A MEETING OF THE BOARD OF DIRECTORS
WILL TAKE PLACE ON TUESDAY 3RD JUNE 2014, 9AM
IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL
AGENDA
No
Item
1.
Apologies and Welcome
2.
To receive any declarations of interests
3.
To approve the Minutes of the meeting of the Board of
Directors held in public on 1ST May 2014
4.
To approve the Action Log in relation to progress to date
and review any outstanding actions
Sponsor
Ref
S Wragg, Chairman
14/06/P-03
14/06/P-04
Strategic Aim 1: Patients will experience safe care
H McNair
Dir of Quality & Nursing
Patient
attending
14/06/p-06 &
Presentation
To review progress on the Trust’s Mortality Ratios
Dr J Mahajan
Medical Director
Dr J Mahajan
Medical Director
8.
To receive and endorse the latest assurance report from
the Clinical Governance Committee
L Christon
Committee Chair
9.
To approve annual reports on safeguarding:
a) Adults
b) Children and Young People
10.
To receive and review monthly update on Nursing &
Midwifery staffing.
11.
To receive and review annual performance report on
implementation of the NHS Friends & Family Test
12.
To receive and note update on the AQuA action plan
5.
To receive and consider a Patient’s Story
6.
To approve the Research & Development strategy
7.
14/06/P-07
14/06/P-08
14/06/P-09
H McNair
Director of Quality &
Nursing
14/06/P-10
14/06/P-11
D Wake,
Chief Executive
14/06/P-12
Strategic Aim 2: Partnership will be our strength
13.
To note monthly report from the Chairman
14.
To note monthly report from Chief Executive
S Wragg
Chairman
D Wake,
Chief Executive
14/06/P-13
14/06/P-14
Strategic Aim 3: People will be proud to work for us
Strategic Aim 4: Performance matters
15.
To note progress on the 2014/15 budget plan
16.
To review the integrated performance report (month 1)
- including Emergency Care <4 hour pathway action plan
Cont/…
BoD Jun 2014: 00 PUM Agenda
S Diggles
Interim Dir of Finance
Verbal
Executive Team
14/06/P-16
No
17.
Item
Sponsor
In accordance with the Trust’s Standing Orders and Constitution, to resolve that
representatives of the press and other members of the public be excluded from the
remainder of the meeting, having regard to the confidential nature of the business to be
transacted.
Date of next meeting:
- 2nd July 2014, 9am, at Education Centre, Barnsley Hospital
Signed:
…………………………..
Chairman
Please see reference section at back of papers for key to business plan and glossary of terms/acronyms
BoD Jun 2014: 00 PUM Agenda
Ref
REF:
14/05/P-03
REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT
MINUTES OF A MEETING OF THE
BOARD OF DIRECTORS
ON 1ST MAY 2014
EDUCATION CENTRE, BARNSLEY HOSPITAL
PRESENT:
Mrs S Brain England OBE
Mrs L Christon
Mr S Diggles
Sir Stephen Houghton CBE
Dr J Mahajan
Mr F Patton
Mr D W Peverelle
Mr P Spinks
Ms D Wake
Mr S Wragg
Non Executive Director
Non Executive Director
Interim Director of Finance
Non Executive Director
Medical Director
Non Executive Director
Chief Operating Officer
Non Executive Director
Chief Executive
Chairman
IN ATTENDANCE:
Ms H Brearley
Mr J Bradley
Mrs L Christopher
Ms C E Dudley
Ms K Kelly
Mr R Kirton
Ms E Parkes
Ms J Pell
Director of HR&OD
Director of ICT
Associate Director of Estates & Facilities (arrived 9.15am)
Secretary to the Board
Director of Operations
Director of Strategy & Business Development
Director of Marketing & Communications
Head of Patient Experience (re Minute 14/80)
14/76
APOLOGIES & WELCOME
Members and attendees as noted above were welcomed. Welcomes were
also extended to Mr Diggles, attending his first meeting since being appointed
to the Board of Directors, and to Ms Kelly, who had recently joined the
executive team. Ms Pell was thanked for attending the meeting to give an
update on the Trust’s new complaints and compliments system.
The Chairman pointed out that the agenda remained structured against the
2013/14 strategic objectives, reflecting month 12 reporting. The agenda
would be aligned to the new objectives in future.
14/77
DECLARATIONS OF INTEREST
None.
14/78
MINUTES OF LAST MEETING
(14/05/P-03)
The Minutes of the meeting of the Board of Directors held in public on 3rd April
2014 were reviewed and accepted as a true record.
14/79
ACTION LOG
(14/05/P-04)
The action log, showing progress on matters arising from the last and previous
meetings held in public, was reviewed and noted. The following updates were
also noted:
• Minute 13/11 – Policy on Governors’ expenses
Ms Brearley advised that the first draft of this new policy had been
presented to the Executive Team, who had recommended a number of
amends. The revised draft was due for final review by the Executive Team
shortly before being presented to the Board for approval.
• Minute 14/51 – Governance review (Monitor guidance)
Mr Spinks confirmed that the Trust’s compliance with Monitor’s Quality
Governance Framework (QGF) and Code of Governance (the Code) had
been reviewed by the Audit Committee. As recorded previously, the
Committee had required further information on some points. Mr Spinks had
progressed work on the QGF with the Head of Governance and this was
expected to be completed shortly. It was agreed that work on the Code
should be referred to the interim Associate Director of Corporate
Governance.
The Board would require assurance on both guidance
documents when assessing the Trust’s Annual Governance Statement and
Annual Report & Accounts for 2013/14.
HB
DW (AK)
• Minute 13/182 – Hospital Standardised Mortality Ratios (HSMR)
It was noted that the minute should refer to revision of the action plan on
HSMR rather than development of a strategy plan. Dr Mahajan confirmed
that the team from the Advanced Quality Alliance (AQuA) had completed
their review of the Trust’s approach to HSMR, the report on which was
expected shortly. The outcomes for the AQuA review would enable the
action plan to be refreshed and a date for the action plan to be presented at
a workshop would be set shortly afterwards.
14/80
OVERVIEW OF REVISED COMPLAINTS SYSTEM
(Presentation)
Ms Pell introduced her presentation (copy attached), giving an outline of the
varied teams and services supporting the Trust’s response to and learning
from complaints and compliments from patients and the public, to ensure a
comprehensive approach to improving patients’ experience. Work was
continuing to improve triangulation with intelligence gathered from other
sources across the Trust, such as the quality and safety visits and the Friends
& Families Test (FFT). The presentation showed the range of issues the
teams dealt with and how, and Ms Pell emphasised that learning was shared
across the Trust and helped to inform and support service improvements as
well as continuously improve investigation and response systems.
The Board was pleased to note that the complaints processes had improved
greatly with the introduction of the new Datix system, making reporting easier
and more accessible for both the patients/public and staff involved.
It was noted that not every complaint required a formal response; many were
resolved at the ‘front line’ by PALS (patients advice & liaison service),
volunteers or ward staff. These were not mechanisms to avoid complaints but
enabled some concerns to be addressed immediately. The Board agreed it
was important that these were recorded alongside more formal complaints, to
ensure that all issues and trends were captured and any learning identified.
The Trust also received a lot of compliments, every one of which was
acknowledged by the Chief Executive, or the Chairman if received directly by
him, with well over 1000 recorded each year. This positive feedback was
shared with staff as well as the learning from complaints and concerns.
The Non Executive Directors sought further information on several aspects of
the system, including how similar trends could be identified across different
BoD June 2014: 03_05 BoD PUM
Page 2 of 12
JM
areas of the Trust, what action would be taken if/when the actions of a team or
any individuals were identified as repeatedly giving cause for concern and
how learning was shared across the Trust. Ms Pell showed a sample report
from the Datix system, which could be repeated for each area and service to
identify trends - by CBU or more widely - and reported on plans for a
complaints review group to be established to provide more support and Trustwide review. In terms of data sharing, Ms Pell affirmed that the quarterly
report (the “LFE” report – Learning From Experience) was shared with
commissioners too and her team would be pleased to work with them on any
issues. It was noted that Ms Pell also attended Governors’ meetings, to keep
them informed on the Trust’s work in this area.
Before leaving the meeting Ms Pell was thanked for providing an informative
presentation on the work and further plans of her team. The Board reiterated
its support for the work outlined and agreed that it was important people knew
they were listened to and that the Trust was willing to learn from their
experiences – good and bad.
14/81
MORTALITY RATIOS
(14/05/P-07)
Dr Mahajan presented the latest data on HSMR, Summary Hospital Mortality
Indicators (SHMI) and crude mortality ratios. Members were reminded that
the latter were presented to provide more up to date insight into the impact of
the Trust’s work on mortality ratios as HSMR and SHMI indicators were
published several months behind - latest data was reported to December 2013
for HSMR and September 2013 for SHMI. As predicted, the Trust’s position
for both SHMI and HSMR indicators was beginning to improve although its
HSMR remained the highest in the region and was still not acceptable to the
Board. Work continued to address this, as outlined in the action plan included
in the report, with the aim of reducing the Trust’s HSMR to 105 by January
2015. The data on crude mortality showed a continued downward trend, with
the Trust currently below the average rate for the region. With reference to
other key indicators within the report Dr Mahajan drew attention to the
recording of palliative care coding and co-morbidity, which remained largely
unchanged (although these too were expected to improve as the Trust’s
action plan made more impact); the relaunch of the sepsis care bundles
(supported by champions across the Trust), audit work ongoing to monitor the
impact of the action plan as it continued to be delivered and the external
review of deaths in December 2012 and April 2013 (outcomes due next
week).
The report and progress to date was noted and appreciated. Dr Mahajan
provided further information in response to questions from the Non Executive
Directors, including:
•
plans for the report to develop as more data became available, which
would enable a key question to be raised and answered in future: have any
avoidable deaths been identified?
•
the distinction between the rolling 12 months data (showing cumulative
totals) and the month by month data for HSMR. It was questioned,
however, whether the difference in reporting implied that the historic
position could have been significantly different than previously reported. It
was agreed that the 12 months historical data should be obtained
•
the increasing need for the work that was being carried out to be better
evidenced and/or more transparent; examples cited included sepsis (the
BoD June 2014: 03_05 BoD PUM
Page 3 of 12
JM
Medical Director was confident that checks for sepsis were being carried
out but not fully recorded) and co-morbidity (impact of proposed work not
clear).
The extensive work underway and progress to date was noted. It was
acknowledged that mortality ratios continued to be a complex issue and it
would be useful if the reporting could be simplified in some manner to make
the key issues, actions and outcomes clearer. The Chief Executive proposed,
and it was agreed, that assistance should be sought from the AQuA Team, to
improve reporting if possible. Dr Mahajan undertook to take this forward.
14/82
MEDICAL DIRECTOR’S QUARTERLY REPORT
JM
(14/05/P-07)
Dr Mahajan presented her quarterly report on activities and items of interest to
the end of April 2014, which was received and noted. She highlighted several
issues, including:
• the quality assurance framework for revalidation, introduced from 1st April,
and the additional reporting requirements for same - including quarterly
reports to the regional revalidation committee, annual reporting to the Board
(building on the regular reports already provided) and subsequent reporting
to NHS England;
• the latest monitoring for the European Working Time Regulation (EWTR),
which showed a disappointingly low level of completed returns, despite a
number of actions taken to encourage a better response. Whilst this was
not uncommon in many hospitals. Dr Mahajan affirmed that the Trust was
not in breach of its obligations under the EWTR as it was carrying out the
required monitoring and any potential breach rested with the junior doctors
but it did mean that the Trust did not have a full picture of actual working
hours to support the rotas. Dr Mahajan would be liaising with the Deanery
to gain further support on this and encourage greater uptake by the junior
doctors. Ms Brearley also assured the Board that her department was
pursuing and working with the doctors who were not completing their
returns for EWTR or working hours. It was agreed that information should
be sought on actual levels of completed returns, how other Trusts deal with
compliance and any learning from those with higher return rates. This
information would be presented in the next report.
JM
Dr Mahajan and Ms Brearley also reported on the latest visit from the
Deanery. Whilst not yet formalised, initial feedback on the day had been very
positive. The Deanery had seemed satisfied with the turnaround since their
last visit and that all of the conditions identified previously had now been met.
The Deanery had highlighted some outstanding examples of good practice, in
particular in relation to the approach to surgical on call, the support provided in
Trauma and Orthopaedics and the extended services in Medicine, which
provided valuable experience and training. A few small issues had been
flagged for further improvement but nothing of significant concern or requiring
immediate action. Linking back to the EWTR, Mr Spinks was pleased to note
that there was no suggestion of any evidence through the Deanery that
doctors were being pressured into working undue hours, which provided a
positive assurance.
Some points were raised in relation to the reporting on Research &
Development (R&D). Dr Mahajan explained that accruals in this context
related to the recruitment of patients for R&D studies; she would be pleased to
provide further information on this outside the meeting for Mr Spinks.
BoD June 2014: 03_05 BoD PUM
Page 4 of 12
JM
Mrs Christon drew attention to the good work in R&D, which would be useful
to highlight when reporting on improvements and to factor into the Trust’s
business planning. The Chairman was pleased to note that feedback from the
R&D team’s evaluation project on the Emergency Department would be
shared with the Board shortly. Another report from the R&D team was also
due to be presented at the June meeting.
14/83
NON CLINICAL GOVERNANCE & RISK COMMITTEE
(14/05/P-08)
As Chair of the Non Clinical Governance & Risk Committee (NCGRC),
Mr Patton presented the report on the Committee’s latest meeting. In addition
to an update on areas of good progress, it identified a number of aspects that
the Committee could not give assurance on at this time pending further work.
These included the Board Assurance Framework (BAF) (an updated version
was required) and the governance structure. Work had been requested on
several issues, including winter breaches to gain learning for the coming
winter, a Trust-wide workforce profile (similar to the data previously received
by the Board for nursing and midwifery staff), the risk register and the deep
dive review on DNAs (did not attends) requested previously.
Mr Patton also advised that where CBUs had not achieved their appraisal
target for 2013/14, the Committee would be requesting the Clinical Director
(CD) to attend the next meeting and provide further information on their
position. The Chief Executive advised that the Trust remained among the top
20% in the country in terms of appraisals overall and it was acknowledged that
any performance around 80-90% was still a good achievement even if below
the Trust’s own target of 90%+. The Chairman reminded the meeting that any
proposal to lower an internal target would be challenged by the Board,
reflecting its aspirations for continuing improvements and higher standards.
It was acknowledged that some of the issues raised by the NCGRC were
operational matters and should be addressed via the performance framework
rather than in a governance committee. This further illustrated the need for a
review of the governance structure (ongoing – as evidenced in next agenda
item) and would be redressed in the future but the report reflected the latest
position and the need for assurance and action on the issues currently being
reviewed through the NCGRC.
Mr Patton reported that the Committee had reviewed and approved the
following revised policies:
•
•
•
•
•
•
Clinical Professional Registration Policy
Employments Check Policy
Home Working Policy
Inclement Weather Policy
Maintaining High Professional Standards in the Modern NHS Policy
Retirement Policy
Based on the Committee’s recommendation, all of the above Policies were
ratified by the Board.
The Committee had also reviewed one new policy - for Employer Based
Awards for Clinical Excellence to Consultants, and recommended it to the
Board for approval. Mrs Christon reminded members of the reason for the
new policy, which had extensively revised the previous policy on clinical
excellence awards for consultants (CEAs) following the problems that had
been experienced last year. She confirmed that the new policy addressed all
of those issues and would be more positive. The Chairman thanked
BoD June 2014: 03_05 BoD PUM
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JM
Ms Brearley and the team who had worked diligently to ensure input and
support from everyone involved, both within and outside the Trust. The Policy
was approved.
14/84
GOVERNANCE COMMITTEE STRUCTURE
(14/05/P-09)
The Chairman presented the report, which included external commentary on
the Trust’s governance structure and a number of recommendations for future
changes, based on extensive review of committee reports and discussions
with the executive team. Whilst comments from Non Executive Directors had
not been sought at this stage, the Board was assured that input from all
Directors would be essential for the next stage before any changes could be
finalised. Members were reminded of other governance review work currently
ongoing, the outcomes of which would also help to inform any decisions on
the Trust’s governance structure moving forward and the appointment of an
associate director lead on corporate governance, who would be in post
shortly. It was agreed that no changes should be implemented until all
information was available but it was accepted that the recommendations from
the work needed to be identified and implemented swiftly, to understand the
role and purpose of the governance committees and how they would fit with
the wider governance requirements at every level and alongside the
performance framework to ensure appropriate information and escalation.
The review would also consider the structure of each committee and
appropriate support. Mr Patton and Mr Spinks reiterated their concerns about
the current support arrangements, often relying on the Committee Chairs for
elements that should be more appropriately provided through executive and/or
administrative support. Mrs Brain England stressed the importance of
distinction between operational issues, which should remain with the
management team and leadership/strategic issues requiring Board direction,
underpinned by robust assurance to the Board on delivery. It was confirmed
that all of these aspects would be integral to the review.
The Chief Executive advised that the outcomes of the independent review
being led by KPMG should be available later in the month. Recommendations
were also awaited from Monitor.
The extensive review work ongoing both internally and externally was
appreciated. Collectively, it would help the Board to build on existing systems
to give stronger assurance and earlier warning of risk issues. It was agreed
that a workshop session should be scheduled when the reviews were
complete to enable the Board to develop a governance structure to take the
Trust forward. The Board agreed that it was important the work was
progressed quickly and was supported by a robust BAF for this year.
Presentation of the 2014/15 BAF would be required for the Board and Audit
Committees’ next meetings.
DW (AK)
As an early step in the anticipated changes, the Chairman reported on recent
discussions regarding the Investment Board. The Finance Committee had
proposed that the Investment Board should cease. This was agreed by the
Board. It was further agreed that the executive team needed to identify how
matters previously referred to the Investment Board should be managed in
future, some of which would be directed to the Finance Committee, subject to
appropriate criteria to be determined. Mr Kirton was requested to prepare a
paper on thresholds and guidelines for referrals to the Finance Committee, to
be presented to the next meeting of the Committee later in the month. This
would also need to be reviewed by the executive team and, when agreed,
BoD June 2014: 03_05 BoD PUM
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BK
disseminated to the CBUs.
14/85
TRUST VISION, AIMS AND OBJECTIVES
(14/05/P-10)
For completeness, Mr Kirton formally presented the business plan objectives,
vision and aims for 2014-16. These had been identified by the Board and
launched across the Trust in April and would be underpinned by the two year
(and five year) strategic plans currently being developed in co-operation with
Monitor and KPMG. In light of the Trust’s current position, the two year plan in
effect would be used as a turnaround plan; the five year plan would focus
more on benchmarking and future direction of services. In terms of
timeframes, it was noted that the two year plan should be finalised by the first
week in June. The submission date for the five year plan would be subject to
further discussion with Monitor. Sir Stephen stressed the importance of
ensuring that the agreed objectives formed the template for in-year monitoring
of progress and delivery of the plan. The Board agreed and further agreed
that it was more important to produce a robust plan for 2014-16 rather than
one driven by external deadlines.
The Chairman reported his observations on the recent launch of the plan
within the Trust to ensure staff engagement; he believed this had been very
effective.
14/86
PATIENTFLOW ACTION PLAN
(14/05/P-11)
Ms Kelly presented the draft patientflow action plan. It was based on the
outcomes of the review carried out in January 2014, to assess the balance of
patients being seen and treated in the right place at the right time. The key
aims for the plan included admission avoidance schemes (working with teams
both internal and external to the Trust), to reduce length of stay and to release
beds. Mrs McNair advised that the new CBU structure would provide better
support to deliver the plan.
Mrs Christon complimented Ms Kelly on the comprehensive plan presented.
The Board endorsed the work to date and noted that (i) the finalised plan
would be presented at the next meeting and (ii) subject to affordability, it was
planned to repeat the bed utilisation review in 12 months to audit
effectiveness.
14/87
KK
2014/15 BUDGETARY POSITION
Mr Diggles advised that the 2014/15 budget remained subject to outcomes
from the ongoing investigations (internal and external) and contract
negotiations with Barnsley Clinical Commissioning Group (CCG). A draft
position was being developed to ensure a robust financial plan, currently
forecasting a £13.5m deficit for 2014/15. The plan would be subject to review
with KPMG and Monitor before being finalised. It would encompass a range
of improvement plans and learning from the investigations and would be
extended into a two year plan. Whilst the Trust was behind normal timelines
in terms of budget planning, Mr Diggles advised that the budget would be
finalised by the first week in June (latest) and possibly ready for sign off at the
Board’s next meeting.
Mr Diggles also advised that in the absence of a signed contract, the
commissioners were still paying the Trust for its work. They were paying in
advance at the moment, largely at current year revenue levels based on the
draft agreement. This support was appreciated.
BoD June 2014: 03_05 BoD PUM
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SD
For clarity Mr Diggles confirmed that whilst the formal plans and budget were
not yet approved, the Trust was already taking actions to save costs. The
cost improvement plans identified to date were fully documented and had
been reviewed at both executive level and by the Finance Committee. Where
practicable work had commenced although some cost improvement
programmes (CIPs) were scheduled to start later, depending on agreed
phasing to achieve each plan. Plans for effective control management and
reporting on all CIPs were also being established. The Chief Executive
reminded the meeting of the CIP meetings held monthly, which Non Executive
Directors were welcome to attend. Mrs Christopher and Mr Kirton also
advised that work was continuing to develop further CIPs for 2014/15 and
2015/16 and to backfill any gaps that might unavoidably arise as the year
progresses. In addition Mr Diggles confirmed that the Trust had received
some short term support from central funding.
The Chairman referred to staff morale within the Trust, which had been
affected by the current position, and the Board was mindful of this. Feedback
to date had quite positive; staff were appreciative of the Board’s openness and
the way in which they had been kept informed of the situation. The Chief
Executive also reported on positive feedback from CD applicants, all of whom
had been every positive and willing to be involved with and help to lead the
Trust’s plans for recovery.
14/88
INTEGRATED PERFORMANCE REPORT
(14/05/P-13)
The latest report on activity, finance, quality and workforce to the end of
2013/14 (month 12) was received and noted. Lead Directors expanded on
their respective sections:
Activity
It was noted that the majority of indicators had been achieved for the month
with the exception of the 95% target for A&E (95% achieved for the month of
March but not for the quarter or full year) and breast symptomatic.
• A&E (<4 hours): performance had improved in March – to 95% - and it was
expected that the target would be met in April too. Mr Peverelle referred to
the emergency care action plan appended to the report, which showed
actions and continuing plans to drive further improvements and support for
the A&E target. The progress in March and April showed the increased
focus across the Trust and the impact of a number of key actions, including
the Clinical Decision Unit/CDU (seeing more patients), the support of the
new service manager in the CDU and the Director of Operations,
effectiveness of the full capacity protocol, better use of the out of hours GP
service (now internally managed), and introduction of ambulatory care
pathways (albeit still limited at present largely due to lack of consultant
capacity within the acute medicine unit). Further work was ongoing as
outlined in the plan to support the trajectory of above 95% throughout the
year and it was intended to revise and refresh the plan itself shortly.
Mr Peverelle confirmed that further information on the longest wait recorded
in the Emergency Department was available.
Increased night time
presentations continued to be an issue; access for a bed on the children’s
ward had also factored this month. He would circulate more data to
members shortly.
• Demand on the breast symptomatic clinic had increased due to a recent
national campaign. Whilst the Trust had struggled to achieve this target, it
BoD June 2014: 03_05 BoD PUM
Page 8 of 12
DWP
had not affected overall performance. Mr Peverelle confirmed that the Trust
did have advance notice of all campaigns via the national programme and
the Trust made all possible plans in readiness but this clinic remained under
pressure. Earlier plans to increase the number of clinics per week had not
come to fruition and the clinic had faced a significant increase in referrals.
Other issues highlighted in the report included
•
the report on DNAs (did not attend): further analysis was required to help
develop an effective action plan.
•
Interpreters: Mrs McNair confirmed that interpreters were available at all
times; the delay in the reported case was unusual and might have arisen
around translation.
Members were reminded that the monthly report on the emergency care
pathway action plan would be shared with Monitor and it was approved for
submission.
Quality
Mrs McNair pointed out the year end reporting on MSSA and E-coli and also
referred to the final outcomes for MRSA and C.Difficile - at zero and 20 cases
respectively, the latter being another year on year reduction. The “red” rated
issues for quality all reflected an increase in serious incidents (SIs). It was,
however, difficult to compare like for like against 2012/13 as the new system
had contributed to an increase in reporting, as had the inclusion of grade 3
and 4 pressure ulcers. Mrs McNair advised that some of the reported ulcers
were inevitable due to a patient’s health on admission and some were largely
unavoidable at end of life; also, as reported previously, following investigation
not every case remained attributable to the Trust although it was important to
record them from the outset. With regard to the pressure ulcers, it was agreed
that it would be useful to expand the report to show actual cases attributed to
the hospital; this would help to make it clearer as to when the issue – and
requirement for action - rested with the Trust.
The Chairman pointed out the death attributed to tuberculosis (TB), which had
been raised by the Governors. It was disappointing to see this in these
modern times but Mrs McNair advised that TB was a growing problem
nationally, particularly in heavily populated areas such as London.
Mrs McNair also responded to a query on the patient safety thermometer.
She reminded the meeting that it reflected a point prevalence – a snapshot of
a particular time on one day each month – which could therefore give rise to
imbalanced reporting. The data on VTE (venous thromboembolism) illustrated
this, showing an uplift in VTEs on the thermometer although the long term
indicators and trends on related aspects, such as VTE risk assessment, more
accurately reflected the Trust’s improved performance.
Mrs McNair also confirmed that the Trust’s financial position had not been
logged as two SIs; the report showed this twice in error but against one SI
number.
Workforce
It was noted that, whilst the position remained good when assessed against
national comparators, the Trust had not met its year end targets for sickness
absence, mandatory training or appraisals. Ms Brearley advised that the new
member of staff appointed to support work on sickness absence had already
carried out an initial assessment and had identified a need for more training
and awareness on certain aspects on the processes and protocols for
BoD June 2014: 03_05 BoD PUM
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DWP
HM
management and reporting/recording of sickness absence. The healthy
workplace group had been reinvigorated recently and its work would also be
supported by the Wellbeing Act launched a few weeks ago. A robust action
plan was being developed to address these issues for 2014/15.
Appraisals would become more integrated to the performance framework in
2014/15. Ms Brearley believed that the new system, which was values and
performance based, would be more meaningful and useful to staff. Quality of
the appraisals remained equally as important as the uptake; to provide data
on this every member of staff was being asked to undertake a short survey as
soon as their appraisal had been registered as complete. The staff element of
the Friends & Family Test was due to be implemented this quarter and would
also provide useful feedback. Additionally the executive team had recently
agreed that the next staff survey should be rolled out to all staff, not just a
random selection.
For completeness, Ms Brearley referred to the query raised last month where
a team from one area believed they had a better record of appraisals than the
reported data provided to the Quality & Safety visiting team. This had been
checked and it was confirmed that the team was actually 94% compliant. It
was likely that the information on display had been out of date.
Finance
Mr Diggles briefly expanded on each of the indicators flagged as red, key
points from which included a reduction in the Trust’s continuity of service risk
rating (CoSRR) to 1, operating cash <10 days and a £7.4m deficit for 2013/14,
subject to audit; income had increased against plan on both a contract and
other income basis. The main reason for the variance in the deficit against
last month’s report was due to adverse pay position and underachievement
against the CIPs. Pay reflected a large amount of unplanned agency spend,
the requirement for which had not been taken fully into account in the financial
plan.
Mr Diggles assured the Board that this had been factored in for
2014/15 and Ms Brearley advised that an improved contract had been
secured with the agency to ensure best rates – possibly unparalleled
elsewhere in the region. Mr Diggles also advised that the additional CIPs
requested by the Finance Committee at the mid year review had made better
achievements than earlier schemes but had still not been sufficient. Cashflow
was behind plan too, reflecting the deficit traded through in the financial year;
over performance on the Trust’s capital schemes had also impacted on it. As
reported earlier, support from central funding support had helped the Trust to
meet pressing obligations and still manage its credit position carefully.
Whilst the report was noted and accepted, Sir Stephen reiterated his previous
request for greater narrative to be included in future reporting, at least
periodically, to enable clearer sight of the financial position and planned
actions to redress shortfalls. Mr Diggles agreed and had already planned to
revise future reporting for both the Board and the Finance Committee.
As a point of accuracy, Mr Spinks requested that the financial table be
amended to make it clearer that the Statement of Comprehensive Income
included reference to the agency spend and overspend on non pay costs and
CIPs. This was agreed. Mr Spinks also requested more information on the
revaluation of the Trust’s estate: it showed a significant reduction, which had
not been expected and was seeking clarification over the accounting
treatment of the revaluation too. Mr Diggles undertook to review this further
but emphasised that any subsequent changes would be an accounting
adjustment rather than any impact on outcomes.
BoD June 2014: 03_05 BoD PUM
Page 10 of 12
SD
SD
SD
The Chairman referred to the non delivery of the CIPs in 2013/14. The Board
had noted the plans for 2014/15 but required further explanation regarding the
2013/14 outcomes. Mr Peverelle advised that, retrospectively, it could be
seen that the initial plans had not been supported by sufficient detail and
understanding. Concerns had been raised by some of the executive team at
the time but due to the backloading of the problem, the shortfall was not fully
identified until later in the year. It was an important lesson for future plans.
Mr Spinks advised that there would be further insight on the 2013/14 CIPs
from an internal audit report (currently in draft) and the work being undertaken
by KPMG. It was noted that these concerns had also been raised at Board
and Finance Committee in year but without sufficient response at that time.
The Chairman emphasised the need for greater assurance for this year’s
plans to prevent any recurrence, which would be unacceptable. Mr Kirton
advised that unprecedented levels of change were being introduced to monitor
the progress of CIPs better – at both executive team and CBU level –
throughout the year. The plans for the new system would be subject to review
by KPMG to ensure that the right approach had been identified. Work was
ongoing with the teams across the Trust to ensure they were ready for the
new approach. Mrs McNair also stressed the importance of ensuring that
focus remained on quality and patient safety too and advised that this would
be supported by closer review of risk registers etc, being introduced alongside
the performance framework.
14/89
COUNCIL OF OVERNORS’
(14/05/P-14)
The latest agenda (April) and approved minutes (February) from the Council
of Governors’ General Meetings were received and noted.
14/90
CHAIRMAN’S REPORT
(14/05/P-15)
The Chairman’s report was noted and accepted. It provided an overview on a
number of activities since the last Board meeting, items of interest, and the
revised Terms of Reference for the Remuneration & Terms of Services
Committee, which were endorsed by the Board.
14/91
CHIEF EXECUTIVE’S REPORT
(14/05/C-08)
The Chief Executive’s report was received and noted, providing informative
updates on a number of internal, regional and national issues.
The Chief Executive also provided a brief update on the ongoing contract
negotiations with the Trust’s main commissioners. The Trust was not yet in a
position to sign the agreement and discussions continued. This was
frustrating for both parties but the Trust still hoped to secure a mutually
acceptable agreement rather than seek recourse to arbitration, as it wanted to
maintain a robust and productive relationship with the CCG. Dr Mahajan
advised that the proposal for the Trust’s work on 7 day services had not been
discussed in any detail at the SSG meeting (a sub-group of the community’s
Health & Wellbeing Board); this was unexpected and could give rise to a
delay.
Members were reminded that the Q4 submission to Monitor had been
reviewed at the Board’s workshop on 24th April and approved for submission
with a declaration against the continued A&E breach and a reduced CoSRR
(to 1). The Board formally ratified the submission.
