Balanced Score Card Report Review of January 2019 Data Balanced - - PowerPoint PPT Presentation

Balanced Score Card Report Review of January 2019 Data

Balanced Scorecard

Patient Access

Quality & Safety Human Resource Management Finance

Patient and Service User

Patient Access – Emergency Department

Mean PET & 8AM TrolleyGAR per 100 ED Attends

CUH 30 Day Moving Average 2018 v 2019

ED Presentation January Comparison

1,000 2,000 3,000 4,000 5,000 6,000 2015 2016 2017 2018 2019 4,768 5,127 4,818 5,456 5,949

ED Attendances & Admissions: Month & YTD Ages: All

ADMITTED from ED (Ages: All)

2019 2018 Hospital Group Hospital January YTD January YTD January YTD

South/South West Hospital Group

CUH 1,815 1,815 1,730 1,730 4.9% 4.9%

Kerry 956 956 948 948 0.8% 0.8% Mercy 605 605 633 633

• 4.4%
• 4.4%

South Tipp. 963 963 778 778 23.8% 23.8% Waterford 1,311 1,311 1,116 1,116 17.5% 17.5% South/South West Hospital Group 5,650 5,650 5,205 5,205 8.5% 8.5%

ED Attendances & Admissions: Month & YTD Ages: 75+

PET >24 Hours January 2019

Bed Day Occupancy >14 Days (30 DMA)

>100 Day Occupancy 30DMA

Project Flow Improving Patient’s Hospital Experience

Project Flow 2018 - Five Fundamentals

Pre Admission

• Acute Floor
• ED

Ambulatory / Paeds Area Redesign

• 24/7 AMAU
• D2A
• Non

Admitted PET

• Citywide

Ambulatory Care Pathways

Post Admission

• SAFER
• Maximising

community services (inc CIT, ICT, OPAT, CREST)

• Weekend

D/C

• Red 2

Green

• Over 14

days/ Egress Themes

• SDU

Delayed Discharge Recommen dations

• Admitted

PET Cross Cutting

• Over 75’s (inc

FIT)

• Diagnostics
• Older person’s

– group wide

• SAFER - group

wide

• FIT – group

wide

• Community

specific including:

• 1. Bed bureau
• 2. Single referral

form for community services

• 3. IPMS
• 4. Performance

metrics

Proposed Next Steps Develop a communication strategy for the project Hold a mini workshop (CUH and CKCH) to review the scope of all current projects to determine:

• What does good look like?
• What benefits are current projects delivering?
• Can projects be prioritised?
• Are optimal project metrics being used to track

improvements?

Develop an implementation plan for a change programme for the next 6 months with targets for all projects (in line with national programmes) Engage with the staff on the ground Local USC governance group to act as project steering board as per TOR

CUH/CKCH Five Fundamental Project

Christmas Plan - Additional Measures

• 24/7 AMAU Service from 27th December
• Additional Emergency Medicine Paediatric Medicine and Acute

Medicine Registrar

• Curtailment of scheduled activity 24th Dec – 7th Jan
• 15 beds purchased in the Mater Private
• Inpatient diagnostics prioritised 27th December – 11th January
• GA 5 Day – 7 days month of January
• Falls Intervention Team
• Series of Daily Operational Meetings
• Additional Assistant Director of Nursing at weekends

AMAU Activity January 2019

AMAU Referrals from ED

5 10 15 20 25

Total AMAU Admissions

50 100 150 200 250 300 Surge ED ED Gp Referral Planned Repeat Admission Other Referral Source 43 256 123 65 16 Total AMAU Admissions

Diagnostic Waiting List

Average Diagnostic Waiting List January 2019

57 32 45

10 20 30 40 50 60 CT MRI ECHO Average number of patients waiting Jan 2019

Patients waiting transfer to SFH & SIVUH January ‘19

Daily waiting SFH & SIVUH Average Waiting SFH & SIVUH

12 4 2 4 6 8 10 12 14 SFH SIVUH Number of patients

Patient Access - Outpatient Waiting Lists

Time to Put a Referral on iPMS by Central Appointments

19 0.78 0.66 0.75 0.59 0.76 0.64 0.77 0.54 0.70 0.83 0.68 0.73 0.79 1 2 3 4 5 6 7 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18

Average Days to Put New Referral on iPMS

Average Time to Put on iPMS

Triage Turnaround Time

20

3.24 2.37 2.67 2.14 2.93 3.38 2.89 3.41 2.36 3.94 3.41 2.74 2.68 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18

Average Working Days to Complete Triage for Central Appointments

Total Medical Patients to be seen by 15 Month Target

(December) (379)

300 19 18 16 10 6 3 2 2 1 1 1 50 100 150 200 250 300 350

Total Surgical Patients to be seen by 15 Month Target

(December) (4095)

744 701 545 495 368 360 215 184 178 93 72 64 49 14 5 3 2 2 1 100 200 300 400 500 600 700 800

Total Paediatric Patients to be seen by 15 Month Target

(December) (110)

