Balanced Score Card Review of January 2016 Data Balanced Scorecard - - PowerPoint PPT Presentation

Balanced Score Card Review of January 2016 Data

Balanced Scorecard

Finance

Patient Access Quality & Safety Human Resource Management

Patient and Service User

Finance

Finance Report -January 2016

Final outturn FY 2015

• Group budget €286.1m (2014 €284.9m)
• Group actual expenditure (net) €285.7m (2014 €284.1m)
• Group actual surplus €0.4m ( 2014 surplus: €0.7m)
• CUH Budget €268.8m (2014:€265.1m)
• CUH /SMOH actual expenditure €268.9m (2014 €265.3m)
• CUH /SMOH actual deficit (€0.1m) (2014 €0.2m)
• Mallow Budget €17.3m (2014:€17.5m)
• Mallow actual expenditure €16.8m (2014 €16.8m)
• Mallow actual surplus €0.5m (2014 surplus: €0.8m )

Finance Report – January 2016

Budget allocation 2016- CUH

• Gross pay & non pay budget (2015) €332.8m
• Gross pay & non pay expenditure (2015) €344.2m
• Gross pay & non pay budget (2016) €341.2m
• Projected expenditure (2016) –Pay €237.7m
• - Nonpay €108.6m
• Projected challenge (2016) €5.1m
• Income budget (2015) €63.9m
• Income actual (2015) €75.2m
• Income budget (2016) €80.5m
• Projected Income (2016) € 76.3m
• Projected challenge (2016) €4.2m

CUH Group –Surplus / (Deficit) percentage %

CUH Group Summary – Budget v Actual Expenditure January 2016

Pay €k Non-Pay €k Total Gross Income €k Net €k CUH

• 246
• 84
• 330
• 417
• 746

SMOH

• 1
• 1

19 18 CUH-SMOH

• 246
• 84
• 330
• 398
• 728

Mallow 25

• 73
• 47

34

• 14

Total

• 221
• 157
• 378
• 364
• 742

CUH Budget v Actual Pay January 2016

2015 Budget €k 2015 Actual €k Variance €k % Variance 2015 Actual €k v 2014 Variance €k Medical/Dental 5,521 5,819

• 298
• 5%

5,451

• 368

Nursing/Midwifery 7,588 7,389 199 3% 7,590 201 Paramedical 2,740 2,887

• 147

5% 2,707

• 180

Housekeeping 608 604 4 1% 546

• 58

Care Assistants 608 605 3 0% 546

• 59

Catering 362 360 2 1% 335

• 25

Portering 499 515

• 16
• 3%

497

• 18

Administration 1,581 1,543 38 2% 1,515

• 28

Other Staff 270 301

• 31%
• 11%

311 10 Total 19,777 20,023

• 246
• 1%

19,497

• 526

CUH Actual Non-pay Expenditure 2016 v 2015

CUH AGENCY COSTS €k 2014-16

CUH AGENCY WTE – 2016

CUH Average Nursing & HCA Agency WTE’s per Week 2014-16

CUH Average Specials /Other Nursing & HCA Agency WTE’s per Week 2014-15 CUH Average Specials /Other Nursing & HCA Agency WTE’s per Week 2014-15

Patient Income 2014 –2016

Mallow Budget v Actual January 2016

Budget €k Actual €k Variance €k %Variance Pay 1,290 1,265 25 2.0% Non - Pay 409 482

• 73
• 17.8%

Gross Expend 1,699 1,746

• 47
• 2.8%

Income 326 360 34

• 10.3%

Total 2,025 2,106

• 14
• 0.7%

Patient Access

INMO Trolley Report Annual data for 2015 and comparative data for 2014

Weekly INMO Trolley Report

Week ending 12th February 2016

ED New Presentations- week ending 21/02/2016

20 40 60 80 100 120 140 160 180 15/02/2016 16/02/2016 17/02/2016 18/02/2016 19/02/2016 20/02/2016 21/02/2016 173 165 173 170 178 136 149

New ED Attendances

New ED Attendances

Triage Categories

20 40 60 80 100 120 140 160 180 15/02/2016 16/02/2016 17/02/2016 18/02/2016 19/02/2016 20/02/2016 21/02/2016 4 2 6 2 2 2 3 32 55 30 42 39 31 39 96 72 106 78 105 75 76 32 31 27 43 26 20 19

Daily Triage Breakdown

(blank) Not Triaged 5 - Non Urgent 4 - Standard 3 - Urgent 2 - Very Urgent 1 - Immediate

Daily Admissions

15/02/2016 16/02/2016 17/02/2016 18/02/2016 19/02/2016 20/02/2016 21/02/2016 70 57 65 63 68 52 43 9 3 14 10 8 4 28 20 30 15 8 2 8