BoD June 2014: 03_05 BoD PUM
Page 11 of 12
14/92
QUARTERLY COMMUNICATIONS UPDATE
(14/05/P-17)
Ms Parkes presented the final quarterly report for 2013/14, which provided a
summary of the status against the agreed action plans for the communications
team. The report showed that the plans had been fully achieved. A new plan
was being developed for 2014/15. Key achievements in 2013/14 had included
the new branding for the Trust (considerable positive feedback to date),
introduction of a regular monthly column from the Chief Executive in the
Barnsley Chronicle (valued and important), and a notable increase in the
number of positive stories issued in year.
Ms Parkes also reported the annual declaration on promotional spend in
accordance with the NHS Promotional Code – at zero, This was noted and
endorsed by the Board. The Chairman thanked the Communications team for
the good progress made throughout the year, which was all the more valuable
when faced with the current situation.
14/93
ANY OTHER BUSINESS AND DATE OF NEXT MEETING
a) Public Comments
Mr Conway, a staff governor, had been involved in one of the quality &
safety visits recently. He had appreciated the opportunity and the
discussions with patients and clinical staff. He asked, however, if the visit
should include the opportunity for talking to support staff too and asking a
more general question about how the trust assessed the quality of its
communications, and how staff evaluated their own communications with
colleagues and patients. Ms Brearley advised that some of this would be
picked up through the staff survey and offered to meet with Mr Conway
outside the meeting to explain further. Ms Parkes also advised that a
greater awareness of how things were said and presented to others had
also been featured as one of the core elements of the recent brand launch
and was included in the guidance; her team would be focussing on seeing
improvements too.
b) Date of next meeting
The next meeting of the Board of Directors was confirmed for 3rd June
2014, commencing at 9am.
In accordance with the Trust’s Constitution and Standing Orders, it was
resolved that members of the public be excluded from the remainder of the
meeting, having regard to the confidential nature of the business to be
transacted.
BoD June 2014: 03_05 BoD PUM
Page 12 of 12
Learning from Experience
at Barnsley Hospital
Jill Pell
Head of Patient Experience
Learning from Patient
Experience - Overview
• Complaints
• Concerns
• Compliments
• Comments/Feedback
• Implementation of NHS Friends & Family Test
• Patient surveys
1
Patient Experience
Activity for 2013-14:
Complaint
Advice/
Information/
Support
Compliment
Concern
Feedback
Quarter 1
70
74
37
259
7
447
Quarter 2
80
132
52
324
9
597
Quarter 3
60
128
46
291
14
539
Quarter 4
69
153
50
333
13
618
Totals:
279
487
185
1207
43
2201
2012/13
245
636
N/A
927
N/A
1808
Complaints – Severity Rating
• Overall in 2013/14 - 279 formal complaints were received by the
Complaints Department.
• To date 245 of these complaints have been responded to.
Risk Rating of Opened complaints
Q1
Q2
Q3
Q4
Low Risk (1-3)
15
13
14
26
Moderate Risk (4-6)
31
39
34
30
High Risk (8-12)
23
28
13
13
Extreme Risk (15-25)
1
0
0
0
Total
70
80
60
69
Total
68
(24%)
133
(48%)
77
(28%)
1
(0.4%)
279
2
Themes from Complaints
from annual data 2013/14
• Care and clinical treatment (63%).
– Diagnosis & assessment – Incorrect diagnosis / lack of
diagnosis
– Treatment – Lack of treatment
• Communication (20%).
– Communication – staff attitude
• Access, admission, discharge & transfer (11%).
– Appointment – delay/cancellation of OP appointments
– Admission – delay in admission
– Discharge – inappropriate discharge
Complaints – Response Times
• On average 42% of complaints were closed within the
timeframe agreed with complainants/families.
Response Times to closed complaints
Q1
Q2
Q3
Q4
Total
within 25 working days
9
10
9
10
38
within 25-35 working days
10
23
16
14
63
within 36-45 working days
6
15
15
12
48
over 45 working days
1
15
21
28
65
Average number of working days
taken
29
38
41
51
40
3
Progress
• Integrated reporting:
– Statistical data has been shared across the Trust.
– Monitoring of emerging trends & themes.
– Evidence used to inform new training package on
communication skills.
– Structured data capture has enabled us to produce
detailed reports for specific ward areas.
– Valuable data to inform Quality & Safety visits.
– Data can be drilled down to clinical area by
subject/sub subject.
Complaints Process
ACTION PLAN FOR IMPROVEMT
Action Plan Agreed by Trust Board
• Investigator Resource Packs
• Introduction of systems to support internal and/or external review of
complaints. (June)
• Update and further development of training to include an e-learning
package for all staff. (July/August)
• Closer performance management of agreed investigation timeframes.
(CBUs & Complaints Team)
• Clear escalation process through CBU & senior management
structure
• Integration into wider quality assurance framework.
• Improved action planning and implementation of lessons learnt.
• Regular reports to Trust Board.
4
COMPLAINTS PERFORMANCE – IMPROVEMENT
PLAN
Closer performance management against KPI by CBUs
and Complaints Team, to address:
QUALITY, TIMELINESS & ACTION PLANNING
• Monitoring of response timeframes.
• Closer performance management against Complaint Resolution
Plan (i.e. agreed timeframes and agreed issues of investigation)
• Quality of investigation (statements and evidence)
• Quality of the response and implementation of agreed actions.
• Monitoring of re-opened cases.
• Action planning and reporting on key themes from feedback to
influence and improve the care we provide.
PALS Front Line Service
• 1207 Concerns were recorded during the year.
• 487 logged requests for advice, support &
feedback
• 912 Interpreting & translation requests.
• PALS/Patient Feedback Volunteers – FFT/Open
& Honest Care
• Support to voluntary services.
• Way-finding & Meet and Greet
• Quality Visits
• FFT & Patient questionnaires
• Dementia
• Learning Disability week
• PLACE
5
Themes of Concerns
• Communication – (33%)
– Communication with the patient
– Communication with family relative
– Staff attitude
• Access, Appointment, Admission, Discharge
& Transfer (23%)
– Appointments – delays & cancellations
– Admission - information
– Discharge – inappropriate discharge
• Clinical Care & Treatment (15%)
– Care
– Diagnosis and Assessment
Compliments
• 185 formal letters of compliment or appreciation received
(all formally acknowledged by the Trust’s Chief
Executive)
– Compliments received mainly registered thanks for the clinical
care provided in both in-patient and out-patient areas of the
hospital.
• New reporting system introduced for ward/department
areas to feedback the number of thank you cards and
gifts adopted. Although not all areas have participated,
areas have reported receiving:
– 1,444 thank you cards
– 1,494 gifts ranging from a box of chocolates to TV’s and
charitable donations.
6
Communication, consent, Confidentiality and Interpreting
Extract from
CCCP ‐ Communication
Statistical
Staff Attitude
Analysis to date Communication with the patient (written/verbal)
of Complaints & Communication between staff teams/departments
Communication with family/relatives
PALS cases for
Communication re: discharge planning
Language skills of staff
Communication, CCCP ‐Consent
Consent,
Consent to treatment
Consent not gained
Confidentiality
Lack of understanding of consent
and Interpreting: CCCP ‐ Confidentiality
Confidentiality of information
Breach of confidentiality
CCCP ‐ Interpreting & Translation
Access to interpreting services
Poor standard of interpreter
TOTAL
Q1
Q2
Q3
Q4
108
18
52
4
31
3
0
0
0
0
0
4
0
4
0
0
0
142
31
64
8
34
5
0
2
1
0
1
3
0
3
0
0
0
121
23
66
2
29
1
0
0
0
0
0
3
2
1
0
0
0
134
27
69
4
31
2
0
0
0
0
0
3
0
3
0
0
0
112
147
124
137
PALS
Complaints
455
71
238
16
119
10
0
2
1
0
1
6
2
4
0
0
0
50
28
13
2
6
1
0
0
0
0
0
7
0
7
0
0
0
463
57
Final Annual Data:
520 in total
Positive Actions from
Negative Feedback
• Concerns around communication and care on Care of The
Elderly Wards & lack of information for both patients and their
carers.
• As a result of both this feedback and the work of the King’s Fund,
Project, Care of the Elderly have set up the Sugar Cube Café. The
aim of which is to improve the well being of our elderly patients whist in
hospital by helping to promote their independence, enhance social
interaction, encourage eating and drinking and to facilitate improved
communication between patients, relatives and nursing staff.
• Additional resources for Elderly Care Specialist Nurses.
7
Positive Actions from
Negative Feedback
• Learning Disability Awareness -Training & LD Week, specific
actions.
• Meet & Greet (front of house)
• Expansion of volunteering – we now have 250 volunteers
registered.
• Patient Feedback Volunteers
• Communication skills training
• Informed new wayfinding & signage system.
• Development of patient feedback questionnaires.
• PLACE & Quality Visits
Qualitative Feedback
“All staff on all shifts were
extremely kind, caring, supportive
and cheerful. Nothing was too
much trouble for any of them at any
time of day or night. They were
prepared to answer any questions
and provide information about my
condition and procedures.”
“felt I was forgotten about when I
moved from ward 31 but was
dealt with quickly once sorted”
Made to feel
safe and
welcome
“very friendly &
approachable staff
10/10. Cleanliness
10/10. Nothing too
much trouble”
Staff need to listen to relatives’
views and understand that they
do sometimes know more about
the patient.
(sleep-out on ward 14)
8
Any Questions
9
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
SUBJECT:
BOARD ACTION LOG
DATE:
JUNE 2014
REF:
14/06/P-04
Tick as
applicable
PREPARED BY:
For decision/approval
Assurance
For review

Governance
For information

Strategy
Carol Dudley, Secretary to the Board
SPONSORED BY:
Diane Wake, Chief Executive
PRESENTED BY:
Stephen Wragg, Chairman
PURPOSE:
STRATEGIC CONTEXT
Tick as
applicable


2-3 sentences
QUESTION(S) ADDRESSED IN THIS REPORT
CONCLUSION AND RECOMMENDATION(S)
The Board of Directors is asked to:
a) note and approve reported progress to date, and
b) review any outstanding actions.
BoD June 2014: 04_Action log
Page 1
Subject:
Ref: 14/06/P-04
Board Action Log
ACTIONS ON PUBLIC AGENDA
Meeting date
& Minute ref
May 2014
14/81
May 2014
14/84
May 2014
14/87
Mar 2014
14/54
Mar 2014
14/C/21
Feb 2014
14/33
Jan 2014
14/06
Item
Mortality Ratios
Governance review
Action
a) Reporting format/style to be
reviewed following
consultation with AQuA
b) Historic data for HSMR to be
obtained and circulated
2014/15 Board Assurance
Framework to be developed for
next Audit Committee and Board
meetings.
2014/15 budget plan to be
finalised early June
Integrated performance Peer comparison data to be
- workforce
included in future reports
Advancing quality
Regular updates to be provided
Alliance Action plan
Performance Report
New reporting format to be
- general
implemented from April 2014
Quality Account
New reporting format for quality
- quality and
and performance being developed
performance reporting – for use from April 2014
Budgetary position
Owner
Medical
Director
Assoc Dir of
Corporate
Affairs
Interim Dir of
Finance
Director of
HR&OD
Chief
Executive
Executive
Team
Executive
Team
Action taken
a) Ongoing:
agenda item 7
refers.
b) Appended to
agenda item 7
Agenda item C-4
refers (presented in
private session due to
development stage
and further work
required)
Not available for Audit
Committee due to
unforeseen
circumstances
Agenda item 15
refers (verbal update)
Agenda item 16
refers
See agenda item 12
See agenda item 16
for first reports (April),
subject to further
development in year
ACTIONS COMPLETED & CLOSED SINCE LAST MEETING
Meeting date
& Minute ref
Item
Action
i) data on long waits in the
emergency department to be
circulated to Board members
ii) monthly EPAP report to be
submitted to Monitor
a) estate valuation to be
reviewed
b) explanation of SoCI to be
revised (month 12 report)
c) future reporting to include
greater narrative
May 2014
14/88
Performance report
- Activity
May 2014
14/88
Performance report
- finance
Mar 2014
14/49
Emergency Care
Pathway action plan
Outcomes of research on ED
admissions to be shared with
Board when available.
Feb 2014
14/33
Performance Report
- workforce
New reporting format for
workforce issues being explored
further through NCGRC
BoD June 2014: 04_Action log
Owner
Action taken
a) Completed
Chief Operating
– by email 28/5
b) Completed
Office
– by email 2/5
Interim Director
of Finance
Completed; a&b
reviewed for annual
report. (c) included in
finance reporting.
Research project
Chief Operating
completed; (draft)
Officer/Medical
report circulated by
Director
email 28 May.
Director of HR &
Agreed: ongoing via
OD / Chair of
NCGRC
NCGRC
Page 1
ROLLING TRACKER OF OUTSTANDING ACTIONS
Meeting date
& Minute Ref
May 2014
14/82
May 2014
14/84
Item
Action
Medical Director’s
Comparative data and good
report
practice re returns and compliance
– EWTR/Junior Doctors in other trusts
Criteria/guidelines to be developed
for referrals to Finance Committee
Governance review
following dissolution of the
Investment Board.
(red = overdue)
Owner
Medical
Director
Action taken
Due for next quarterly
report (August)
Dir of Strategy For review at next
& Business
Finance Committee
Development meeting (June)
Patient Flow action plan
To be finalised and re-presented to Director of
the Board for approval.
Operations
Originally due June;
deferred to be
included with wider
action plan supporting
patient safety.
April 2014
14/65
7 Day services
Actions to be implemented if
business case approved: outcome Medical
of application to CCG to be
Director
advised.
Presentation to CCG
Governing Body due
12 June 2014
Mar 2014
14/43
Review of staffing and skillmix to
Late admissions:
be undertaken to ensure
Emergency Department
appropriate cover at all times
Mar 2014
14/51
Governance review
(Monitor documents)
Referred to Audit Committee
(March 2014)
- May: confirmed QGF actions
being addressed; Code of
Governance queries to be
referred to Interim Assoc Dir of
Corporate Governance
Mar 2014
14/54
Review of shared pathways to be
Integrated performance
presented when SLA review
- activity
complete.
Feb 2014
14/32
CGC
May 2014
14/86
Jan 2014
14/10
Review of Terms of Reference to
be progressed for implementation
from April 2014.
a) Inreach model for AMU to be
refined to ensure consultant
Emergency Care 4 hour
ownership of each patients’
action plan
care
b) Structure of AMU to be
reviewed
Chief
Operating
Officer
Review ongoing –
outcomes due April
(report to Board
shortly)
Audit Chair /
Dir of Nursing
& Quality /
Assoc Dir of
Corp Gov
Further clarification
requested on some
points
Dir of Finance
& Info / Chief
Operating
Officer
Chair of CGC/
Dir of Nursing
& Quality
Medical
Director (a)
Chief
Operating
Officer (b)
Ongoing: outcome or
SLA review
anticipated June/July
Awaiting outcome of
governance review
a) Review
completed;
subject to funding
b) Part of 2014/15
CIP programme
Jan 2014
14/14
Integrated Performance Future reporting on EPR to include
Dir of ICT
- transformation
timelines
Will be reflected in
next report on EPR
Nov 2013
13/299
Integrated Performance Options for review of CQUINs to
- Finance
be progressed with CCG
Ongoing
Oct 2013
13/260
System for appointment letters to
be reviewed to ensure timely issue
Chief
and reduction in DNAs.
Integrated Performance
- Report on DNAs presented to
Operating
- activity
NCGRC (February) not accepted: Officer
further report requested (NCGRC
April 2014)
Aug 2013
13/211
Chairman’s report
- Governors’ request
BoD June 2014: 04_Action log
Protocol for Governors’ expenses
to be developed, for approval via
Executive Team and agreement
with Council of Governors
Dir of Finance
& Information
nd
Detailed report (2
request) due to
NCGRC June 2014
Draft policy agreed by
Exec Team; to be
reviewed at June
Director of HR
NCGRC and shared
& OD
with Governors for
comment, prior to
Board approval (July)
Page 2
Meeting date
& Minute Ref
July 2013
13/182
July 2013
13/188
Dec 2012
12/306
Item
Action
Owner
HSMR
Strategy to be developed
Medical
Director
Performance report
Concerns for the Elective Care
and Working Together CIPs to be
recorded on the Board Assurance
Framework
Dir of Finance
& Information
NCGRC Assurance
report
Process for development, approval
Dir of Nursing
and dissemination of policies to be
& Quality
reviewed (“policy on policies”)
BoD June 2014: 04_Action log
Action taken
To be progressed via
Board workshop
(2014), following
AQUA review work.
Will be added to
revised BAF when
finalised
May update: work
progressing, final
policy due to be
presented at NCGRC
meeting June 2014
Page 3
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
14/06/P-06
SUBJECT:
RESEARCH AND DEVELOPMENT STRATEGY
DATE:
JUNE 2014
Tick as
applicable
PURPOSE:
PREPARED BY:
Tick as
applicable
For decision/approval
Assurance
√
For review
Governance
For information
Strategy
√
Dr Christine Smith, Director of Research and Development
SPONSORED BY:
PRESENTED BY:
Dr Jugnu Mahajan, Medical Director
STRATEGIC CONTEXT
Research is a core function of the NHS (NHS Operating Framework 2012/13).
2-3 sentences
Active engagement with research improves quality of healthcare; organisations where research
is fully integrated into the organisational structure out-perform other organisations that pay less
formal heed to research and its outputs.
Recent reports (Francis, Berwick, Keogh) have highlighted that research and development
should be part of the solution to the challenge of providing high quality and safe patient care
QUESTION(S) ADDRESSED IN THIS REPORT
This report presents the R&D Strategy for the period 2014 - 18, together with a 2-year business
plan for 2014 - 15. Will the Board approve this Strategy and Business Plan?
CONCLUSION AND RECOMMENDATION(S)
• This strategy is a robust solution to the challenges of meeting the Trust's obligations to
engage with the national and regional R&D and Quality agendas.
• This strategy sets the vision for R&D in the Trust and aligns it to the business objectives of
the Trust in order to benefit the population of Barnsley.
• Dr Christine Smith will be presenting the key facts of the Research and Development
Strategy.
Recommendation: the Board to approve the strategy and business plan.
BoD June 2014: R&D Strategy
Page 1
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
1d. Deliver a successful Research and Development (R&D)
programme within the Trust and promote clinically led service
innovation.
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
Where applicable, state
resource requirements:
Academic isolation contributes to poor quality staff due to lack of skills
investment and low levels of recruitment.
New contract with Local Clinical Research Network is expected to contain
penalty clauses for poor activity
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
SMT:\Board\June 2014_R&D Strategy
Page 2 of 4_
Subject:
1.
Research and Development Strategy
Ref: 14/06/P-06
STRATEGIC CONTEXT
1.1 During the last 10 years the issue of how health research knowledge is applied and
used in practice has become a central policy concern. The 2008 Darzi Report and
the 2011 Carruthers Review have resulted in high levels of investment in research
and innovation practice, to improve patient outcomes by translating research into
practice and developing and implementing integrated health care services. More
recently the Francis, Berwick and Keogh reports have detailed how Trusts might use
research and innovation to improve their focus on quality and patient care.
1.2 The Trust delivers a wide range of research, which is funded through several routes.
More recently the Trust has begun to attract funding to deliver evaluation of internal
initiatives focussed on quality, patient safety and patient experience, and has
committed match funded activity into the Collaboration for Leadership in Applied
Research and Care for Yorkshire and Humber.
1.3 The NHS Outcomes Framework 2013/14 highlights that high quality care is made up
of effectiveness, patient experience and safety and that research and its use in
practice impacts on the design and delivery of services at a local level. The NHS
England Business Plan commits the NHS to participate in research funded by both
commercial and non-commercial organisations, to improve patient outcomes and
contribute to economic growth.
1.4 NHS England has made clear that the consideration and use of appropriate
technology to improve clinical outcomes is expected in service reconfiguration; this is
echoed in the Academic Health Science Network (AHSN) goal of transforming
healthcare. Barnsley Hospital has a particular strength in Telehealth and Technology
and is ideally placed to evaluate the impact of such innovation.
2.
INTRODUCTION
2.1 Research is a core function of the NHS. Over the last three decades there has been
a sustained focus to fund and manage health research such that the UK has a wellearned reputation for high quality and delivery. In recent years the focus has shifted
and now there is more emphasis on how to ensure that research evidence is used in
practice and of value for money. In the wake of the Francis, Keogh and Berwick
reports there is now an additional expectation that NHS research activity will have
direct benefits in terms of quality and patient care.
2.2 These shifts in research policy are set within an NHS landscape undergoing seismic
shifts, and moreover an environment that is under enormous financial constraint.
However, these challenges contain much opportunity for the Trust to deliver world
class research and to create the conditions at the coalface to utilise research and
evaluation to meet the challenges of the Business Plan.
2.3 We have been issued the challenge to become a Centre of Excellence in R&D. This
means that not only do we honour our commitment to the NIHR to deliver Portfolio
research to time and target (Appendix 2), but that we increase our activities and
income from commercial research and engage fully with our local and regional
partners such as Collaboration for Leadership in Applied Health Research and Care,
Yorkshire and the Humber (CLAHRC YH) and the YH AHSN; to embed both the
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Page 3 of 4_
production of research and evaluation evidence and its use into our daily activities,
and thereby improve the quality of the care we provide to our patients.
2.4 Key Aims of this strategy (Appendix 1) are to:
2.4.1 Establish Trust as centre of excellence in R&D by cultivating priority areas of
clinical, applied health and translational research, which have clear potential to
inform commissioning, service improvement and transformation
2.4.2 Increase research and development capacity throughout the Trust, to fully
exploit potential across all professional groups and services
2.4.3 Significantly increase research and development activity and income, including
commercial, to sustain a robust infrastructure, to deliver high quality clinical
and health services research and development
2.4.4 Establish and ensure continued support of robust structures to initiate, deliver
and manage high quality research and evaluation for direct patient benefit,
including appropriate patient and public involvement
Appendices:
•
Appendix 1 – CLRN ‘6 years’ poster
•
Appendix 2 – Research & Development Strategy 2014 - 18
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Page 4 of 4_
Barnsley Hospital NHS FT
6 years of research supported by SY CLRN
2008/09 - 2013/14
Increased Activity
64% increase
Research activity has increased
in recruitment
2008/09 - 2013/14*
436 recruits
across 27 studies
31
27
in 2008/09
536 recruits
across 31 studies
in 2013/14* to date
Number
of Studies
2008-09
2013-14
to date*
Consistently Wide Breadth
Consistently
active across
14-19
a broad
specialties range
of
specialties
Actively engaged in
commercial
research
since 2008/09
Improved Performance
137%
On track to exceed 2013/14
recruitment target
NHS Permission
achieved within 30 days for
100% of studies
by more than 37%
2013/14 to
FREE: Family reported
experiences evaluation study
100%
2012/13
55%
2011/12
First English patient
70%
2010/11
10%
Bridging the age gap
in breast cancer
2009/10
33%
Source: CCRN recruitment data cut 24/01/2013. Includes only NIHR Portfolio study activity
* 2013/14 data is incomplete: figures noted as 'to date' cover approximately 3/4 of the financial year, other figures are year-end forecasts
v1.0
–
Prepared by Dr Christine Smith, Director R&D
June 2014
Contents
Executive Summary .................................................................................................. 3
Introduction ............................................................................................................... 4
Research, Evaluation and Innovation in the NHS .................................................. 4
Vision ..................................................................................................................... 5
Mission ................................................................................................................... 5
Research in Context .................................................................................................. 5
Political and Regulatory Environment .................................................................... 5
Regulation of Research ...................................................................................... 8
Economic Environment .......................................................................................... 8
Sociological and Cultural Factors ......................................................................... 10
Technological Context .......................................................................................... 13
Summary .............................................................................................................. 14
Strategy 2014 - 18 ................................................................................................... 15
Initiating High Quality Research and Development .............................................. 15
NIHR Portfolio ...................................................................................................... 15
Commercial Research .......................................................................................... 16
Governance of Research ..................................................................................... 16
Collaboration for Leadership in Applied Health Research and Care .................... 17
Academic Health Science Network ...................................................................... 17
Medical Technology Research and Development ................................................ 17
Research and Evaluation Alliance ........................................................................ 17
Intellectual Property ............................................................................................. 18
Patient Public Involvement ................................................................................... 18
Key Strategic Aims and Objectives ...................................................................... 19
Strategy Implementation and Monitoring .............................................................. 21
R&D Business Plan 2014 – 15 .............................................................................. 22
Appendix 1: Current Research and Development Infrastructure ............................. 26
Appendix 2: References .......................................................................................... 27
Executive Summary
Research is a core function of the NHS. Over the last three decades there has been
a sustained focus to fund and manage health research such that the UK has a well
earned reputation for high quality and delivery. In recent years the focus has shifted
and now there is more emphasis on how to ensure that research evidence is used in
practice and of value for money. In the wake of the Francis, Keogh and Berwick
reports there is now an additional expectation that NHS research activity will have
direct benefits in terms of quality and patient care.
These shifts in research policy are set within an NHS landscape undergoing seismic
shifts, and moreover an environment that is under enormous financial constraint.
However, these challenges contain much opportunity for the Trust to deliver world
class research and to create the conditions at the coalface to utilise research and
evaluation to meet the challenges of the Business Plan and the Quality Strategy.
We have been issued the challenge to become a Centre of Excellence in R&D. This
means that not only do we honour our commitment to the NIHR to deliver Portfolio
research to time and target, but that we increase our activities and income from
commercial research and engage fully with our local and regional partners such as
CLAHRC YH and the YH AHSN; to embed both the production of research and
evaluation evidence and its use into our daily activities, and thereby improve the
quality of the care we provide to our patients.
Key Aims of this strategy are to:
1. Establish Trust as centre of excellence in R&D by cultivating priority areas of
clinical, applied health and translational research, which have clear potential
to inform commissioning, service improvement and transformation
2. Increase research and development capacity throughout the Trust, to fully
exploit potential across all professional groups and services
3. Significantly increase research and development activity and income,
including commercial, to sustain a robust infrastructure, to deliver high quality
clinical and health services research and development
4. Establish and ensure continued support of robust structures to initiate, deliver
and manage high quality research and evaluation for direct patient benefit,
including appropriate patient and public involvement
Introduction
This document sets out a 5-year research and evaluation strategy for Barnsley NHS
Foundation Trust (BHNFT). This strategy aims to provide a context and framework
to promote and support research, evaluation and their implementation throughout
BHNFT. It is the responsibility of BHNFT to support healthcare professionals in the
achievement of this aim.
Research, Evaluation and Innovation in the NHS
"The promotion and conduct of research continues to be a core NHS function and
continued commitment to research is vital if we are to address future challenges.
Further action is needed to embed a culture that encourages and values research
throughout the NHS" (NHS Operating Framework, 2012/13)
"The NHS „ will become a truly integrated system defined by its commitment to
innovation, demonstrated both in its support for research and its success in rapid
diffusion of high value innovation." (Innovation, Health and Wealth, IHW, 2012)
“ Research is a core part of the NHS because it enables the NHS to improve the
current and future health of the population. Therefore, the NHS will do all it can to
give patients, from every part of England, with any illness or disease, a right to know
about research that is of particular relevance to them and, if they choose, to take part
in approved medical research that is appropriate for them.” (Handbook to the NHS
Constitution, 2009)
Innovation, Health and Wealth (DH, 2012) defines innovation as „ an idea, service or
product, new to the NHS, or applied in a way that is new to the NHS, which
significantly improves the quality of health and care wherever it is applied.‟ In the
NHS Research and Development is innovation. Research and Development is all
about finding new knowledge that could lead to changes to treatments, policies or
care. Clinical research is, and has always been, at the very heart of the NHS: only
by carrying out research into "what works" can we continually improve treatment for
patients, and understand how to focus NHS resources where they will be most
effective. In recent years health services research has come more to the fore
because whilst it is important to discover new therapies, it is equally important to
discover whether these, in fact, work in practice, and whether they are both effective
and efficient.
Vision
Barnsley Hospital is a Centre of Excellence for health research. High quality
research and development is considered core business within clinical service
delivery across the Trust, and is recognised both as an essential component of
clinical excellence and a contributor to the provision of high quality evidence-based
patient care.
Mission
To create a health research environment in which the research active
individuals and teams in the Trust are well supported in undertaking research
and evaluation that focuses on the needs of the patients and public to improve
the health and wellbeing of people in Barnsley
To embed a research and evaluation culture and increase research capacity
within the Trust
To undertake high quality research and evaluation that supports the goals of
the Trust
To work with our stakeholders in the Barnsley health and social care
communities to deliver high quality research of local and national relevance,
and through this activity bring access to improved, world class and relevant
innovation in care.
Research in Context
Political and Regulatory Environment
The last 25 years have seen significant change in the way that research and
development in the NHS is funded and managed; and a raft of new policy placing
research and innovation at the heart of the NHS (Table 1).
Table 1. Brief summary of major reports on health research and development since
1988
Year
1988
1991
1994
1995
1999
2001
Reports
House of Lords Science and Technology Select Committee publishes „ Priorities in medical
research‟ criticizing lack of DHSS and NHS attention to research and calling for NHS
research investment and National Health Research Authority.
First ever director of research and development for the NHS and DH appointed and
„ Research for health – a research and development strategy for the NHS‟ published by
Department of Health, recommending NHS spends 1.5% of budget on R&D, advocating a
knowledge based health service and setting out plans for research infrastructure.
Culyer report „ Research and development task force: supporting research and development
in the NHS‟ recommends funding reforms for NHS R&D – separating research and health
care delivery funding, and controlling and allocating research funding centrally.
House of Lords second report titled „ Medical research and the NHS reforms‟ revisits
reforms
New government publishes „ Research and development for a first class service‟ which
announces further funding reforms to split research funding into support for science and
NHS priorities and needs funding.
Department of Health produces „ Science and innovation strategy‟ which summarizes
2004
2004
2006
2006
2007
2011
2011
2012
2012
research policy and sets out goals including new research areas, better knowledge
management and changes to research governance.
National Audit Office report on „ Getting the evidence‟ which highlights need for better
strategic direction of government research and more proactive and innovative dissemination
and research utilization.
Department of Health publishes „ Research for patient benefit working party final report‟
which proposes founding UK Clinical Research Collaboration to coordinate health research
and clinical research networks.
DH publishes „ Best research for best health‟ strategy setting out five-year strategy including
establishing National Institute for Health Research, expanding funding programmes and
research centres, investing in faculty/research staff, and further
reforms to how funding is allocated.
HM Treasury publishes „ A review of UK health research funding‟ led by Sir David Cooksey.
Recommends better coordination of MRC and NIHR and separation of NIHR from
Department of Health. Highlights first and second „ translational gaps‟ in research
process,
and economic/wealth dimension of health research.
Department of Health publishes „ High quality care for all‟ by Sir Ara Darzi which highlights
patchy and slow innovation, introduces statutory duty of innovation and investments in
innovation, and proposes new Academic Health Science Centres – partnerships of
universities and the NHS
Academy of Medical Sciences produces „ A new pathway for the regulation and governance
of health research‟ which notes the complex and fragmented structures for health research
in the NHS, and variable engagement in research among NHS organisations. Leads to
creation of new Health Research Authority.
NHS chief executive publishes Carruthers report „ Innovation, health and wealth: accelerating
adoption and diffusion in the NHS‟ which emphasizes „ health and wealth‟ agenda,
critiques
slow pace of innovation, and sets out eight themes including development of Academic
Health Science Networks, better incentives for innovation and focus on „ high impact‟
innovations
Dept. for Business, Innovation and Skills publishes the Strategy for UK Life Sciences; the UK
will become the global hub for life sciences in the future, providing an unrivalled ecosystem
that brings together business, researchers, clinicians and patients to translate discovery into
clinical use for medical innovation within the NHS.
