottish Government regarding resilience around this target and discussion is live regarding resourcing of the demand-capacity gap. This will include consideration of outsourcing of activity, local waiting times initiatives and other local provision (e.g. expansion of the work within the Urology DTC). Recovery Trajectory Recovery Plan The Recovery Plan for 18 Weeks RTT is covered by the delivery of the Patient Treatment Time Guarantee and Outpatient Waiting Times Recovery Plans shown in the relevant sections on the following pages. Page 11 of 63

12 PATIENT TREATMENT TIME GUARANTEE We will ensure that all eligible patients receive inpatient or day case treatment within 12 weeks of such treatment being agreed Performance in this area continues to improve and is currently ahead of trajectory. Key Concerns & Risks At risk specialties for Inpatients and Day Cases continue to be Orthopaedics and Oral Surgery. Whilst an internal mitigation is the delivery of additional activity, this is not as resilient as we would wish due to issues such as the availability of anaesthetic cover, use of locums and availability of Operating Department Practitioner (ODP) staff. Recovery Trajectory Recovery Plan Situational Analysis Recruitment into Consultant posts remains challenging. The transfer of Gynaecology day surgery activity has seen a significant improvement in the use of day surgery at QMH. The Day Surgery clinical group meets monthly with the aim of improving usage of the Day Surgery Unit in QMH and improvements are planned in terms of theatre utilisation, pre-assessment and procedure selection. It is hoped that this action will move this measure from Amber to Red-RAG The measure to transfer Phase 2 to Phase 3 theatres is being explored via a review of theatres as part of the Optimising Surgical Efficiencies project. Page 12 of 63

13 OUTPATIENT WAITING TIMES At least 95% of patients (stretch target of 100%) will have their first outpatient appointment within 12 weeks of referral. Additionally, we must eradicate waits over 16 weeks. Key Concerns & Risks Performance in outpatients continues to be a significant challenge. The at-risk specialties are Urology, Dermatology, Neurology, Gastroenterology, Cardiology, Respiratory Medicine, Orthopaedics and Oral Surgery. Recruitment into Consultant vacancies in key specialties is particularly challenging. NHS Fife continues to meet with the Scottish Government to consider resources to clear the backlog in outpatients waiting over 12 weeks as well as sustainable solutions to meet the ongoing gap in outpatient capacity identified through the capacity and demand exercise. Recovery Trajectory Recovery Plan Situational Analysis The recovery plan shows that there are four measures which are rated as amber for delivery. The outpatient demand and capacity work is now moving to monitor current demand against capacity and activity delivered against plans. Detailed work by directorates to identify solutions to meet the gap in outpatient capacity has started and increased focus on this along with the realignment of clinical services within planned care will hopefully move this measure and the redesign of urology DTC to green for the next report. The outpatient redesign work is a three year programme and baseline data for this will be presented to the next Scheduled Care Programme Board. Page 13 of 63

14 EMERGENCY CARE A&E 4-HOUR WAITING TIME At least 95% of patients (stretch target of 98%) will wait less than 4 hours from arrival to admission, discharge, or transfer for accident and emergency treatment For four successive months performance has been ahead of trajectory and is on target to achieve the year end required performance. A number of risks remain in the system including recruitment to vacant medical posts in the Emergency Department, admission numbers, flexibility of the ambulance service response to discharge and a significant increase in the number of patients in delayed discharges within NHS Fife hospital beds. Recovery Trajectory Note that the Actual Performance figures shown are 12-month averages, not figures for the individual months. The August performance figure for all Fife was 97.3%, with the ED at VHK itself recording a performance of 96.1%. Recovery Plan Page 14 of 63

15 AMBULATORY CARE DIAGNOSTICS WAITING TIMES No patient will wait more than 6 weeks to receive one of the following 8 key diagnostic tests - Imaging: barium studies, non-obstetric ultrasound, CT, MRI Endoscopy: upper endoscopy, lower endoscopy, colonoscopy, cystoscopy Key Concerns & Risks The actions described are reducing the number of patients waiting over 6 weeks well ahead of trajectory. Recovery Trajectories All Diagnostics Non-Obstetric Ultrasound MRI Endoscopy Page 15 of 63

16 Recovery Plan Situational Analysis In the recovery plan there are two measures which are amber-rag rated. Work has started on these two measures for specific examinations. Due to vacancies the completion date has been extended to December. Neither of these is adversely impacting on performance against the target. Page 16 of 63

17 BOARD WIDE HAI SABS We will achieve a maximum rate of staphylococcus aureas bacteraemia (including MRSA) of 0.24 Key Concerns & Risks The actions described will ensure that reductions already achieved in preventable (hospital acquired) SAB numbers are maintained and increased. Infections related to invasive devices such as peripheral venous cannulae (PVC) and urinary catheters constitute the single biggest preventable cause and are a particular area of focus. Hospital SABs made up 28% of the total in the last twelve months (25 of 92), with the remainder arising spontaneously in the community. To achieve target, the current average 8 cases per month (2 hospital, 6 community) must be reduced below five. There is a risk that fluctuations in community case numbers may negate gains made through hospital improvement programmes. Recovery Trajectory Recovery Plan Page 17 of 63

18 SICKNESS ABSENCE We will achieve and sustain a sickness absence rate of no more than 4% Key Concerns & Risks Each of the operational parts of the systems are developing action plans in partnership, and at a time of significant change this is more difficult to manage and monitor for services in the community. The three biggest risks to sustaining the planned reductions are: Management and HR capacity Any community outbreak of illness (e.g. norovirus) which can impact on short term absence. Increased pressure on the system in terms of patient numbers which in turn increases pressure on staff capacity can also result in increased absence Recovery Trajectory NOTE the figures quoted are 12-month rolling absence rates, not those for the individual month. This is a better way of demonstrating an improvement trend. Delivery Process The sickness absence reduction will be managed through the local operational groups in the Acute Services Division and Health and Social Care using the locally developed action plans. This will be monitored through the NHS Fife Management of Attendance group which will report into the Staff Governance Group at every meeting. Recovery Plan Page 18 of 63

19 WORKFORCE ATTENDANCE MANAGEMENT 1. NHS Fife Absence Comparison April to July 6.00% 5.00% 4.00% 4.57% 4.79% 4.85% 4.81% 4.71% 4.93% 5.21% 5.29% 3.00% 2.00% 1.00% 0.00% Apr May Jun Jul /15 /16 NHS Fife absence trend for /16 follows a similar trend to /15 but with the exception of May the rate has been higher in /16. This is despite increased scrutiny of sickness absence by managers. By splitting short term and long term absence figures we have been able to establish the work undertaken so far has had an impact on the short term figures but has seen long term absence increase in the same period. 2. Short Term Absence % Comparison April to July 2.50% 2.45% 2.40% 2.35% 2.30% 2.25% 2.20% 2.15% 2.10% 2.05% 2.00% April May June July /15 /16 Page 19 of 63

20 3. Long Term Absence % Comparison April July 3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% April May June July /15 /16 Short term absence is variable, but is a reducing trend from /15. Long term absence has increased over the same period. This led to analysis of the short/long term position detailed in Graphs 2 and NHS Fife Absence 5. Nursing & Midwifery Absence July July Short Term 38% Short Term 36% Long Term 62% Long Term 64% Breakdown of short and long term absence for the Board indicates long term absence is proportionally greater than short term absence during July. Nursing and midwifery staff group has the highest overall absence rate; a review of the breakdown of short and long term absence indicated that long term absence within this staff group was 2% higher than the Board position in July. Efforts have recently concentrated on ensuring that the management of short term absence is in line with policy. Our efforts will now turn to long term sickness absence, by analysing age profile, reasons for sickness and length of service. This information will help support the areas that should be concentrated on. This work has only just commenced. Page 20 of 63

