Review of May 2015 Data Balanced Scorecard Patient and Service User - - PowerPoint PPT Presentation

Balanced Score Card Review of May 2015 Data

Balanced Scorecard

Patient and Service User

Finance

CUH Group Budget 2015

Budget 2015

Group Budget €283.6m (2014 €284.9m) Group projected expenditure €283.3m (2014 €284.2m) Group Projected Surplus €0.3m (2014 surplus 0.7m) CUH Budget €264.1m (2014:€262.8m) CUH projected actual €264.1m (2014 €265.2m) CUH projected Deficit €20k (2014 €2.4m) MGH Budget €17.3m (2014:€17.5m) MGH Projected Actual €17.0m (2014 €16.8m) MGH Projected Surplus €0.3m

Actual Outturn YTD - May 2015

• Group budget €116.95m (2014 €113.6m)
• Group actual expenditure €116.86m (2014 €118.7m)
• Group actual deficit €91k ( 2014 €5.1m)
• CUH Budget €109.8m (2014:€105.5m)
• CUH /SMOH actual expenditure €110.1m (€110.3m)
• CUH /SMOH actual deficit €247k (2014 €4.8m)
• Mallow Budget €7.1m (2014:€6.9m)
• Mallow actual expenditure €6.8m (2014 €7.3m)
• Mallow actual surplus €338k ( 2014 deficit €404k)

CUH Summary Budget v Actual Expenditure May 2015 Pay €k Non-Pay €k Income €k Total CUH

• 271
• 538

787

• 22

SMOH

• 2

19 17 CUH-SMOH

• 271
• 540

806

• 5

Mallow 98

• 143

199 154 Total

• 173
• 683

1,005 149

CUH Actual Non-pay Expenditure €k YTD May 2015 v 2014

CUH Group –Surplus / (Deficit) percentage %

CUH AGENCY COSTS €k 2013– May 2015

CUH Agency Costs – April 2015

CUH Average Nursing & HCA Agency WTE’s per Week 2013-15

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

Patient Income 2013 – May 2015

Cost Containment

Consultant Private Insurance Claims

O/s Consultant claims at 29th May 2015 Directorate

Value €k Prev

Value €k Current

Diagnostics

17

19 Medicine

3,299

3,818 Surgery

2,148

2,293

Women and Children CUH

401

430 Total-CUH Primary

5,864

6,560

Women & Children CUMH

500

500 Total-CUH /CUMH Primary

6,364

7,060

Consultants at 16th June No of claims Value €k

HARTY, JAMES 169 529,945 POWER, DEREK 240 331,388 CROSBIE, ORLA 20 280,233 ANDREWS, EMMET J. 76 245,273 TAYLOR, COLM 56 223,890 PLANT, WILLIAM 46 193,670 KAAR, GEORGE 18 169,432 GILMORE, JENNIFER 1 149,341 KEARNEY, PETER 56 136,655 O'MAHONY, DENIS 10 112,194 FLEMING, PAT 23 109,286 O'HALLORAN, D. J. 24 104,411 O'CONNOR, MICHAEL 15 102,430 KELLY, PETER 38 100,093 PLANT, BARRY 15 98,147 GUERIN, SHANE 19 96,869 HARTY, JAMES 169 529,945 O'LEARY, PAULA 28 95,219 TOTAL 3,168,791

Access

CUH Weekly INMO Trolley Report

Week ending 19th June 2015

Daily Trolley Numbers – May - June 2015 ( 21/06/2015)

ED – 6hr Target (April Dashboard)

R

ED – 9hr Target (April Dashboard)

R

ED >24hrs

(April Dashboard)

R

ALOS for all Patients

(April Dashboard)

G

Medical ALOS

(April Dashboard)

A

Surgical ALOS

(April Dashboard)

R

ALOS – Excluding LOS over 30 days

(April Dashboard)

G

HIPE Coding

(April Dashboard)

G

Day of Procedure Admission Rate for Surgical Inpatients

(April Dashboard)

G

Delayed Discharges - 2015

January – June (9th June)

Inpatient – Day case Waiting Lists

Total Adult Waiting List (Active – 1310)

May (1310) and June (1245)

100 200 300 400 500 600 Breast Surgery Cardiology Cardio Thoracic Gastro Gen Surgery Gynaecology Neurology Neurosurgery Orthopaedics Plastic Surgery Respiratory Urology Vascular June May

Prospective View – June 2015 (48 Active)

Cardio Thoracic – 1 suspended per patients Gen Surgery – I TCI, 4 Suspension per patients, I date to be arranged Gynaecology – presently being transferred to outside provider Urology – 2 Suspensions per patient Vascular - 6 to Outpatients per consultant

Prospective View – December 2015 (381)