The NIHR Clinical Research Network (CRN) is partnering with The Guardian to create The
Clinical Research Zone. This will publish data on individual NHS Trust participation in clinical
research, and sit beneath the existing Guardian Healthcare Network site.
The AHSNs will present a unique opportunity to align clinical research and evaluation,
informatics innovation, training and education and healthcare delivery.
NHS Chief Exec One Year Review of IHW highlights the need to:
create „ pull‟ for new ideas from patients and the NHS, rather than relying on
the traditional top-down „ push‟
reward those individuals and organisations that adopt best practice and new ideas
through CQUINs, and calls for those organisations that do not to explain why
Clinical Commissioning Groups will be under a duty to seek out and adopt best practice, and
promote innovation
2012
AHSN Y&H Business Plan published.
This document includes a commitment to a Y&H AHSN Charter for Quality, Research and
Innovation which all NHS partners will sign up to and promote‟ .
The AHSN has three primary goals:
To improve health and reduce inequalities in population health by focusing on the
chronic diseases which make the biggest impact on regional morbidity.
To transform the quality and efficiency of health services in the network through
supporting the development, testing and rapid adoption of effective service
innovations whether developed internally or outside the NHS.
To generate wealth in the region and the UK by stimulating innovation in partnership
with medical technology, digital health, pharmaceutical and other commercial
enterprises.
These goals are linked, and establish mechanisms to routinely translate research
and learning into practice, stimulate collaboration on education and training and
increase participation in research.
Adapted from Walshe and Davies (2013).
It is generally recognised that the UK has an excellent record of doing health
research. However, during the last 10 years the issue of how research knowledge is
applied and used in practice has become a central policy concern (Walshe and
Davies 2013). Until recently research policy has been more concerned with the
production of research, with the assumption that its use by healthcare organisations
would automatically follow; although it is increasingly evident that this is not the case.
The 2006 Cooksey Review identified the „ 2nd Gap in Translation‟ ; that of the
implementation of new products and approaches into frontline care. This was
followed by the Darzi Report in 2008 in which health innovation was recognised as a
concept wider than pure research, encompassing clinical practice and service
design. One of the outcomes of the Darzi report were the Collaborations for
Leadership in Applied Health Research and Care (CLAHRC), collaborations between
the NHS and universities who jointly could demonstrate both a portfolio of health
services research and a track record of implementing research into practice, thereby
improving patient outcomes. Most recently, the 2011 Carruthers „ Health and Wealth
‟
report proposed the creation of Academic Health Science Networks (AHSN), whose
primary goal is to improve patient outcomes by translating research into practice and
developing and implementing integrated health care services.
In the aftermath of the Francis Report there has been a succession of reports
detailing how Trusts might improve their focus on quality and patient care. In
particular, the Berwick Report highlighted that investment in human development is
absolutely necessary in order to measure and continually improve the quality of
patient care, and that patient safety is better served when patients and carers are
actively involved in their care.
In 2013 the Keogh Report further highlighted the importance of academic isolation in
contributing to poor quality staff. It also found that Trusts struggle to make sense of
the wealth of rich data available, particularly qualitative data and recommended that
Trusts ensure that they employ staff with the specific expertise to gather, analyse
and use such data to drive improvement. Engagement with academic partners and
regional experts through CLAHRCs and AHSNs will lead to a culture of professional
and academic ambition. Furthermore, active engagement with research improves
healthcare (Hanney, 2013). Organisations in which the research function is fully
integrated into the organisational structure out-perform other organisations that pay
less formal heed to research and its outputs.
Regulation of Research
The regulation of health research in the UK is extremely complex. Table 2
summarises the main organisations which make up the environment. The Trust
engages with these organisations through the activities of the R&D Department.
Table 2. Regulation of Health Research
Organisation
Health Research Authority
(HRA)
Medicines and Healthcare
Products Regulatory Agency
(MHRA)
Clinical Practice Research
Datalink (CPRD)
National Institute for Health
Research Clinical Research
Network (NIHR CRN)
Role
to protect and promote the interests of patients and the public
in health research, and to streamline the regulation of
research. responsible for the National Research Ethics
Service and Research Governance
regulate all medicines and medical devices in the UK
ensures clinical trials meet robust standards and safeguard
patient‟ s interests
maximise the way anonymised NHS clinical data can be
linked to enable many types of observational research and
deliver research outputs that are beneficial to improving and
safeguarding public health
to support organisations to deliver the national Portfolio of
high quality research studies that deliver in line with the
study's planned delivery time and patient recruitment targets
to double the number of participants recruited into studies on
the Portfolio
to reduce the time it takes to get NHS permission for a study
to start
to reduce the length of time it takes to recruit the first
participant onto Portfolio studies
to increase the number of life-sciences studies on our
Portfolio
to increase the percentage of NHS Trusts that are involved in
delivering our Portfolio
Economic Environment
The Trust delivers a wide range of research, which is fully funded through a
combination of external routes. More recently the Trust has begun to attract funding
to deliver evaluation of internal initiatives focussed on quality, patient safety and
patient experience.
The NIHR Portfolio consists of high-quality clinical research studies (Clinical Trials
and other research studies) that are eligible for consideration for support from the
Clinical Research Network in England. The Local Clinical Research Network
(LCRN) provides core funds to the Trust for:
the provision of dedicated skilled research support staff including research
nurses and other allied health professionals, who identify eligible patients,
arrange consent to participate in the study and monitor patients as they
progress through the study
financial support to ensure that research can be successfully undertaken in
the NHS including pharmacy, imaging and pathology services and the
possibility of securing protected time for NHS staff to conduct research
commercial research may also be included on the Portfolio. An advantage of
engaging with commercial research is the additional income available for the
monitoring of patients throughout the lifetime of the study. There is an
Industry Costing Template to assist in the calculation of study costs.
Excess Treatment Costs. These are patient care costs which would continue
to be incurred if the patient care service in question continues to be provided
after the Research has ended. These are agreed through the normal
commissioning process
The R&D department receives an annual core funding allocation from the LCRN,
based on the previous year‟ s accruals into Portfolio research studies, which support
our cohort of research nurses and the governance function
Non portfolio research does not lead to accruals onto the Portfolio and therefore
does not attract LCRN financial support. Such research and evaluation e.g. student
research and locally commissioned/in-house projects attracts income. In particular,
commercial research that is not on the NIHR portfolio still attracts income, based on
the Industry Costing Template, for research support staff and NHS costs e.g.
pharmacy, imaging etc.
CLAHRC match funding The Trust and Charitable Fund have committed 'match'
funding into CLAHRC over the next 5 years, totally £650,000. The match funding
model is intended to foster a virtuous circle of research and implementation; the
CLAHRC YH principle of coproduction promotes the identification of local research
priorities, which are then developed in collaboration into defined projects that deliver
both academic outputs and clear impact on patients and services. Match funding
takes several forms:
Cash match: real cash from a range of sources that can be used to support
CLAHRC Theme budgets and is sourced from local charities and the NHS
„ match‟ in kind, people time: collaborating organisations will provide „
people
time‟ on theme activity/ further grant preparation/ project negotiation and
priority setting. This might include meetings and activity undertaken for
protocol development, grant submissions, or CLAHRC research activity
(recruitment/ clinic time).
match‟ in kind, infrastructure: NHS desk space/ meeting space. The NHS
may
also count desk space as match in kind.
Research project costs not funded by the NIHR grant. Such as NHS Excess
treatment costs/ research support costs for NHS organisations.
The match commitment into CLAHRC provides an excellent opportunity to link the
Trust's Business Plan and priorities of quality, patient safety and patient experience
with the CLAHRC YH Themes, to answer specific questions for the benefit of our
patients and services. This opportunity can be further enhanced through link with
the AHSN and other partners, enhancing our reputation as a Centre of Excellence
for research.
Sociological and Cultural Factors
The NHS Outcomes Framework 2013/14 highlights the shift in governmental thinking
from measuring process targets to measuring health outcomes. The five domains
(Table 3) were derived from the three part definition of quality first set out by Lord
Darzi as part of the NHS Next Stage Review; that high quality care comprises:
effectiveness, patient experience and safety. The Framework makes clear that
research and its use in practice impacts on the design and delivery of services at a
local level.
Table 3. Domains of the NHS Outcomes Framework
Domain 1
Preventing people from dying prematurely
Domain 2
Enhancing quality of life for people with long term conditions
Domain 3
Helping people to recover from episodes of ill health or following injury
Domain 4
Ensuring that people have a positive experience of care
Domain 5
Treating and caring for people in a safe environment; and protecting them from
avoidable harm
This recognition is reflected in the NHS England Business Plan and its commitment
to “ ensure that the new commissioning system promotes and supports
participation
by NHS organisations and NHS patients in research funded by both commercial and
non-commercial organisations, to improve patient outcomes and contribute to
economic growth.” The NHS England Research Strategy is expected in Summer
2014, and will have a focus on the coordination of NHS research priorities and the
improvement of the interface between commissioners and providers so that research
is recognised and facilitated in local contracting. NHS England has commissioned
the AHSNs to be the local centres for innovation. They have strong links with clinical
research networks, academic institutes and the commercial sector to identify,
evaluate and test innovative practices locally and support their adoption. They will
also act as a catalyst for rapid diffusion of other nationally designated innovations.
The Yorkshire and Humber AHSN has four workstreams (Table 4), which link into
the Improvement Academy.
Table 4. AHSN Workstreams
Workstream
Information at the core
1.
2.
3.
4.
Increasing participation in
research
5.
1.
2.
3.
4.
5.
6.
7.
8.
Strategic Goals
Refining clinical information and management systems to
ensure accurate and timely information is delivered to every
point of need within the network. This will improve both the
quality of care and the efficiency of care delivery.
Building on existing strengths in health informatics and clinical
analytics to improve the functional integration of health
databases across different sectors in order to
Improve quality and outcomes for patients and value for money.
Combining our academic and NHS expertise in computer
science, health informatics and clinical information systems we
will bring the latest developments in “ Big Data” , “
cloud
computing” and data modelling to the frontline of research
and
healthcare.
Giving healthcare professionals access to analytical skills and
Increase the proportion of patients participating in high quality
research studies and aim to increase research within the
identified priority areas including dementia, respiratory diseases
and diabetes, to the levels already being achieved within cancer.
Increase participation in studies by working with patients, public
and partners to measure and promote involvement in research.
Treble the number of individuals participating in commercial
research over 5 years.
Adopt a single system for research approvals based on mutual
assurance and ensure that more than 90% of NIHR trials
achieve the set-up and delivery targets stated in the NIHR
Clinical Research Network high level objectives.
Increase the number of commercial studies fourfold over five
years.
Increase the proportion of Medtech studies in the commercial
study portfolio to one third in 5 years.
Double the number of early phase studies over 5 years.
Ensure every NHS organisation includes research KPIs within,
regular, core board performance reports, supported by core
performance management processes
Translating research into
practice
1. Maximise our existing collaborations and using our expertise in
applied research and implementation science to support the
healthcare workforce and patients to access, appraise and use
evidence and knowledge to drive improvement.
2. Develop a cadre of individuals who can lead and champion
knowledge mobilisation across the AHSN partners.
3. Better understand the needs of patients and identify exemplars
of good practice across the service and share these lessons.
4. Make evidence from research more accessible for managers,
frontline staff and patients to drive change.
5. Facilitate the translation of research findings into evidencebased tools, such as decision aids and best practice statements.
6. Identify gaps in the existing evidence base to generate new
insights and funding opportunities with local Universities and
Industry.
7. Use social media and new technologies to share knowledge.
Collaboration on education
and training
1. To develop values and behaviours to enable research,
innovation and improvement to become „ business as
usual‟
across the NHS in the region.
2. Build the skills and capabilities within the NHS workforce to
successfully deliver the Innovation and Commercialisation
pathway. This means equipping the workforce in all aspects
from idea generation, the development of solutions and
ultimately leading to consistent deployment across Y&H.
3. Underpin the work of the Improvement Academy by creating
new skills and capabilities to deliver specific innovations. This
will include the change management skills to support changes to
existing roles, or the developments of new ones to deliver the
innovation, device or pathway.
4. Build closer relationships and learning across the NHS and
industry by collaborating with industry through training and
capability building programmes e.g. apprenticeships, cross
sector secondments or placements.
The Improvement Academy is a team of improvement scientists, patient safety
experts, patients and clinicians, which aims to:
Ensure evidence-based solutions become routine practice
Bring about lasting change using improvement methods, human factors
psychology and implementation science
Co-create improvement with front-line clinicians, patients and the public
Reduce unwarranted variations in outcomes of care
Address professional and geographical isolation through network learning
The AHSN is a relatively new organisation and there are many opportunities for the
Trust to work with our local partners (CCG and BMBC) and the AHSN to drive quality
improvement; and for the R&D Department to act as a hub, linking the Trust, the
AHSN and the CLAHRC YH. Current examples of such work include:
the patient safety PRASE (Patient Reporting and Action for a Safe
Environment) initiative, which is a collaboration between the AHSN and the
Trust. This initiative is pioneering in being based on the premise that patients
can provide useful feedback about the safety of the care they receive and that
wards can use this information, together with other locally gathered
intelligence, to make improvements.
a CCG-commissioned evaluation of Emergency Department attendances,
which will inform the CCGs planning around unplanned care. This evaluation
added depth and detail to routine ED attendance data. It used additional
audit, patient questionnaire, patient interview and staff focus group data, to
understand this local picture in the context of the existing but modest national
and international research literature.
Yorkshire and the Humber has some of the highest levels of social deprivation and
health inequalities in the country. This, coupled with an ageing and diverse
population, has resulted in significant health and social care challenges. These
challenges are compounded by the current turbulence within the NHS and social
care environment in England, and by the recommendations of the Francis report
which encourages the NHS to improve the quality of patient care whilst enduring
year on year financial restraints.
The CLAHRC YH is a new collaboration whose purpose is to ensure research
evidence is used to improve health services (address the 2nd Gap in Translation)
and whose focus will be on the self-management of complex long-term conditions,
including the use of telehealth technologies, to improve patient outcomes. The
CLAHRC YH has an alignment of purpose with the AHSN and the two organisations
will work in partnership to implement research evidence from the CLAHRC to a wider
geographical area. An example of this is a workstream on telehealth supporting the
region‟ s CCGs and providers in the delivery of the 3millionlives high impact
innovation.
The Trust and Charitable Fund have committed 'match' funding into CLAHRC over
the next 5 years, totally £650,000. The match funding model is intended to foster a
virtuous circle of research and implementation; the CLAHRC YH principle of
coproduction promotes the identification of local research priorities, which are then
developed in collaboration into defined projects that deliver both academic outputs
and clear impact on patients and services.
The match commitment into CLAHRC provides an excellent opportunity to link the
Trust's Business Plan and Quality Strategy priorities of quality, patient safety and
patient experience with the CLAHRC YH Themes, to answer specific questions for
the benefit of our patients and services. This opportunity can be further enhanced
through link with the AHSN and other partners, enhancing our reputation as a Centre
of Excellence for research.
Technological Context
As a society, we are making increasing use of the internet and its related
technologies. But the NHS has been relatively slow to adopt these consumer-facing
technologies. The use of technology has the potential to support the delivery of
health care in a number of areas:
providing and storing information and advice
administration and transactions – e.g., making appointments
diagnosis – making diagnostic technology available to the
consumer monitoring – particularly helpful in an ageing population
relationships – improving communication between the patient, carers and
professionals.
Over 15 million people in England have at least 1 long term condition. In conjunction
with the ageing population, this population constitutes the majority of our service
users in the Trust. NHS England have made clear that the consideration and use of
appropriate technology to improve clinical outcomes is expected in service
reconfiguration; this is echoed in the AHSN goal of transforming healthcare. The
Department of Health believes that at least three million people with long term
conditions and/or social care needs could benefit from the use of telehealth and
telecare services and has initiated the 3 Million Lives project, which aims to
accelerate the use of assistive technologies in the NHS. The Trust is already
implementing and testing new technologies into front line care to address issues of
patient safety and improve quality of care and the R&D Department is ideally placed
to evaluate the impact of these technologies on our patients and services.
•
Barnsley Hospital has a particular strength in Telehealth and Technology. Our
Medical Physics department shares a Director with the Rehabilitation and
Assistive Technology Group in the University of Sheffield and the Centre for
Assistive Technology and Connected Healthcare (CATCH). The medical
physics team is very active in research projects with the aim of providing
electronic assistive technology to people in South Yorkshire through the NHS.
•
The Trust is a partner in the Healthcare Technology Cooperative Devices for
Dignity (D4D), which has a remit to drive forward innovative new products,
processes and services to help people with long-term conditions. D4D can
support the adoption of new technologies and treatments into practice.
The proposed Research and Evaluation Alliance will strengthen our capacity to
evaluate care pathway technology solutions both within the Trust and those that
cross organisational boundaries.
Summary
The NHS is mandated to engage with and actively promote research, evaluation and
innovation. BHNFT can do this in three main ways, facilitated by the activities of the
R&D Department:
By increasing the proportion of patients participating in high quality research
and evaluation studies, including commercial research
By normalising research, innovation and its evaluation within the quality
culture at all levels of the Trust and recognise its place in relation to the
standardisation of practice, to provide high quality care through transforming
health care based on evidence
By creating an intelligence-led approach across the Trust to drive future
innovation and improvement in direct patient care
Strategy 2014 - 18
Initiating High Quality Research and Development
Besides collaborating in large multicentre studies, through our links with CLAHRC
YH and other National Institute for Health Research (NIHR) infrastructure, this
strategy will encourage Trust staff to initiate high quality research, development and
evaluation; through the exploitation of existing and new links, such as the proposed
Barnsley Research Alliance. This initiative will work to support research and
development that crosses organisational boundaries, focussed on whole systems,
care pathways and the patient experience, to the benefit of both patients and all the
partner organisations. It will also act with a view to securing competitive funding
from national schemes. As reflected in the Trust‟ s Business Plan innovation, and its
evaluation will be supported throughout the organisation. Such support is essential
to both attract and retain the highest possible calibre of staff; those who are willing to
challenge the evidence base underpinning clinical practice, through critical thinking
and research.
The Trust will celebrate research and development as core business and will
promote the concept that there is a need for all services to be established on a
sound evidence base. The research and development agenda must be aligned with
and influence changes of clinical services within the Trust, whilst being flexible in
responding to rapid changes in NHS priorities. This strategy reflects the specific
local context; conducting and commissioning research and development to benefit
the local population with high burdens of common disease. Quality research,
development and evaluation programmes will support the consistent achievement of
local quality improvement goals, in line with the Commissioning for Quality and
Innovation (CQUINS), and the delivery of the Quality Strategy.
NIHR Portfolio
The Trust will encourage the development and submission of research proposals to
qualify for inclusion on the NIHR Portfolio. Continued Portfolio engagement, both as
a lead in research studies and as a site for multicentre research is crucial to achieve
sustained growth in research across the clinical areas. Such engagement with the
Portfolio will ensure high quality delivery of research whilst increasing capacity in key
Trust areas including, but not limited to, rheumatology, diabetes, stroke,
gastroenterology, paediatrics, emergency services and critical care.
The Trust will continue to engage enthusiastically with national initiatives supported
by the NIHR Clinical Research Network, with the aim of streamlining internal
processes and supporting the implementation of best practice. The success of the
Trust in delivering Portfolio activity is highly influenced by the mutually supportive
partnerships between the Trust and the regional research networks, primarily the
Local Clinical Research Network. These relationships have enabled the realisation
of the shared objectives of demonstrating growth in and consistent delivery of high
quality research, whilst meeting (and exceeding where possible) predefined
performance targets. Such targets must continue to be key delivery priorities, to
ensure the continued delivery of the local research agenda is not compromised.
This includes a commitment to meeting annual recruitment targets set by the NIHR,
which for 2013/14 was 521 participants for Portfolio studies.
Commercial Research
The Trust has a long history of collaboration with industry in the field of research
including pharmaceutical and medical technology partners, and recognises the value
to the Trust and our patients, and the opportunities that such collaboration brings.
The Trust will develop a robust infrastructure, capable of meeting the unique
requirements of all research, including those in the commercial sector. The Trust
maintains a commitment to support a responsive workforce that is able to achieve
sustainable and reliable delivery or trials, research and evaluation across all
specialities. This includes affording all staff the opportunity to partake in research
and evaluation, thus improving the potential to markedly improve clinical care
delivery for existing and future service users.
The Trusts research business model, in respect of financial and resource
management, will ensure appropriate support and recompense for research activity,
to incentivise participation by Clinical Business Units. Monies generated will be
distributed in accordance with an agreed Trust Income Distribution Model, to ensure
transparency and support reinvestment in research active clinical areas.
An environment conducive to the delivery of high quality research will be further
supported, to ensure shared performance targets with commercial partners. A
formal model is being developed to allow the rapid consideration of commercial
opportunities, using dedicated research staff, thus ensuring the integrity of
information provided in terms of feasibility, recruitment potential, and opportunities to
delivery to time and target. Proactive study management will continue to be
maintained throughout the strategy period, to ensure the transparency and
accountability of Trust performance.
The swift initiation and successful study delivery will continue to be underpinned by
the provision of a robust RM&G service, acting as a „ one stop shop‟ to ensure
consistency of approach and streamlined communication, maintaining personal
dialogue between site and sponsor. As part of this service the Trust will develop an
approach to ensure review of costings and contracts within 5 working days (subject
to full disclosure of appropriate information), in order to ensure Trust permission is
not hindered. In this way the Trust will commit to maximising study recruitment
windows.
Governance of Research
The management of risk will continue to be the highest priority for the Trust. The
Trust will support the R&D infrastructure to deliver this Strategy. The R&D
Department will, on behalf of the Trust, continue to lead the delivery of the LCRN
recruitment target for portfolio research, in addition to other commercial,
commissioned and collaborative research and evaluation. It will also work with the
wider Trust to ensure that the management of staff and finances associated with
research are managed professionally and transparently, such that activity is effective
and efficient.
Collaboration for Leadership in Applied Health Research and Care
The Trust was a founding member of and had a successful relationship with the
CLAHRC South Yorkshire, contributing match funding of over £500,000 over 5
years. This collaboration supported work in Telehealth, older people, workforce
research and research capacity building.
The Trust and the Charitable Trust have collectively committed matched funding;
totalling £650,000 over 5 years, to the nascent CLAHRC for Yorkshire and Humber,
to support work which will be mutually beneficial and consistent with the Business
Plan and Quality Strategy. This match funding will generate further income for
research and development, in addition to providing the opportunity to collaborate
with regional experts and research and development teams, and play a part in
mutual learning.
Academic Health Science Network
The AHSN has a responsibility for innovation and its spread across the region.
Several AHSN aims will impact directly on the Trust‟ s approach to research and
development e.g. it aims to ensure a greater number of people in Yorkshire and
Humber actively participate in health service and health science related research
activities, with clear implications for the way the Trust engages our patients in
research and development. The Trust will fully engage with the AHSN Business
Plan and work alongside it to further develop a culture of innovation, learning and
change in which the workforce actively seeks out evidence, tries new ways of doing
things and shares success, to improve patient care.
Medical Technology Research and Development
The Trust is an active member of the Devices for Dignity (D4D) Healthcare
Technology Co-operative and the University of Sheffield, through our links in the
Medical Physics Department. The Trust further recognises the need to support
further work, developing the medical technology within which the development of
new products and improved interventions may be supported. The Trust will continue
to encourage the establishment of productive relationships with medical technology
companies e.g. by providing early clinical expertise in the development of medical
technology initiatives, with a view to informing both relevance and quality of potential
innovations that have the potential to impact on service transformation and delivery.
Research and Evaluation Alliance
The Trust will explore the potential for an Alliance of our local healthcare partners
(BHNFT, BMBC, CCG, SWYT), with the aim of evaluating new initiatives, developing
new knowledge and exploring new ways of working, focussed on our patients and
care pathways to improve the health and wellbeing of our population
Intellectual Property
The Trust is committed to ensuring equitable access for all patients in new
technology and innovations. This includes supporting the appropriate development
and dissemination of innovations by Trust staff members, which have commercial
potential.
In conjunction with the regional NHS Innovation Hub, staff will be guided through a
clearly defined innovation pathway, to ensure the appropriate exploitation and
commercialisation of IP. In accordance with Trust policy requirements, a robust
model will ensure benefits of these innovations are maximised and the generation of
IP is appropriately rewarded.
Patient Public Involvement
Barnsley Hospital has a strong tradition of engagement with patients and the public
in research and development. Dr Ade Adebajo is a Board Member for INVOLVE, (a
not-for-profit organisation of public participation specialists). The long established
Consumers in Research Advisory Group (CRAG) provides a consumer perspective
to teams who are planning to undertake a research project within the trust. During
the CLAHRC SY the CRAG was commissioned to provide patient perspective during
the Independent Scientific Review process and contribute to projects across the
South Yorkshire region, and this remit will be further expanded and developed as
part of the nascent CLAHRC Yorkshire and Humber. The Trust will support a PPI
Coordinator, through its match commitment, for the first two years of CLAHRC YH:
to support the CRAG group to ensure a patient voice in all CLAHRC YH research, to
support cross-theme working and to collaborate in bids for research funding. the
Trust will explore the potential for a Patient Research Ambassador, in line with the
NIHR CRN proposal (2014), to provide a „ front line‟ patient voice to champion
public
access to healthcare research through their local NHS Services, and thereby
contribute to the development of a positive and inclusive NHS research culture.
This strategy will further support the CRAG group to forge links with other patient
groups within the Trust in collaboration with the existing Patient Experience Team,
with a view to shaping the evidence base that informs wider clinical practice.
Partnerships with external organisations offering PPI opportunities with be
maintained and promoted.
Key Strategic Aims and Objectives
Aim 1.
Establish Trust as centre of excellence in R&D by cultivating
priority areas of clinical, applied health and translational research, which have
clear potential to inform commissioning, service improvement and
transformation.
Objective 1.1 Ensure that research, development and evaluation is strategically and
operationally integrated with Trust business planning
Objective 1.2 Facilitate the translation of research achievements into healthcare
practice and service innovation, to deliver research and development programmes
relevant to our local population and improve quality, safety and patient care
Objective 1.3 Initiate high quality Commercial and non-commercial research and
evaluation, which may qualify for support from the NIHR Clinical research Network,
including Trust sponsored investigator-led trials and other research studies
Aim 2.
Increase research and development capacity throughout the
Trust, to fully exploit potential across all professional groups and services
Objective 2.1 Support staff to deliver successful joint funding applications with
academic partners, to address clinically relevant questions for the benefit of our local
population
Objective 2.2 Establish research, development and evaluation as an integral part of
continuing professional development across all staff bases including nursing,
midwifery, allied health professionals and management
Objective 2.3 Identify areas that require enhanced infrastructure to improve research
and development performance, working with necessary teams to develop specific
initiatives that will assist them to meet planned objectives
Aim 3. Significantly increase research and development activity and income to
sustain a robust infrastructure, to deliver high quality clinical and health
services research and development
Objective 3.1 Collaborate closely with local networks to sustain growth and generate
income through local, regional and national funding streams
Objective 3.2 Provide high quality and cost effective nursing and other R&D support
for the delivery of research and development projects
Objective 3.3 Provide skilled support for the development of innovative research and
development ideas into well designed and competitive research proposals
Objective 3.4 Establish clear communication channels to enable the rapid
dissemination of research opportunities, initiatives and funding calls
Aim 4. Establish and ensure continued support of robust structures to initiate,
deliver and manage high quality research and evaluation for direct patient
benefit
Objective 4.1 Ensure operational oversight of all research and evaluation activity,
sharing performance targets with key partners, in order to consistently deliver to time
and target
Objective 4.2 Increase the quality and relevance of local research programmes
through appropriate patient and public engagement and through supporting the
CRAG and Research Champions
Objective 4.3 Maintain Trust-wide compliance with all applicable regulatory
requirements, through continued consultations between the Research Department
and other key support departments
Strategy Implementation and Monitoring
The success of this strategy requires robust structures to be in place through which
the implementation and performance of the strategy can be monitored and
supported. An R&D Strategy Group will be established and will meet biannually to
maintain a strategic overview of the R&D agenda and to ensure the congruence of
the R&D Strategy with the Trust‟ s Business Plan and priorities.
Recognised as core Trust business, the performance of this strategy will be a
standard reporting item on the Trust Board agenda. There will be quarterly reporting
to the Clinical Governance Committee of all research and development activity
against key performance indicators, as detailed in the Strategy‟ s Delivery Plan.
These reports will detail activity across all Clinical Business Units, which will be
required to demonstrate integration of R&E planning within service plans from 2015.
Performance reports will be provided to a newly established Research Advisory
Group (RAG) on a biannual basis by the Director of Research and Development.
The RAG will comprise a multidisciplinary team, with representation from the Trust
CBUs. The RAG will provide a forum by which performance can be discussed in the
operational context of clinical service delivery.
R&D Business Plan 2014 – 15
Aim 1. Establish Trust as centre of excellence in R&D by cultivating priority areas of clinical, applied health and translational research, which have clear potential to inform
commissioning, service improvement and transformation.
Objective
Lead
Key Performance Indicator
Completion Date
Link Documents
1.1. Ensure that research,
development and evaluation is
strategically and operationally
integrated with Trust business
planning
CS
Integrate research aims into CBU business plans
December 2014
Quality Strategy
Provide quarterly performance reports to all CBUs
August 2014
Trust Business Plan
Integrate Research into Nursing and Quality Strategies
April 2015
Nursing Strategy
1.2. Facilitate the translation of
research achievements into healthcare
practice and service innovation, to
deliver research and development
programmes relevant to our local
population and improve quality, safety
and patient care
CS
Active engagement in the CLAHRC YH Programme. Delivery
of 3 projects linked to Trust priorities and CLAHRC YH
Themes, as part of the Trust's match funding commitment
April 2015
Trust Business Plan
Active engagement in Academic Health Science Networks.
