Balanced Score Card Report Review of January 2019 Data
Balanced Scorecard Quality Patient & Access Safety Patient and Service User Human Resource Finance Management
Patient Access – Emergency Department
Mean PET & 8AM TrolleyGAR per 100 ED Attends
CUH 30 Day Moving Average 2018 v 2019
ED Presentation January Comparison 6,000 5,000 4,000 5,949 3,000 5,456 5,127 4,818 4,768 2,000 1,000 0 2015 2016 2017 2018 2019
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 1,730 1,815 1,730 4.9% 4.9% Kerry 956 948 956 948 0.8% 0.8% Mercy 605 633 605 633 -4.4% -4.4% South Tipp. 963 778 963 778 23.8% 23.8% Waterford 1,311 1,116 1,311 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
CUH/CKCH Five Fundamental Project Proposed Next Steps Pre Admission Post Cross Admission Cutting • Acute Floor Develop a communication strategy for the • SAFER • ED • Over 75’s (inc • Maximising project FIT) Ambulatory community • Diagnostics Hold a mini workshop (CUH and CKCH) to / Paeds services (inc • Older person’s Area review the scope of all current projects to CIT, ICT, – group wide Redesign OPAT, determine: • SAFER - group • 24/7 AMAU CREST) • wide What does good look like? • Weekend • D2A • FIT – group • What benefits are current projects delivering? D/C • Non wide • Can projects be prioritised? • Red 2 • Community Admitted • Are optimal project metrics being used to track Green specific PET • Over 14 improvements? including: • Citywide days/ 1. Bed bureau Develop an implementation plan for a change Ambulatory Egress 2. Single referral programme for the next 6 months with targets Themes Care form for • SDU for all projects (in line with national Pathways community Delayed services programmes) Discharge 3. IPMS Recommen Engage with the staff on the ground 4. Performance dations metrics • Admitted Local USC governance group to act as project PET steering board as per TOR
Christmas Plan - Additional Measures 24/7 AMAU Service from 27 th December Additional Emergency Medicine Paediatric Medicine and Acute Medicine Registrar Curtailment of scheduled activity 24 th Dec – 7 th Jan 15 beds purchased in the Mater Private Inpatient diagnostics prioritised 27 th December – 11 th 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 25 20 15 10 5 0 Total AMAU Admissions 256 300 250 200 123 150 65 43 100 16 50 0 Surge ED ED Gp Referral Planned Repeat Other Referral Source Admission Total AMAU Admissions
Diagnostic Waiting List Average Diagnostic Waiting List January 2019 57 60 Average number of patients waiting Jan 50 45 40 32 2019 30 20 10 0 CT MRI ECHO
Patients waiting transfer to SFH & SIVUH January ‘19 Daily waiting SFH & SIVUH Average Waiting SFH & SIVUH 14 12 12 Number of patients 10 8 6 4 4 2 0 SFH SIVUH
Patient Access - Outpatient Waiting Lists
Time to Put a Referral on iPMS by Central Appointments Average Days to Put New Referral on iPMS 7 6 5 4 3 2 0.78 0.68 0.75 0.76 0.77 0.70 0.64 0.83 1 0.73 0.59 0.54 0.66 0.79 0 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 Time to Put on iPMS 19
Triage Turnaround Time Average Working Days to Complete Triage for Central Appointments 4.5 4 3.94 3.5 3.41 3.41 3.38 3.24 3 2.93 2.89 2.74 2.68 2.67 2.5 2.37 2.36 2.14 2 1.5 1 0.5 0 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 20
Total Medical Patients to be seen by 15 Month Target (December) (379) 350 300 300 250 200 150 100 50 19 18 16 10 6 3 2 2 1 1 1 0
Total Surgical Patients to be seen by 15 Month Target (December) (4095) 800 744 701 700 600 545 495 500 400 368 360 300 215 184 178 200 93 100 72 64 49 14 5 3 2 2 1 0
Total Paediatric Patients to be seen by 15 Month Target (December) (110) 50 46 45 40 35 30 27 25 21 20 15 15 10 5 1 0 Paediatric Neurology - Olivia Paediatric Neurology - Niamh Paediatrics - Louise Gibson Paed Endocrinology - Daniel Paed Endocrinology - Stephen 23 O'Mahony McSweeney Colm Costigan O'Riordan
Patients Currently Waiting Longer Than 12 Months (December) (5666) 4000 3618 3500 3000 2500 2000 1500 887 1000 397 500 130 127 107 96 83 66 37 26 23 20 17 16 12 4 0
Patients to be seen by 15 Month Target ) 1600 1400 1410 1200 1099 1000 967 800 731 600 400 276 200 100 0 1 12-15 15-18 18-21 21-24 24-36 36-48 48+ Months Months Months Months Months Months 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) Grand wl type ACTIVE PREADMIT SUSPENSION 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 Patients In/Out of Target January 2019 OUT OF TARGET, 9, 11% IN TARGET, 71, 89% Total Patients 80
Reasons for Delay - January 2019 6 5 4 3 2 1 0 Personal Medical Capacity Data Other choice Missing Total 1 6 1 0 1
Medical Oncology KPI – January 2019 Patients In/Out of Target January 2019 Outside Target, 3, 5% In Target, 54, 95% Total Patients 57
Reasons for Delay - January 2019 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 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 CUH – Total % Sick Leave 2017 v 2018 6 4.56 4.72 4.77 3.98 4.15 4.17 3.65 4.01 4.22 3.9 4.32 4.35 3.8 4.02 3.82 3.89 3.92 3.8 3.84 3.54 4 4.42 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 % 3.84 3.5 3.84 2 0 Jan Feb Mar April May June July August Sept Oct Nov Dec 2017% 2018% % Target CUH Long Term Sick Leave – WTE’s 50 42.01 40.09 40 28.89 31 37.62 WTE’s 29.2 30 33.99 33.23 32.62 29.83 29.39 26.8 26.11 20 24.1 10 0 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
EWTD Compliance June – December 2018 & January 2019
Finance
Draft Cost Containment Plan 2019 Actual 2018 Savings € k 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 : Managed service 2,064 700 (1H18 € 1.4m; 2H18 € 0.7m) 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
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