21 6. NHS Fife Nursing & Midwifery 7. NHS Nursing & Midwifery Long Age Group Profile July Term Sickness Absence, % of Hours Lost by Reason July 20% 13% 5% 1% 4% 9% 8% 10% 12% 18% % 3.50% 2.11% 4.84% 5.27% 6.09% 15.11% 15.56% 25.07% 19.84% Stress/other psychiatric illnesses Unknown causes/not specified Other musculoskeletal problems Other known causes Genitourinary & gynaecological disorders Back problems Injury, fracture Benign and malignant tumours, cancers Heart, cardiac & circulatory problems Chest & respiratory problems 8. NHS Fife Distribution of Workforce (% by Job Family) July The following charts will support the development of our future workforce strategy including recruitment and retention of staff. Further analysis of this data will inform future reports on our performance on staff turnover including our recruitment and retention plans. 3% 1% 0% 13% Administrative & Clerical 47% 18% 9% 5% 1% 1% 2% Allied Health Professionals Dental Support Healthcare Sciences Medical & Dental Medical Support Nursing & Midwifery Other Therapeutic Personal & Social Care Senior Managers Support Services Page 21 of 63

22 9. Consultant Vacancies 10. Consultant Vacancies (Pre New Starts) as at (Posts New Starts) as at September September 16% 11.8% 84% Consultants in Post as a % of Establishment (250.44) Consultant Vacancies 88.2% Consultants in Post as a % of Establishment (250.44) Consultant Vacancies Following Commencement of New Consultants Page 22 of 63

23 HEALTH & SOCIAL CARE INTEGRATION The Chief Officer (Director of Health and Social Care) will report to the Chief Executive, NHS Fife and the Chief Executive, Fife Council. Joint performance review meetings involving both Chief Executives and the Director of Health and Social Care will take place on a regular basis in accordance with each organisation s normal performance management arrangements. The Director of Health & Social Care has overall responsibility for the delivery of the Standards reported in this section and for determining further activity, commissioning and performance data for measuring progress in delivering the aims and objectives of the partnership. WEST DEMENTIA REGISTRATION AND POST DIAGNOSTIC SUPPORT We will have a QOF-registered proportion of diagnosed dementia patients consistent with the European measure of prevalence, all of whom will have a minimum of a year s post-diagnostic support and a person centred support plan The offer of Dementia Post-Diagnostic Support (PDS) which meets the Alzheimer s Scotland (5 Pillars) standard is relatively new and is in direct response to the national standard having been set. It is in addition to other support/care/treatment which would have been taking place as a matter of routine work. The current workforce identified for the task comprises a mixture of mental health, psychology, Alzheimer s Scotland and other resources operating from three geographically based hubs. There has been success in clearly articulating and streamlining pathways to diagnosis and to PDS. This success has now left us with the challenge of managing high referral volumes. In order to future proof this offer of Dementia PDS in Fife we need to do two things: Identify additional resources (from within our existing workforce/budgets) Devise a management arrangement which provides a functional level of coordination, standardisation and quality assurance Identifying additional resource is currently proving challenging but recent clarification of responsibilities for the Dementia target should make the second action easier to achieve. Key Concerns & Risks Dementia Registrations The main risks to achieving the standard are: Failure to respond adequately to demands for PDS (as it is the existence of PDS which has been used to incentivise GPs and others to refer early to secondary care for diagnosis) Failure to keep the profile of dementia and dementia registration high with Primary Care colleagues Dementia Post Diagnostic Support The main risk to achieving this target is: Managing demand and capacity Page 23 of 63

24 Dementia Registration Recovery Trajectory Recovery Plan Dementia Post-Diagnosis Support Recovery Trajectory There is currently no performance data for this target. Data started to be gathered in October, so we will have to wait until October this year before we can assess the % of patients who were registered in October who then had a full year of support a year later. Recovery Plan Situational Analysis Task 2.2 Completion of this task was delayed because of the complexities involved in bringing together, under one system of management, a small number of Health and non-health staff sitting within two of the H&SC Divisions. Page 24 of 63

25 DELAYED DISCHARGE No patient will be delayed in hospital for more than 2 weeks after being judged fit for discharge Key Concerns & Risks The actions described in the recovery plan below are expected to support a working solution to the target that no patient will be delayed in hospital 2 weeks beyond being clinically fit for discharge. Analysis of previous and current performance and projected demand highlighted risks in respect of demand out-stripping capacity. The risk in meeting this target remains high. While the actions described below will improve the operational delivery and allow managers to quickly identify potential barriers in the patients pathway, the risk associated with capacity and demand is of concern. The delivery plan is closely monitored and every effort will be made to mitigate any risk. Recovery Trajectory Note that the Actual Performance figures relate to the situation at the monthly census, generally taken around the 15 th of the month the number in delay will vary from day to day. Page 25 of 63

26 Recovery Plan Situational Analysis The actions described in the plan above are largely on track for delivery with the exception of Task 6.1, the development of an overnight care service. A limited service is available but all posts required to support this service are unlikely to be filled until the end of October. Page 26 of 63

27 SMOKING CESSATION We will deliver a minimum of 602 post 12 weeks smoking quits in the 40% most deprived areas of Fife Key Concerns & Risks The actions described are expected to ensure that NHS Fife will meet its target of successful quits by March There are a number of risks that must be considered: Pharmacy changes which require a new follow-up model to become embedded The increasing rise of e-cigarettes which are being seen by smokers as a stop smoking aid These challenges are addressed at a monthly task meeting and actions are put in place where possible. Recovery Trajectory Recovery Plan Page 27 of 63

28 FIFE-WIDE CHILD AND ADOLESCENT MENTAL HEALTH SERVICE WAITING TIMES At least 90% of clients will wait no longer than 18 Weeks from referral received to treatment for specialist child and adolescent mental Health Services (CAMHS) Key Concerns & Risks There was a significant spike in referral numbers earlier this year which had a negative impact on our performance over the summer months. Poor performance against this target is primarily the result of a lack of overall capacity but there are also bottlenecks which are being addressed through minor pathway redesign. Current improvement plans are focused heavily on investing in additional staff. Part of our allocation through the mental health innovation fund will be invested in additional capacity. This will have the greatest impact on therapeutic services for looked after children and in the training of the school nurses. In addition, the Scottish Government are still devising their allocation strategy for the new funding ( 85M over 5 years), some of which is specifically to improve access to CAMHS. The current improvement plan and predicted trajectory - which sees us achieving the target by the end of the financial year is contingent upon receipt of this new funding. Once the allocation strategy for this new funding has been determined and shared it will be possible to predict more accurately when the target can be achieved. Positive news in relation to our current performance is that NHS Fife s most recent published average waiting time was 8 weeks and as such is below the national average. In summary, the main risks to achieving the standard are as follows: Inadequate capacity to meet demand A sub-optimal distribution of resources and coordination across tiers of service leading to bottlenecks The risks are being managed by planned new investment bidding for Scottish Government mental health innovation fund money and anticipated additional nationally allocated resources; and by a re-design of the existing service to address the distribution issues. The service has received confirmation that the funding bid has been successful but we still await a formal letter advising on the allocation. Recovery Trajectory Page 28 of 63