Participation in 2 AHSN linked projects
April 2015
Submit a proposal to the Trust and partner organisations, for
December 2014
Quality Strategy
AHSN Business Plan (www.yhahsn.org.uk/
download/ clientfiles/ files/
20130111%20AHSN%205%20Yr%20BP%20FINAL.
pdf)
a Barnsley Alliance, to support research and evaluation of
inter-organisation initiatives
1.3. Initiate high quality Commercial
and non-commercial research and
evaluation, which may qualify for
support from the NIHR Clinical
research Network, including Trust
sponsored investigator-led trials and
other research studies
CS
Introduction to CLAHRC YH (http://clahrcsy.nihr.ac.uk/resources/CLAHRCYH/CLAHRC%20YH%20Introduction%20brochure%
20Nov%202013.pdf)
Secure two new commercially sponsored Studies, per annum
April 2015
Quality Strategy
Implement feasibility and financial systems to ensure all
research projects are appropriately costed within 5 working
days (subject to full disclosure)
August 2014
AHSN Business Plan
10% increase in number of studies approved in year
compared with previous year
April 2015
Aim 2. Increase research and development capacity throughout the Trust, to fully exploit potential across all professional groups and services
Objective
Lead
Key Performance Indicator
Completion Date
Link Documents
2.1. Support staff to deliver successful
joint funding applications with
academic partners, to address
clinically relevant questions for the
benefit of our local population
CS
Successful application to CLAHRC YH Research Capability
Fund, to support one funding bid to NIHR
July 2014
Trust Business Plan
Submission of one funding bid to NIHR
April 2015
2.2. Establish research, development
and evaluation as an integral part of
continuing professional development
across all staff bases including
nursing, midwifery, allied health
professionals and management
CS
Integrate research responsibility and activity into CBU
Nursing Lead and Specialist Nurse workplans
October 2014
Incorporate research-related activity into all job descriptions
at Band 7 and above
December 2014
Nursing Strategy
2.3. Identify areas that require
enhanced infrastructure to improve
research and development
performance, working with necessary
teams to develop specific initiatives
that will assist them to meet planned
objectives
CS
Initiate two projects in a CBU with previous low/absent
research activity
October 2014
Trust Business Plan
Quality Strategy
Trust Business Plan
Quality Strategy
Aim 3. Significantly increase research and development activity and income to sustain a robust infrastructure, to deliver high quality clinical and health services research and
development
Objective
Lead
Key Performance Indicator
Completion Date
Link Documents
3.1. Collaborate closely with local
networks to sustain growth and
generate income through local,
regional and national funding streams
CS
10% increase in research income compared with previous year
April 2014
Trust Business Plan
10% increase in income from commercial trials, compared to
previous year
April 2014
Introduction to CLAHRC YH
3.2. Provide high quality and cost
effective nursing and other R&D
support for the delivery of research
and development projects
CS
Restructure the R&D Dept to provide cost-effective nursing
support for research
December 2014
Deliver one Trust-wide workshop on GCP
August 2014
Implement quality system for delivery of high quality research
and development
December 2014
Promote a programme of internal and external workshops
through the communications strategy, to advise on study
design, ethics and research governance procedure and the
provision of statistical and other research expertise, linked to
the LCRN, CLAHRC YH and the YH RDS
October 2014
Deliver two internal workshops to staff with the YH RDS, to
promote their services
April 2014
Develop and implement a communications strategy for the
Trust and external stakeholders
October 2014
3.3. Provide skilled support for the
development of innovative research
and development ideas into well
designed and competitive research
proposals
3.4. Establish clear communication
channels to enable the rapid
dissemination of research
opportunities, initiatives and funding
calls
CS
CS
YH AHSN Business Plan
Trust Business Plan
Introduction to CLAHRC YH
YH AHSN Business Plan
Trust Business Plan
Introduction to CLAHRC YH
YH AHSN Business Plan
Trust Business Plan
Introduction to CLAHRC YH
YH AHSN Business Plan
Aim 4. Establish and ensure continued support of robust structures to initiate, deliver and manage high quality research and evaluation for direct patient benefit
Objective
Lead
Key Performance Indicator
Completion Date
Link Documents
4.1. Ensure operational oversight of
all research and evaluation activity,
sharing performance targets with key
partners, in order to consistently
deliver to time and target
CS
Meet LCRN performance and quality targets
April 2015
Trust Business Plan
Meet CLAHRC YH reporting requirements for match and
activity
April 2015
Introduction to CLAHRC YH
4.2. Increase the quality and
relevance of local research
programmes through appropriate
patient and public engagement and
through supporting the CRAG and
Research Champions
CS
Develop and launch an accurate external website with key
research patient and public involvement (PPI) links for service
users
October 2014
4.3. Maintain Trust-wide compliance
with all applicable regulatory
requirements, through continued
consultations between the Research
Department and other key support
departments
CS
YH AHSN Business Plan
Trust Business Plan
Introduction to CLAHRC YH
YH AHSN Business Plan
Research governance and research management SOPs
approved and released within the Trust
Feb 2015
Meet NIHR target for approval times across all studies
April 2015
10% of site files audited
April 2015
Trust Business Plan
Introduction to CLAHRC YH
YH AHSN Business Plan
Appendix 1: Current Research and Development Infrastructure
Medical Director
Director
Research and
Development
Department
Manager
Administrative
Staff
CLRN Research
Nurses
Senior Research
Fellow
Research
Governance
Team
Research Nurses
Research Fellow
in Secondary
Care
NIHR Research
Fellow
NIHR Research
Associate
Commercial
Research Staff
Research Support
Functions
Pathology
Pharmacy
Medical Imaging
Medical Records
NIHR CLAHRC
SY Research
Fellow
Appendix 2: References
Berwick Report. A promise to learn, a commitment to act: improving the safety of
patients in England. HMSO 2013.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/22670
3/Berwick_Report.pdf. Accessed 25/02/14
CLAHRC Yorkshire and Humber. Introduction CLAHRC Yorkshire and Humber:
Building on success to meet the challenges, 2014 to 2018. NIHR 2013.
Cooksey Review. A review of UK health research funding. London: HMSO, 2006.
http://www.official-documents.gov.uk/document/other/0118404881/0118404881.pdf.
Accessed 25/02/14
Darzi Report. Department of Health (2008) High quality care for all: NHS Next Stage
Review final report. London: DH
Francis Report. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.
London: HMSO 2013
Hanney S, Boaz A et al. Engagement in research: an innovative three-stage review
of the benefits for healthcare performance. Health Services and Delivery Research
2013;1(8).
Keogh Report. Review into the quality of care and treatment provided by 14 hospital
trusts in England: overview report. London: DH 2013
NHS England. Putting Patients First: The NHS England Business Plan for 2013/14 –
2015/16. DH 2013
NHS Outcomes Framework 2013-14. DH 2012
Walshe K, Davies HTO. Health research, development and innovation in England
from 1988 to 2013: from research production to knowledge mobilization. J Health
Serv Res Policy OnlineFirst, published on August 28, 2013 as
doi:10.1177/1355819613502011
Yorkshire and Humber AHSN. Creating world class partnerships for health and
wealth. Business Plan 2013 - 2018. http://www.yhahsn.org.uk/news-casestudies/2013/04/30/ahsn-business-plan-published/. Accessed 25/02/14
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
14/06/P-07
SUBJECT:
HOSPITAL STANDARDISED MORTALITY RATIO (HSMR) AND
SUMMARY HOSPITAL MORTALITY INDICATORS (SHMI)
DATE:
JUNE 2014
Tick as
applicable
PURPOSE:
For decision/approval
For review
For information
√
Tick as
applicable
Assurance
Governance
Strategy
PREPARED BY:
SPONSORED BY:
PRESENTED BY:
Dr Jugnu Mahajan, Medical Director
STRATEGIC CONTEXT
2-3 sentences
Meets the requirement to provide high quality and safe services: Strategic Objective 1a.
QUESTION(S) ADDRESSED IN THIS REPORT
1. Does the report provide an update on mortality figures for both HSMR and SHMI?
2. Does this report provide a progress report on the actions to reduce HSMR to 105 by end of
the year?
3. Does this report give an update on external reviews of mortality?
CONCLUSION AND RECOMMENDATION(S)
• The Trust position for SHMI remains in the ‘as expected’ range
• HSMR for the rolling 12 months has shown a reduction since last month
• Crude Mortality has remained below the mean
• External review of April 2013 deaths provides assurance that the standard of care at
Barnsley Hospital is good and no significant system factors was found to account for high
mortality in April 2013
Recommendation
• Note the Trusts’ performance on hospital mortality and progress against actions being
taken to reduce mortality in the Trust
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
Meets the requirement to provide high quality and safe
services: Strategic Objective 1a.
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
High mortality is a patient safety indicator and a risk to patient safety. High
mortality may adversely affect the Trusts’ reputation.
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
Hospital Standardised Mortality Ratio and Summary
Hospital Mortality Indicator
Subject:
Ref: 14/06/P/07
1
STRATEGIC CONTEXT
This report covers performance on mortality ratios and action plans which relate to Strategic
Objective 1c: Patients will experience safe care.
2
INTRODUCTION
2.1 This report provides the latest available mortality figures and an update on the mortality
action plan.
2.2 The mortality figures presented included
•
summary Hospital Mortality Indicator values (SHMI) for October 2012 – September
2013 as pre-released by the Health and Social Care Information Centre
•
the current Hospital Standardised Mortality Ratio (HSMR) position including the
latest month’s data for January 2014 (12 months rolling figure)
•
additional information to support outstanding changes in the rolling 12 month
figure, and to ensure transparency of when any individual month has a high HSMR,
the monthly figures will be routinely included, as shown in Appendix one
•
hospital’s Crude Mortality Rate including the latest month’s data for April 2014
•
a summary of the action plan to date
3 SUMMARY HOSPITAL MORTALITY INDICATOR
3.1
Latest 12 Month Value is from October 2012 – September 2013
3.2 The Trust’s SHMI position for October 2012 to September 2013 is 107.2 (89 – 112).
BHNFT remains in the band two ‘as expected’ group.
3.3 BHNFT's national position is 35 of 141 hospitals. BHNFT has the 4 highest SHMI in
the Yorkshire and Humber region
BoD June 2014: 07_Mortality
Ratios .docxRatios
Page 1
4 HOSPITAL STANDARDISED MORTALITY RATIO
4.1 Latest rolling 12 Months, February 2013 – January 2014, Yorkshire and Humber Non
Specialist Trusts is presented. The 12 Month rolling HSMR up to the month of January
2014 is 111. This has again fallen slightly from last month’s rolling value of 112.
4.2 This table shows the latest rolling 12 Months HSMR.
115
110
105
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
100
Apr- May Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan12 -12 12 12 12 12 12 12 12 13 13 13 13 -13 13 13 13 13 13 13 13 14
HSMR 114 112 113 111 112 111 111 108 110 111 111 110 111 112 113 113 112 111 112 113 112 111
4.3 The initiatives taken so far to reduce HSMR and avoidable deaths are outlined in
appendix two
4.4 The trajectories for reduction in mortality are shown in appendix three
BoD June 2014: Mortality Ratios
Page 2
5
CRUDE MORTALITY RATES FOR BARNSLEY HOSPITAL NHSFT
5.1 Crude Mortality Rates
No. of Deaths
No. of Discharges*
Crude Mortality
Rate per 1000
Discharges*
2007/08
1052
37651
27.9
2008/09
1062
40028
26.5
2009/10
1072
42583
25.2
2010/11
1051
40914
25.7
2011/12
1012
42023
24.1
2012/13
1034
42588
24.3
2013/14
1021
* excludes Day cases unless a death
42550
24.0
Financial Year
5.2 Statistical Process Control (SPC) Chart, Crude Mortality Rate, BHNFT
Crude Mortality Rate per 1000 Discharges*
Mean
Lower Control Limit
Upper Control Limit
45
40
35
30
25
20
15
Apr-07
Jun-07
Aug-07
Oct-07
Dec-07
Feb-08
Apr-08
Jun-08
Aug-08
Oct-08
Dec-08
Feb-09
Apr-09
Jun-09
Aug-09
Oct-09
Dec-09
Feb-10
Apr-10
Jun-10
Aug-10
Oct-10
Dec-10
Feb-11
Apr-11
Jun-11
Aug-11
Oct-11
Dec-11
Feb-12
Apr-12
Jun-12
Aug-12
Oct-12
Dec-12
Feb-13
Apr-13
Jun-13
Aug-13
Oct-13
Dec-13
Feb-14
Apr-14
10
5.3 The table and the SPC chart, above shows the trends in Crude Mortality in the Trust.
As already reported there was a peak in mortality in December 2012 and April 2013.
However, since May 2013 the Crude Mortality rates are below the mean average.
6.
PALLIATIVE CARE CODING
6.1 These charts show the variation in the prevalence of Palliative Care and Co-Morbidity
coding in the HSMR Group. It is clear that Rotherham and Hull Hospitals are delivering
and coding more Palliative Care than other Yorkshire and Humber Hospitals. Variation
is also seen in comorbidity coding.
% of HSMR Admissions with a Palliative Care Code
Highest 3 and Lowest 3 Yorks & Humber Non Specialist Trusts
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Rotherham NHS FT
Hull & East Yorks NHS Trust
Barnsley NHS FT
York Teaching NHS FT
BoD June 2014: Mortality Ratios
2013/14 Q3
2013/14 Q2
2013/14 Q1
2012/13 Q4
2012/13 Q3
2012/13 Q2
2012/13 Q1
2011/12 Q4
2011/12 Q3
2011/12 Q2
2011/12 Q1
Sheffield Teaching NHS FT
Bradford Teaching NHS FT
Page 3
HSMR Admissions, Average Comorbidities per Admission
Highest 3 and Lowest 3 Yorks & Humber Non Specialist Trusts
7.0
6.5
6.0
Airedale NHS FT
5.5
2013/14 Q3
2013/14 Q2
2013/14 Q1
2012/13 Q4
2012/13 Q3
2012/13 Q2
Sheffield Teaching NHS FT
2012/13 Q1
Bradford Teaching NHS FT
3.0
2011/12 Q4
Barnsley NHS FT
3.5
2011/12 Q3
North Lincs & Goole NHS FT
4.0
2011/12 Q2
Hull & East Yorks NHS Trust
4.5
2011/12 Q1
5.0
7. OVERARCHING MORTALITY DRIVER DIAGRAM
Aim
Primary Devices
Clinical Care
• Implement evidence base
care pathways
• Strategies to reduce harm
• Ensure scrutiny of all deaths
Reliable Care Systems
• Implement 7 Day Services
Keogh Standards
• Robust escalation systems
• Reliable reporting and acting
on Never Events
Leadership
• Effective communication of
mortality statistics
• Clinicians take responsibility
for processes – monitored by
Performance Meetings
• New CBU structures to
prioritise mortality as CBU
business
To reduce avoidable
deaths
Reduce HSMR to
105.0 by January
2015
Documentation and
Informatics
End of Life Care
BoD June 2014: Mortality Ratios
Secondary Devices
• Improvement of
competences of coding
• Improvement in Clinician –
coder interface
• Improvement in
documentation in notes
• Ensuring skill mix adequate
in Clinical Coding
• Improve opportunities for
people to die in preferred
place
• Review of End of Life Care
extension to 7 Day Service
Page 4
7.1 Presented here is an overarching Mortality Driver diagram which outlines the primary
and secondary drivers which influence mortality. In the past year we have focused on
improving care provisions in all these areas however the main priorities have been
‘Clinical Care’, implementing ‘Reliable Care Systems’ and documentation and
informatics’.
7.2 With the new Clinical Business Unit (CBU) structure it is anticipated that clinical
leadership will be strengthened and organisational ‘buy in’ into this area will further
improve. Further plans to improve End of Life care will also be developed in this year.
8. GOALS AND PRIORITIES TO REDUCE AVOIDABLE DEATHS IN THE TRUST
8.1 Goal 1:- Delivering Consistently Effective Care
How will we do it?
Improving outcomes and effectiveness means saving lives, improving the quality of life
for our patients, speeding up their recovery and reducing readmissions. The Trust will
achieve the improved health outcomes through delivery of safe, effective and
evidence-based care.
What are our priorities?
• Reduce Avoidable
Deaths
• Measured by Reduction
in HSMR to 105.0 by
January 2015
Reduce the number of in hospital
avoidable deaths;
Improve recognition and management of the
adult deteriorating patient;
Improve sepsis recognition and response;
and
Ensure scrutiny of all in hospital deaths to
ensure learning is achieved where possible.
How will we measure progress?
The Trust will use SHMI and HSMR to measure progress in our reductions of
avoidable deaths. The Trust will also build on learning from best practice examples
to improve the quality of health outcomes for our patients. There is a commitment to
continuous improvement and challenge to ensure that there is appropriate
modification of key indicators of care and that reflection on the results of audits and
enquires is embedded throughout the Trust.
The Trust’s quality improvement and performance dashboards will continue to be
used to assist the Trust in understanding the quality of care we are providing and
monitor our performance against these priorities.
Targets for 2014/15
• reduce the number of avoidable in hospital deaths,
The Trust’s rolling 12 month HSMR value up to December 2013 is 111.8. The
Trust aims to reduce this rate further to 105.0 by January 2015 and 100.0 by
January 2016.
The Trust’s SHMI latest pre-release position (12 month period, October 2012 –
September 2013), is 107 and is ‘as expected’, Band 2.
BoD June 2014: Mortality Ratios
Page 5
•
improve recognition and management of the deteriorating adult patient,
The Trust implemented National Early Warning Score, (NEWS), across the
organisation in January 2014. By April 2015 the Trust aims to demonstrate 95%
compliance with the implementation of NEWS in the adult patient. Audit will
commence in July 2014 auditing notes from 1 April 2014 – 31 May 2014 with a
plan to re-audit six months after.
•
improve sepsis recognition and response,
As at January 2014 the Trust was 8% compliant with the implementation of
the Sepsis Six Bundle. By April 2015 the Trust aims to increase this to 95%
compliance. The next Sepsis Six Bundles audit is scheduled for July 2014,
auditing June’s activity, the results of this audit will be published in August 2014.
•
ensure scrutiny of all in hospital deaths to ensure learning is achieved where
possible
From April 2014 the Trust has implemented a formal process for reviewing all
in hospital deaths. By April 2015 the Trust aims to formally review 95.0% of all
applicable in hospital deaths within 15 working days of the death occurring.
8.2 Goal 2:- Delivering Consistently Safe Care
How will we do it?
Delivering consistently safe care means taking action to reduce harm to patients
in our care and protecting the most vulnerable. It means ensuring that the
workforce receives the right education and training in preparation for the delivery
of competent and skilful intervention.
The organisation is committed to ensuring that service users are cared for in
surroundings which are clean, by caring and competent staff. This
organisation wants to eliminate hospital acquired, infections, medication
errors, VenousThrombo-Embolism (VTE), patient falls, pressure ulcers and
other examples of harm which can occur within a healthcare setting.
What are our priorities?
• Reduce Hospital
acquired harms, VTE,
Falls, CAUTIs &
Pressure Ulcers to
national average
• Reduce inpatient falls by
50% by January 2015
To reduce hospital acquired
harms in relation to VTEs, Falls,
CAUTIs & Pressure Ulcers;
Reduction in inpatient falls;
To improve clinical note keeping standards
thereby ensuring robust patient assessments
and plans of care.
How will we measure progress?
In order to know whether we have been successful in achieving our priorities, the
Trust will report progress through the Quality, Safety, Improvement and
Effectiveness Board (QSIEB) in the monthly Safety and Quality Report. Information
and data will also be monitored at local clinical specialty level and at Clinical
Business Unit level to ensure lessons are learnt, improvements to care are
identified and implemented and best practice is shared.
BoD June 2014: Mortality Ratios
Page 6
Targets for 2014/15
• To reduce hospital acquired harms in relation to VTE, Falls, Catheter-Associated
Urinary Tract Infection (CAUTI) & Pressure Ulcers
For 2014/15 the Trust aims to reduce hospital acquired harms in relation to
VTEs, Falls, CAUTIs and Pressure Ulcers with the aim of achieving the national
average for harm free care against all areas; VTEs, Falls, CAUTIs and
pressure ulcers. Each area will be monitored separately.
•
Reduction in inpatient falls
Since April 2013, (to January 2014), the Trust has reported 895 inpatient falls.
For 2014/15 the Trust aims to reduce the number of inpatient falls by 50%.
•
To improve clinical note keeping standards thereby ensuring robust patient
assessments and plans of care
To achieve 75% compliance with 2014/15 clinical note keeping standard audits.
8.3 Goal 3:- Enhancing Clinical Leadership
How will we do it?
Embedded clinical leadership at service delivery level with a focus on improved quality
of care prevents avoidable deaths. Both nursing and medical leadership along with
General Manager at CBU level will ensure effective and safe care is delivered.
What are our priorities?
• Adequate nursing
members and skill mix
• New CBU structure
• Supervisory Band 7
• Extended AMU
consultant cover to 16
hours (8 am – mid night)
by March 2015
Regular daily reporting of
nursing members and skill mix
Review of skill mix and team
structure to ensure that we have
the right people with the right
skills at the right time
Recruitment of AMU consultants
to full establishment
Target for 2014
•
•
•
To reduce sickness absence to 3.5%.
To demonstrate 90.0% compliance with staff appraisals
To demonstrate 90.0 % compliance with mandatory training
How we will measure progress
The Trust will monitor the number of appraisals undertaken to ensure that all staff have
appropriate objectives aligned to Trust objectives, values and behaviours. Skill mix of
nursing will be monitored and reported to the Board on a six monthly basis. A record of
training undertaken by all staff will be held and areas for improvement identified. The
staff survey will be used as a measure to identify improvement.
8.4 Goal 4:- Documentation and Informatics
BoD June 2014: Mortality Ratios
Page 7
How will we do it?
We will work with each CBU to review the quality of documentation and the associated
quality of coded data. The rolling programme of clinical coding audits at a
specialty/department level will continue.
Audit processes for the quality of
documentation will be introduced. A restructure of the Clinical Coding team is planned
within the next 6 – 12 months this will introduce senior posts that can provide improved
audit and training functions.
What are our priorities?
• Improve documentation
of primary conditions
and co-morbidities
• Appropriate clinical
coding team skill mix
Implement documentation
reviews this will be implemented
within 6 months by working
closely with the CBUs
Improve depth of coding for each
clinical area
Implement trainee
clinical coding
posts
in
Implement senior posts in
clinical coding to include training
and audit roles
Target for 2014/15
Increase average number of co-morbidities per spell to at least the regional average.
Improve documentation quality, objectives to be set after ample audits completed.
Whilst this target has been set there is still an expectation that we will see a continuous
increase in engagement between CBUs, Clinicians and coders throughout the year.
Compliance will be identified through re-audits any lessons that can be learnt will be
shared with the CBU’s.
8.5 Goal 5:- End of Life Care
How will we do it?
End of Life care in BHNFT is being developed in accordance with the Barnsley End of
Life Care Strategy and Vision. The strategy is inclusive of all life limiting illness and
recognises that delivery of compassionate and high quality care is everybody’s
business. The district wide end of life care strategy group provides strategic direction
for the local developments.
What are our priorities?
• Identification of end of
life care needs
• Care planning
• Coordination of care
• Development of high
quality care
• Last days of life care
• Care after death
• Introduction of AMBER Care
Bundles
Last days of life care
Last days of life care pathways
Target for 2014/15
BoD June 2014: Mortality Ratios
Page 8
Measurable targets for 2014/15 are in the process of being set. Amber Care Bundles
have been introduced on four wards and the plan to roll out on a further two wards.
Last days of life care pathway is to be developed in the next six months. Work has
started on End of life care pathways and further national guidance is awaited.
9. ON-GOING ACTIONS
9.1 Mortality Reviews
Patient deaths are being reviewed within CBUs however there has not been a
standardised approach to this throughout the Trust to date. The hospital’s revised
Mortality Review Process will ensure that the review of all patient deaths is
standardised throughout the Trust. There will be a clear review structure that meets
the duty of candour and ensures the process is open and transparent. Any lessons
that can be learnt will be shared throughout the Trust, with action plans developed as
required. The review process has been launched on 1st April 2014.
A Mortality Case Note Review will be performed by the Consultant responsible for the
patient’s care, within 15 working days of death. The Mortality Review Group, who
meets on a weekly basis, has started reviewing all Mortality Case Note Reviews.
Where there is any cause for concern relating to the patient’s death, the death will be
referred for a ‘Clinical Business Unit Multi-disciplinary Mortality Review’. The CBU
Multi-disciplinary Mortality Review will be conducted by the consultant responsible for
the patient’s care and the Lead Nurse from the ward/clinical area where the patient
died. This will be completed within 15 working days of referral from Mortality Review
Group. This review will be presented to the CBU by the Consultant and Lead Nurse.
This will constitute a peer review of the patient’s death. Lessons learnt from the
mortality review will be shared across the CBU.
The Mortality Steering Group will review all Mortality Case Note Reviews and CBU
Multi-disciplinary Mortality Reviews. Any lessons learnt from the mortality reviews will
be shared through exception reporting to QSIEB.
9.1.1 Update from May 2014
A new Mortality Review process has been established whereby every in-patient
death will be reviewed by the Consultant responsible for the patient – a
standardised Mortality Review form is being used. In cases where there are
issues of concern, a more detailed in-depth review will be carried out by the
Consultant and the Lead Nurse of the clinical area where the patient died; again
a standardised form will be used. The in-depth review will be reviewed at the
CBU Governance committee (forming a peer review) and this will be presented
to the Mortality Steering Group. So far the issues identified and the mitigation
offered is as below.
Issue
• Introduction of
new system
Detail
• Issues of embedding new process
• Completion of
• Issues of embedding new process whilst
Mortality
previous CSU processes in place
Review forms
• Management
• On–going management of the process, to
of new process
ensure that the process is supported and
that all deaths are reviewed within the
timescale
BoD June 2014: Mortality Ratios
Mitigation
• Weekly Mortality
Review meeting is
reviewing this
• Weekly Mortality
Review meeting is
reviewing this
• Weekly Mortality
Review meeting is
reviewing this
Page 9
9.2 The Deteriorating Patient
9.2.1 National Early Warning Score (NEWS)
Following completion of a pilot of the National Early Warning Score (NEWS), it
was decided in January 2014 to implement NEWS across BHNFT for all adult
patients. An escalation pathway was formulated to reflect national and local
requirements. This has been incorporated into ‘Recognising and responding to
the Acutely Ill Adult Patient: Including Sepsis Recognition and Treatment’
document.
In order to ascertain that our hospital has implemented NEWS effectively a
clinical audit is to be undertaken at the end of April 2014. The audit will initially
cover 60 sets of patient healthcare records: 30 from medicine, 20 from surgery
and 10 from the Emergency Department. This will be a retrospective audit of
healthcare records from discharged patients and will include records of
deceased patients. The outcome of this audit will be communicated through the
quality and governance structures of the organisation. The outcomes of the
audit will direct and focus further efforts in ensuring good levels of
implementation and compliance. There will be an additional audit, the timeframe
for which will be determined by the outcome of this initial audit.
The Trust has a target to demonstrate 95% compliance with the implementation
of NEWS by April 2015. Whilst this target has been set there is still an
expectation that we will see a continuous increase in compliance throughout the
year. Compliance will be identified through re-audits and the results of these will
be reported accordingly.
9.2.2 Update from May 2014
NEWS was adopted for all adult patients (excluding obstetric patients) in
January 2014.
All areas follow the same escalation pathway for the
deteriorating patient with the exception of the ED/AMU
Issue
• NEWS Charts for
ED/AMU
• Use of NEWS in
PACU and
transfer to wards
Detail
• Incorrect Charts delivered
from Printers – underlying
issues following transfer of
contracts
• Patients score a 2 in PACU
routinely for supplemental
oxygen – generating
escalation
Mitigation
• Artwork drafted and
approved – printed
and suitable for use
•
Task and finish group
(patient safety
champion from areas)
formed.
9.2.3 Patient Safety Champions (PSC’s)
Patient Safety Champions to be appointed for all clinical areas and specialities,
they will be responsible for key projects related to patient safety, such as NEWS
and Sepsis.
Issue
• Establishment of
PSC’s
BoD June 2014: Mortality Ratios
Detail
• Lead Nurses and AHP’s
appointing PSC’s
• Representation from
medical staff
Mitigation
• Inaugural meeting
• Associate Medical
Director has emailed
Clinical Directors to
nominate staff.
Page 10
9.2.4 Sepsis Recognition and Management Tool incorporating Sepsis Six Care
Bundle
The adult observation chart incorporates NEWS and the associated Escalation
Pathway, also includes the Sepsis Screening and Management Tool.
A number of patients who deteriorate in the acute hospital settings have an
infection and develop sepsis. Sepsis is a recognised and under identified cause
of deterioration in adult patients in acute hospital settings. The Sepsis Six Care
Bundle has been demonstrated to reduce mortality from sepsis.
All patients identified as having sepsis should be commenced on the Sepsis Six
bundle of care within an hour of recognition. The timings of this should be
documented on the Fluids, Antibiotics, Blood Cultures, Urine, Lactate, Oxygen,
Sepsis Six (FABULOS) stickers and page four of the Observation Chart.
A pilot audit completed in February 2014 demonstrated poor compliance with
the Sepsis Six Care Bundle. Patient Safety Champions from both the nursing
and medical teams have been nominated in clinical areas to support the
implementation of initiatives such as NEWS and Sepsis Recognition and
Management Tool.
Whilst this is a Trust-wide re-launch of the Sepsis Six Care Bundle there will be
an initial focus on three defined clinical areas; Emergency Department, Acute
Medical Unit and Surgical Decisions Area. An audit will be undertaken in these
three areas at the beginning of June 2014 to confirm there has been a
successful re-launch of the Sepsis Six Care Bundle. Assuming the audit
provides the level of assurance required, the roll out of implementation will
continue in 8 weekly cycles across individual clinical areas. Each cycle of
change will be supported by a re-audit. We believe that by supporting the relaunch and implementation of the Sepsis Six Care Bundle with the PDCA
process; plan–do–check–act, the continuous improvement of the implement of
this process will be effective and sustainable throughout the organisation.
The Trust has a target to demonstrate 95% compliance with the implementation
of Sepsis Six Care Bundle by April 2015. Whilst this target has been set there is
still an expectation that we will see a continuous increase in compliance
throughout the year.
9.2.5 Update from May 2014
A Screening and Management Tool for the early recognition and treatment of
sepsis was introduced in August 2013. Recent audit showed compliance with all
components of Sepsis Six with 1 hour to be 8%.
Issue
Detail
• Sepsis Six to be re- 1. Audit presented at April
QSIEB
launched
2. Sepsis Six re-launched
from April
3. To be part of role of PSC
4. Publicity to on Intranet and
distributed to clinical areas
Printers
– underlying issues
• Availability of
following transfer of contracts
FABULOS sticker
BoD June 2014: Mortality Ratios
Mitigation
1. Completed
2. Ongoing
3. Ongoing
4. May 2015
Artwork
drafted
and
approved – printed and
suitable for use May 2014
Page 11
9.2.6 Community Acquired Pneumonia (CAP) Care Bundle
During March 2014 the CAP Care Bundle has been implemented in the ED and
AMU. Plans are to implement for an additional eight weeks and then audit
levels of implementation. Feedback of the audit will be reported to the Mortality
Steering Group where a process of continuous audit will be monitored and
actions to improve levels of compliance will be agreed.
9.2.7 Understanding our Patient Safety Culture
A Staff Survey is currently running using the Manchester Patient Safety
Framework to review how our staff views the organisation and patient safety.
This survey can be accessed through the Intranet Homepage.
9.3 End of Life Care (Update from May 2014)
End of Life care in BHNFT is being developed in accordance with Barnsley’s End of life
care strategy and vision. The district wide end of life care strategy group provides
strategic direction for the local developments, within BHNFT this is led by the end of life
care steering group. The Specialist Palliative Care (SPC) team provide clinical
leadership for palliative and end of life care in BHNFT and they work in close
partnership with Barnsley Hospice and SWYPFT end of life care team who are
commissioned to provide generalist training and support for the use of nationally
recommended end of life care developments across health and social care providers in
Barnsley.
What are our priorities?
• Identification of end of life care needs
• Care Planning
(LCP)
• Coordination of care
• Development of high quality care
• Last days of life care
• Care after death
Introduction of AMBER care bundle
Replacement of Liverpool care pathway
7 day week working SPC
Training needs analysis
Proactively seek bereaved carer feedback
Targets for 2014/2015
The publication of the care of the dying audit in May 2014 has provided a benchmark
for BHNFT end of life care against national Key Performance Indicators (KPI) and an
action plan is currently being developed as an outcome of this audit; the above
priorities will be reflected in this action plan.
As a result of the recent independent review of the Liverpool Care Pathway (LCP) in
July 2013 national guidance is that the LCP and adapted versions are replaced by an
individualised care plan for the last days of life by July 2014. This is currently being
developed and piloted with the aim to introduce in July and it is recognised that this will
require significant education and clinical support and will take time to embed in
practice.
The AMBER care bundle is a nationally recognised tool to support identification of end
of life care needs (last 1-2 months of life), good planning and recognition of a person’s
preferences and wishes. The need to communicate uncertainty about prognosis is
clinically challenging and education about the AMBER care bundle aims to improve
this. The AMBER care bundle has currently been introduced in six clinical areas and it
is aimed that it will be rolled out to all medical wards by the end of the year. Whilst it is
BoD June 2014: Mortality Ratios
Page 12
recognised that numbers are relatively small and this project remains in its infancy
early audits appear to show that it has helped recognition of end of life care need,
improved communication, coordination and patient involvement and reduced
readmissions for those discharged.