23

46 27 21 15 1 5 10 15 20 25 30 35 40 45 50 Paediatric Neurology - Olivia O'Mahony Paediatric Neurology - Niamh McSweeney Paediatrics - Louise Gibson Paed Endocrinology - Daniel Colm Costigan Paed Endocrinology - Stephen O'Riordan

Patients Currently Waiting Longer Than 12 Months

(December) (5666)

3618 887 397 130 127 107 96 83 66 37 26 23 20 17 16 12 4 500 1000 1500 2000 2500 3000 3500 4000

Patients to be seen by 15 Month Target

)

276 1099 967 731 1410 100 1 200 400 600 800 1000 1200 1400 1600 12-15 Months 15-18 Months 18-21 Months 21-24 Months 24-36 Months 36-48 Months 48+ Months

4584 Urgent and Routine Patients who need to be seen in relation to the 15 month deadline by month end of December 2018 Count of Patients % No of Patients with an Appointment before or on End of Month 51 1.11% Number of Patients with an Appointment Post End of Month 130 2.84% Number of Patients with No Appointment 4403 96.05%

Patient Access - Inpatient Waiting List

Total Inpatient & Day case Waiting List (13/02/2019)

wl type ACTIVE PREADMIT SUSPENSION Grand Total

Adult 1201 392 46 1639 Child 137 46 1 184 GI Scope 103 206 4 313 Grand Total 1441 644 51 2136

Prospective Adult Pivot - to be Treated by December 2019

(as of 13/02/2019)

Rescheduling of Appointments post INMO Industrial Action

Quality & Safety

Risk Management - January KPI data

• Serious Reportable Events – 3 communicated in January
• Medication Safety Incidents reported - 54
• Complaints –8 with 12.5% closed within the 30 day timeframe
• New claims notified to hospital - 3

Risk Register No new risks added

Scope Waiting List

(February 2019)

Cancer KPI – Breast-Lung-Prostate

July – December 2018 & January 2019

Radiation Oncology KPI – January 2019

IN TARGET, 71, 89% OUT OF TARGET, 9, 11%

Patients In/Out of Target January 2019

Total Patients 80

Reasons for Delay - January 2019

1 2 3 4 5 6 Personal choice Medical Capacity Data Missing Other Total 1 6 1 1

Medical Oncology KPI – January 2019

In Target, 54, 95% Outside Target, 3, 5%

Patients In/Out of Target January 2019

Total Patients 57

Reasons for Delay - January 2019

0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Personal Medicial Total 2 1

CPE - Current Status

• Currently two patients confirmed with CPE
• CPE Working Group has been reconvened
• The CPE Working Group will oversee the

implementation of the recommendations in the report issued by HIQA. Flu Pandemic

• 24 confirmed cases

38

Human Resource Management

Total Sick Leave

4.77 3.84 3.92 4.22 4.17 3.9 3.65 3.98 3.89 3.84 4.15 4.35 4.42 3.8 4.01 3.8 4.02 3.84 3.54 3.82 4.72 4.32 4.56

3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5

2 4 6

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

%

CUH – Total % Sick Leave 2017 v 2018

2017% 2018% % Target

29.2 26.8 29.83 26.11 31 24.1 32.62 40.09 37.62 29.39 28.89 33.23 33.99 42.01

10 20 30 40 50

Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18

WTE’s

CUH Long Term Sick Leave – WTE’s

EWTD Compliance

June – December 2018 & January 2019

Finance

Draft Cost Containment Plan 2019

Actual 2018 €k Savings target €k Basis Pay: Medical overtime 11,044 552 5% target reduction Nursing agency-conversion 2,766 277 10% saving HCA agency- CAMHS 300 300 Charge to CH04 HCA agency-conversion 3,289 329 10% saving Other overtime 981 98 10% saving Misc-Time related savings 300 Delay in filling posts Non-pay : 2,064 700 (1H18 €1.4m; 2H18 €0.7m) Managed service Procurement 250 New contract prices Medicines excl PCRS 22,278 500 Biosimilars PCRS Budget uplift 600 Blood 5,565 278 5% reduction Non-DLU 795 200 25% reduction Energy 2,889 144 5% reduction Storage 882 114 Doughcloyne rent Lab external tests 1,396 70 5% reduction Staff recruitment/training 1,074 54 5% reduction Computer 947 36 ILAB support Other 82,227 300 Reduced activity year-end Add funding-demographics, equipment replacement etc 500 Total 5,602

Capital Projects

Capital Projects

Project Status Paediatric Unit Phase 1 - build programme completed Phase 2 – funding received – proceed to Design Stage Radiation Oncology Unit  Building Handover scheduled for 25th March 2019 Education and Training Centre Draft Statement of Need completed and discussion ongoing with UCC Meeting held with UCC Blood Sciences Project Design Team appointed Infrastructural works are near completion Oncology Service  Expansion of Day Unit – plan signed off  Refurbishment of Ward 2D – capital funding in place  Medical Oncology Centre – developing Statement of Need  Mammography Units replacement programme completed Ophthalmology Transfer – Phase 2 

• OPD & Day Care – Tender documents ready to issue in

January ‘18 

• Theatre Accommodation tender documents being

prepared for early ’18 Helipad Approval received from the IAA Planning queries being addressed