29 Recovery Plan Waiting Times There are currently 508 patients on the CAMHS Waiting List of which 172 have breached the Waiting Time Target. There are 85 patients that have waited over 26 weeks and 3 patients over 52 weeks. The longest wait is currently 57 weeks. The additional money once received from the Scottish Government will be used to increase the staffing complement and we will then target this resource at the high volume work to cover all tiers of the service. Once there is clarity on the basis of the funding allocation an action plan will be developed setting out targets and delivery dates. Page 29 of 63

30 PSYCHOLOGICAL THERAPIES WAITING TIMES At least 90% of clients will wait no longer than 18 weeks from referral received to treatment for psychological therapies Key Concerns & Risks Poor performance against this target is primarily the result of a lack of overall capacity. This assertion has been confirmed by work that was done with Scottish Government QuEST Current improvement plans are focused heavily on investing in additional therapists. The Scottish Government are still devising their allocation strategy for the new funding ( 85M over 5 years) some of which is specifically to improve access to Psychological Therapies. The current improvement plan and predicted trajectory - which sees us achieving the target by the end of the financial year is contingent upon receipt of this new funding. Once the allocation strategy for this new funding has been determined and shared it will be possible to predict more accurately when the target can be achieved. In the meantime strategies are being progressed for: diverting referrals at an earlier stage towards self help expanding our group work programme (appropriate for a proportion of new referrals for people with anxiety and depression). A recent success in relation to self help has been the rollout of computerised CBT ('Beating the Blues') as part of an EU wide programme being organised and supported in Scotland by NHS24. Within Fife over 350 people have been referred to 'Beating the Blues' since it was first made available ten months ago. The main risks to achieving the standard are as follows: Inadequate capacity to meet demand An absence of other signposting options for referrers leading to high referral volumes An absence of suitable community venues across Fife The risks are being managed by bidding for anticipated additional nationally (Scottish Government) allocated resources; and by supporting developments such as an investment in a European wide initiative widening access to computerised CBT as an alternative to referral. Work is about to start to identify the required community venues for therapy. Recovery Trajectory Page 30 of 63

31 Recovery Plan Situational Analysis Task 1.7 There is a possibility of this action overrunning. The main problem area for under provision is Levenmouth, and work is ongoing to attempt to resolve this. The Psychological Therapies Development Lead has joined an H&SC group set up to allocate accommodation across the partnership. The apparent improvement may not continue due to the temporary absence through the holiday period of a disproportionate number of staff who, in previous months, targeted the high number of patients waiting. Due to the way performance is measured as a percentage of all newly seen patients who are seen within target, this can lead to anomalies. Page 31 of 63

32 RECOMMENDATION The Finance & Resources Committee is asked to: Note the key items of information highlighted within the Integrated Performance Report Endorse the revised Improvement Trajectories identified on Pages 11 (18 Weeks Referral to Treatment), 12 (Patient Treatment Time Guarantee) and 15 (Ambulatory Care) CHRIS BOWRING Director of Finance 29 September Page 32 of 63

33 SECTION B CAPITAL PROGRAMME /16 1. INTRODUCTION 1.1 This report provides an update on the /16 Capital Programme as approved by the Board at its meeting on 24 February. 1.2 The report provides information on the following: Expenditure to 31 August ; Changes to the Board s Capital Resource Limit (CRL); Details of changes in Planned Expenditure; Estimated Capital Expenditure outturn; and Capital Receipts 2. EXPENDITURE TO DATE 2.1 The expenditure position shown is for the period to 31 August. Appendix A provides details of the current expenditure. 2.2 For /16 each of the Project Leads have provided an estimated spend profile against which actual expenditure is being monitored. 2.3 The estimated spend profile for the period to 31 August is 3.276m (24.8% of the total allocation). 2.4 The expenditure to date amounts to 2.968m. This represents 22.5% of the estimated annual expenditure (Appendix B). The main areas where expenditure has been incurred since the previous report to the Board are as follows: Stratheden IPCU 0.376m Equipment 0.057m Information Technology 0.062m 3. CHANGES TO CAPITAL RESOURCE LIMIT 3.1 Since the approval of the Capital Programme for /16 by the Board, no changes have been made or are expected to be made to the available Capital Resource Limit. Page 33 of 63

34 4. CHANGES TO PLANNED EXPENDITURE / Appendix C shows the changes in the plan resulting from changes in allocations and from updated estimates for schemes already approved. 4.2 There have been no significant changes made since the previous report to the Board. 5. CAPITAL EXPENDITURE OUTTURN 5.1 At this early stage of the financial year it is currently estimated that the Board will spend the Capital Resource Limit in full. 6. CAPITAL RECEIPTS 6.1 For /16 the Capital Programme is partly funded through Capital Receipts from the sale of properties. The estimated value of Capital Receipts required to fund the Capital Programme is 3.650m and is based on the expected sale of Land at Lynebank Hospital and the sale of Forth Park Hospital. At this point of the year there is concern that the land sales will not be processed by 31 March. Discussions with Scottish Government Places for People have not resulted in any positive outcome for the sale of the Forth Park site. 7. RECOMMENDATION 7.1 The Finance and Resources Committee is asked to: note the Capital Expenditure to 31 August ; note the current Capital Resource Limit position; note the changes in Planned Expenditure; note the Capital Expenditure outturn; and note the Capital Receipts position. CHRIS BOWRING Director of Finance 29 September Page 34 of 63

35 NHS FIFE - TOTAL REPORTS CAPITAL PROGRAMME EXPENDITURE REPORT - AUGUST CRL Total Projected New Expenditure Expenditure Projected Project Funding to Date /16 Variance Major Capital Stratheden - IPCU 3,757, ,164 3,757,000 Statutory Compliance Cameron - Heating & Drainage Pipework Wards 1&2 90,000 4,293 90,000 Stratheden - Roofing Replacement 40,000 40,000 Stratheden - Generator Installation 20,000 20,000 Whytemans Brae - Ravenscraig Refurbishment 8, ,869 Lynebank - Window Replacement 20,000 20,000 Lynebank - Roofing Works 84,000 4,469 84,000 Lynebank - Water Mains 100,000 2, ,000 West Fife - Asbestos Removal 38, ,000 West Fife - Legionella Works 20,000 1,771 20,000 Central & NEF - Asbestos Removal 30,000 30,000 Leslie Dental Clinic - Roof Protection 7,000 7,000 7,000 North East Fife - Legionella Works 10,000 10,000 Total Statutory Compliance 467,869 20, ,869 Capital Minor Works Minor Works Balance 3,777 3,777 Cameron - SGSU OT Bathroom 18, ,000 Kirkcaldy Health Centre - Nursing Offices 12,000 12,000 Stratheden - Ceres Centre - Electronic Doors 10,000 10,000 Stratheden - Lomond Ward 90,000 90,000 Whytemans Brae - Ravenscraig Reception 37,000 3,617 37,000 Whytemans Brae - Rheumatology Office Conversion 11,000 11,000 11,000 Whytemans Brae & RWMH - Podiatry Clinical Stores 12,000 12,000 Lynebank - Campsie Flat 3 Works 25,000 25,000 Lynebank - OT Corridor 20,000 20,000 Glenrothes Hospital - PCES 15,000 15,000 Glenrothes Hospital - Ward 3 46,223 1,223 46,223 Total Minor Works 300,000 15, ,000 Capital Equipment Equipment Balance Cameron Hosp - Bladder Scanner 6,714 6,750 6,714 Cameron Hosp - Diabetic Retina Camera 22,000 13,986 22,000 Stratheden Hosp - Oven 9,000 9,000 Whytemans Brae Hosp - Portable Fibroscan 36,500 33,594 36,500 Lynebank Hosp - Electric Profiling Bed 6,203 6,203 6,203 QMH - 2 * Burlodge Food Trolleys 12,000 12,000 QMH - OccupEye 6,320 6,320 Adamson Hosp - Bladder Scanner 6,714 6,714 Glenrothes Hosp - 3 * Multigen Trollies 16,777 16,777 Glenrothes Hosp - Falls Guard System 7,772 7,772 Total Capital Equipment 130,000 60, ,000 Page 35 of 63