10
INDEPENDENT REVIEW OF DEATHS IN APRIL 2013
10.1 The report of the above review performed by Dr Alan Fletcher was presented at the
Clinical Governance Committee and discussed in detail.
The report was
commissioned to provide external scrutiny by performing individual case note review
to establish
•
•
•
whether or not there is explanation for higher mortality in April 2013
and in particular if there is any common theme that may influence preventability
and to note if any of the deaths that occurred were preventable
The author states that the general impression formed is that the standard of care at
Barnsley Hospital is good and that he could not see any significant system factor that
can account for high mortality.
10.2 Dr Fletcher goes on to note that “having reviewed many deaths in many hospitals, I
do not believe the cases and factors I have identified are substantially different at
Barnsley Hospital than comparable hospitals”.
“Nevertheless, there are aspects of care where if tightened up upon could reasonably
be expected to avoid some future deaths. I have summarised these below in no
particular order.
•
•
•
•
prescription and administration of thromboprophylaxis
review of radiographer and chest drain insertion practice (in the light of these
serious incidents, I am sure this must already be in hand)
recognition of and escalation of raised Early Warning Scores
delay in assessment and review, particularly out of hours and at weekends”
10.3 The following comments were also made by Dr Fletcher
•
•
•
•
•
“there were very few surgical deaths and none after elective surgery
similar to my findings on a previous review, the availability of intensive care
specialists and their willingness to take patients is of very high standard. In my
view several patients were taken to intensive care where other units would
decline intervention
there is an increase in young people dying in Barnsley. It is puzzling, why young
patients have died at Barnsley Hospital, I suspect this is a combination of factors
but with poor general health and social depravation in Barnsley and surrounding
areas, this is not particularly surprising
there were several deaths attributable to end stage alcohol related liver disease.
There were exclusively in surprisingly young people and more than one would
expect in this number of deaths. In my view these deaths were not preventable
but their young ages have the potential to skew statistics
on the same theme, there were several deaths attributable to cancer in young
patients where palliative measures had not been employed because of the
sudden rapid progression of cancer. In one case the sudden tragic cardiac arrest
out of hospital that led to return of circulation but with significant hypoxic cerebral
infarction of a recently delivered young woman could not have been avoided.
BoD June 2014: Mortality Ratios
Page 13
Again, these deaths were not preventable in my view but young ages will affect
the statistics when looked at as a whole in combination with the alcohol related
deaths”
•
Summary
“108 deaths occurring in April 2013 were reviewed. Missing data occurred for a
further six. There were eleven possibly preventable deaths and two probably
preventable deaths. It should be noted that preventability is by no means certain
and of those felt to be possibly preventable, many patients were seriously ill, frail
and had multiple co-morbidities.
I did not find any significant persistent system problem but there are some areas
the Trust may wish to consider to avoid the possibility of future preventable
deaths. There are areas of vulnerability around thromboprophylaxis, weekend
and out of hours review, and escalation of Early Warning Scores in a small
number of cases.
It is beyond the scope of my report to comment on statistical analysis but from a
general perspective, there were a number of unavoidable deaths in April 2013 in
relatively young patients with significant medical problems, which may skew
mortality rates.
An action plan is being progressed to action the areas of improvement highlighted
and will be incorporated in the overall mortality action plan and will be presented
to the Clinical Governance Committee”
11. AQuA MORTALITY REVIEW: MARCH 2014
The draft report was received in May 2014. A top level presentation was made to the
Executive Team. Comments on the draft report have been collated and fed back to AQuA.
The final report is awaited. A workshop has been planned with the Clinical Directors,
Senior Nurses and Managers on 13th June 2014 to develop an overarching Trust wide
mortality action plan. Once the final report is received it will be communicated along with
the action plan in the Trust as well as to the Board and Clinical Governance Committee.
12. PERFORMANCE MONITORING
CALENDAR YEAR 2014
12.1
HSMR
AND
SHMI
REDUCTION
PLAN
FOR
Appendix three (Performance Monitoring HSMR and SHMI Reduction Plan for
Calendar Year 2014) shows mortality indicator reduction targets and their ongoing
performance.
This appendix also includes the performance monitoring of
workstreams likely to contribute to these reductions. This is a working document
and actions will be incorporated in the action log which is reviewed and updated at
the Mortality Steering Group.
Appendices:
•
•
•
Appendix 1 – Monthly HSMR figures
Appendix 2 – Time Line of actions completed
Appendix 3 - Performance Monitoring HSMR and SHMI Reduction Plan for Calendar Year
BoD June 2014: Mortality Ratios
Page 14
Appendix 1
HSMR by Month: Current & Previous Financial Year, BHNFT
[email protected]
The main report on mortality rates presents the rolling 12 months HSMR as the most stable
indicator of mortality rates. Monthly HSMRs are volatile, due to the relatively small numbers
involved and this is reflected in the wide confidence intervals (95%).
To provide additional information to support understanding of changes in the rolling 12
month figure, and to ensure transparency of when any individual month has a high HSMR,
the monthly figures will be routinely included as an appendix to the main report.
The months highlighted in bold in the table show months that “alert” due to a high HSMR.
The alert is triggered where the lower confidence interval is above 100. When an alert
occurs this will be reviewed by the Mortality Steering Group and individual action taken. For
example for December 2012 and April 2013, internal reviews and external reports have been
commissioned to examine if there any significant contributing factors that require action to be
taken.
Month
HSMR
Month
Number of
Expected
Deaths
Number of
Deaths
95% Lower
CI
95% Upper
CI
Apr-12
115.3
74.6
86
92.2
142.4
May-12
102.7
77.0
79
81.3
127.9
Jun-12
108.3
64.6
70
84.5
136.9
Jul-12
103.7
66.6
69
80.7
131.2
Aug-12
125.0
64.8
81
99.2
155.3
Sep-12
104.8
63.9
67
81.2
133.1
Oct-12
95.8
61.6
59
72.9
123.6
Nov-12
89.0
79.8
71
69.5
112.2
Dec-12
133.7
83.8
112
110.1
160.8
Jan-13
111.8
86.8
97
90.6
136.4
Feb-13
107.6
76.2
82
85.5
133.5
Mar-13
114.0
81.6
93
92.0
139.7
Apr-13
134.7
65.3
88
108.0
165.9
May-13
109.1
66.0
72
85.3
137.3
Jun-13
123.1
63.4
78
97.3
153.6
Jul-13
104.0
66.3
69
80.9
131.6
Aug-13
113.1
63.7
72
88.5
142.4
Sep-13
100.1
66.9
67
77.6
127.1
Oct-13
100.5
68.6
69
78.2
127.2
Nov-13
107.2
69.0
74
84.2
134.6
Dec-13
115.6
77.9
90
92.9
142.1
Jan-14
108.3
85.9
93
87.4
132.7
Feb-14
Mar-14
Monthly HSMRs are volatile, due to
the relatively small numbers involved.
This is reflected in the wide
confidence intervals (95%)
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
BHNFT Monthly HSMRs with 95% CIs
Green Represents the latest 12 month period
180
160
140
120
100
80
60
Appendix 2
Mortality Group Timeline
John Taylor
Principal Information Analyst
Management Information Services
2014/15 Quarter 1
Barnsley Hospital NHS Foundation Trust
(01226 433951
Information/Data
Intervention and Actions
Alert System now being utilised from HED (CUSUM
HSMR), at trust and CCS diagnosis group level.
'Mortality Rates' final report released by 360
Assurance containing 8 recommended action points.
Apr-14
Monthly and rolling 12 months figures now being
monitored for all 56 CCS diagnosis groups
Pneumonia Bundles now operating in the Emergency
Department
Report Released: Independent Review Of Deaths In
April 2013 At BHNFT, Dr A Fletcher
Mortality Review team to review compliance %s for
Mortality review completion.
Draft Report Released: BHNFT Mortality Review,
March 2014, AQUA
May-14
HSMR data produced at specialty level for inclusion in
monthly CBU Performance reports
Review of Acute Bronchitis deaths completed:
Coding changes recommended from Acute Bronchitis
Deaths Review
Action Plan Workshop: Arranged for 13th June, to
discuss progression of the action points from AQUA
and Dr Fletchers Mortality reports
Jun-14
Appendix 3
Management Information Services Report
May 2014
Barnsley Hospital NHS FT
Performance Monitoring
HSMR & SHMI Reduction Plan
For Calendar Year 2014
This report contains performance data related to workstreams which will
contribute to Barnsley Hospital's HSMR & SHMI reduction plans.
Contents
HSMR Reduction Target
SHMI Reduction Target
Serious & Safety Incidents
Sepsis Bundles
Produced By:
[email protected]
Tel:
01226 433951
Date:
17th December 2013
Version:
1.0
File Location:
-
HSMR Reduction Target: Barnsley Hospital NHS Foundation Trust
-A target HSMR of 105.0 for the calendar year 2014 period
Set December 2013
Owner Dr J Mahajan, Medical Director
-Reduction from 2012/13 HSMR (110.3)
HSMR data is released monthly
Sepsis Bundles
Mortality Reporting
Streamline Process
Increase Clinician Involvement
Pneumonia Bundles
HSMR: Barnsley NHSFT Rolling 12 Month Target
Target Trajectory
115
National
HSMR Rolling 12 Month
110
105
100
95
Reduce Serious Incidents
and Never Events
Reduce Inpatient Deaths
End of Life Care
Amber Care Bundles
Reduce Patient Safety
Incidents
(Severe & Moderate Harm)
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
90
Mar-13
NEWS & Escalation
SHMI Reduction Target: Barnsley Hospital NHS Foundation Trust
-A target SHMI of 102.0 for the calendar year 2014 period
Set December 2013
Owner Dr J Mahajan, Medical Director
-Reduction from 2012/13 SHMI (103.6)
SHMI is a 12 Month value released quarterly
Sepsis Bundles
Mortality Reporting
Streamline Process
Increase Clinician Involvement
Pneumonia Bundles
SHMI: Barnsley NHSFT Rolling 12 Month Target
110
Target Trajectory
108
National
SHMI Rolling 12 Month
106
104
102
100
Q3
2014/15
Q2
2014/15
Q1
2014/15
Q4
2013/14
Q3
2013/14
Q2
2013/14
Q1
2013/14
98
Q4
2012/13
News & Escalation
* Q2 2013/14 is a pre-re
Reduce Serious Incidents
and Never Events
Reduce Inpatient Deaths
End of Life Care
Amber Care Bundles
Reduce Patient Safety
Incidents
(Severe & Moderate Harm)
Incident Reduction - HSMR Reduction - Performance
Lead: Trustwide
Start Date: Oct 2013
Septicemia HSMR Reduction - Performance
Lead: Dr P McAndrew
Start Date: Oct 2013
Action Description
A Sepsis bundles is a recommended pathway to be followed following a suspected
septicemia diagnosis.
Chart Description
Chart 1 shows the actual number of deaths in Barnsley Hospital NHSFT's
Septicemia HSMR Diagnosis Group, alongside the expected number of deaths.
Chart 2 shows the HSMR for Barnsley Hospital NHSFT's Septicemia HSMR
Diagnosis Group.
This is a ratio of the values in Chart1: (Actual/Expected) * 100
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
14/06/P-8
SUBJECT:
CLINICAL GOVERNANCE COMMITTEE (CGC)
HIGHLIGHT ASSURANCE REPORT
DATE:
JUNE 2014
Tick as
applicable
Tick as
applicable
PREPARED BY:
For decision/approval

Assurance

For review

Governance
For information
Strategy
Linda Christon, Non-Executive Director and CGC Chair
SPONSORED BY:
Linda Christon, Non-Executive Director and CGC Chair
PRESENTED BY:
Linda Christon, Non-Executive Director and CGC Chair
PURPOSE:
STRATEGIC CONTEXT
2-3 sentences
This highlight assurance report is presented following the recent meeting of the Clinical
Governance Committee (CGC) held on 15 May 2014.
QUESTION(S) ADDRESSED IN THIS REPORT
Are the matters from the Board being appropriately reported to and actioned by the CGC?
Is the Committee enforcing sufficient overview of clinical governance arrangements?
Is the Committee providing rigorous overview and monitoring of clinical risks and highlighting
these to the Board appropriately?
CONCLUSION AND RECOMMENDATION(S)
1. The report show progress on actions delegated from the Board and a number of issues
being actively pursued by the Committee.
2. This report identifies areas of concern/risks receiving special attention by the Committee,
and Board is asked to note the action being taken.
3. The Committee reviewed the new DNA (Did not Attend) Policy and Procedures for
Children and Young People and this is recommended to the Board for approval.
BoD June 2014: 08_a Clinical Governance Assurance report
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD June 2014: 08_a Clinical Governance Assurance report
Subject:
1.
CLINICAL GOVERNANCE COMMITTEE (CGC)
HIGHLIGHT ASSURANCE REPORT
Ref: 14/06/P-8
INTRODUCTION
The Clinical Governance Committee (CGC) receives exception reports from its reporting
Committees and receives assurance reports that are directly aligned to the Business Plan
and Assurance Framework specifically for the principal objectives where this committee is
identified as the assurance provider.
2.
MATTERS TO NOTE
2.1 Matters delegated from the Board or Board Committees
2.1.1 The Committee actioned the request from the Board to regularly review the
progress of the newly established 7 day service delivery group. This will be
included in the regular Quality Report.
2.1.2 The Committee agreed, as required by the Board, that the Mortality Steering
Group should provide further data to the Committee as part of its core data set.
2.2 Compassion in Practice Action Plan
The Committee received a useful update and is able to report on good progress in
rolling out the Compassion in Practice initiative across the hospital. It was noted that
in the section Supporting Positive Staff Experience, there is an action point that “Each
Chair to allocate a board member, as good practice, to be responsible for ensuring
staff are able to raise concerns and that issues raised are acted on in a timely manner
in line with the new statutory duty of candour.” It was not clear to the Committee
whether this had been actioned as the update shows this is still to be agreed.
2.3 National Emergency Laparotomy Audit
The Committee was presented with the summary report of this audit which identified
that nationally there is an increased risk of post operative complications following an
emergency laparotomy and advises that hospitals review the adequacy of their
arrangements. The Committee has requested a further report detailing our position to
provide further assurance to the Board.
2.4 Stroke Performance
The on-going work programme to improve performance against stroke targets was
reviewed and discussed. It was pleasing to note that performance is improving
against all targets, with the exception of TIA. The target of 60% of TIA patients being
scanned and treated within 24 hours is erratic and showing a downward trajectory. A
more detailed report has been requested for the next meeting.
2.5 HSMR/SHMI
Dr Mcandrew attended the meeting to present the outcome of the independent
review undertaken by Dr Alan Fletcher of the “spike” of deaths which occurred in the
hospital during April 2013. Dr Fletcher undertook an analysis of all the case notes of
the deaths according in this period and concluded that “the standard of care at
Barnsley Hospital is good” with “no significant factors” which would account for an
excess of mortality. He did note that several deaths were attributable to alcohol
BoD June 2014: 08_a Clinical Governance Assurance report
Page 1
related liver disease in surprisingly young people, which might have skewed the
statistics.
2.6 NICE compliance
A detailed update on the process for ensuring compliance with NICE Guidance and
Guidelines was provided by Mrs Marshall, the NICE Lead for the Trust. It was noted
that we were mostly compliant in meeting the Clinical Guidelines and the Committee
reviewed in detail areas of the Quality Standards that are red RAG rated as further
work is on-going in these areas.
2.7 Quality Report
The quality dashboard to the end of March was received and discussed. A copy is
appended to this report for information.
3.
EXCEPTION REPORTS
3.1 Exception reports were considered from Quality Safety Improvement and
Effectiveness Board (QSIEB), Infection Prevention and Control (IP&C) Committee,
Patient Experience Group, Safeguarding Children, Dementia Strategy Group and
Medicines Management.
Matters to note included;
4.
•
A concern that we have failed to achieve CQUIN targets for Dementia for the past
two years.
•
Good progress has been made in reducing post operative infection following knee
replacement there are still concerns about some mattresses, including dynamic
mattresses.
•
The Trust continues to compare favourably on the Friends and Family Test.
POLICIES FOR RECOMMENDATION/APPROVAL
The Committee considered the new DNA (Did Not Attend) Policy for Children and Young
People, which is aimed to support staff to identify where there may be safeguarding
concerns. This policy is recommended to the Board for approval.
Post meeting note
Board requested at its meeting on 27 May 2014, that the Monitor quality governance self
assessment framework be monitored by the Committee – this will be added to the
Committee’s forward plan.
Appendices:
•
Appendix 1 – RAG rated information from quality report
•
Appendix 2 – DNA Policy
SMT:\Board\Templates & Agenda\08_a Clinical Governance Assurance report
Page 2_
Appendix 1
1.0
INTRODUCTION
This report provides an overview of key quality, safety and performance measures across the Trust
for March 2014. This monthly dashboard will identify any key achievements and challenges that are
facing the Trust. Where there is an indication that identified Key Performance Indicators have not
been met these issues will be highlighted within the narrative of the report with the inclusion of
actions taken to address any deficiencies identified.
Because of the recent change to the meeting schedule, this report also includes information for April
2014, for Serious Incidents.
The monthly dashboard may be supplemented by additional summary reports on a quarterly,
biannually and annual basis from relevant departments/service areas to ensure the Committee(s) is
provided with an up to date review of quality and safety activity across the organisation.
2.0
RECOMMENDATION
QSIEB is asked to;
•
Review and note the dashboard report.
KPI
January
2014
Number of complaints received
20
28
21
↑
No
18%
38%
38%
→
Yes (see section
4.1)
1
3
2
↑
No
Number of complaints re-opened
2
2
6
↓
No
Number of extreme risk complaints
0
0
0
→
No
Number of Concerns received
114
129
90
↑
No
Number of inpatients with LD seen by
someone with specialist LD skills within
two days of admission
18
5
11
↑
No
Number of inpatients with LD not seen by
someone with specialist LD skills within
two days of admission
1
0
4
↓
No
90% of complaints responded to within
agreed target
Number
of
complaints
investigation with ombudsman
under
February
2014
March 2014
Status
Any exceptions
to report?
Appendix 1
January
2014
KPI
Number of inpatients with LD offered an
“All About Me” Passport
0
February
2014
0
Number of staff trained on the “Last Days
of Life Care Pathway”
March 2014
0
Status
Any exceptions
to report?
→
No
Data to be
verified
Risk Management
Number of incidents reported
*The number of incidents is updated
retrospectively.
595
528
483
↓
No
% of incidents closed
60%
57%
56%
↓
No
Number of Never Events
0
0
0
→
No
Number of SIs reported
5
6
11
↓
See Report
Number of SI’s requiring extension
6
6
1
↑
See report
Number of overdue SI Investigations
6
6
1
↑
No
Number of inpatient falls
99
75
50
↑
No
Number of inpatient falls resulting in
moderate harm
2
0
2
↑
No
Number of inpatient falls resulting in
severe harm
0
1
0
↑
No
Number of inpatient falls resulting in
death (a direct result of fall)
0
0
0
→
No
Appendix 1
KPI
January
2014
Number of repeat falls
28
15
10
↑
Yes (see 4.2
separate board
report)
Number of incidents resulting in severe
harm/death
2
1
1
↑
No
0.34%
0.19%
0.21%
↑
As above
Number of category 2 pressure ulcers
30
21
23
↓
See separate
board report
Number of category 3 pressure ulcers
2
8
8
↓
See separate
board report
Number of category 4 pressure ulcers
0
0
0
→
No
Number of CAS alerts closed outside of
timeframe
2
1
0
↑
No
Number of clinical claims
7
5
5
→
No
0
3
3
→
No
9
12
16
↓
No
10
10
10
→
No
5
5
5
→
No
1
2
1
↑
No
Severe harm/death rate
Number of personal injury
claims
Number of requests for disclosure
Number of clinical
red risks on risk register
Number of non-clinical
red risks on risk register
February
2014
March 2014
Status
Any exceptions
to report?
Infection Control
Clostridium difficile
(Target: 5)
Appendix 1
January
2014
KPI
MRSA bacteraemia
February
2014
March 2014
Status
Any exceptions
to report?
0
0
0
→
No
E Coli bacteraemia
1
2
3
↓
Verbal report
MSSA bactereamia
1
0
0
↑
No
Friends & Family Response Rate (Acute
Inpatient)
38%
35%
34%
↓
No
Friends & Family Response Rate (A&E)
4%
11%
21%
↑
No
17%
20%
26%
↑
No
26%
24%
28%
↑
No
75%
68%
70%
↑
No
100%
100%
→
No
75.1%
79.3%
↑
No
(Target: 0)
CQUIN
Friends & Family Combined Response
Rate
(Target: 15%)
Friends &
(Maternity)
Family
Response
Rate
Friends & Family Net Promoter Score
(combined)
Safety Thermometer Submission
(Target: 100%)
Dementia Find
85.7%
(Target: 90%)
(Final position)
Dementia Assess
(Target: 90%)
Dementia Investigate
(Target: 90%)
Dementia Refer
(Target: 90%)
(Final position)
Data not available
Data not available
Data not available
Appendix 1
January
2014
KPI
VTE Risk Assessment Completion
February
2014
March 2014
Status
Any exceptions
to report?
96.43%
96.21%
95.45%
↓
No
1
2
1
↑
No
0
0
0
→
No
E Coli bacteraemia
1
2
3
↓
Verbal report
MSSA bactereamia
1
0
0
↑
No
Friends & Family Response Rate (Acute
Inpatient)
38%
35%
34%
↓
No
Friends & Family Response Rate (A&E)
4%
11%
21%
↑
No
Friends & Family Combined Response
Rate
17%
20%
26%
↑
No
26%
24%
28%
↑
No
75%
68%
70%
↑
No
100%
100%
→
No
75.1%
79.3%
↑
No
(Target: 95%)
Infection Control
Clostridium difficile
(Target: 5)
MRSA bacteraemia
(Target: 0)
CQUIN
(Target: 15%)
Friends &
(Maternity)
Family
Response
Rate
Friends & Family Net Promoter Score
(combined)
Safety Thermometer Submission
(Target: 100%)
Dementia Find
85.7%
(Target: 90%)
(Final position)
Dementia Assess
(Final position)
Data not available
Appendix 1
January
2014
KPI
February
2014
March 2014
Status
Any exceptions
to report?
(Target: 90%)
Dementia Investigate
Data not available
(Target: 90%)
Dementia Refer
Data not available
(Target: 90%)
VTE Risk Assessment Completion
(Target: 95%)
96.43%
96.21%
95.45%
↓
No
Mortality
January
2014
KPI
February
2014
March 2014
Status
Any exceptions
to report?
HSMR
(National average: 100)
12 month rolling figure
(Nov 12 to
Oct 13)
(Dec 12 to
Nov 13)
(Dec 12 to
Nov 13)
111.8
114.2
114.2
(Jul 12 to
Jun 13)
(Jul 12 to
Jun 13)
(Jul 12 to
Jun 13)
→
No
SHMI (published quarterly)
(National average: 100)
→
Latest 12 month SHMI
106.9
106.9
No
106.9
4.0 EXCEPTIONS
4.1
Issue: 90% of complaints responded to within the agreed target
26 complaints were closed during March; only 10 (38%) of these were within
the agreed target. 16 complaints were closed outside, these were;
•
Cardio-Respiratory CSU (1)
COM-2655. Target was 35 working days; actual 45 working days
Appendix 1
4.2
•
Corporate CSU (2)
COM-1910. Target was 25 working days; actual 127 working days. This
includes time taken to arrange a meeting and then provide an update to the
complainant of the actions taken
COM-2516. Target was 35 working days; actual 67 working days.
•
Emergency Medicine CSU (6)
COM-2284. Target was 45 working days; actual 81 working days
COM-2688. Target was 25 working days; actual 27 working days
COM-2750. Target was 25 working days; actual 42 working days
COM-2736. Target was 25 working days; actual 41 working days
COM-1666. Target was 35 working days; actual 156 working days
COM-2171. Target was 35 working days; actual 108 working days
•
General Medicine CSU (1)
COM-2282. Target was 25 working days; actual 92 working days
•
General Surgery (3)
COM-2835. Target was 25 working days; actual 31 working days
COM-2853. Target was 35 working days; actual 36 working days
COM-2744. Target was 35 working days; actual 41 working days
•
Radiology CSU (1)
COM-2608. Target was 35 working days; actual 53 working days
•
Theatres (1)
COM-2758. Target was 25 working days; actual 32 working days
•
Trauma & Orthopaedics (1)
COM-2539. Target was 25 working days; actual 48 working days
Issue: Number of Patient Falls/Repeat Fallers
The position has improved significantly with a reduction in the total number of fall
and repeat fallers in March 2014.
Attached to this report is data for this month.
A separate is presented to QSIEB regarding action and progress.
4.3
Issue: Number of Pressure Ulcers
There has been a deterioration in the number of grade 3 pressure ulcers.
Attached to this report is data for this month.
A separate report is presented to QSIEB regarding action and progress.
Appendix 1
4.4
Issue: Number of Red Risks
There was no change to the Register in March 2014.
The profile of risks remains:
Emergency Department 4 hour target.
Financial pressures arising from the 4 Hour ED Target
Delivery of the Cost Improvement Programme
Challenges to the delivery of our Transformation Projects
Overall Financial position.
The Radiology Department continues to report service pressures but additional mitigation is
taking plave to reduce these risks from April 2014.
The underlying issue for the Trust as a feature of some of these risks is the timely and
succesful recruitment to vacant posts.
Appendix 2
POLICY CONTROL SHEET
Policy Title
and ID number:
DNA (Did Not Attend) Policy and Procedures for Children and Young People
(GEN 6.25)
Sponsoring Director:
Implementation Lead:
Impact:
Training implications:
(a) To patients
(b) To Staff
(c) Financial
(d) Equality Impact Assessment (EIA)
(e) Counter Fraud assessed
(e) Other
To be incorporated into induction: Yes / No
Approval Process
Executive Led Committee/Board
Date
Board Committee:
• Clinical Governance
Date of consultation:
• Non Clinical Governance & Risk
• Audit Committee
• Finance Committee
• RATS
Trust Board Approval / Ratification
Other:
Approval/Ratification at Trust Board:
Date on Policy Warehouse:
Circulation Date:
Yes / No
Yes / No
Yes / No
Completed: Yes / No
Completed:
Yes / No
Local Consultation
Joint Partnership Forum
Local Negotiating
Committee
Infection Control
Committee:
Health & Safety Board
Date
Quality Safety Improvements
& Effectiveness Board
Investment Board
Patients Experience Board
Information Governance
Board
Workforce Board
Version Number:
Team Brief Date:
Date of next review:
For completion by ET for new policies only:
Budget Code:
Additional Costs
(a) Training
(b) Implementation
(c) Capital
(d) Other
£
£
£
£
DNA policy Version 3- 6.25 - H McNair - April 2014 – Review April 2017
Revenue or Non
Revenue
Barnsley Hospital
NHS Foundation Trust
DNA Policy and Procedures for Children and Young People
(GEN 6.25)
DNA policy Version 3- 6.25 - H McNair - April 2014 – Review April 2017
1.
STATEMENT OF INTENT
The intention of this policy is to ensure that BHNFT has policy and guidance in place for the
management of children who are not brought to hospital for appointments or their
appointments are cancelled by parent/carer or for whom a no access visit has been made. It
aims to ensure that information is shared with relevant agencies and professionals as
necessary and that appropriate action is taken. This would include the need to consider any
actual or potential safeguarding issues. Additionally, to ensure the service offered in respect of
failure to attend booked appointments is in line with joint guidance and policy that are agreed
across the health community of Barnsley.
2.
INTRODUCTION
2.1 All health trusts providing services to children and young people are required to have a
policy in place regarding children who are not brought or who fail to attend booked
appointments (NHS Chief Executive Letter to all NHS Trusts, 16 July 2009). There have
been numerous Serious Case Reviews that have highlighted failures in attending
appointments that could have indicated the underlying safeguarding issues and concerns
about a family’s engagement and prioritisation of the healthcare needs of the child in
question. The duties and responsibilities of all those working with children and young
people and their families in promoting the welfare of children, are outlined in statutory
guidance Working Together to Safeguard Children a guide to inter-agency working to
safeguard and promote the welfare of children (HM Government, 2013b).
The guidance defines safeguarding and promoting the welfare of children as follows.
• Protecting children from maltreatment;
• Preventing impairment of children’s health or development;
• Ensuring that they are growing up in circumstances consistent with the provision of safe
and effective care; and
• Undertaking that role so as to enable those children to have optimum life chances and
to enter adulthood successfully (HM Government, 2010b: 34).
In addition it is a recommendation of our local safeguarding board that we have robust
policies in place for following up DNA’s that includes a safeguarding review.
2.2 Many hospitals report high DNA rates. Paediatric departments across the country have
historically experienced high DNA rates for a multitude of reasons, including the fact that
many childhood illnesses are self limiting, competing priorities for families, accessibility to
services, convenience, administrative errors, difficulty in rearranging appointments, in
addition to a small minority of families who fail to meet their child’s healthcare needs.
Consequently this is a complex area to manage; however, Section 11 of the Children Act
2004, clearly states that as a Trust we have responsibilities to safeguard and promote the
welfare of children, and having a policy in place for the management of DNAs is a clear
component of this.
Please note this policy should be read in conjunction with the Trust Access policy.
DNA policy Version 3- 6.25 - H McNair - April 2014 – Review April 2017
3.
IMPLEMENTATION
3.1 Scope
3.1.1 The policy and accompanying procedure applies to all BHNFT services and staff
groups that offer services to children and should formalise what is already current
best practice.
3.1.2 This policy applies to all children from 0>16 years of age attending any clinic offered
by the Trust. This may be extended to 19 years of age if the child has special
educational needs.
4
GENERAL PRINCIPLES
4.1 It is often difficult to quantify the likely risk to the child/young person of non-attendance or
no access. In view of this it is preferable to discuss this with the referrer, parent/carer and
possibly other professionals who have knowledge of the family i.e. health visitor for 0>5s or
school nurse for older children. In this way more information can be obtained, allowing for a
holistic assessment of the possible health impact on the child/young person from nonattendance/no access. The definitions below may help the practitioner quantify the risk and
subsequent level of concern.
4.2 High Risk - All children/young people whom it is thought require assessment/Intervention to
prevent permanent or serious deterioration of their condition or whom there is a risk of
significant harm as a result on non-attendance/no access or who was not brought, should
be considered high risk. It is essential to consider all children/young people who are subject
to a child protection plan or have a social worker as a high risk and the case should be
discussed with the social worker involved with the family.
4.3 Medium risk - All children not classified as high risk (as detailed above) should be
considered to be medium risk i.e. no concerns and minor clinical situation.
4.4 Low risk - By the virtue of the fact that children have been referred into an acute provider
they should not be classed as low risk.
4.5 To aid assessment of risk, the Framework for the Assessment of Children in Need and their
Families and/or the Common Assessment Framework Pre-Assessment Checklist may be
useful (available via the safeguarding intranet pagehttp://bdghnet/Departments/protection/.
Please see additional flow charts and check lists that summarise the process to follow
5.
MANAGEMENT ARRANGEMENTS
Roles and Responsibilities
5.1 The Executive Team - It will be the responsibility of the Executive Team to ensure that this
policy is implemented across the Trust.
5.2 Managers - It will be the responsibility of managers to ensure this policy is disseminated to
all relevant staff and implemented as appropriate.