20 40 60 80 100 120 140 160 180 15 8 43 170 2 3 1 15 3 21 74 June

Scopes Urgent - April 2015

G

Scopes Routine – April 2015

G

Outpatient Waiting Lists

Medical Patients to be seen by the 30th of June 2015

Surgical Patients to be seen by the 30th of June 2015

Women and Children Patients to be seen by the 30th

• f June 2015

OPD Potential Breach Report

Count of ID Specialty 18Mth by June 30th 17.6.15 Expected Total as of 22.6.15 for June 30th deadline Comments /Update 22.6.15 Current RAG Status Expected RAG Status Diabetes Mellitus Yes 287 287

• Regular Clinics fully booked to 30th June
• Discussed Registrar post & GP Clinics with

Michael Murphy - No further update

• Dr. Sean Manning sees additional patients when his schedule allows

Endocrinology Yes 159 ?150

• Regular Clinics fully booked to 30th June
• Discussed Registrar post & GP Clinics with

Michael Murphy today - No further update

• 9 to be removed pending confirmation of their attendance privately

General Surgery Yes 42

• 3 returned for capacity in Mr. McCourt's Clinic
• 39 Purchased Care

Gynaecology Yes 1057 1057

• Discussed again with Miriam - there was agreement

to put on additional clinics however the service has now requested this be used for urgent patients

• Dr. Babiker left end of May
• Routine patients that were booked with agreement have since been

cancelled by the service - so numbers may actually increase

Neurosurgery Yes 45

• Out of Hours Clinics held
• Physiotherapists commenced clinics
• Registrar to do Saturday Clinics - - last one on 27th June
• Entire list will be cleared

Ophthalmology Yes 81

• SLA agreed for purchased care with Dr. Mr. Traynor
• Referrals transferred and all patients notified by letter

Plastic Surgery Yes 138

• Met with consultants who agreed to request their teams to see

suitable patients on a See & Treat Basis - 30 deemed suitable - Additional funding required for Theatre time (CUH) to treat these patients.

• 59 + 6 agreed under Purchased Care - Additional funding required for

Theatre time in SIVUH to treat these patients

• 41 previously seen in Mater Private to receive required treatment under

purchased care

• 2 Patients suspended per validation as unavailable to attend on 30th

June

Rheumatology Yes

• Clerical Error - Patient cancelled appointment for 1.5.15

Urology Yes 41

• 39 Referrals transferred to Mallow General Hospital
• 1 Suspended to later date per patient request
• 1 to go to Purchased Care

Vascular Surgery Yes 62

• SLA for purchased care agreed with consultant
• Clinics commencing 25th June

Grand Total 1912 1606

Quality

Emergency Hip Fracture Surgery – April

R

Emergency Re-admission - Medical

R

Emergency Readmission - Surgical

R

Cancer KPI – Breast-Lung-Prostate -Jan – May

Radiotherapy -New Treatments - May

CUH Patients undergoing Radical Radiotherapy

commenced treatment within 15 working days of being deemed ready to treat

Treatment Delay

New Patients Treated Within Target January 2014 - May 2015

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Outside Target 11% 12% 9% 12% 10% 9% 14% 5% 7% 11% 19% 14% 21% 16% 18% 18% 20% In Target 89% 88% 91% 88% 90% 91% 86% 95% 93% 89% 81% 86% 79% 84% 82% 82% 80% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Complaints Management - Action Plan

CUH Hygiene Quality Improvement Team

A

CUH Hygiene Quality Improvement Plan

B

Jul-05

C D 2015 Quarter Recommendation Action Required Measurement/Evidence of Implementation Responsible Person for Action Due Day for full Implementation

2

Standard 3 & 6 Improve Governance, improve reporting systems

• 1. Under the leadership of the CEO, continue a focussed team

driving improvements in the area of hand hygiene and cleanliness

• f environment and facilities.

Minutes of CEO led team meetings Chief Executive Officer

30th June 2015 A

• 2. IPCC to develop portfolio of qualitative and quantative

measures of compliance, reporting and frequency of reporting to timely identify & address poor compliance and/or incidents. Portfolio to be presented to CEO Chair IPC Committee

30th June 2015 B

• 3. Revise the outbreak management policy to ensure significant
• utbreaks are notified, reviewed to identify possible areas of poor

compliance and /or incidents, escalated and managed appropriately. Update policy with defined escalation & communication criteria Chair IPC Committee

30th June 2015 A

• 4. Revise bedside alerts for effective communicational and

identification of patients requiring isolation precautions (particularly in six bedded / recovery). Update IPC Policy with revised bedside alerts IPC Team

30th June 2015 A

• 5. Reporting structure for IPCN Team, IPC Committee, Hygiene

walkabout team, CEO Team, SMT Lead for hand hygiene in addressing audit report, outbreaks and incidents requires definition. Organisational flow chart for reflecting reporting structure IPC Team

30th June 2015 B

• 6. Plan for every ward to improve hand hygiene and cleanliness

to be developed by CNM / CNMs under the leadership of the DON / DOM and monthly progress against the plan to be reported to CEO Led team. Individual documented Ward Plan with monthly progress reports Chair IPC Committee

30th June 2015 A

• 7. Assess progress against planned timelines for implementation
• f QIPs.