36 Information Technology Telephone System 511,000 9, ,000 Desktop Replacement 423, , ,360 Network Development 60,000 17,630 60,000 Server/System Replacement 388, ,640 Data Centre Upgrade 180, ,000 Total I.T. 1,563, ,669 1,563,000 Radiology Equipment NHS Fife Wide Radiology Equipment Balance 315, ,102 Interventional Radiology Works 35,923 35,923 35,923 A&E Ultrasound 30,009 30,024 30,009 Fundus Camera 72,966 70,904 72,966 Gamma Camera 300, ,000 Immediate Reporting 90,000 90,000 VHK & QMH - Ultrasounds * 6 432, ,000 Mammo Room Biopsy/Wheelchair Access Total Radiology Equipment 1,276, ,851 1,276,000 Vehicle Replacement Vehicle Balance 100, ,000 Total Vehicle Replacement 100, ,000 Acute Services Division Main Schemes GHMS - Aseptic Suite VHK 984, , ,000 GHMS - White Space VHK 230, , ,000 GHMS - Carnegie QMH 1,664,000 1,664,000 GHMS - Dental QMH 108, , ,710 GHMS - Audiology QMH 112, , ,290 GHMS - General 180,000 85, ,000 Total Main Schemes 3,279,000 1,106,009 3,279,000 Acute Services Div Statutory Compliance VHK - Workplace Transport 96,500 5,024 96,500 VHK - Water Ingress 15,000 1,000 15,000 VHK - Ward 9 Refurbishment 720,000 10, ,000 VHK - Ward 13 Hazard Rooms 40,000 40,000 VHK - Stairwell Alterations Ph 1 & 2 VHK 140,000 1, ,000 VHK - Recycled Waste Compactor 20,000 20,000 VHK - Mortuary De-Commissioning 10,000 10,000 VHK - LV System 75,000 3,438 75,000 VHK - Legionella Works 20, ,000 VHK - Hayfield House Cladding 30,000 30,000 30,000 VHK - Diabetic Access Ramp 34,714 34,419 34,714 VHK - Asbestos Removal 75,000 11,602 75,000 QMH - Theatre Lights 11,286 11,286 11,286 QMH - Roof Works 12,000 12,000 12,000 QMH - Roads/Car Parks Surfaces 35,000 6,691 35,000 QMH - Renal Dialysis UPS 7,176 7,176 7,176 QMH - Medical Air Plant 52,000 52,000 Total Statutory Compliance 1,393, ,666 1,393,676 Acute Services Division Minor Capital Minor Works Balance 11,700 11,700 VHK - Plaster Room 10,000 10,000 VHK - Phase 3 Reception Area 12,300 12,300 Page 36 of 63

37 VHK - Pharmacy Works 11,000 8,340 11,000 VHK - Outpatients Ph2 Upgrade 50,000 49,041 50,000 VHK - Ophthalmology Clean Room 44,000 41,124 44,000 VHK - Level 12 Office Works 25,000 15,085 25,000 VHK - Laser Clinic Works 20,000 20,000 VHK - Diabetic Centre Works 25,000 25,000 VHK - Dermatology Dept Works 60,000 60,000 VHK - Basement Tunnel 25,000 25,000. Total Minor Works 294, , ,000 Acute Services Division Capital Equipment Flexible Laryngoscopes 37,895 37,895 37,895 Plasmajet 36,000 36,000 36,000 Endoscopy Stack 70,000 70,000 Ophthalmology Slit Lamp 8,600 8,600 Laparascopic Camera 17,850 17,604 17,850 Renal Machines * 2 32,000 30,000 32,000 Ultrasound Scanner (Babies Hips) 25,908 25,908 25,908 Endoscope Storage Cabinets * 2 29,320 26,727 29,320 Ultrasound Scanner (Neonatal) 40,860 40,860 40,860 Respiratory Machine 25,000 25,000 Treadmill (CCU) 25,000 25,000 Coverslipper (Labs) 30,975 30,975 30,975 Total Capital Equipment 379, , ,408 Condemned Equipment Ultrasound 16,850 16,850 16,850 Labs Coverslipper 30,975 30,975 30,975 Micro Torque Drill System 12,810 12,810 12,810 Birthing Beds * 7 39,957 39,957 Total Condemned Equipment 100,592 60, ,592 NHS Fife Wide Statutory Compliance/Backlog Maintenance Food Waste Collection 80,000 80,000 Hearing Induction Loops 4,455 4,455 4,455 Gas Compliance Works 40,000 9,600 40,000 Total Statutory Compliance/Backlog Maintenance 124,455 14, ,455 Fife Wide Scheme Development 37,000 37,000 TOTAL ALLOCATION FOR /16 13,202,000 2,968,315 13,202,000 Page 37 of 63

38 Cumulative 000's Capital Spend Profile / Actual Forecast Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Months Page 38 of 63

39 Capital Expenditure Proposals /16 Board F & R 28/08/ Adj '000 '000 '000 Specific Schemes Dunfermline & West Fife CHP Glenrothes & North East Fife CHP Kirkcaldy & Levenmouth CHP Stratheden IPCU Acute Services Division General Hospitals & Maternity Services - Aseptic Suite VHK General Hospitals & Maternity Services - QMH Carnegie General Hospitals & Maternity Services - QMH Dental General Hospitals & Maternity Services - QMH Audiology General Hospitals & Maternity Services - VHK White Space General Hospitals & Maternity Services - General Fife Wide Telephone System Routine Expenditure Community & Primary Care Minor Capital Capital Equipment Statutory Compliance Condemned Equipment Acute Services Division Capital Equipment Minor Capital Statutory Compliance Condemned Equipment Fife Wide Vehicles Information Technology Radiology Equipment Backlog Maintenance/Statutory Compliance Condemned Equipment Scheme Development Fife Wide Equipment Page 39 of 63