DNA policy Version 3- 6.25 - H McNair - April 2014 – Review April 2017
5.3 The safeguarding team - It will be the responsibility of the safeguarding team to offer
advice and support on the implementation of this policy.
5.4 Staff - Whilst some of the tasks may be delegated, it is the responsibility of the
professional who the child is due to see, to ensure the above processes are followed.
6
REVIEW DATE
Review date February 2016 or earlier as local and national recommendations and procedures
change.
7.
REFERENCES
Appleton JV (2011) Safeguarding and protecting children: where is health visiting now?
Community Practitioner 84:21-25
DSCF (2009) Understanding Serious Case Reviews and their impact: A Biennial Analysis of
Serious Case Reviews 2007-07 London: HMSO.
NHS Chief executive Letter to all NHS Trusts, 19 July 2009, Gateway reference number
12228.
Powell C (2011) Safeguarding and Child Protection for Nurses, Midwives and Health Visitors:
A practical guide. Maidenhead; Open University Press.
DFE. Working Together to Safeguard Children 2013: HMSO. London.
DNA policy Version 3- 6.25 - H McNair - April 2014 – Review April 2017
1st DNA
Complete DNA checklist
Appendix A Procedures for All
Healthcare
Professionals
From 2nd DNA or
Was Not Brought, No
Access Visit
No obvious concerns
More than 1 DNA
Consultant review &
outcome. Further
appointment as
appropriate
Could this patient have got
themselves to this appointment?
(Consider age and other
vulnerabilities)
Yes
No
This patient was not brought to this
appointment!
Consider phone call to patient
Review notes for safeguarding
concerns
Review the notes for any concerns
Phone call to parents/patient/carer
to enquire why non-attendance
ARE YOU CONCERNED?
ARE YOU CONCERNED?
No
Consultant
review &
outcome
Yes
Follow Cause for Concern flowchart
Further
appointment
as appropriate
Please contact the Safeguarding
team on ext 2092/1224 for advice
or support
DNA policy Version 3- 6.25 - H McNair - April 2014 – Review April 2017
No
Consider phone
call to HV/SN/GP
or referrer
Consultant review &
outcome
Further appointment as
appropriate
Appendix B
Missed Appointment Process for Patients 0-16 yrs
Cause for Concern Flowchart
Safeguarding Alert in Reason for concern?
the records or other
paperwork indicating
child/patient known to
No safeguarding alerts
safeguarding
but multiple DNA’s/
agencies.
changed appointments.
Medical Urgency to be
• Complete
seen.
safeguarding list
check, register
and log your
concerns on
01226 772361.
•
•
•
•
Social Care still
involved– discuss
with social worker
assigned to this
family.
Share information
with HV/SN,
GP/School or other
relevant
professionals.
No current Social
care involvement –
Go to Yellow box
Document ALL
enquiries/discussion
s and outcomes
(sign & date).
•
•
•
•
•
•
•
•
Complete
safeguarding list
check register and log
your concerns on
01226 772361
Make enquiries with
relevant professionals
i.e. HV/SN/GP/
School.
Referral to Social
care not required.
Consultant letter to
GP & parents with
concerns and plan of
action.
Document ALL
enquiries/discussions
and outcomes (sign &
date
Referral to social
care required. Go to
red box
Assessment and Joint Investigation Team
438831
Complete Request for services form within
24hrs.(found on the intranet)
Contact the Safeguarding Children team on ext
2092
DNA policy Version 3- 6.25 - H McNair - April 2014 – Review April 2017
DNA Paediatric Admin Checklist
Patient ID label
Clinic Code……
Date……
Address and GP
Contact Number
Is this a cancellation?
Is this a repeat DNA ?
Number of missed appointments?
When was the child last seen?
GP checked
Alerts on PAS
+/- Call to parents
Signed----------------------------------------Date-------------This form must be completed for each DNA and clipped to the front of the patient’s
notes.
Paediatric Cancellation Admin Checklist
Actions to be taken by Appointments Staff when they receive a cancellation of
appointment for a child
DNA policy Version 3- 6.25 - H McNair - April 2014 – Review April 2017
Date of clinic…………………………………………………………………….
Time of appointment…………………………………………………………….
Time & date of call received……………………………………………………
By whom…………………………………………………………………………
What was the reason for cancellation?..........................................................
Is this the first cancellation?……………………………………………………..
How many previous cancellations?.................................................................
How many previous DNAs?……………………………………………………..
When was child last seen?.....................................................................................
You need to stress at this point that this appointment could have been given to
another child and that if another appointment is given at this time then they MUST
attend.
Was this discussed with parent? Y/N……………………………………………..
If no why not/……………………………………………………………………..
OR
Can this information be sent with the new appointment?.......................................
Signed………………………………………………………..Date………………
Inform Norma Pendriss on ext 2092 of any concerns or issues you may have and
email the form to Norma on completion to [email protected]
DNA policy Version 3- 6.25 - H McNair - April 2014 – Review April 2017
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
14/06/P-9a
SUBJECT:
ANNUAL SAFEGUARDING ADULTS REPORT (2013-14)
DATE:
JUNE 2014
Tick as
applicable
SPONSORED BY:
For decision/approval
Assurance
For review

Governance
For information
Strategy
Tracey Bostwick, Learning Disabilities Liaison Nurse
Alison Bielby, Deputy Director of Nursing
Heather McNair, Director of Nursing & Quality
PRESENTED BY:
Heather McNair, Director of Nursing & Quality
PURPOSE:
PREPARED BY:
STRATEGIC CONTEXT
Tick as
applicable

2-3 sentences
To provide the Board of Directors with an annual report regarding the Safeguarding Vulnerable
Adults agenda.
QUESTION(S) ADDRESSED IN THIS REPORT
1. Are we appropriately safeguarding vulnerable adults as per multi-agency policy?
2. Are we discharging legal responsibilities correctly regarding Deprivation of Liberty
Safeguards and the Mental Capacity Act?
3. Are staff educated and trained to the appropriate level to safeguard vulnerable adults?
CONCLUSION AND RECOMMENDATION(S)
This report provides the Board with the information required to evidence we have systems in
place to ensure we are appropriately safeguarding adults.
BoD June 2014: 09a_Safeguarding Adults Annual Report
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD June 2014: 09a_Safeguarding Adults Annual Report
Subject:
1.
Safeguarding Adults Annual Report
Ref:
14/06/P-9a
STRATEGIC CONTEXT
1.1 This paper presents the annual report on the delivery of the Safeguarding Vulnerable
Adults agenda within the Trust for 2013-14. It provides an overview of progress
made, identifies challenges and provides the Board with assurance that ensuring the
safety of vulnerable adults is key work within the Trust.
2.
INTRODUCTION
2.1 Multi-agency work regarding adult protection has been taking place in Barnsley since
2001. This work is led by the Local Authority and includes health, social care, police
and voluntary sector organisations. The original work was guided by No Secrets
(Department of Health 2000) and is currently influenced by Safeguarding Adults: A
National Framework of Standards for Good Practice and Outcomes in Adult
Protection Work (DoH 2005) and links strongly with the Mental Capacity Act (2005).
2.2 The strategic approach to safeguarding adults within the Trust is led by the Director of
Nursing and Quality who delegates this to the Deputy Director of Nursing, who also
represents the Trust on the Barnsley Multiagency Safeguarding Adults Board.
2.3 Operationally the Trust has a Named Nurse for Safeguarding Adults and a Learning
Disability Liaison Nurse (LDLN). Their remit is to deliver local training regarding
Safeguarding Adults, Learning Disabilities and the Mental Capacity Act, provide
operational guidance and support within the hospital and lead on internal
safeguarding investigations.
2.4
3.
In December 2013 the Named Nurse Safeguarding Adults in post left the
organisation. This allowed for a review of the post to be undertaken which was
subsequently replaced by the post of Safeguarding Adults Lead, this post was
appointed to in March 2014.
GOVERNANCE
3.1 Internally the Trust has a Safeguarding Adults Steering Group which meets quarterly
to lead and monitor the operational implementation of safeguarding work. This group
is chaired by the Deputy Director of Nursing. This year the group has widened its
remit to include assurance and monitoring of the PREVENT agenda and Tissue
Viability. There are two sub groups which report into the Steering Group: the Learning
Disabilities Steering Group and the PREVENT Steering Group. The Safeguarding
Adults Steering Group gives assurance to the Board through the Quality and Safety
Improvement and Effectiveness Board (QSIEB) and the Clinical Governance
Committee.
3.2 Externally the Trust is represented on the Safeguarding Adults Board and its
subgroups. The Trust is also a member of the Barnsley Silver Prevent Group, chaired
by South Yorkshire Police and attends the Regional NHS prevent meeting.
3.3 Following an assessment against the outcome 7, regulation 11, Safeguarding
Vulnerable people the Trust found no significant gaps.
BoD June 2014: 09a_Safeguarding Adults Annual Report
Page 1
4.
TRAINING
4.1 Safeguarding Adults training is delivered in a number of ways including as part of the
mandatory training week, e- learning and locally organised sessions.
Number of Employees who have received Safeguarding Adults Training up to 1st April
2013 is detailed below.
Total
5.
Percentage of Trust employees trained in Safeguarding Adults Basic
Awareness
92%
Percentage of appropriate Trust employees trained in Mental
Capacity Act and Deprivation of Liberty
58%
FORMAL SAFEGUARDING ADULTS ACTIVITY
5.1 The number of formal safeguarding cases investigated this year was 54. This is an
upward trend. In 2012-2013 the number of cases recorded was 33 cases.
Out of the 54 safeguarding cases this year 68% of referrals were ‘internal’ referrals,
predominantly related to poor care whilst the patient was hospitalised. The remaining
32% were referrals received from multi-agency colleagues based outside of the Trust
but still related to care delivered whilst the patient was hospitalised.
Thirteen of the 54 cases have been taken to Case Conference following the strategy
meeting. The case conference is led by an independent ‘chair’ who has had no
previous involvement in the case. All of the 13 cases taken to this stage were
substantiated in terms of abuse, all of which were in the form of abuse of Neglect/
Omissions of Care.
5.2 The chart below contains data related to alerts that have been received and have
progressed into formal safeguarding cases.
6
5
April
May
4
June
3
July
2
Aug
Sep
1
Oct
0
Nov
Dec
Jan
Feb
March
The Chart below reflects the classification of abuse for 2013/14 for formal cases.
BoD June 2014: 09a_Safeguarding Adults Annual Report
Page 2
12
10
8
Neglect
Physical
6
Financial
Psychological
4
Other
2
0
Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar
The cases identified within the Trust during 2013/2014 include;
•
•
6.
Development and poor management of pressure ulcer – actions from case
conferences were training in specific ward areas, development of documentation
through Tissue Viability team and Senior Nurse Forum and feedback to ward
teams in ward meetings.
Poor discharge processes, including medication errors, no equipment in place on
discharge, no referrals to District Nurse for reinstatement of services (warfarin) led
to a Serious Incident investigation and change in documentation from Bed &
Breakfast admissions to everyone having a full admission.
INFORMAL SAFEGUARDING ACTIVITY
The chart below contains data related to alerts that have been received but have not
progressed into formal safeguarding cases. These cases still require investigation but are
subsequently found not to meet the safeguarding threshold. The two charts below illustrate
type and source of referrals.
30
25
20
15
Neglect
Financial
Physical
Psyc
10
5
Self Neg
Social
Sexual
0
BoD June 2014: 09a_Safeguarding Adults Annual Report
Page 3
30
25
20
15
10
Wards
ED/AMU
S Care
Care Home
Hosp SW
OPD
Police
5
0
Amb
Rels
GP
7.
MENTAL CAPACITY ACT AND DEPRIVATION OF LIBERTY SAFEGUARDS ACTIVITY
The Deprivation of Liberty Safeguards (DoL) became active on the 1st April 2009. This is an
aspect of the Mental Capacity Act, where an individual who lacks capacity may be detained
within a care setting as a result of it being in their ‘Best Interest’. The safeguards require a
process of authorisation, which is achieved through an assessment process undertaken by
our ‘Supervisory Authority’.
In line with the legal requirements of the Act, throughout 2013/2014 twenty applications
were made for urgent and standard authorisation, eleven of which were authorised. This is
an increase from 2012/2013 where the numbers were twenty applications with eight
authorised. The majority of DoLS applications are made from the general medical wards
(10) and the care of the elderly wards (8).
5
4
3
2
1
DoLS Enquiries
Formal Aut Requests
Authorised
Not Authorised
0
Not authorised DoLS are due to:
- the assessors determining that the conditions are not met for a DoLS; or
- the person does not meet the mental capacity requirement; or
- the person does not meet the best interest requirement; or
- the person is discharged from hospital before the assessment is concluded.
BoD June 2014: 09a_Safeguarding Adults Annual Report
Page 4
8.
LEARNING DISABILITIES
During the past year a strong working partnership has continued and developed between
the Learning Disability Liaison Nurse and Learning Disability Community Services. A
number of initiatives have been undertaken as follows:
8.1 Guidelines for the care of a Patient with a Learning Disability in the Acute Hospital
have been developed to assist staff. This includes flow charts with core principles and
specific areas within the trust. This will be monitored through the Quality and Safety
Improvement and Effectiveness Board (QSIEB).
8.2 Guidelines for mental capacity assessment and best interest form for health
investigations/treatment have been developed to be used within the Trust.
8.3 An acute risk assessment matrix (learning disabilities) has been developed to identify
areas where the person may be at risk, identify if additional support is required to
reduce the risk over the 24 hours period, identify who can most effectively provide the
support to maintain the persons safety and well-being and agree how this support will
be delivered and resourced.
8.4 Two versions of the reasonable adjustments guidance have been in place for several
years, one for Children and Young People and one for Adults. Since the employment
of the LDLN the implementation of reasonable adjustments has become far more
operationally based. Examples of this are:
• Theatre – Where someone is admitted for a planned procedure, they are placed
first on the list where clinically possible. Family/Carer support, as required, who
can go to theatre and stay with the person throughout their stay, is usually
arranged through pre-assessment.
• Outpatients Department (OPD):
Where the patient is allocated a double appointment, on occasions appointments
without the person are undertaken if it is deemed not suitable for them to attend.
Best Interest decisions also made in the OPD. Furthermore, support and advocate
for the person is achieved by the attendance of the LDLN.
• Direct Liaison with Community Nurses/Support Teams and the Restraint Team
when it is appropriate to take bloods to assist in diagnosis when the patient is
assessed as having no capacity.
• Inpatient Care:
Family/Carer support is undertaken using a risk assessment tool, resulting in
continuity with the patient's usual carers being involved in care delivery.
8.5 All patients on the Local Authority Learning Disability Register now have a Trust
Patient Administration System (PAS) alert in place. This enables adjustments to be
made quickly on admission to the Trust. The challenge remains for those patients
who use Trust services who reside in Barnsley but originate from outside of the
Barnsley Borough. The LDLN has worked with care providers to ensure all out of
area patients have an alert placed on PAS.
8.6 Since May 2012 Learning Disability training has been integrated into the
Safeguarding Adults Mandatory, Induction and Student Nurse Training.
BoD June 2014: 09a_Safeguarding Adults Annual Report
Page 5
More recently a training DVD specifically focusing on the experience of a patient with
a Learning Disability has been used as part of concentrated Dignity Training. 345 staff
have attended this training; attendance has come from both clinical and non-clinical
areas.
8.7 The Trust successfully worked with Barnsley community to plan events to raise
awareness. A team of health care professionals in Barnsley who support people with
learning disabilities hosted three events in August to raise awareness and celebrate
learning disability awareness week.
Learning Disability Week is Mencap’s national awareness week and last year it was
held from 19th – 25th August, celebrating the ‘superheroes’ in people’s families. Staff
from the Barnsley learning disability service, Barnsley Hospital NHS Foundation Trust
and Mencap worked together to organise the events. The public health service also
supported the events.
The events were held at Barnsley Hospital, Greenacre School and The Alhambra
Centre.
9.
PREVENT
9.1 As part of the government's ‘PREVENT’ anti-terrorism strategy the Trust is required to
develop and implement policy and training for staff in order to try to identify those
people, both staff and patients who are vulnerable from radicalisation this was added
to the NHS contract for the first time in 2013/14. The Trust is working closely with
local partners through the Silver Prevent meeting.
9.2 In response to these requirements the Trust has developed a new prevent policy and
updated both the safeguarding children and safeguarding vulnerable adults policies.
9.3 Five staff have been trained to the national standard and are able to undertake the
training with staff. The initial area identified for roll out of the training is the Emergency
Department, as directed nationally, to date 37 staff have been trained.
9.4 Moving forward from April 2014 prevent training will be incorporated into the
corporate induction and mandatory training schedules.
10. CHALLENGES FOR 2014/2015
In order to maintain the high level of training the Trust has now implemented a
safeguarding training day on the corporate induction from April 2014 this will be evaluated
over the year.
The changes in the requirements regarding MCA/DoLs due to new case law will be
reviewed and policy and procedure updated and implemented as required.
The Trust has a local CQUIN regarding learning disabilities that will ensure that quality of
patient experience is delivered and measured by the Trust.
11. CONCLUSION
The past year has seen the continued growth of the Safeguarding Vulnerable Adults
agenda especially with the implementation of the prevent agenda. However the team has
maintained the level of training required and support clinical staff to discharge their duties
in this area ensuring patients are safe.
BoD June 2014: 09a_Safeguarding Adults Annual Report
Page 6
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
14/06/P-9b
SUBJECT:
SAFEGUARDING CHILDREN ANNUAL REPORT
DATE:
JUNE 2014
Tick as
applicable
Tick as
applicable

SPONSORED BY:
For decision/approval
Assurance
For review

Governance
For information
Strategy
Teresa Burkill, Named Nurse Safeguarding Children
June Pollard, Named Midwife
Dr D Kerrin, Named Doctor Safeguarding Children
Heather McNair, Director of Nursing & Quality
PRESENTED BY:
Heather McNair, Director of Nursing & Quality
PURPOSE:
PREPARED BY:
STRATEGIC CONTEXT
2-3 sentences
To provide year end update on progress and give reassurance to the Board that the Trust is
discharging it’s duties in Safeguarding Children.
QUESTION(S) ADDRESSED IN THIS REPORT
Is the Trust discharging its statutory duties in Safeguarding Children?
CONCLUSION AND RECOMMENDATION(S)
This report provides the Board with the necessary assurance and information to satisfy the
requirements of its statutory duties in safeguarding children.
S:\Meetings\Board\2014 Meetings\06 June\Public\09b_Safeguarding Children Annual Report.docx
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
1a and 2e (2013/14)
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD June 2014: 09b_Safeguarding Children Annual Report
Subject:
1.
SAFEGUARDING CHILDREN ANNUAL REPORT
Ref: 14/06/P-9b
STRATEGIC CONTEXT
1.1 This paper is the annual report regarding the delivery of the Safeguarding Children
agenda within the Trust for 2013-14, it provides an overview of progress made,
identifies challenges and provides the Board with assurance that ensuring the safety
of vulnerable children is key work within the Trust.
2.
INTRODUCTION
2.1 The majority of staff employed at the Hospital comes into contact with children and
families and have a role to play.
2.2 Safeguarding and promoting the welfare of children is defined as, protecting children
from maltreatment, preventing impairment of children’s health and development,
ensuring children grow up in circumstances consistent with the provision of safe and
effective care and taking action to enable all children to have the best outcomes.
Children are best protected when professionals are clear about what work is required
of them individually and how they need to work together. (Working Together to
Safeguard Children March 2010)
2.3 At Barnsley Hospital NHS Foundation Trust we continue to strive to ensure we are
meeting all safeguarding requirements of an ever challenging safeguarding agenda.
2.4 In the summer of 2012, Barnsley was subject to a joint inspection by Ofsted and the
Care Quality Commission (CQC), with a focus on safeguarding and promoting the
welfare of children within the borough. As a health community we were given an
adequate rating, however, there were clear areas noted for improvement. Barnsley
Metropolitan Borough Council (BMBC) was assessed as inadequate therefore as a
Trust we have been delivering specific actions of the improvement plan which is being
monitored by an Improvement Board, chaired by an independent chair and reporting
to the Department for Education. Areas of particular note were the need to improve
level 3 training for all staff (multi-agency training), to develop pathways for the
management of vulnerable young people attending the Emergency department and to
improve the services offered to Looked After Children (LAC).
2.5 An OFSTED re-inspection of the local authority is imminent and we are working with
partner agencies to ensure that all actions are achieved and services for children
continue to improve and be safe
3.
GOVERNANCE ARRANGEMENTS
3.1 Internally the Trust has a Safeguarding Children Steering Group which meets every
two months to lead and monitor the operational implementation of safeguarding
children work. This group is chaired by the Director of Nursing & Quality. The
Safeguarding Children Steering Group gives assurance to the Board through the
Quality and Safety Improvement and Effectiveness Board (QSIEB) and the Clinical
Governance Committee.
3.2 Externally the Trust is represented on the Safeguarding Children’s Board and its
subgroups.
BoD June 2014: 09b_Safeguarding Children Annual Report
Page 1
4.
KEY AREAS OF WORK 2013/14
4.1 The safeguarding department has continued to provide advice and support to health
staff to ensure that Barnsley Hospital NHS Foundation Trust has effective processes
in place to safeguard and promote the welfare of children. Additionally, the
department represents the organisation on relevant multi-agency safeguarding
forums and groups.
4.2 Providing early help is more effective in promoting the welfare of children than
reacting later. Early help means providing support as soon as a problem emerges, at
any point in a child’s life, from the foundation years through to the teenage years. All
agencies have been working hard to ensure more children are receiving the right
service appropriate to their needs. Thresholds guidance has been provided for all
staff and is being embedded into practice.
4.3 The department has established strong links with the Sexual Abuse and Rape Centre
(SARC) at Sheffield Children’s Hospital and worked with them to ensure effective
local follow up for children who have been seen there following acute incidents.
4.4 The department continues to provide formal safeguarding supervision for Community
Midwives and Children’s Community Nurses. The Supervision Policy has been
revised to ensure that these staff groups receive a one 1:1 supervision session and 2
group supervision sessions. A system for recording and monitoring take up of
supervision has been implemented to ensure compliance of the policy. Additionally,
we are developing a plan to ensure regular group supervision sessions for ED staff.
4.5 Over the last three years the specialist midwives in Barnsley have developed a very
successful partnership with South Yorkshire Fire & Rescue service which led to them
being awarded two Awards (SYFR community partnership working award and BHNFT
Innovation Award). This was for setting up a process for undertaking a safe sleep risk
assessment for mothers and babies and a quick referral and fast track for a free
home safety check/fitting of smoke alarms to vulnerable families.
4.6 In 2012/13 a safeguarding Commissioning for Quality and Innovation (CQUIN) was
established for the management of Did Not Attends (DNAs) this required a review to
be undertaken each time a child failed to attend an appointment. We were successful
in achieving this, and secured £500,000. During 2013/14 we were required to
continue to meet 100% review rate as part of the quality contract, but with no funding
attached. A Policy has been developed to ensure that children are followed up if they
miss an out patient appointment and all staff are expected to contribute to a
safeguarding risk assessment. This process is supported by the Safeguarding Nurse
Advisor role to ensure that neglect issues are addressed and children’s health needs
are met.
4.7 In 2012/13 a safeguarding CQUIN was also set around frequent attendances to the
Emergency Department. This process includes undertaking a safeguarding review of
all children under the age of 19 years who attend the Emergency Department 3 or
more times in a rolling 3 month period. Information is also routinely shared with other
relevant health professionals including GP, HV and School Nurse in order to ensure
continuity of care. Again, in 2013/14 we have achieved the criteria required as part of
the quality contract and have continued to maintain a 100% review rate.
BoD June 2014: 09b_Safeguarding Children Annual Report
Page 2
4.8 Both the DNA and frequent attender to ED processes have been a difficult and time
consuming challenge but one that has been extremely beneficial for children.
Reviewing all DNAs has led to safeguarding concerns being identified that would not
have been identified had this process not been in place. It has also increased
communication/information sharing between the various agencies that work with
children and young people. Previous local and national serious case reviews have
highlighted the concerns when families disengage from services and fail to attend
appointments, and where appropriate information sharing does not take place. Thus
the work is essential in safeguarding terms.
4.9 Additionally, the work undertaken has already identified areas for improvement in
terms of helping to reduce the DNAs; and has taken or is taking action to address
these. These include introducing appointment reminders by text, examining the
current appointment system, identifying incorrect addresses, looking at waiting list
times, the necessity for follow up for some self limiting conditions, routinely informing
Health Visitors of all DNAs. These actions are helping to reduce the number of DNAs
saving a significant amount of time and money for the Trust. We have now
introduced a review of all cancelled appointments by parents to ensure that the health
needs of children are being met and that any neglect issues are addressed.
4.10 A review of DNA Policy within the Health Community has been undertaken recently
by the Designated Nurse and the valuable work undertaken by the Safeguarding
Nurse Advisor role has been recognised. A business case is being developed to
present to the CCG for funding for continuation of this post.
4.11 All of the team has continued to be active members in the child death process,
facilitating the sharing and collating of information following a child death and
contributing to the rapid response process. We have also contributed significantly to
the updated Child Death Rapid Response procedures. In the period of this 2013/14
report there have been 21 child deaths compared to 13 in the previous year. A report
is undertaken separately by The Public Health Team to identify any themes or issues
Last year deaths from co sleeping was identified as an issue and the Safeguarding
Midwife contributed to a safe sleeping campaign as described earlier in the report.
4.12 During this year there have been no serious case reviews or Individual management
reviews. There has however been 2 learning lessons events and these are
undertaken when the criteria for a serious case review or internal management review
are not met but there are lessons that could be learnt from a particular incident. All
agencies with involvement in these particular cases have contributed and we have
taken the appropriate actions to address the concerns raised as part of these reviews.
The actions are monitored through the Performance, Audit, Quality and Assurance
subgroup of Barnsley Safeguarding Children Board (BSCB).
4.13 Following the OFSTED/CQC inspection an action plan was established to address
the required areas of improvement. Since this time we have worked with other
agencies to develop a pathway for the management of young people attending the
Emergency Department with alcohol/substance misuse and mental health / self harm
issues. The pathway has now been implemented and audits have taken place to
ensure compliance. As the audits have identified some gaps in compliance, further
actions have been taken to improve this position and further audits will be completed
to monitor achievement. This is being monitored through the Safeguarding Children
Steering Group
BoD June 2014: 09b_Safeguarding Children Annual Report
Page 3
4.14 We have worked with other relevant agencies to develop a pre birth pathway for use
where safeguarding concerns exist. This multi agency pathway has been audited
twice and improvement in practice has been noted.
4.15 We have also been working to ensure level 3 training statistics are improved. More
details training information is addressed below.
4.16 A considerable amount of work has also taken place in order to ensure improvements
in the care of Looked After Children. Work has been ongoing to improve the multiagency provision as a whole in line with ‘Promoting the Health and Wellbeing of
Looked After Children’ (Department of Health, 2009). Since October 2013 there have
been staffing pressures within the community paediatric department which led to an
impact on the delivery of the service, including the ability to undertake initial medicals
for children coming into care of the Local Authority and adoption medicals. A robust
action plan has been developed to address the key issues and facilitate improvement
of the situation to meet national requirements.
4.17 We have continued to ensure policies, procedures and guidance remain up-to-date
and appropriate and have also developed some new policies and guidance as
required to meet staff/service needs. These include Safeguarding Children Policy,
Domestic Abuse Policy, Escalation Policy, DNA Policy, Child Death Procedure and
Thresholds Guidance/ Continuum of Assessment.
4.18 In response to the new commissioning arrangements, the Named Doctor has made
links with relevant staff in the new Clinical Commissioning Group (CCG) structure to
try to ensure seamless safeguarding work between the Trust and the community.
5.
TRAINING
5.1
In line with the Trust Safeguarding Strategy developed, the team currently deliver
training as part of the mandatory training week, through e-learning or bespoke
sessions. A rolling programme of training (starting with induction) has been
developed to ensure healthcare staff at BHNFT who comes into contact with children
and their families are aware of the predisposing factors, signs and indicators of child
harm. They should also have the knowledge and skills to collaborate with other
agencies and disciplines in order to safeguard the welfare of children.
5.2
In order to ensure staff are aware of the lessons from the serious case reviews and
serious incidents, update training has been delivered and has also been rolled out as
e-learning.
5.3
As discussed above, the department has been working with managers to ensure staff
are also up-to-date with level 3 training and to support this has been delivering level 3
training in house.
5.4
The department continues to produce a safeguarding quarterly newsletter in order to
keep staff updated in relation to local and national developments and regularly write
briefings for the weekly bulletin. The department has also produced briefings of
relevant safeguarding papers/reports for safeguarding leads within the organisation to
provide a summary of these documents and implications for BHNFT.
The Named Doctor for Safeguarding Children also makes a significant contribution to
training by ensuring that all Consultants, Registrar’s and Senior House Officers
BoD June 2014: 09b_Safeguarding Children Annual Report
Page 4
receive Safeguarding Children awareness sessions. He has also facilitated a
multiagency training session with the Police and Social care.
5.5 Number of Employees who have received Safeguarding Children Training up to
31.03.2014
Course
Total
Number of employees trained (non clinical / no client contact) – Level 1
88%
Number of employees trained (clinical / client contact) – Level 2
90%
Number of employees trained (clinical / client contact) – Level 3a
89%
Number of employees trained (clinical / client contact) – Level 3b
81%
It should be noted that the figures above do not account for those on maternity leave
or long term sick and include bank nursing and medical staff. In order to assure the
department that level 3a and b training figures are as high as possible we have
removed those on long term sickness or maternity leave and new starters
The Safeguarding Children Training Strategy aims to ensure that all staff that have
significant involvement with children will be knowledgeable and will also access
domestic abuse training, sexual exploitation training and PREVENT training.
A recent evaluation of safeguarding children training was undertaken with 200 of our
staff using survey monkey. The results were very positive and suggest that the
training is beneficial and of a good standard.
The Workforce and Development Subgroup of BSCB have recently reviewed and
approved our internal safeguarding awareness training material. Their feedback was
very positive and they considered the training to be of a good standard.
6.
AUDIT
An audit single and multi agency programme has been developed and is under continual
review to ensure a strategic approach and evidence of ongoing compliance and
identification of improvement. Regular audits are undertaken on the quality of case
conference reports, record keeping, medical assessment pack, skeletal survey, substance
misuse pathway, pre-birth pathway and routine screening for Domestic Abuse. Overall the
audits show that staff awareness and practices are improving.
An audit is currently being developed to assess the experiences of children, parents and
other professionals who come to the hospital for a child protection medical. Their views will
inform and improve the service we deliver in future.
7.
OPERATIONAL MANAGEMENT
The Safeguarding Children Team comprise as follows:
Named Doctor = 2 PAs
Named Nurse = 1.0 WTE
Named Nurse = 0.6 WTE
Named Midwife = 0.5 WTE
BoD June 2014: 09b_Safeguarding Children Annual Report
Page 5
Safeguarding Nurse Advisor = 0.5 WTE
In February 2014 one of the full time Named Nurses for Safeguarding Children
commenced maternity leave which has reduced the capacity of the team. However, to
ensure continuity and capacity during this time one of the named nurses has increased her
hours to 1.0 WTE and the Safeguarding Nurse Advisor has increased her hours to 0.8
WTE.
8.
CHALLENGES FOR 2014/15
The challenges for 2014/15 in addition to the regular commitments, will be to continue to
support the OFSTED improvement plan, including ensuring that all staff are fully aware of
the Thresholds Guidance / continuum of assessment.