Daily Admissions

ED Admissions Other unscheduled admissions Elective admissions

ED – 6hr & 9hr Target – All Patients

(Quarter 4 2015 & January 2016)

R

76.00% 78.10% 77.20% 73.90% 62% 62.10% 60.80% 60.20% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% Oct-15 Nov-15 Dec-15 Jan-16 9hr PET 6hr PET Linear (9hr PET)

• Expon. (6hr PET)

ED – 6hr & 9hr Target – Admitted Patients

(Quarter 4 2015 & January 2016)

48.40% 51.50% 54.90% 46.20%

37.00% 37.70% 39.50%

35.30%

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% Oct-15 Nov-15 Dec-15 Jan-16 9hr PET 6hr PET

• Expon. (9hr PET)
• Expon. (6hr PET)

ED – 6hr & 9hr Target – Non Admitted Patients (Quarter 4 2015 & January 2016)

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% Oct-15 Nov-15 Dec-15 Jan-16 Series1 Series2

• Expon. (Series1)
• Expon. (Series1)
• Expon. (Series2)

Daily Ambulance Distribution

Time & Distribution of Ambulances

Delayed Discharges Jan- Feb 2016

5 10 15 20 25 5th Jan 12th jan 19th Jan 26th Jan 2nd Feb 9th Feb 16th Feb 23rd Feb

13 15 14 20 13 21 18 17

Outpatient Waiting Lists

28

Patients to be seen by 15 Month Timeline

614 601 148 72 180 30 7

100 200 300 400 500 600 700 12-15 Months 15-18 Months 18-21 Months 21-24 Months 24-36 Months 36-48 Months 48+ Months Total Patient Count - 1652 1652 Urgent and Routine Patients who need to be seen by month end (February 2016) to meet the 15 month maximum wait timeline Count of Patients % No of Patients with an Appointment before or on End of Month 250 15.13% Number of Patients with an Appointment Post End of Month 111 6.72% Number of Patients with No Appointment 1291 78.15%

Breast & Genera Surgery Activity combined

29

Medical Patients to be seen by 15 Month Timeline – 29/02/2016

101 93 53 30 20 15 15 13 7 6 5 2 1 20 40 60 80 100 120 Total Patient Count 361

Breast & General Surgery Activity combined

30

Surgical Patients to be seen by 15 Month Timeline 29/02/2016

103 99 97 93 89 69 54 45 35 31 30 27 24 22 20 19 12 12 2 1 1 1 20 40 60 80 100 120 Total Patient Count - 886

Breast & General Surgery Activity combined

31

Women and Children Patients to be seen by 15 Month Timeline – 29/02/2016

91 61 55 43 41 39 33 29 7 4 1 1 10 20 30 40 50 60 70 80 90 100 Gynaecology

• Richard

Greene Gynaecology

• Daniel

McKenna Gynaecology

• John

Higgins Gynaecology

• Suzanne

O'Sullivan Gynaecology

• Barry

O'Reilly Gynaecology

• Cathy Burke

Gynaecology

• Helen

Doran Gynaecology

• Moya

McMenamin Paediatrics - Jonathan Hourihane Gynaecology

• Mairead

O'Riordan Paediatric Neurology - Audrone Giedraitiene Paediatrics - Louise Gibson Total Patient Count - 405

Breast & General Surgery Activity combined

32

Patients Currently Waiting Longer Than 12 Months as per 03/02/2016 Waiting List

767 695 283 241 228 194 153 131 102 99 87 60 30 28 10 9 3 2 1 100 200 300 400 500 600 700 800 900

Total Patient Count - 3123

Breast & General Surgery Activity combined

New and Return DNA Rate in CUH

33

12% 9% 10% 11% 11% 12% 12% 13% 11% 12% 11% 10% 12% 13% 12% 12% 11% 12% 12% 11% 12% 12% 12% 12% 11% 12% 0% 2% 4% 6% 8% 10% 12% 14% January 2015 February 2015 March 2015 April 2015 May 2015 June 2015 July 2015 August 2015 September 2015 October 2015 November 2015 December 2015 January 2016

New DNA % Return DNA %

Breast & General Surgery Activity combined

Scope Waiting List

Scopes Urgent – December

G

Scopes Routine - December

R

INPATIENT WAITING LIST

Total Inpatient & Day case Waiting List

(22/02/2016)

3-6 Months 6-8 Months 8-12 Months 12-15 Months 15-18 Months 18-24 Months 24-36 Months Grand Total 268 147 197 65 45 13 3 1191 53 10 18 9 4 266 2 4 8 1 46 321 157 215 76 49 25 4 1503 98 46 79 25 19 6 1 483 11 11 6 2 3 2 131 1 3 6 110 57 85 27 25 8 1 620 431 214 300 103 74 33 5 2123