40 SECTION C FINANCIAL POSITION TO 31 AUGUST 1. INTRODUCTION 1.1 This report provides an overview of the financial position of the Board for the five month period to 31 August. The Financial Framework for /16 was approved by the NHS Fife Board on 28 April, subject to further action to close the gap in the level of savings identified at that time. 1.2 Approval of the Financial Framework by the NHS Board enabled Executive Directors to receive details of their initial annual budgets for /16 and any further delegation within their approved management structures. All opening budgets have been signed off by the relevant Executive Director. 2. ALLOCATIONS FOR THE YEAR 2.1 Since the previous report to the NHS Board, we have received additional allocations from the Scottish Government Health and Social Care Directorate (SGHSCD) of 0.679m. These include additional recurring funding of 0.153m, a reduction in earmarked recurring funding of 0.632m and additional non-recurring funding of 1.158m. 2.2 The new allocations include 0.550m to deliver waiting times targets and the Treatment Time Guarantee and to increase Diagnostics capacity. The carryforward surplus from /15 of 0.234m has also been confirmed. 2.3 A reduction in allocation of 0.747m has also been made in respect of charges for the National Distribution Centre. 2.4 A full list of allocations received is shown in Appendix A. 2.5 In addition to allocations from SGHSCD the Board also received miscellaneous income from other sources. For the month of August additional sources of income amounted to 25k. 3. REVENUE EXPENDITURE TO DATE 3.1 The Revenue Resource Limit position for NHS Fife for the five months to 31 August is showing an overspend of 2.234m. This compares with a 2.581m estimated overspend as included within the Board s LDP and is an improvement on previous months. 3.2 A summary of financial performance for individual divisions and Corporate Directorates is shown below. The overall position for NHS Fife is largely driven by the overspend reported within Acute Services. The key drivers are consistent with the recognised cost pressures and it is encouraging to see the positive impact of efforts to more tightly manage these. Page 40 of 63

41 Outturn Value Budget Expenditure FY CY YTD Actual Variance Variance '000 '000 '000 '000 '000 % Acute Services Division 184, ,079 77,477 81,385 3, % Integration Services - Community & Primary Care Services 134, ,618 59,926 59,906 (20) -0.03% - FHS 35,889 40,353 16,825 16, % - Prescribing 74,058 74,058 31,123 31,035 (88) -0.28% - PMS 46,859 48,783 20,344 20,332 (12) -0.06% Estates & Facilities 65,411 65,474 27,222 27,135 (87) -0.32% Board Admin & Other Services 31,629 45,834 22,147 21,821 (326) -1.47% Non Fife & Other Healthcare Providers 97, ,590 42,600 42,425 (175) -0.41% OHSAS 3,949 4,436 1,984 1,934 (50) -2.52% Depreciation 17,967 18,710 8,235 8, % Reserves - Impairments & provisions 10,000 9, % - General 29,924 10, (811) % Efficiency Savings (4,963) (5,879) % Total Expenditure 727, , , ,033 2, % Miscellaneous Income (80,987) (39,484) (39,589) (105) 0.27% Net position including income 727, , , ,444 2, % This position is also shown in the following graph which shows the Board s performance to date against the trajectory included in the LDP submission. Outturn against Trajectory Plan (500) (1,000) 0 Jun- 15 Jul-15 Aug- 15 Sep- 15 Oct-15 Nov- 15 Dec- 15 Jan- 16 Feb- 16 Mar- 16 (1,500) (2,000) (2,500) (3,000) (3,500) Period Page 41 of 63

42 Acute Services Division 3.3 The Acute Services Division is reporting an overspend of 3.908m for the period which reflects a slowing down in the rate of overspend. The key drivers are consistent with those reported last month ie the purchase of healthcare from other providers, medical staffing and nursing: There is an overspend ( 531k) on the use of independent healthcare providers for Orthopaedic activity, Dermatology activity and Radiology. The measures put in place to control the use of the independent sector capacity to address treatment time guarantees are starting to reduce the rate of overspend. This is expected to continue to reduce over the coming months. The use of agency and locum medical staffing to meet the recruitment challenges continues to have a major impact within Orthopaedics, General Surgery, Anaesthetics, Urology, General Medicine, Paediatrics, Neurology, Obstetrics & Gynaecology and Ophthalmology. The overspend on medical staffing is 1.1m for the period. There is a relatively significant overspend reported within nursing ( 1.5m) which is attributed to both bank and agency usage, and the residual impact of incremental progression. The pressures are apparent across a number of specialties including: Orthopaedics, Obstetrics & Gynaecology, Elderly Medicine, Theatres and Critical Care. Strict controls on the use of agency staff are now in place and whilst any specific requests on the grounds of patient safety need to be considered, this action is reducing the level of additional expenditure with the rate of overspend continuing to slow down. These actions are now leading to improved performance and this has again been seen in the Emergency Care Directorate this month. Integration Services 3.4 Across the former CHP budgets, primary medical services, primary care emergency service (PCES) and family health services, the budgets are showing a net underspend of 120k for the period to date. There are underspends across a range of budgets largely due to: vacancies in community nursing, health visting, school nursing and administrative posts. However, these are offset by the level of expenditure on complex care packages; incremental progression within the Palliative Care service; and Mental Health nursing and medical locums. There remains an issue within the Primary Care Emergency service due to sessional rates, however this has reduced slightly during August. Corporate Services 3.5 Within the Board s corporate services, including Estates & Facilities, there is an underspend of 413k due mainly to vacancies across a number of departments. However, this continues to mask a pressure within Estates & Facilities on equipment costs, relating to service contracts across the system. Page 42 of 63

43 Non Fife and Other Healthcare Providers 3.6 The budget for healthcare services provided out with NHS Fife is showing an underspend of 175k for the period. This is based on an estimated underspend of 419k on Service Level Agreements with other Health Boards and an overspend of 244k on Unplanned Activity (UNPACs) and Out of Area Treatments (OATS) activity. The major driver of this overspend is the estimated increased UNPACs activity with NHS Lothian for cancer drugs and the additional cost of Renal Transplants. The OATS expenditure has increased due an additional Learning Disability patient being treated in England as well as treatment for a high cost ICU patient. These remain estimates at this point in the year pending ongoing discussions. Reserves 3.7 Current estimates suggest that the Board could incur 9.2m on property impairments and provisions during /16. The actual amounts will not be fully known until later in the year, for example once property revaluations have been carried out. The actual costs are matched with additional funding from SGHSCD. 3.8 Funding of 811k has been released from the Fife-wide general reserve, offsetting the overall financial position across the system. This recognises any slippage from financial plan commitments and new allocations received, and is reviewed on a monthly basis. Miscellaneous Income 3.9 A small over-recovery in income of 105k is shown for the first five months of the financial year. 4. EFFICIENCY SAVINGS 4.1 The Board s Financial Framework set out the need to deliver a total of m cash efficiency savings to support financial balance for /16. At the end of August, cash releasing schemes totalling 8.8m had been identified (including those which require further action) with a balance of 1.3m remaining. As previously highlighted, more than 40% of savings delivery remains high risk, which equates to 4.3m for the full year. If non delivery of high risk savings were to be recognised in the financial position to the end of August, it would increase the overspend for the period from 2.2m to 4m. 4.2 Members are asked to note, however, that shortfall in the delivery of the required efficiency savings for the year has not yet been factored into the reported overspend for the period. The graph below highlights that the planned trajectory assumes backloading of savings toward the second half of the year and delivery of savings is ahead of trajectory for the period. This will be further reviewed following the month 6 results. Page 43 of 63