The team will also need to ensure that training figures are maintained at the current high
level. In order to maintain the high level of training the Trust has now implemented a
safeguarding training day on the corporate induction from April 2014 this will be evaluated
over the year
The Team would also like to be more of a presence across the Trust ensuring staff in all
departments know who to contact for advice and support for safeguarding children,
including professional disagreements.
9.
CONCLUSION
The safeguarding agenda continues to be an ever challenging one and the added
dimension of the frequent attendance to ED and DNA work and the imminent Ofsted reinspection has put a significant amount of pressure on the team. The department has
continued, however, to manage the competing demands and has maintained their regular
commitments such as training, supervision, advice, support, audit, supporting the child
death process and representing BHNFT at various Barnsley Safeguarding Children Board
(BSCB) sub groups.
BoD June 2014: 09b_Safeguarding Children Annual Report
Page 6
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
14/06/P-10
SUBJECT:
MONTHLY UPDATE ON NURSING & MIDWIFERY STAFFING
DATE:
JUNE 2014
Tick as
applicable
PREPARED BY:
For decision/approval
Assurance
For review
Governance
For information
Strategy
Alison Bielby, Deputy Director of Nursing
SPONSORED BY:
Heather McNair, Director of Nursing & Quality
PRESENTED BY:
Heather McNair, Director of Nursing & Quality
PURPOSE:
STRATEGIC CONTEXT
Tick as
applicable
2-3 sentences
To provide the Trust Board with monthly information regarding the nursing and midwifery
(trained and untrained) staffing levels across in patient areas of the Trust as per the
requirements of NHS England and the Care Quality Commission.
QUESTION(S) ADDRESSED IN THIS REPORT
What are current nursing and midwifery staffing shortfalls across the Trust and how is
this being managed?
CONCLUSION AND RECOMMENDATION(S)
The Board is asked to note the report and support ongoing mitigations being put in place to
manage ongoing staffing shortfalls.
BoD month 2014: 10_1_N&M staffing paper
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD month 2014: 10_1_N&M staffing paper
Subject:
1.
MONTHLY UPDATE ON NURSING & MIDWIFERY
STAFFING
Ref: 14/06/P-10
STRATEGIC CONTEXT
1.1 To provide the Trust Board with monthly information regarding the nursing and
midwifery (trained and untrained) staffing levels across in patient areas of the Trust as
per the requirements of NHS England and the Care Quality Commission.
2.
INTRODUCTION
2.1 The National Quality Board (NQB) issued 10 expectations of trusts regarding nursing,
midwifery and care staffing capacity and capability in their November 2013 report
“How to ensure the right people, with the right skills, are in the right place at the right
time.” Expectation 7 requires Trust Boards to receive monthly updates on workforce
information.
2.2 The workforce information should include; the number of actual staff on duty during
the previous month, compared to the planned staffing level, the reasons for any gaps,
the actions being taken to address these and the impact on key quality and outcome
measures.
2.3 Expectation 8 requires providers to clearly display information about the nurses,
midwives and care staff present on each ward, clinical setting, department or service
each shift.
2.4 In March 2014 the Care Quality Commission (CQC) and NHS England delivered
further guidance regarding the implementation of these expectations, including a
requirement to publish staffing data on NHS Choices.
2.5 This paper sets out the requirements to meet the above expectations and will be
presented on a monthly basis to the Board.
3.
NATIONAL REPORTING REQUIREMENTS
3.1 From the 24 June 2014, data on staffing fill rates for nurses, midwives and care staff
will be presented on the NHS Choices website. This will allow patients and the public
to see how hospitals are performing on the indicator in an easy and accessible way.
The data will sit alongside a range of other safety indicators.
3.2 To enable the above to happen the Trust is required to start reporting centrally
planned versus actual staffing figures via the UNIFY system using a national
template.The first upload of information will be for the dates 01 to 31 May 2014,
Trusts are asked to publish their actual versus planned staff fill rates on a ward by
ward basis on their Trust website and there will be link from NHS Choices to this
website to enable the public access to the Board paper.
3.3 Data on NHS Choices will be presented by:
• Ward
• Speciality
• Total monthly planned staff hours split by registered staff and care (non
registered) staff and by day and by night
• Total monthly actual staff hours split by registered staff and care (non registered)
staff and by day and by night (two shifts only)
BoD month 2014: 10_1_N&M staffing paper
Page 1
•
Average fill rate split by registered staff and care (non registered) staff and by day
and by night
3.4 NHS England will be managing the communications regarding this as there will be a
RAG rating (yet to be determined) attached to the published data.
4.
BACKGROUND
4.1 BHNFT is committed to ensuring that levels of nursing staff, match the acuity and
dependency needs of patients in order to provide safe and effective care. Nurse
staffing includes:
• Registered Nurses
• Registered Midwives
• Unregistered health care/midwifery care assistants
• Unregistered nursing/midwifery auxillary’s.
4.2 The Trust uses an e-rostering system with duty rosters created eight weeks in
advance to ensure the levels and skill mix of the nursing staff on duty are appropriate
for providing safe and effective care.
4.3 This allows for contingency plans to be made where the roster identifies the planned
staffing falls short of the minimum requirement, for example; where there are vacant
nursing posts or staff appointed have not started in post. These contingency plans
can include; moving staff from a shift which is above the minimum required level,
moving staff from another ward/area which is above the minimum required level or
the use of flexible/temporary staffing from the Trust’s internal bank or via an external
nursing agency.
4.4 Safe staffing levels are also monitored and managed on a daily basis by the ward
Sister and Matron for that clinical area. Shortfalls as a consequence of short term
sickness or other unplanned leave for which cover cannot be found internally by the
movement of staff or the use of nurse bank staff are escalated to the Heads of
Nursing for authorisation of temporary staffing via a nursing agency.
4.5 Current nursing and midwifery staffing vacancies across the Trust (In patient areas,
week ending 23.05.14) are 4.39 wte midwives, 43.63 wte registered nurses (includes
vacancies recruited to but not yet started in post) and 7 wte non registered staff.
5.
EXPECTATION EIGHT
5.1 The Trust has developed a standardised ward “Safe Staffing Board” to meet the
requirements set out in expecation eight. The Boards are mainly sited just inside the
ward/clinical area.
5.2 The boards give information regarding the name of the Matron responsible for the
area, the ward sister and the nurse in charge of the shift should patients or their
relatives wish to contact the senior nursing team.
5.3 The boards also set out by shift the “actual” against “planned” staffing levels. These
are completed on a shift by shift basis and are visible in all ward areas.
5.4 A poster showing the nursing and midwifery uniforms that are worn within the in
patient clinical areas has been devloped and is being displayed in next to the staffing
boards to give clarity to patients and the publics about who is who in the areas.
SMT:\Board\Templates & Agenda\10_1_N&M staffing paper
Page 2
6.
EXPECTATION SEVEN
Process for collection and validation of nursing shifts
6.1 Currently there is no national standardised tool for collection and presentation of
staffing levels data to Trust Boards therefore a specific template was designed in
order to compare the planned staffing and the actual staffing on duty.
6.2 Within the Trust the majority of ward areas have three shift patterns; it is known that
an additional 12 hour day shift exists in some areas however for purposes of
standardisation the data was collected using the shift patterns as detailed below
M=Morning Shift 07.30-15.30
E= Afternoon/Evening Shift 12.30-20.30
N= Night Shift 20.00 – 07.45
6.3 Details of the planned shift by shift versus the actual shift by shift staffing for the adult
in-patient ward areas during April 2014 is found at appendix 1.
6.4 In summary 3% (242 out of 8650) of the shifts were identified as being uncovered.
The Trust has an electronic incident reporting system (DATIX) for recording potential
or actual incidents where harm may have ocurred. There were a total of 11 reports on
DATIX which identified a potential risk to patients due to a lack of suitably
trained/skilled staff although no subsequent DATIX reporting actual harm
subsequently reported. Of the 11 reports 7 were generated by the Acute Medical
Unit.
6.5 The majority of staffing shortfalls during April were due to either short term sickness
or small numbers of vacant posts. The exceptions to this are:
•
Acute Medical Unit (AMU) currently has 11 vacant nursing posts, 10 of the posts
are band 5 registered posts to which 9 student nurses have been recruited
however they do not qualify until September 2014, 1 post is for a band 3 HCA.
This means that on a weekly basis 60 day shifts (7.5 hours each) were unable to
be filled with the current number of staff in post during April. The majority of the
vacant hours were filled using bank and agency however there was a deficit with
6% of the shifts (67 out of 1200) not being covered. The vacancies were created
partly due to individuals gaining promotion either in the Trust or another hospital
or staff leaving to gain further experience for professional development as well as
individuals moving due to a change in personal circumstance. As identifed above
although the posts have been appointed due ot the student nurses not qualifing
until September 2014 the posts will continue to be filled using internal bank
staffing or external staffing via a nursing agency.
•
Trauma and Orthopaedic Ward 33 has 5 vacant nursing posts, these are all
registered staff posts. This means that on a weekly basis 25 day shifts (7.5 hours
each) were unable to be filled from the staff in post. Cover was obtained for the
majority of the vacant hours using bank and agency in April but there was a deficit
of 5% of the shifts (27 out of 510) not being covered. There is an ongoing
recruitment drive for Trauma and Orthopaedics as although posts have been
recruited to previously there have been a few cases where candiates have
chosen not to accept the offer of a post.The recruitment campaign is using local
media as well as NHS jobs.
SMT:\Board\Templates & Agenda\10_1_N&M staffing paper
Page 3
7.
•
Trauma and Orthopaedic Ward 34 currently has 3 vacant nursing posts all are for
registered nurses. This means on a weekly basis 15 day shifts (7.5 hours) are
unable to be filled with the number of staff in post. Whilst cover was obtained for
the majority of the vacant hours there was a deficit of 7% of the shifts (34 out of
480) not being filled. Ward 34 has a joint recruitment process with ward 33 and
the posts have been readvertised in May 2014.
•
Acute Stroke Ward 23 currently has 4 vacant nursing posts 3.6 wte of these are
for registered nursing staff. This means that on a weekly basis 18 day shifts
(7.5hours each) are unable to be filled by the staff in post. Whilst cover was
obtained for the majority of shifts there was a deficit with 5% of the shifts (23 out
of 450) not being filled. These posts have now been appointed to with individuals
undergoing statutory checking process before commencing in post.
CONCLUSION
Overall the total number of shifts where the actual staffing on duty fell below the planned
number of staff was 242; this equates to 3% of the overall total number of shifts in April.
Whilst the areas identified above as having a significant number of vacant posts have
either recruited to the vacancies or are in the recruitment process there are a number of
individuals who will not start in post until September 2014 due to needing to complete their
nurse training coures at university and therefore these shortfalls will require ongoing close
monitoring to ensure staffing levels meet the required number to provide safe and effective
care.
Appendices:
•
Appendix 1 – planned shift by shift versus the actual shift by shift staffing for the adult inpatient ward areas - April 2014
SMT:\Board\Templates & Agenda\10_1_N&M staffing paper
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April 2014 - Staffing
Appendix 1
Tuesday
01/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
8
5
7
8
8
16
6
4
6
7
8
7
7
7
14
2
6
Non
Registered
4
5
6
7
7
13
6
4
8
6
5
4
6
6
3
2
2
Actual
Registered
Non
Registered
7
6
7
8
7
15
6
4
6
7
7
6
6
7
14
4
8
4
5
6
7
11
13
8
4
5
6
5
4
7
5
3
2
2
Total
Above Roster
Below Roster
Actual Roster
1
Nights
Planned
Variance Registered
-1
3
1
2
0
2
0
2
3
2
-1
7
2
2
0
2
-3
2
0
2
-1
2
-1
2
0
2
-1
2
0
7
2
2
2
3
0
-8
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
0
1
1
2
2
4
1
1
2
1
2
1
2
1
0
0
0
Wednesday
02/04/2014
3
2
2
2
2
6
2
2
2
2
2
2
2
2
7
2
3
Registered
Variance
0
1
1
3
4
4
1
1
1
1
2
1
2
1
0
0
0
0
0
0
1
2
-1
0
0
-1
0
0
0
0
0
0
0
0
0
-2
Actual
Non
Registered
Registered
Non
Registered
Variance
8
6
6
8
8
16
6
5
6
8
8
8
7
5
5
6
7
7
13
6
3
8
6
6
3
6
7
6
7
7
8
14
6
5
6
8
7
7
6
5
5
6
6
11
14
6
3
6
6
6
3
7
14
4
6
3
2
2
14
4
6
3
2
2
Total
Nights
Planned
Registered
-1
0
1
-2
4
-1
0
0
-2
0
-1
-1
0
0
0
0
0
0
-8
Actual
Non
Registered
Non
Registered
Registered
Variance
3
2
2
2
2
7
2
2
2
2
2
2
2
0
1
1
2
2
4
1
0
2
1
2
1
2
3
2
2
2
2
6
2
2
2
2
2
2
2
0
1
1
3
4
4
1
0
1
1
2
1
2
7
2
3
0
0
0
7
2
3
0
0
0
Total
0
0
0
1
2
-1
0
0
-1
0
0
0
0
0
0
0
0
0
-2
April 2014 - Staffing
Appendix 1
Thursday
03/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Actual
Non
Registered
Registered
Non
Registered
Registered
2
Variance
8
6
7
5
5
6
7
6
6
4
5
6
8
16
6
4
6
8
8
8
7
7
14
4
6
7
13
6
4
8
6
6
3
6
6
3
0
2
9
13
6
4
6
8
8
7
7
6
14
4
7
11
12
6
4
8
6
6
4
4
7
3
0
2
Total
Nights
Planned
Registered
-2
0
-1
0
5
-4
0
0
0
0
0
0
-2
0
0
0
1
0
-9
Days
Actual
Non
Registered
Friday
04/04/2014
Planned
Non
Registered
Registered
2
2
2
1
1
1
2
2
2
1
1
1
2
7
2
2
2
2
2
2
2
2
7
2
3
2
4
1
0
2
1
1
1
2
1
0
0
0
2
8
2
2
2
2
2
2
2
2
7
2
3
4
2
1
0
2
1
1
1
2
1
0
0
0
Total
Non
Registered
Registered
Variance
0
0
0
0
2
-1
0
0
0
0
0
0
0
0
0
0
0
0
-1
Actual
Non
Registered
Registered
Variance
8
6
6
4
5
6
6
6
6
4
5
6
8
16
6
5
6
8
8
6
7
7
14
4
6
7
13
6
3
8
6
6
5
6
6
3
2
2
8
13
5
5
6
8
8
6
6
5
14
4
8
11
12
7
3
7
6
6
5
6
8
3
2
2
Total
Nights
Planned
Registered
-2
0
0
0
4
-4
0
0
-1
0
0
0
-1
0
0
0
2
0
-8
Actual
Non
Registered
Non
Registered
Registered
Variance
2
2
2
1
1
1
2
2
2
1
1
1
2
7
2
2
2
2
2
2
2
2
7
2
3
2
4
1
1
2
1
1
1
2
1
0
0
0
2
7
2
2
2
2
2
2
2
2
7
2
3
1
3
1
1
2
1
1
1
2
1
0
0
0
Total
0
0
0
0
-1
-1
0
0
0
0
0
0
0
0
0
0
0
0
-2
April 2014 - Staffing
Appendix 1
Saturday
05/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Actual
Non
Registered
Registered
Non
Registered
Registered
3
Variance
5
5
6
2
5
6
6
6
6
2
5
5
8
16
6
4
6
6
6
7
7
7
14
4
6
7
13
6
3
8
6
6
4
6
6
1
2
2
6
13
6
4
6
6
7
6
7
5
14
4
6
6
15
6
3
8
6
6
5
6
8
1
2
2
Total
Nights
Planned
Registered
1
1
-1
0
-3
-1
0
0
0
0
1
0
0
0
0
0
0
0
-5
Days
Actual
Non
Registered
Sunday
06/04/2014
Planned
Non
Registered
Registered
2
2
2
1
1
1
2
2
2
1
1
1
2
7
2
2
2
2
2
2
2
2
7
2
3
2
4
1
1
2
1
1
1
2
1
0
0
0
2
7
2
2
2
3
2
2
2
2
7
2
3
2
5
1
1
2
1
1
1
2
1
0
0
0
Total
Non
Registered
Registered
Variance
0
0
0
0
0
-1
0
0
0
-1
0
0
0
0
0
0
0
0
-2
Actual
Non
Registered
Registered
Variance
6
5
6
2
5
5
6
5
6
2
5
5
8
16
6
4
6
7
6
7
7
7
13
6
3
8
6
6
4
6
6
15
6
4
6
6
6
6
6
8
12
6
3
8
6
6
5
7
14
4
6
0
2
2
14
4
8
0
2
2
Total
Nights
Planned
Registered
0
0
0
0
-1
-2
0
0
0
-1
0
0
0
0
0
0
2
0
-4
Actual
Non
Registered
Non
Registered
Registered
Variance
2
2
2
1
1
1
2
2
2
1
1
1
2
7
2
2
2
2
2
2
2
2
4
1
1
2
1
1
1
2
2
7
2
2
2
2
2
2
2
2
4
1
1
2
1
1
1
2
7
2
3
0
0
0
7
2
3
0
0
0
Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
April 2014 - Staffing
Appendix 1
Monday
07/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
7
6
7
8
8
16
6
5
6
7
4
6
7
7
14
4
6
Non
Registered
4
5
6
7
7
13
6
4
8
6
7
5
6
6
3
0
2
Actual
Registered
Non
Registered
6
6
6
8
7
14
7
5
6
7
6
5
7
7
13
4
6
4
5
6
7
7
12
6
4
7
5
7
6
6
6
3
0
2
Total
4
Nights
Planned
Variance
Registered
-1
0
-1
0
-1
-3
1
0
-1
-1
2
0
0
0
-1
0
0
0
-9
2
2
2
2
2
7
2
2
2
3
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
1
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
Tuesday
08/04/2014
2
2
2
2
2
7
2
2
2
3
2
2
2
2
7
2
3
1
1
1
3
2
5
1
0
1
1
2
1
2
1
0
0
0
Total
Registered
Variance
0
0
0
-1
0
-1
0
0
1
0
0
0
0
0
0
0
0
0
-2
7
5
6
8
8
16
6
5
6
7
5
6
7
7
14
4
6
Non
Registered
5
5
6
7
7
15
6
4
8
6
6
5
6
6
3
2
2
Actual
Registered
Non
Registered
6
6
6
8
7
14
6
5
6
7
5
5
7
6
14
4
6
5
5
6
7
7
15
4
4
8
5
7
6
6
6
3
2
3
Total
Nights
Planned
Variance
Registered
-1
1
0
0
-1
-2
-2
0
0
-1
1
0
0
-1
0
0
1
0
-8
Actual
Non
Registered
3
2
2
2
2
7
2
2
2
3
2
2
2
2
7
2
3
Non
Registered
Registered
0
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
3
2
2
2
3
7
2
2
2
3
2
2
2
2
7
2
3
Variance
0
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
Total
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
April 2014 - Staffing
Appendix 1
Wednesday
09/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
8
7
7
8
8
16
6
5
6
7
5
7
7
7
14
6
6
Non
Registered
5
6
6
7
7
15
6
3
8
6
5
4
6
6
2
0
2
Actual
Registered
Non
Registered
8
6
6
7
7
14
6
5
6
7
7
5
7
6
14
6
6
5
6
6
6
6
13
9
3
8
6
6
5
7
6
2
0
2
Total
5
Nights
Planned
Variance
0
-1
-1
-2
-2
-4
3
0
0
0
3
-4
1
-1
0
0
0
0
-15
Registered
3
2
2
2
2
7
2
2
2
3
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
0
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
Thursday
10/04/2014
3
2
2
2
3
6
2
2
2
3
2
2
2
2
7
2
3
0
1
1
3
2
4
1
0
2
1
2
1
2
1
0
0
0
Total
Registered
Variance
0
0
0
1
1
-1
0
0
0
0
0
0
0
0
0
0
0
0
-1
8
6
6
8
8
16
6
4
6
7
5
6
7
7
14
4
6
Non
Registered
4
5
6
7
7
15
6
3
8
6
4
5
6
6
3
0
2
Actual
Registered
Non
Registered
8
6
6
7
8
15
6
4
6
7
5
5
7
6
14
4
8
4
5
6
7
9
13
8
3
7
6
6
6
6
7
3
0
2
Total
Nights
Planned
Variance
Registered
0
0
0
-1
2
-3
2
0
-1
0
2
0
0
0
0
0
2
0
-5
Actual
Non
Registered
3
2
2
2
2
7
2
2
2
3
2
2
2
2
7
2
3
Non
Registered
Registered
0
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
3
2
2
2
3
6
2
2
2
3
2
2
2
2
7
2
3
Total
Variance
0
1
1
3
2
4
1
0
2
1
2
1
2
7
0
0
0
0
0
0
1
1
-1
0
0
0
0
0
0
0
6
0
0
0
0
-1
April 2014 - Staffing
Appendix 1
Friday
11/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
7
6
7
8
8
16
6
5
6
7
5
5
7
7
14
4
6
Non
Registered
4
5
6
7
7
15
6
3
8
6
5
5
6
6
3
2
2
Actual
Registered
Non
Registered
6
6
6
4
7
14
6
5
6
7
6
5
7
6
14
4
6
4
5
6
7
7
12
5
3
7
5
9
5
5
6
3
2
2
Total
6
Nights
Planned
Variance
-1
0
-1
-4
-1
-5
-1
0
-1
-1
5
0
-1
-1
0
0
0
0
-17
Registered
2
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
1
1
1
2
2
4
1
0
2
1
1
1
2
1
0
0
0
Saturday
12/04/2014
2
2
2
2
3
7
2
2
2
2
2
2
2
2
6
2
3
1
1
1
3
2
6
1
0
2
1
1
1
2
1
0
0
0
Total
Registered
Variance
0
0
0
1
1
2
0
0
0
0
0
0
0
0
-1
0
0
0
-1
6
6
6
8
8
14
6
5
3
6
5
5
7
7
14
4
6
Non
Registered
2
5
6
7
7
13
6
3
8
6
3
5
6
6
1
2
2
Actual
Registered
Non
Registered
5
6
6
8
6
11
5
5
6
6
6
5
8
5
14
4
6
2
5
6
7
7
12
5
3
8
6
7
6
7
6
1
2
2
Total
Nights
Planned
Variance
Registered
-1
0
0
0
-2
-3
-1
0
3
0
1
0
1
-2
0
0
0
0
-9
Actual
Non
Registered
2
2
2
2
2
7
2
2
2
2
2
2
2
2
6
2
3
Non
Registered
Registered
1
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
2
2
2
2
2
7
2
2
2
2
2
2
2
2
6
2
3
Variance
1
1
1
3
3
4
1
1
2
1
1
1
2
1
0
0
0
Total
0
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
April 2014 - Staffing
Appendix 1
Sunday
13/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
6
6
6
8
8
14
6
5
4
6
3
6
7
7
14
4
6
Non
Registered
2
5
6
7
7
13
6
4
8
6
6
5
6
7
1
2
2
Actual
Registered
Non
Registered
6
6
6
7
6
14
5
5
6
6
4
5
8
4
14
4
8
2
5
6
8
9
13
5
4
7
6
6
6
6
6
1
2
2
Total
7
Nights
Planned
Variance
Registered
0
0
0
0
0
0
-2
0
1
0
1
0
1
-4
0
0
2
0
-6
2
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
1
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
Monday
14/04/2014
2
1
2
1
2
7
2
2
2
2
2
2
2
2
7
2
3
1
1
1
3
3
4
1
1
2
1
1
1
2
1
0
0
0
Total
Registered
Variance
0
-1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
-1
8
6
6
8
8
16
6
5
6
7
4
7
8
7
14
4
6
Non
Registered
5
5
6
7
7
13
6
4
8
6
6
4
6
6
3
0
2
Actual
Registered
Non
Registered
6
6
6
6
8
16
7
4
6
7
6
6
7
6
12
4
6
5
5
6
8
8
13
7
4
8
6
10
5
6
5
3
0
2
Total
Nights
Planned
Variance
Registered
-2
0
0
-1
1
0
2
-1
0
0
6
0
-1
-2
-2
0
0
0
-9
Actual
Non
Registered
2
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Non
Registered
Registered
1
1
1
2
2
4
1
0
2
1
1
1
2
1
0
0
0
2
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Variance
1
1
1
2
2
4
1
0
2
1
1
1
1
1
0
0
0
Total
0
0
0
0
0
0
0
0
0
0
0
0
-1
0
0
0
0
0
-1
April 2014 - Staffing
Appendix 1
Tuesday
15/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
8
6
6
8
8
16
6
5
6
7
5
6
7
7
12
4
6
Non
Registered
6
5
5
7
7
13
6
4
8
6
7
5
6
6
3
2
2
Actual
Registered
Non
Registered
8
6
6
9
7
15
7
5
6
7
7
5
7
6
12
4
6
6
5
6
6
7
11
7
4
8
6
11
6
6
5
3
2
1
Total
Nights
Planned
Variance
Registered
0
0
1
0
-1
-3
2
0
0
0
6
0
0
-2
0
0
-1
0
-7
3
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
0
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
Wednesday
16/04/2014
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
0
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
Total
Registered
Variance
0
-1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-1
8
6
6
8
8
16
6
5
6
7
5
6
8
7
14
4
6
Non
Registered
3
6
6
7
7
13
6
3
8
6
7
4
6
6
3
2
2
Actual
Registered
Non
Registered
8
6
6
9
7
14
6
5
6
7
6
5
8
6
14
4
7
3
6
6
7
6
14
8
3
8
6
10
7
6
8
3
2
1
Total
Nights
Planned
Variance
Registered
0
0
0
1
-2
1
2
0
0
0
4
2
0
1
0
0
0
0
-2
3
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Non
Registered
Registered
0
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Variance
0
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
Total
1
8
Actual
Non
Registered
0
-1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-1
April 2014 - Staffing
Appendix 1
Thursday
17/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
8
6
6
8
8
16
6
5
6
8
4
6
8
7
12
4
6
Non
Registered
5
5
6
7
7
13
6
5
8
6
7
5
6
6
3
2
2
Actual
Registered
Non
Registered
8
6
6
7
8
14
6
7
6
8
6
5
7
6
12
4
7
4
5
6
8
7
13
9
4
8
6
9
6
7
8
3
2
2
Total
9
Nights
Planned
Variance
Registered
-1
0
0
0
0
-2
3
1
0
0
4
0
0
1
0
0
1
0
-3
3
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
0
1
1
2
2
4
1
0
2
1
1
1
2
1
0
0
0
Friday
18/04/2014
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
1
1
1
2
2
4
1
0
2
1
1
1
2
1
0
0
0
Total
Registered
Variance
1
-1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-1
6
6
6
8
8
16
6
4
6
8
4
7
8
7
14
6
6
Non
Registered
Actual
Registered
2
5
6
7
7
13
6
3
8
6
7
4
6
6
1
0
2
6
6
6
6
7
14
6
4
6
8
4
7
8
6
14
6
6
Total
Non
Registered
2
5
6
8
8
13
6
3
9
6
8
4
5
5
1
0
2
Nights
Planned
Variance
Registered
0
0
0
-1
0
-2
0
0
1
0
1
0
-1
-2
0
0
0
0
-6
Actual
Non
Registered
2
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Non
Registered
Registered
1
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
2
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Variance
1
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
April 2014 - Staffing
Appendix 1
Saturday
19/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
6
6
6
8
8
16
6
4
3
7
4
6
8
7
14
4
6
Non
Registered
2
5
6
7
7
13
6
3
8
6
7
5
6
6
1
0
2
Actual
Registered
Non
Registered
6
5
6
5
6
13
6
4
5
7
4
6
6
6
14
4
6
2
5
6
10
7
14
5
3
5
6
9
5
6
5
1
1
2
Total
10
Nights
Planned
Variance
0
-1
0
0
-2
-2
-1
0
-1
0
2
0
-2
-2
0
1
0
0
-11
Registered
2
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Total
Planned
Non
Registered
Registered
1
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
Sunday
20/04/2014
Registered
Variance
2
3
2
2
2
7
2
2
2
2
2
2
1
1
1
2
2
4
1
1
2
1
1
1
2
7
2
3
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
-4
0
0
0
0
0
-4
6
6
6
8
8
16
6
4
4
7
2
6
8
7
14
4
6
Non
Registered
2
5
6
7
7
13
6
3
8
6
6
4
6
6
1
0
2
Actual
Registered
Non
Registered
6
5
6
6
8
13
6
4
5
7
6
6
7
5
14
4
4
2
3
6
8
7
13
4
3
8
6
9
4
8
5
1
0
2
Total
Nights
Planned
Variance
0
-3
0
-1
0
-3
-2
0
1
0
7
0
1
-3
0
0
-2
0
-14
Actual
Non
Registered
Registered
2
3
2
2
2
7
2
2
2
2
2
2
2
2
6
2
3
Non
Registered
Registered
1
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
2
3
2
2
2
7
2
2
2
2
2
2
2
2
6
2
3
Variance
1
1
1
2
2
4
1
1
2
1
1
1
2
1
0
0
0
Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
April 2014 - Staffing
Appendix 1
Monday
21/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
6
6
6
8
8
16
6
4
6
7
7
6
7
7
13
4
6
Non
Registered
2
5
6
7
7
13
6
3
8
6
5
5
6
6
1
2
2
Actual
Registered
Non
Registered
6
6
5
6
6
14
6
4
6
7
5
6
6
4
13
4
7
2
5
6
9
7
13
6
3
8
6
7
4
6
8
1
2
3
Total
11
Nights
Planned
Variance
Registered
0
0
-1
0
-2
-2
0
0
0
0
0
-1
-1
-1
0
0
2
0
-8
2
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
1
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
Tuesday
22/04/2014
2
3
2
2
2
7
2
2
3
2
2
2
2
2
7
2
3
1
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
Total
Registered
Variance
0
1
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
8
6
7
8
8
16
6
5
6
7
8
6
7
7
13
4
6
Non
Registered
6
5
5
7
7
13
6
4
8
6
4
5
6
6
3
0
2
Actual
Registered
Non
Registered
7
6
6
6
8
14
7
5
6
7
7
6
5
6
13
4
8
6
5
6
7
5
13
8
4
8
6
4
5
10
9
3
0
2
Total
Nights
Planned
Variance
Registered
-1
0
0
-2
-2
-2
3
0
0
0
-1
0
2
2
0
0
2
0
-8
Actual
Non
Registered
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Non
Registered
Registered
0
1
1
2
2
4
1
1
1
1
2
1
2
1
0
0
0
3
2
2
2
2
7
2
2
3
2
2
2
2
2
7
2
3
Variance
0
1
1
2
2
4
1
1
1
1
2
1
2
1
0
0
0
Total
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
April 2014 - Staffing
Appendix 1
Wednesday
23/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
8
6
7
8
8
16
6
5
6
7
7
6
7
7
12
4
6
Non
Registered
6
5
6
7
7
13
6
4
8
6
5
5
6
6
3
0
2
Actual
Registered
Non
Registered
8
6
6
8
7
15
6
5
6
7
6
5
6
6
12
4
6
6
6
6
7
8
12
8
4
8
6
6
6
7
7
3
0
2
Total
12
Nights
Planned
Variance
Registered
0
1
-1
0
0
-2
2
0
0
0
0
0
0
0
0
0
0
0
-3
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
0
1
1
2
2
4
1
1
2
1
2
1
2
1
0
0
0
Thursday
24/04/2014
3
2
2
2
2
7
2
2
3
2
2
2
2
2
7
2
3
0
1
1
2
2
4
1
1
2
1
2
1
2
1
0
0
0
Total
Registered
Variance
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
7
6
7
8
8
16
6
4
6
6
9
5
7
7
12
4
6
Non
Registered
6
5
6
7
7
13
6
4
8
6
3
6
6
6
3
2
2
Actual
Registered
Non
Registered
7
5
6
6
7
14
5
4
6
6
6
5
6
6
12
4
8
6
5
6
10
9
13
5
4
8
6
6
6
8
8
3
2
2
Total
Nights
Planned
Variance
Registered
0
-1
-1
1
1
-2
-2
0
0
0
0
0
1
1
0
0
2
0
-6
Actual
Non
Registered
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Non
Registered
Registered
0
1
1
2
2
4
1
1
2
1
2
1
2
1
0
0
0
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Variance
0
1
1
2
3
4
1
1
2
1
2
1
2
1
0
0
0
Total
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
April 2014 - Staffing
Appendix 1
Friday
25/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
7
6
7
8
8
16
6
5
6
6
7
6
7
7
12
4
6
Non
Registered
6
5
6
7
7
13
6
4
8
6
4
5
6
6
3
2
2
Actual
Registered
Non
Registered
6
6
6
6
7
15
6
5
6
6
5
6
7
4
12
4
6
6
5
6
10
8
13
6
4
8
6
7
5
6
9
3
2
2
Total
13
Nights
Planned
Variance
Registered
-1
0
-1
1
0
-1
0
0
0
0
1
0
0
0
0
0
0
0
-3
2
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
1
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
Saturday
26/04/2014
2
3
2
2
2
7
2
3
2
2
2
2
2
2
7
2
3
1
1
1
2
2
3
1
0
2
1
2
1
2
1
0
0
0
Total
Registered
Variance
0
1
0
0
0
-1
0
1
0
0
0
0
0
0
0
0
0
0
-1
5
6
6
8
8
16
6
4
3
8
8
6
7
7
12
4
6
Non
Registered
2
5
6
7
7
13
6
3
8
7
3
5
6
6
1
0
2
Actual
Registered
Non
Registered
6
5
6
6
8
15
4
4
6
8
6
6
7
6
12
4
6
2
5
6
9
6
13
3
3
8
7
7
5
6
7
1
0
1
Total
Nights
Planned
Variance
Registered
1
-1
0
0
-1
-1
-5
0
3
0
2
0
0
0
0
0
-1
0
-9
Actual
Non
Registered
2
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Non
Registered
Registered
1
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
2
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Variance
1
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
Total
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
April 2014 - Staffing
Appendix 1
Sunday
27/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
6
6
6
8
8
16
6
4
4
8
5
7
7
7
14
4
6
Non
Registered
2
5
6
7
7
13
6
3
8
6
4
4
6
6
1
0
2
Actual
Registered
Non
Registered
5
5
6
8
7
15
5
4
6
8
5
7
5
5
14
4
6
2
5
6
7
7
13
4
3
8
6
7
4
6
6
1
0
1
Total
14
Nights
Planned
Variance
-1
-1
0
0
-1
-1
-3
0
2
0
3
0
-2
-2
0
0
-1
0
-12
Registered
2
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
1
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
Monday
28/04/2014
2
3
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
1
1
1
3
2
4
1
0
2
1
2
1
2
1
0
0
0
Total
Registered
Variance
0
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
6
7
8
8
16
6
5
6
8
6
5
7
7
13
4
6
Non
Registered
4
5
6
7
7
13
6
4
8
6
7
4
6
6
3
2
2
Actual
Registered
Non
Registered
5
6
6
8
7
14
5
5
6
8
6
6
5
7
13
4
6
4
5
6
7
7
12
5
4
8
6
8
5
7
6
3
2
3
Total
Nights
Planned
Variance
Registered
-1
0
-1
0
-1
-3
-2
0
0
0
1
2
-1
0
0
0
1
0
-9
Actual
Non
Registered
2
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Non
Registered
Registered
1
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
2
2
Variance
1
1
2
1
2
2
7
2
2
2
2
2
2
2
2
7
2
3
3
2
4
1
0
2
1
2
1
2
1
0
0
0
Total
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
April 2014 - Staffing
Appendix 1
Tuesday
29/04/2014
Days
Planned
Ward
14
17
18
19
20
AMU
23
24
27
28
31
32
33
34
ITU
SHDU
CCU
Registered
8
6
6
8
8
16
6
4
6
8
6
5
7
7
13
4
6
Non
Registered
5
5
6
7
7
13
6
4
8
6
8
5
6
6
2
2
2
Actual
Registered
Non
Registered
7
6
6
8
6
15
6
4
6
8
6
5
5
5
13
4
6
5
5
6
7
7
11
6
4
8
6
8
5
8
8
2
2
3
Total
15
Nights
Planned
Variance
Registered
-1
0
0
0
-2
-3
0
0
0
0
0
0
0
0
0
0
1
0
-6
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Days
Actual
Non
Registered
Planned
Non
Registered
Registered
0
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
Wednesday
30/04/2014
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
0
1
1
3
2
4
1
0
2
1
2
1
2
1
0
0
0
Total
Registered
Variance
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
8
6
6
8
8
16
6
5
6
6
6
5
7
7
14
4
6
Non
Registered
6
5
6
7
7
13
6
4
8
6
8
5
6
6
3
2
2
Actual
Registered
Non
Registered
8
6
6
8
6
14
4
5
6
6
6
5
6
6
14
4
8
5
5
6
7
6
12
5
4
8
6
8
5
8
7
3
2
2
Total
Nights
Planned
Variance
-1
0
0
0
-3
-3
-3
0
0
0
0
0
1
0
0
0
2
0
-10
Actual
Non
Registered
Registered
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Non
Registered
Registered
0
1
1
2
2
4
1
0
2
1
2
1
2
1
0
0
0
3
2
2
2
2
7
2
2
2
2
2
2
2
2
7
2
3
Variance
0
1
1
3
2
4
1
0
2
1
2
1
3
1
0
0
0
Total
0
0
0
1
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
14/06/P-11
SUBJECT:
PERFORMANCE REPORT ON IMPLEMENTATION OF THE NHS
FRIENDS & FAMILY TEST
DATE:
JUNE 2014
Tick as
applicable
PREPARED BY:
For decision/approval
Assurance
For review
Governance
x
For information
Strategy
x
Jill Pell, Head of Patient Experience
SPONSORED BY:
Heather McNair, Director of Nursing & Quality
PRESENTED BY:
Heather McNair, Director of Nursing & Quality
PURPOSE:
STRATEGIC CONTEXT
Tick as
applicable
x
X
2-3 sentences
To provide an overview of the Trust’s performance in 2013/14 on the NHS Friends & Family
Test (FFT) National CQUIN targets and to give assurance on the plans to achieve performance
against the 2014/15 FFT CQUIN Targets.