Formal periodic reports on achievement of QIPs to CEO Director of Nursing & Director of Midwifery & CNM/CMMs

30th June 2015 A

• 8. Business Case to progress a Senior Nursing Leadership post

dedicated to Infection Control across the hospital group Business Case to progress a Senior Nursing Leadership post dedicated to Infection Control across the hospital group

Chief Executive Officer 30th June 2015 B

Standard 3 The physical environment, facilities and resources are developed and managed to minimise the risk of service users, staff and visitors acquiring a Healthcare Associated Infection. Ward Managers 1. Implement across all ward/department accountability and responsibility for ensuring patient equipment is clean through the individual identification of staff to check compliance on cleaning with identified types of equipment. 2. Immediate notification to Ward Manager where there is visual contamination of equipment sent for repair. Daily allocation checklists records in all wards/departments

• 1. Director or Nursing & Director of Midwifery.
• 2. Biomedical Engineering Manager

30th June 2015 B

Bio Medical Engineering Planned preventative programme introduced Formal documented Programme Biomedical Engineering Manager

A

National Standards for Safer Better Healthcare Theme Status

Theme 1 - Peron Centred Care & Support Self Assessment Completed Theme 2 – Effective Care & Support Self Assessment Completed Theme 3 – Safe Care & Support Self Assessment Completed Theme 4 – Better Health & Wellbeing Self Assessment Completed Theme 5 – Leadership, Governance & Management Self Assessment Completed Theme 6 – Standards for Workforce Self Assessment Completed Theme 7 – Use of Resources Self Assessment Completed Theme 8 – Use of Information Self Assessment Completed

Clinical Adverse Event Report 2014

Count of Incident Type Incident Near Miss Slips/Trips/Falls 679 18 Treatment Incident 108 24 Medication Incident 95 15 Equipment/Devise Incident 49 40 Absconsion 39 Peri-operative/Perif -procedure Incident 28 7 Indentification/Records/Documentation Incident 28 29 Discharge Incident 15 Infection Control Incident 13 1 Unplanned Events 7 Blood Transfusion Incident 6 3 Other 6 3 Diagnosis Incident 4 1 Unexplained Injury/Unknown Cause 4 Consent/confidentiality Incidents 3 1 Radiation Harm 1 Self-Harm 1 Total 1086 142

Clinical Adverse Event Report 2014

• 406,631 episodes of patient care activity in CUH in 2014
• 1228 clinical adverse events reported ( 0.3% clinical adverse

rate – national average 2.9%)

• Patient Safety Culture Survey of staff highlighted that 53% of

staff surveyed CUH staff believe clinical incidents or near miss incidents are reported

• Data quality is key in the analysis of clinical adverse events

Recommendations

Area for Improvement Recommendation Data Quality (a) Incomplete incident report received to be returned to the line manager to ensure that all data is complete (b) (b) the progression of an electronic reporting system to allow for prompt reporting Adverse Incidents Trending of adverse outcomes to be undertaken

HIQA Report - Portlaoise

• An overview of the report was presented to the Executive Quality and

Safety Committee in May with a focus on the recommendations on governance.

• A large volume of the report is in relation to governance structures and

the report was critical of the governance structures in place in Portlaoise hospital.

• HIQA have identified in all their recent reports that the sustainable

delivery of safe, effective and reliable person-centred care depends on service providers having competent capacity and capability in areas of leadership, governance & management.

• There were 47 non compliances with National Standards at hospital level,

28 at HSE level and 9 at a governance level.

Human Resource

Sick Leave – April 2015

4.01 3.79 3.74 3.16 4.58 4.44 4.16 4.09 3.68 3.37 3.7 3.74 3.89 3.8 3.86 4.22

0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Jan Feb Mar April May June July Aug Sept Oct Nov Dec % Month

CUH - Total % Sick Leave 2014 v 2015

% 2015 Sick Leave % 2014 Sick Leave % Target

EWTD Compliance

(April Dashboard)

G

Challenges

• Recruitment of Nursing staff
• Management of Unscheduled Care

Implementation of Change Programme Initiatives

• Scheduled Care

Implementation of plan to meet waiting list targets –Hospital Group approach to maximise capacity

• Budget Control and Cost Containment measures
• Mental Health Service