44 Value ( k) 12,000 10,000 Cash Releasing Efficiency Savings Delivery Against Trajectory 8,000 6,000 4,000 2,000 Plan Act/F'cast 0 Jun- 14 Jul-14 Aug- 14 Sep- 14 Oct- Nov Period Dec- 14 Jan- 15 Feb- 15 Mar A detailed report is provided as a separate agenda item for the Finance & Resources Committee. 5. RISKS 5.1. As previously highlighted, the approved Financial Framework sought to address all likely costs and national, regional and local priorities. However it is evident that there will always remain inherent uncertainties and associated risks. Some of these are specific operational issues and reflect the cost pressures referred to in the narrative above Through ongoing discussion with the Executive Director Group and the focus on ongoing financial performance management, a view will be taken on the extent to which any of the previously reported risks can be mitigated at an operational level or require a system-wide approach. These include : Continued financial exposure of the delivery of elective and unscheduled care capacity requirements for RTT and waiting times targets; Ongoing delivery of agreed recurring efficiency schemes and identification of further initiatives to close the current gap; Management of sickness absence and the resultant impact on additional staff for both medical and nursing; Pressures within the Primary Care Emergency Service(PCES); 5.3. Given the extent of the financial challenges, it is imperative that early decisions are taken on opportunities to reduce costs for 2016/17 onwards. It is expected that the Programme Management approach being implemented will support the identification and delivery of specific projects and workstreams to deliver the efficiency requirements in future. Page 44 of 63

45 6. RECOMMENDATION 6.1. The Finance and Resources Committee is asked to: note the financial position for the five month period to 31 August. CHRIS BOWRING Director of Finance 29 September Page 45 of 63

46 New Allocations Received Baseline Earmarked Non - Description Recurring Recurring Recurring Total Waiting Times & Treatment Times Guarantee 550, ,000 Carry Forward /15 Surplus 234, ,000 Diagnostic Capacity 180, ,000 Prescription for Excellence 81,000 83, ,000 AAA Screening Programme 152, ,991 Better Than Well 70,000 70,000 Regional CAMHS Development Post 35,000 35,000 Advocacy Provision 33,935 33,935 Occupational Therapy Rheumatology Pathways 5,981 5,981 National Distribution Centre -747, ,233 Total New Allocations Received 152, ,298 1,157, ,674 Page 46 of 63

47 SECTION D THE SCOTTISH PATIENT SAFETY PROGRAMME (SPSP) 1. PURPOSE The purpose of this report is to update NHS Fife F&R Committee of the ongoing activity underway across NHS Fife to implement the Scottish Patient Safety Programme (SPSP). This report incorporates progress over July and August. 2. SITUATION The aim of the SPSP is to reduce the HSMR by 20% by December ; and to ensure that 95% of patients receiving acute care should be free from harms as identified by the Scottish Patient Safety Indicator (SPSI). The (three) SPSI harms are: Cardiac arrests Falls Pressure ulcers The Cauti harm which was removed is expected to join the suite of outcome measures in December since a new definition has been agreed. The new definition is: CAUTI Definition: Does the patient have a urethral urinary catheter insitu or has it been removed within the previous 48 hours CAUTI defined as: Temp <36 c or >37.9 c OR 1.5> baseline on 2 occasions in last 12 hours and 1 or more of the following: o Shaking chills (rigors) o New costovertebral (central lower back) tenderness o New onset or worsening delirium (confusion) AND: on antibiotics for treatment of UTI Page 47 of 63

48 HSMR Chart 1 Chart 2 Chart 1 demonstrates NHS Fife s HSMR rate in comparison to NHSScotland Chart 2 demonstrates NHS Fife s HSMR with regression line. Target reached The most recent HSMR data released in August which incorporated the quarter Jan to March demonstrated a percentage reduction of 22.7% since Dec 2007 with a HSMR ratio of NHS Fife s position has deteriorated since the previous HSMR data release which demonstrated 22.8% reduction at that time with a HSMR ratio of Although the HSMR target has been reached, the ratio has been climbing for the last four quarters. 2. SPSI HARMS Cardiac Arrests Acute Hospitals Chart 3 Chart 3 demonstrates an increase in the median from Jan when it increased from 1.3 to 1.6. The hospital huddles began in July and the data points for July and August sit just on and under the median. The data has been extracted from the Resuscitation Officer database. Sustained Deterioration Chart 4 demonstrates random variation. However although run chart rules cannot be applied yet the performance from November appears visually more stable with a decrease in falls with harm during July and August. Data has been extracted from the Datix system. Random Variation Falls With Harm Acute Hospitals Chart 4 Page 48 of 63

49 Pressure Ulcers Grade 2 to 4 Developed in Acute Hospitals Chart 5 Chart 5 demonstrates random variation Median 1 is based on the first 12 months data (to provide a benchmark) Median 2 is based on a new median from month 14 (April ) to provide a more stable benchmark of activity (Recording of pressure ulcers on datix began with Phase 2 of SPSP which may explain why the first 12 months appear artificially low) Again although run chart rules cannot be applied the performance from June appears improved with the data points sitting under the median. Random Variation 3. BACKGROUND 3.1 In September 2013, CEL 19 outlined ten patient safety interventions ten essentials that should be reliably delivered to every patient in NHSScotland that can benefit from them. The ten patient safety essentials are: 1. Hand washing 2. Leadership walkrounds 3. Communications: surgical pause and brief 4. Communications: general ward safety brief 5. ICU daily goals 6. VAP bundle 7. Early warning scores 8. CVC insertion 9. CVC maintenance 10. PVC maintenance 3.2 In May, an additional letter from the Chief Executive of Health Improvement Scotland (HIS) advised Boards that they were no longer required to submit national reporting on the ten essential data in recognition of the reliable local self-assurance and governance mechanisms that Boards had set in place to ensure that each of these processes were reliably implemented and sustained. Healthcare Improvement Scotland has agreed with the Scottish Government that external assurance of the reliable implementation of the ten essentials should be sought via the new Quality of Care Reviews which are currently being designed, within the scope of the annual review processes and through ad hoc Minister updates. Page 49 of 63

50 3.3 A series of RAG reports have been developed and are used locally to provide an overview of the implementation and spread of the ten essentials within the Acute and Community Hospitals. In addition, an overview of progress of the additional specialised strands of SPSP is also fed back to the relevant teams regularly. 3.4 A monthly SPSP update is provided for each of the Directorates in the Acute Hospitals and form part of the performance reviews. 3.5 A self-assurance framework tool based on the Acute Adult Measurement Plan has been developed locally to assist Directorates within the Acute Hospitals and Community Services to support NHS Fife s self-monitoring process. The tool provides general guidance around sustainability and stepping down processes when improvement measures are truly embedded and are reflected in associated outcomes. 3.6 The development of the Clinical Dashboard across NHS Fife is being led by the Associate Director of Nursing in Acute Services and will provide an overview of the status of performance once all of the patient safety / quality interventions have been migrated onto the system. 3.7 Ward based data will be entered into LANQIP and exported to the Clinical Dashboard. A series of Standard Operating Procedures (SOP) are being developed to support the robust implementation of the ten essentials. The SOPs are designed to incorporate clear escalation mechanisms and improvement plans to drive improvement. 4. ASSESSMENT 4.1 SPSI HARMS 4.2 Cardiac Arrest / Deteriorating Patient Following on from the review of cardiac arrests undertaken by the Resuscitation Committee Lead Consultants following a rise in the number of cardiac arrests in January a Deteriorating Patient Short Life Working Group was set up to address key areas for improvement. 4.3 The group has agreed five key components that should be prioritised: Robust processes are in place to ensure that Patientrack is embedded. Appropriate management of patients that trigger FEWS by ensuring that the correct skills and education around Acute Illness Management Training are available to staff Clear escalation processes in every clinical area Improved decision making around DNACPR and clear management plans Standardised review processes for patients that have previously triggered 4.4 The daily hospital huddles led by Professor Mclean launched the widespread rollout of the Scottish Structured Response to all wards at VHK. Patients with elevated Early Warning Scores are highlighted during the huddle and assurance sought that the correct interventions are in place. 4.5 An audit tool has been developed to monitor compliance of the Scottish Structured Response at VHK. Weekly monitoring is expected to commence in October. Page 50 of 63