18 month Breaches (26)

2 4 6 8 10 12 14 16 18 Cardiothoracic General Surgery Gynaecology Plastic Surgery Urology

2 4 18 1 1

16 month Breaches (97)

Quality & Safety

Day Surgery Admission Rate – December 2015

G

Surgery – Length of Stay - December

A

Emergency Readmission – Surgery -December 2015

G

Medical ALOS – December 2015

G

ALOS for All Patients – December 2015

A

ALOS – Excluding LOS over 30 days - December 2015

G

Emergency Re admission – Medicine – December 2015

Day Case Rate – Elective Cholecystectomy December 2015

G

Emergency Hip Fracture Rate – December 2015

R

NEWS Full Implementation – December 2015

G

IMEWS Implementation for pregnant patients December 2015

G

Reducing Healthcare Acquired Infection (MRSA)

December 2015

R

Reducing Healthcare Acquired Infection- C diff

December 2015

R

Antibiotic Consumption Rate

December 2015

G

Cancer KPI – Breast-Lung-Prostate January 2016

CUH OPAT Referrals Quarter 4 2015 & January 2016

CUH OPAT Bed days saved Quarter 4 2015 & January 2016

20 40 60 80 100 120 140 160 180 200 Oct Nov Dec Jan-16

107 131 41 185

CUH

CIT Referrals (weekly) – February 2016

CIT Referral Source - January 2016

(01/01/2016 – 12/02/2016) 5 10 15 20 25 Warfin Service CDU Ward 3B MSSU OPAT CUH CUH Other 22 5 1 4 1 4

Validation of MRI Waiting List

• General adult waiting list inherited - 2601

Protocolled to a more urgent category or specific date - 346 Validated list

• Not required by patient
• Scanned elsewhere

Privately scanned in Scancor

• DNA x 2 and returned to referrer
• Un contactable by letter and phone and returned to referrer – 488

Scanned to date 1101 in new MRI

• Now remaining from the original waiting list 666 as of 12/02/16

Adult MRI Waiting List – February 2016

Paediatric Waiting List – February 2016

50 100 150 200 250 300 350

244 312

Quality and Safety

• Appointment of Lead for Clinical Audit
• Appointment of Risk Manager
• Appointment of Quality Assurance manager
• Housekeeping Services Project Group – Job Descriptions signed off
• Quality Improvement Programme for Outpatient services
• Interviews for post of Risk Manager, Quality Assurance Manager and

Quality Improvement Manager completed – In place 1st Quarter 2016

Risk Management - January KPI data

• Serious Reportable Events reported - 0
• Medication Safety Incidents reported - 1
• Complaints – 26 complaints raised in January on average

7.7% closed within 30 day timeframe

• New claims notified to hospital - 0
• Risk(s) escalated in December - 0

Human Resource Management

Sick Leave – November 2015

Staffing & Costs 2015 & January 2016

EWTD Compliance – Quarter 4 2015 & Jan 2016

0% 20% 40% 60% 80% 100% 120% 140% 160% 180% 200% Oct-15 Nov-15 Dec-15 Jan-16

99% 99% 99% 99% 95% 95% 94% 94%

48 hour 24 hour

Capital Projects

Project

Status

MRI Unit

Completed and operational

Paediatric Unit

Phase 1 - build programme commenced in July Phase 2 – submitted for capital funding

Mental Health Unit

Completed and operational

Acute Medical Assessment Unit – Phase 3 & Endoscopy Unit

Completed and operational

Radiation Oncology Unit

 Planning permission granted  Enabling works to commence in January 2016  Funding received for Bracktherapy Equipment

Cystic Fibrosis/ Respiratory Ward

Completed and operational

Education and Training Centre

Statement of Need being developed

Blood Sciences Project

Design Team appointed – request for managed service approved

Oncology Service

 Expansion of Day Unit – plan signed off – submitted for Philanthropic funding (ACT)  Refurbishment of Ward 2D – capital funding in place  Medical Oncology Centre – developing Statement of Need

Ophthalmology Transfer – Phase 2

Project group in place

Helipad

Interim helipad in place – contractor to be appointed in February 2016

Interim Transitional Care Unit

Completed

Key Issues

• Reopening of 30 inpatient beds (Transitional Care Unit)
• Recognition of Budgetary performance
• Dependency on patient income
• 2016 Budget / Estimates
• Undergraduate Training costs - €6.5m per annum
• Management of Unscheduled Care
• Implementation of Change Programme Initiatives