51 4.6 Patientrack has now been implemented (at some level) in fourteen wards within the Acute Division. The electronic system provides a standardised track and alerting system that identify patients at risk of deteriorating and then alerts the responsible Clinician so that a timely response is initiated. 4.7 The introduction of Emergency Bleep Meetings to review cardiac arrests when there is evidence to suggest that clinical deterioration was evident prior to the event. The purpose of these meetings is to establish if any learning can be gleaned during the reviews to improve systems and processes to improve patient outcomes. 5. FALLS PROCESS 5.1 The improvement work around falls is being led by the Associate Director of Nursing in Acute Services. This work is linking to the Frailty Intervention Group led by Dr Sue Pound. The Falls Implementation Group has implemented a number of interventions across NHS Fife which includes a complete overview of the Falls documentation used across NHS Fife. This has resulted in: Development and implementation of a Falls Pathway across NHS Fife Development of a Falls Prevention care plan Implementation of comfort rounds across the organisation with ongoing revisions to ensure that the tool reduces duplication for nursing staff Development of care bundles and associated measurement tools to record compliance 5.2 The group is attended by representatives across NHS Fife and a number of initiatives for improvement have been tested which include: Falls hazard walkrounds Use of measles charts to highlight high risk areas Provision of slippers if required Please call, don t fall bedside cards Review of equipment Review of Procedural documentation 5.3 Agreement on the process measurement plan has recently been reached and wards have been supported to implement these bundles and commence reporting their compliance. Pareto charts have been developed to highlight areas for prioritised interventions. 5.4 A Standard Operating Procedure is being developed to support implementation of the Falls care bundles and their use in the drive to reduce patient harm. Page 51 of 63

52 6. Pressure Ulcers - Process The improvement work around pressure ulcer care is being led by the Associate Director of Nursing/Head of Service Delivery GNEF. The group have progressed a number of interventions which include: Review of the grading tool Development of SOP for bundle compliance Standardisation of the levels of harm and recording on Datix A Datix prompt to reduce duplicate pressure ulcer recording Implementation of a Patient Information Leaflet across NHS Fife NHS Fife-wide REI tool developed NHS Fife-wide approach to data measurement Development of pareto charts to focus priority areas for improvement Development of Tissue Viability Posters Themes and trends to from REIs to drive improvement 7. CAUTI 7.1 The Catheter Urinary Tract Infection Prevention Insertion and Maintenance bundles have been widely implemented in inpatient areas throughout the Acute Services Division and Community Services. 7.2 The Urinary Catheter Insertion and Maintenance Bundles and processes have been reviewed over the last two to three months in recognition of feedback received from staff. A Short Life Working Group convened to review the improvement processes and documentation used across both the Acute Hospitals and Community Services Division. This is evolving into a wider stakeholder group led by the Associate Director of Nursing NHS Fife that will lead further improvement interventions to reduce the number of urinary catheter infections. 7.3 The national CAUTI Short Life Working Group was reconvened in June with the aim of agreeing a national CAUTI definition. At the meeting the group agreed that the signs and symptoms definition was the preferred operational definition that would more effectively drive improvement. The group also agreed that catheter bed days as a denominator was a useful measure to determine if the numbers of catheters inserted ultimately reduced. 8. NINE PRIORITIES Sepsis - Improvement work around sepsis began in Since that time the bundles have been applied: o 865 occasions in A&E o 381 occasions in AU1 o 28 times in AU2 o 65 times in ward 34 Page 52 of 63

53 Hrs:Mins 02:09 01:55 01:40 01:26 01:12 00:57 00:43 00:28 00:14 00:00 Admissions to A & E Time Zero to TFAD TFAD: 03:00hrs - Tazicon - 01:00 00:55 00:45 00:45 00:45 00:40 00:40 00:25 00:30 00:30 00:25 00:15 00:10 00:15 00:14 00:02 00:20 00:35 01:00 00:20 00:15 00:45 01:00 02:09 TFAD: 01:20hrs - 01:00 00:23 00:25 00:17 00:17 00:10 00:13 00:05 01:20 00:28 00:15 00: Triggered Sepsix Six Pathway Patients July Chart 6 demonstrates the time to first antibiotic dose for patients that trigger the sepsis 6 pathway in the Emergency Department. The target of one hour has been reached in the majority of cases; the one significant breech was due to exceptional circumstances which required an external consultation. The ED Team review every breech to discuss reason for the breech and to implement learning if required. A & E - Average time/month first antibiotic administered 01:12 01:04 00:57 00:50 00:43 00:36 00:28 00:21 00:14 00:07 00:00 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2013 Chart 7 demonstrates the improvement that has been made over the last 3 years with compliance in patients receiving the first antibiotic dose once triggering the Sepsis 6 bundle. In July, average compliance was 32 minutes. Deteriorating patients Previously covered Heart failure - embedded Pressure ulcers Previously covered Surgical site infections Page 53 of 63

54 Venous thromboembolism (VTE) The assessment bundle has been implemented within AU1, and the reassessment bundles have been implemented within ward 52 (Surgical). Plans to implement the VTE improvement interventions more widely are currently being developed. Catheter associated urinary tract infections Previously covered Falls with harm Previously covered Safer medicines - The Pharmacist based in AU1 is measuring compliance with medicines reconciliation on admission within AU Forthcoming Events SPSP IA Networking Day 4 th February 2016 World Sepsis Day 10 th September SPSP Acute Adult Regional Learning Session East 8 th October SPSP National Event 9 th November 9. RECOMMENDATIONS 1.1 The Finance & Resource Committee is asked to: Note the overview of progress for each work stream. Advise on aspects of the report that they found valuable and if they would value continuing reports in this format Executive Sponsor Dr Frances Elliot Patient Safety Manager Cathy Gilvear Page 54 of 63

55 Cases NHS Scotland SECTION E Healthcare Associated Infection Reporting Template (HAIRT) Update Section 1 Board Wide Issues 1. Key Healthcare Associated Infection Headlines for September 1.1 Achievements SAB case numbers have fallen from their high rates last year and the annual figure for Fife is the lowest since records began. C difficile rates continue to be below target and below national average. 1.2 Challenges SAB case rates have started to rise (primarily from community sources). PVC related SABs were virtually eliminated in, but reappeared in. This trend must be reversed if the 2016 target is to be met. CDI case numbers must be reduced by an average 4% per year to offset the decrease in TOBD denominator for the rate calculation. 2. Staphylococcus aureus (including MRSA) 40 Hospital vs Out-of-hospital SABs (rolling quarters) Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Hospital Community Total Three months to: 2.1 Trends National SAB data for Jan-Mar showed NHS Fife annual rate below the Scottish average and falling. NHS Fife annual rate was 0.30 per 1,000 AOBD compared with Scotland at The Mar 2016 target is Page 55 of 63

56 Cases Local data shows Fife rising to 0.32 in Aug and SAB HEAT remains RED on the Balanced Scorecard. After two very good quarters, Q2 (Apr-Jun 15) saw a rise (primarily in community cases) and that trend has continued into Q3 (Jul-Sep 15). Having virtually eliminated PVC related SABs by the end of, numbers have started to creep up and in, they average one per month. This is being taken back to clinical teams by the ICD. 2.2 National MRSA screening programme NHS Fife remains well ahead of the target 90%, and well ahead of national average. 2.3 NHS Fife local targets for SAB reduction By end in NHS Fife Jan-Aug 15 MRSA to be 5% of total SABs. 8.60% 6 of 70 Behind plan Vascular access device SAB to be 35% of hospital SAB 57% 12 of 21 Behind plan PVC related SABs to be halved compared with Plan = 4 Behind plan 2.4 Current initiatives Continued focus on reducing and eliminating vascular access device related SABs 3. Clostridium difficile Hospital vs Out-of-hospital CDIs (rolling quarters) Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Total Hospital Community Three months to: Page 56 of 63

57 Dec-10 Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12 Dec-12 Mar-13 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun NHS Fife Quarterly TOBD Trends CDI data for Jan-Mar showed NHS Fife annual rate (age 15+) fell to 0.30 per 1000 Total Occupied Bed Days (TOBD). This is below the Scottish average of 0.34 and surpassed the HEAT Target. Current management data indicates a rate of 0.27 to Jun which is well on track for the 2016 HEAT target of Current initiatives Continued follow up of all hospital and community cases. 3.3 Risks The denominator for CDI rate calculations is still based on Total Occupied Bed Days (acute plus community) in Boards, despite the majority of cases arising outside hospital. TOBD in Fife has been falling since 2009 at an average 4% per year. To maintain the current rate, which meets the HEAT target, case numbers must reduce by a corresponding 4% per year. 4. Outbreaks 4.1 Norovirus The late seasonal rise in norovirus seen during March in both in the community and in hospitals has tailed off. Preparations are underway for the -16 season. 5. Assessment SAB numbers continue to fluctuate from quarter to quarter, but the fall in cases has not been maintained and further work is needed if the March 2016 HEAT target is to be achieved. Continuing low levels of C difficile indicate that the initiatives in place to reduce infection rates are working long-term. DAVID LIVINGSTONE Projects Manager, Infection Control Page 57 of 63

58 Section 2 Healthcare Associated Infection Report Cards NHS FIFE REPORT CARD Staphylococcus aureus bacteraemia (SAB) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug MRSA MSSA Total SABS Clostridium difficile infection (CDI) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Ages Ages > Total VICTORIA HOSPITAL, KIRKCALDY REPORT CARD Staphylococcus aureus bacteraemia (SAB) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug MRSA MSSA Total SABS Clostridium difficile infection (CDI) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Ages Ages > Total QUEEN MARGARET HOSPITAL, DUNFERMLINE REPORT CARD Staphylococcus aureus bacteraemia (SAB) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug MRSA MSSA Total SABS Clostridium difficile infection (CDI) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Ages Ages > Total Page 58 of 63

59 NHS FIFE COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: QMH - Queen Margaret Hospital wards 1-4 LH - Lynebank Hospital WBH - Whyteman's Brae Hospital RWH - Randolph Wemys Hospital CH - Cameron Hospital GH - Glenrothes Hospital SH - Stratheden Hospital AH - Adamson Hospital SAC- St Andrews Community Hospital QH - QMH Ward 16 Hospice VH - Victoria Hospital Hospice Staphylococcus aureus bacteraemia (SAB) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug MRSA MSSA Total SABS Clostridium difficile infection (CDI) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Ages Ages > Total OUT OF HOSPITAL INFECTIONS REPORT CARD Staphylococcus aureus bacteraemia (SAB) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul MRSA MSSA Total SABS Aug Clostridium difficile infection (CDI) monthly case numbers Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Ages Ages > Total Page 59 of 63

60 National Statistics National data for C difficile and SABs (including MRSA) has not been updated by Health Protection Scotland (HPS) since the HAIRT tabled for the August Board Meeting For C difficile, the NHS Fife quarterly rate was 0.19 cases per 1000 Total Occupied Bed Days (TOBD). This is below the Scottish quarterly average of 0.27 For all SABs the NHS Fife quarterly rate fell to 0.22 cases per 1000 Acute Occupied Bed Days (AOBD) below the Scottish quarterly average of 0.30 For MRSA SABs, NHS Fife quarterly rate was 0.01 compared with a Scottish average of 0.03 C difficile (age 15-64) Jan-Mar 15 NHS Fife is shown as FF (just on the bottom line) C difficile (over 65) Jan-Mar 15 NHS Fife is shown as FF (just below the centre line) Total SAB Jan-Mar 15 NHS Fife is shown as FF (just below the centre line). MRSA SAB Jan-Mar 15 NHS Fife is shown as FF (just below the centre line). Page 60 of 63

61 SECTION F Freedom of Information Requests Freedom of Information Requests received in the period 1 st August 31 st August Number Received MP / MSP / SGHSCD Source Commercial Media Other Number responded to Responded within 20 days Responded outwith 20 days %age of responses within 20 days August % August % Please note that at the time of writing 15 requests are still outstanding and remain within the 20 working days. Page 61 of 63

62 COMPLAINTS SECTION G We will achieve and sustain response times of no less than 95% (acknowledged within 3 working days) and 65% (responded to fully within 20 working days). Key Concerns and Risks Each of the operational parts of the system is developing action plans in partnership with Patient Relations Team. The actions described will ensure that response times improve whilst the quality of responses are maintained. The three biggest risks to achieving and sustaining the planned improvements are: Delays that include a number of factors, which impact on the overall process across the system Complexity of complaints which cross different organisational units Patient Relations Capacity Recovery Trajectories 3-day Acknowledgement 20-day Completion Recovery Plan Page 62 of 63

63 Complaints, Concerns, Compliments and Comments Compliments Comments Complaints Concerns 20 0 April May June July Context of complaints in relation to other forms of feedback The Patient Relations Team deals with concerns from patients, their families and the general public. In many instances, this promotes local resolution and prevents issues being progressed to formal complaints. There is no related target to this work although this forms a significant part of the Patient Relation Team s daily workload. Ombudsman Cases concluded in July The SPSO considered a case concerning clinical care and discharge arrangements and decided not to progress with it in view of the clinical advice they received which confirmed that the patient s treatment had been reasonable and that the patient was fit for discharge. As the Board had addressed these issues in their response and offered an apology and details of actions taken, it was decided that there would be no merit in the SPSO pursuing the case. The SPSO did not uphold a complaint concerning community paediatric care. The clinical advice received by the SPSO was supportive of the Fife clinician s approach to care. The SPSO did not uphold a complaint about timely treatment of back pain. The SPSO was however critical of a factual inaccuracy in the response from the Service which indicated the health record had not been reviewed thoroughly. This information has been shared with the Service concerned. The SPSO did not uphold a complaint concerning a Fife GP Practice. The complaint raised was about the care and treatment of a patient. The SPSO concluded that the patient had been seen appropriately by the GP and within a reasonable timeframe. Page 63 of 63