QUESTION(S) ADDRESSED IN THIS REPORT
Has the Trust achieved nationally mandated performance on implementation of the FFT in the
last 12 months?
Are plans in place to meet the increased targets in the new national FFT CQUIN for 2014/15?
CONCLUSION AND RECOMMENDATION(S)
The Board of Directors is asked to receive and consider the contents of the report, which
demonstrate our achievement with the mandatory requirements to date and plans for 2014/15.
BoD June 2014: 11_Friends and Family Test
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
The report is intended to show progress against the Trust’s Business
Plan (2014/15) Strategic Aim 1 – Patients will experience safe care.
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
There would be financial and reputational risks to the Trust not
achieving the FFT CQUIN Target.
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD June 2014: 11_Friends and Family Test
PERFORMANCE REPORT ON IMPLEMENTATION OF
THE NHS FRIENDS & FAMILY TEST
Subject:
Ref: 14/06/P-11
1. STRATEGIC CONTEXT
1.1
The purpose of this paper is to update the Trust Board on achievement of the FFT
national Commissioning for Quality and Innovation (CQUIN) target for 2013/14. The
paper also summarises the key priorities in the FFT CQUIN target for 2014/15.
2. INTRODUCTION
2.1
The Friends and Family Test (FFT) is a single question survey which asks patients
whether they would recommend the NHS service they have received to friends and
family who need similar treatment or care. It was initially for providers of NHS funded
acute services for inpatients (including independent sector organisations that provide
acute NHS services) and patients discharged from A&E (type 1 & 2) from April
2013. As of 1st October 2013 the survey was extended to include all women of any
age who use NHS funded maternity services. From 1 April 2014 all NHS organisations
providing acute, community, ambulance and mental health services are required to
implement the Staff Friends & Family Test.
3. PERFORMANCE AGAINST THE CQUIN TARGET 2013/14
3.1
The Trust achieved all targets in the CQUIN for phased expansion to the nationally
agreed roll-out plan; also for achieving a combined response rate of 15% in Quarter 1
and by increasing this in Quarter 4 to over 20%. The Trust received a response rate in
Q1 of 15.4% (Net Promoter Score/NPS 71%) which increased to 21% (NPS
maintained at 71%) in Q4. The value attached to the national CQUIN target was
£158,243.
4. NATIONAL CQUIN TARGET FOR 2014/15
4.1
The targets within the new CQUIN have been increased as follows:
•
•
•
30% of the funding for implementation of the staff FFT across the Trust from April
2014.
15% of the funding for early implementation of the patient FFT in outpatient and
day case departments by 1 October 2014.
15% per cent of the funding for increasing and or maintaining response rates in
A&E and inpatient areas. The response rates for A&E and inpatient departments
will be monitored as separate elements and will not be combined, but payment of
this CQUIN element will be dependent upon achievement in both areas, as follows:
a.
for increasing or maintaining response rates in acute inpatient services.
Providers will need to achieve either:
i.
ii.
a baseline response rate in Q1 of at least 25 per cent and by Q4 a
response rate that is both (a) higher than the response rate for Q1 and
(b) 30 per cent or over; or
maintaining a response rate that is over 30 per cent.
BoD June 2014: 11_Friends and Family Test
Page 1
b.
for increasing or maintaining response rates in A&E. Providers will need to
achieve either:
i.
ii.
•
4.2
a baseline response rate of at least 15 per cent and by Q4 a response
rate that is both (a) higher than the response rate for Q1 and (b) 20 per
cent or over; or
maintaining a response rate that is over 20 per cent.
40% of the funding for further increasing response rates within inpatient services.
The CQUIN payment to be triggered if the provider achieves a response rate of
40% or more for the month of March 2015.
Implementation
The Trust is continuing to use the feedback methodologies adopted last year i.e.
tokens and feedback cards.
Work is underway scoping alternative feedback
methodologies for wider roll out across day case and outpatients. There will also need
to be a targeted approach at paediatrics and adolescents and patients with a learning
disability. Work is on-going by the Patient Experience Team, Matrons and Lead
Nurses to ensure response rates are improved on during the coming year.
4.3
The Trust has received the following response rates in April 2014:
In-patient FFT
Month
April 2014
Response
NPS
28%
81
FFT in ED
Month
April 2014
Response
NPS
15%
62
Appendices:
•
Appendix 1 – Annual Statistical Board Summary Report
S:\Meetings\Board\2014 Meetings\06 June\Public\11_Friends and Family Test.docx
Page 2 of 4_
Friends & Family Response Rate and Net Promoter Score (NPS) Summary
Appendix 1
Emergency Department
Inpatients
NPS Score
<0%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
0-40%
>40%
Response Rate
2%
7%
8%
5%
7%
8%
7%
8%
6%
4%
11%
21%
Response Rate
30%
38%
34%
34%
35%
37%
36%
33%
37%
38%
35%
34%
Promoters
39
163
186
130
180
160
146
179
115
81
203
464
Promoters
413
510
455
473
492
505
519
477
513
558
441
477
Detractors
3
9
15
10
12
10
10
9
18
3
31
42
Detractors
17
21
17
17
13
12
15
15
18
16
18
15
Passive
19
75
86
57
67
78
64
60
57
30
71
158
Passive
104
137
88
111
122
100
106
95
112
139
105
100
59%
62%
60%
61%
65%
60%
62%
69%
51%
68%
56%
64%
NPS
74%
73%
78%
76%
76%
80%
79%
79%
77%
76%
75%
78%
NPS
Q1 & Q2
Response
Rate
<=0%
0.1-16%
>16%
Friends & Family Response Rate and NPS
Inpatients
Friends & Family Response Rate and NPS
Emergency Department
80%
Response Rate
30%
60%
15%
55%
10%
50%
5%
45%
0%
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Apr
12%
May
18%
Jun
17%
Jul
15%
Aug
17%
Sep
18%
Oct
17%
Nov
17%
Dec
18%
Jan
17%
Feb
20%
Mar
26%
Promoters
452
673
641
603
672
665
665
656
628
639
644
941
Detractors
20
30
32
27
25
22
25
24
36
19
49
57
Passive
123
212
174
168
189
178
170
155
169
169
176
258
NPS
73%
70%
72%
72%
73%
74%
74%
76%
71%
75%
68%
70%
Friends & Family Response Rate and NPS Trust
30%
78%
25%
76%
20%
74%
15%
72%
10%
70%
5%
68%
66%
Jun
Jul
Aug
Sep
Month
Oct
Nov
Dec
Jan
Feb
Mar
Response Rate
NPS
72%
70%
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Response Rate
NPS
Response Rate
May
74%
10%
Month
NPS
Trust
Apr
76%
15%
Apr
Response Rate
0%
20%
0%
Mar
Month
78%
25%
5%
40%
Apr
Response Rate
82%
35%
65%
20%
Response Rate
40%
70%
25%
Q3 & Q4
Response
Rate
<15%
15-19%
>19%
Historical Summary
Quarterly Trend - ED
Quarterly Trend - Inpatients
68%
Q1
Q2
Q3
Q4
Response Rate
6%
7%
7%
12%
Promoters
129
157
147
249
Detractors
9
11
12
25
Passive
60
67
60
86
61%
62%
61%
62%
NPS
Response Rate
10%
Inpatients
40%
66%
8%
64%
6%
62%
4%
60%
2%
0%
58%
Q1
Q2
Q3
Q4
Quarter
80%
35%
Q1
Q2
Q3
Q4
Response Rate
34%
35%
35%
36%
Promoters
459
490
503
492
30%
78%
25%
20%
76%
15%
Detractors
18
14
16
16
10%
Passive
110
111
104
115
5%
NPS
75%
77%
78%
76%
74%
0%
72%
Q1
Q2
Q3
Q4
Quarter
Response Rate
Response Rate
NPS
Trust
Quarterly Trend - Trust
22%
75%
20%
18%
Q3
Q4
16%
17%
21%
Promoters
589
647
650
741
Detractors
27
25
28
42
Passive
170
178
165
201
NPS
71%
73%
74%
71%
74%
16%
14%
73%
12%
10%
72%
8%
NPS
Q2
15%
Response Rate
Q1
Response Rate
6%
71%
4%
2%
0%
70%
Q1
Q2
Q3
Q4
Quarter
Response Rate
NPS
70%
12%
Response Rate
14%
NPS
Emergency Department
NPS
NPS
Friends & Family Response Rate and Net Promoter Score (NPS) Summary
Ante-natal Service
Response Rate
Promoters
Detractors
Passive
NPS
Labour Ward
Sep
15%
27
3
7
65%
Oct
19%
33
3
8
68%
Nov
17%
27
1
8
72%
Dec
22%
36
0
17
68%
Jan
23%
35
1
17
64%
Feb
14%
20
1
9
63%
Mar
12%
24
3
0
78%
Response Rate
Promoters
Detractors
Passive
NPS
Friends & Family Response Rate and NPS
Ante-natal Service
80%
75%
70%
15%
65%
10%
5%
60%
Response Rate
Response Rate
20%
55%
0%
Oct
Nov
Dec
Jan
Feb
Oct
50%
89
9
17
70%
Nov
33%
54
0
15
78%
Dec
42%
70
4
26
66%
Jan
28%
48
2
16
70%
Feb
28%
39
5
16
57%
60%
80%
50%
75%
40%
70%
30%
65%
20%
60%
10%
55%
0%
Mar
Sep
Oct
Nov
Response Rate
Month
Dec
Jan
Feb
Mar
Response Rate
Month
NPS
NPS
Post-Natal (Health Visitor Transfer)
Response Rate
Promoters
Detractors
Passive
NPS
Sep
5%
11
0
1
92%
Oct
22%
42
0
9
82%
Post-Natal Ward
Nov
15%
25
1
6
75%
Dec
25%
53
0
8
87%
Jan
24%
42
0
15
74%
Feb
26%
43
2
10
75%
Mar
20%
36
1
7
80%
Response Rate
Promoters
Detractors
Passive
NPS
Friends & Family Response Rate and NPS
Post-Natal (Health Visitor Transfer)
Sep
25%
47
4
10
70%
Oct
48%
82
5
23
70%
Nov
33%
48
3
18
65%
Dec
41%
70
4
25
67%
Jan
29%
48
2
17
69%
Feb
27%
35
4
18
54%
Mar
40%
65
1
23
72%
Friends & Family Response Rate and NPS
Post-Natal Ward
30%
95%
60%
80%
25%
90%
50%
75%
20%
85%
40%
70%
15%
80%
30%
65%
10%
75%
20%
60%
5%
70%
10%
55%
65%
0%
Sep
Oct
Nov
Dec
Month
Jan
Feb
Response Rate
Response Rate
Mar
42%
69
0
25
73%
Friends & Family Response Rate and NPS
Labour Ward
25%
Sep
Sep
26%
51
4
10
72%
0%
50%
Sep
Mar
Response Rate
NPS
Oct
Nov
Dec
Month
Jan
Feb
Mar
Response Rate
NPS
NPS Score
<0%
0-40%
>40%
Q3 & Q4
Response
Rate
<15%
15-19%
>19%
Historical Summary
20%
70%
15%
68%
10%
66%
5%
0%
70%
20%
60%
80%
78%
10%
76%
5%
74%
72%
0%
Q3
41%
67
4
22
68%
Q4
32%
49
2
19
66%
NPS
NPS
70%
40%
68%
30%
20%
66%
10%
0%
64%
Q3
Q4
Response Rate
Response Rate
Promoters
Detractors
Passive
NPS
50%
Response Rate
82%
Response Rate
Quarterly Trend - Post-Natal Ward
Post-Natal Ward
15%
Q4
Quarter
NPS
20%
Quarter
65%
10%
NPS
Response Rate
84%
Q3
75%
30%
0%
Quarterly Trend - Post-Natal (Health Visitor
Transfer)
Response Rate
Response Rate
Promoters
Detractors
Passive
NPS
80%
40%
Q3
25%
Q4
23%
40
1
11
76%
Q4
33%
52
2
19
68%
Q4
Quarter
Post-Natal (Health Visitor Transfer)
Q3
42%
71
4
19
70%
50%
64%
Q3
Q3
21%
40
0
8
83%
Response Rate
Promoters
Detractors
Passive
NPS
NPS
Q4
17%
26
2
9
67%
NPS
Q3
20%
32
1
11
69%
Response Rate
Response Rate
Promoters
Detractors
Passive
NPS
Quarterly Trend - Labour Ward
Labour Ward
72%
Response Rate
25%
NPS
Quarterly Trend - Ante-natal Service
Ante-natal Service
Q4
Quarter
Response Rate
NPS
Friends Family Test Quarterly Comparison to Local Trust
Inpatient Response Rate
40%
37%
33%
35%
29%
30%
25%
34%
35% 36%
32% 34%
30%
27%
25%
24%
23%
20% 20%
20%
34%
31%
18%
16%
15%
11%
10%
5%
0%
England (including
Independent Sector
Providers)
Barnsley Hospital NHS
Doncaster And
Foundation Trust
Bassetlaw Hospitals NHS
Foundation Trust
Q1
Q2
Sheffield Teaching
Hospitals NHS
Foundation Trust
Q3
The Rotherham NHS
Foundation Trust
Q4
A&E Response Rate
25%
22%
21%
20%
18%
18%
15%
15%
10%
13%
12%
12%
11%
9%
8%
6%
8%
7% 7%
6% 7%
6%
5%
3%
2%
0%
England (including
Independent Sector
Providers)
Barnsley Hospital NHS Doncaster And Bassetlaw
Foundation Trust
Hospitals NHS
Foundation Trust
Q1
Q2
Q3
Sheffield Teaching
Hospitals NHS
Foundation Trust
The Rotherham NHS
Foundation Trust
Q4
Combined Response Rate
30%
25%
23%
25%
21%
20%
20%
15%
17%
15%
24%
22%
20%
19%
16% 17%
16%
13%
11%
10%
12%
10%
14%
7%
5%
5%
0%
England (including
Independent Sector
Providers)
Barnsley Hospital NHS
Doncaster And
Foundation Trust
Bassetlaw Hospitals NHS
Foundation Trust
Q1
Q2
Q3
Sheffield Teaching
Hospitals NHS
Foundation Trust
Q4
The Rotherham NHS
Foundation Trust
REF:
14/06/P-12
REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT
SUBJECT:
ADVANCING QUALITY ALLIANCE ACTION PLAN
DATE:
JUNE 2014
Tick as
applicable
PREPARED BY:
For decision/approval
Assurance
For review

Governance
For information
Strategy
Heather Mcnair, Director of Nursing and Quality
SPONSORED BY:
Heather Mcnair, Director of Nursing and Quality
PRESENTED BY:
Diane Wake, Chief Executive Officer
PURPOSE:
STRATEGIC CONTEXT
Tick as
applicable
2-3 sentences
To update the Board on progress with the Advancing Quality Alliance action (Aqua) plan.
QUESTION(S) ADDRESSED IN THIS REPORT
Is the review and assessment of progress of all actions toward proposed outcomes progressing
in a timely manner?
CONCLUSION AND RECOMMENDATION(S)
The Board is advised to note progress and continue to support the on-going actions.
BoD JUNE 2014: P_12_AQuA action plan
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD JUNE 2014: P_12_AQuA action plan
AQuA Action Plan – January 2014
Action
Timescale
Lead
Comments
Complete
1.
Real time monitoring of
staffing levels three times
a day with Board reports
Immediate action –
30 days
Heather Mcnair
Paper solution adopted from 1
January 2014 to monitor staffing
levels.
White Boards ordered for all
clinical areas to display daily
staffing levels to patients and the
public based on Salford model.
Information to be incorporated
into board reports.
2.
Ensure that we have
process for immediate
reporting for all Sis and
never events
Immediate action –
30 days
Heather Mcnair
All SIs reportable under
STEIS/potential SIs to be
reported under STEIS are
reported immediately using a 24
hour escalation process. Once
confirmed that the SI is
reportable under STEIS this is
logged by the Risk Manager.
All other incidents are internal
reviewed with a period of two
weeks, the results of which are
reviewed by the Strategic Risk
Group. Should the review identify
that the incident is reportable
under STEIS this is logged by
the Risk Manager.
Complete –
Boards in place
Posters in place
First upload to
UNIFY on 10 June
2014 as per
national
requirements.
Monthly Board
reports from May
2014.
Complete Process in place
and being
implemented.
3.
Speak to Salford
regarding theatres
Immediate action –
30 days
David Peverelle
Conversation held with Salford
regarding their programme to
review theatre “culture”. PID of
programme of work received.
BoD JUNE 2014: P_12_AQuA action plan
Page 1
Yes
Action
Timescale
Lead
Comments
Follow up required re progress
and adaptability to BHNFT
Escalation framework obtained
from Liverpool (DW)
4.
Escalation framework for
governance committees
Immediate action –
30 days
Diane Wake/Hilary
Brearley
5.
Scope exercise on help
line
30 day action
Heather Mcnair
6.
Safety culture audit tool
30 day action
Heather Mcnair
7.
Raising concerns
30 day action
Heather Mcnair
SMT:\Board\ JUNE \P_12_AQuA action plan
Complete
Conference call with Salford to
share learning and scoping
approach to implementation at
BHNFT is underway.
Integration of helpline with
national Care Connect project.
Training for key users planned
for 9.6.14 with a view to go live
end of June.
Being undertaken by Corporate
Matron; Patient Safety Lead.
This is to be completed by end of
February with feedback to
QSIEB.
The Trust has a new Raising
Concerns policy, which is being
launched trust-wide throughout
February via all internal
communication channels. The
first Join the Conversation staff
MaPSaf
implemented
throughout month
of May. Analysis
to be undertaken
beginning of June
and action plan
developed. To be
monitored by
QSIEB. Patient
Safety Culture tool
to be launched on
an annual basis.
An internal
communications
campaign to
promote the
Raising Concerns
Policy has been
Action
Timescale
Lead
Comments
Complete
engagement session, held on 22
January 2014, featured raising
concerns as a discussion topic.
Comments are being collated
into themes and fed back to
wider staff as part of the policy
awareness raising. In tandem
with this, an internal
communications campaign, Not
on My Watch, supports staff in
raising security matters and
concerns with their manager.
carried out,
themed ‘If you see
something, say
something’. In
addition a
campaign
supporting staff in
raising security
concerns, themed
Not On My Watch,
has been
completed. Both
campaigns
featured posters, a
screensaver, and
items in staff
bulletins.
8.
Cleveland video
30 day action
Emma Parkes
A storyboard concept has been
drafted in consultation with a
videographer and scriptwriter. In
line with the Nursing Conference
strapline, the Barnsley video will
be entitled ‘Passion for
Compassion’. Nursing staff have
been invited to a production
meeting with the scriptwriter in
order to ensure their views are
fed into the process and that they
are engaged with the video
production throughout.
9.
Visible leadership – back
to the floor
30 day action
Diane Wake/Hilary
Brearley
All Directors have planned back
to the floor exercises. A
SMT:\Board\ JUNE \P_12_AQuA action plan
Yes
Action
Timescale
Lead
10.
Revise dashboards –
objectives/key drivers
• Split
compliance/stretch
• Predictive
(possible 6
months+)
• Numbers not %
30 day action
David
Peverelle/Janet
Ashby
11.
Quality Strategy
• big dots
• Use of checklists
90 day action
Heather Mcnair
12.
Staff engagement
• Survey
• Focus groups
90 day action
Hilary Brearley
SMT:\Board\ JUNE \P_12_AQuA action plan
Comments
Complete
programme has been developed
and this will ensure that the
Executive Team can have face to
face interaction with staff and
patients. This will highlight areas
of good practice and areas of
concern
Performance dashboards being
Yes
developed and reviewed at ET
on a weekly basis. Some
refinement required.
Quality Strategy day undertaken. Yes
3 year Quality Strategy
developed and launched May
2014. For annual review.
Focus Groups:
Yes
Monthly staff engagement
sessions branded as ‘Join the
Conversation’ have been
launched from January 2014,
with the first being held on 22
January where 27 staff from
different areas within the Trust
discussed concerns, things we
do well and things we might need
to change, together with how we
raise concerns. Feedback about
the session has been very
positive. Themes raised will be
Action
Timescale
Lead
Comments
collated and fed back to the
wider organisation for information
and potential further discussion.
Alongside the Join the
Conversation sessions, the Chief
Executive has launched monthly
lunches, where ten staff
members, chosen at random, are
invited to lunch with Diane to
discuss their roles and raise any
concerns.
13.
Mission and values
90 day action
Diane Wake
Mission and values worked up
with Jay Bevington and
discussed with Chairman
14.
Review governance
arrangements
90 day action
Diane Wake
15.
Review all deaths...how
quickly
90 day action
Jugnu Mahajan
Recruitment underway of a
Corporate Secretary to
understand this piece of work
with the BAF.
A new Mortality Review process
has been established whereby
every in-patient death will be
reviewed by the Consultant
responsible for the patient – a
standardised Mortality Review
form will be used. In cases
where there are issues of
concern, a more detailed indepth review will be carried out
by the Consultant and the Lead
Nurse of the clinical area where
the patient died; again a
SMT:\Board\ JUNE \P_12_AQuA action plan
Complete
Action
Timescale
Lead
Comments
Complete
standardised form will be used.
The in-depth review will be
reviewed
at
the
CBU
Governance committee (forming
a peer review) and this will be
presented to the Mortality
Steering Group.
16.
Use staff experience as
patients
90 day action
Heather Mcnair
Scoping new approaches to
feedback from staff & volunteers.
Internal communications plans
and scoping use of electronic
and paper based feedback
options.
Staff FFT will provide opportunity
to triangulate feedback themes
against patient feedback.
Feedback questionnaire for
volunteers to be piloted in July.
17.
Board meetings to finish
with lunch in restaurant
Carol Dudley
18.
Clinical audit – WHO
checklists
David Peverelle
19.
Board papers
Corporate
Secretary/Diane
Wake and Stephen
Wragg
SMT:\Board\ JUNE \P_12_AQuA action plan
Yes
Confirmation received of Trust
WHO checklists audits being
undertaken in Theatres and Day
Case Unit
January 2014 – Board paper
template and agenda amended.
Yes
Yes
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
SUBJECT:
CHAIRMAN’S REPORT
DATE:
JUNE 2014
REF:
14/06/P-13
Tick as
applicable
PURPOSE:
PREPARED BY:
For decision/approval
For review
For information

Stephen Wragg, Chairman
Tick as
applicable
Assurance
Governance
Strategy
SPONSORED BY:
PRESENTED BY:
Stephen Wragg, Chairman
STRATEGIC CONTEXT
2-3 sentences
QUESTION(S) ADDRESSED IN THIS REPORT
CONCLUSION AND RECOMMENDATION(S)
The Board of Directors is asked to:
a) receive, note and support this report
b) invite and note any further reports on their activities from the wider Non Executive team.
BoD June 2014: 13_Chairs report
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD June 2014: 13_Chairs report
Subject:
1.
CHAIRMAN’S REPORT
Ref: 14/06/P-13
INTRODUCTION
1.1 This report is intended to give a brief outline of some of the work and activities
undertaken as Trust Chairman over the past month and highlight a number of items
of interest.
1.2 The items reported are not shown in any order of priority.
2.
FINANCIAL SITUATION
2.1 As is reported in other papers in this Board meeting, work to stabilise our position
continues at pace, with a view to having a robust turnaround plan to put before
Monitor on 30th June. I am confident that we will have the plan in place that will
return us to financial stability, clearly the critical part will be to deliver the plan in its
entirety.
2.2 In my last report I noted that Monitor would inform the Trust of their decision in the
third week of May, this decision has been delayed until 2 June, so we will be able to
report it verbally at the Board meeting.
2.3 I will re-iterate the message from previous meetings as I think it should be constantly
in people’s minds. Whilst we will bring about the return to stability, we must not
compromise on quality of care and patient safety.
2.4 Our governance structure is now under review and we have made some changes
already to strengthen these. We must ensure that we have all the indicators in place
to allow the Board to scrutinise the whole performance of the Trust and not be
drawn to focus solely on Finance at this extremely testing time.
2.5 We must continue to give confidence to the population of Barnsley and our key
stakeholders that care will not be compromised and that we will turn this current
situation around.
3.
A & E 4 HOUR STANDARD
3.1 It is not my normal practice to discuss operational issues in this report, however
given that Monitor are also investigating our performance I feel it is worth making
reference to our current performance.
3.2 I receive our daily performance figures and I am pleased to be able to see the
improvement in our performance in this area since March. This shows that we now
have the best acute Trust performance in South Yorkshire and are only slightly
behind Sheffield Childrens Hospital on year to date results.
3.3 I believe that this is an example of what we can do as a Trust with the correct mind
set, delivering quality care in the right place at the right time.
3.4 Clearly this needs to be sustained throughout the year, but this attitude to changing
the way we work will need to be rolled out throughout the Trust to ensure we deliver
all our targets in the coming year.
BoD June 2014: 13_Chairs report13_Chairs report
Appx 2
4.
COUNCIL OF GOVERNORS
4.1 I have not been able to attend the Council of Governors sub-group in this month as I
was attending the annual NICE conference.
5.
NEWS & EVENTS
5.1 On 13 and 14 May, I attended the annual NICE conference where I heard about a
number of initiatives that are taking place in healthcare and sat in on a number of
informative discussions.
5.2 On 15th May the Trust hosted a meeting of the Chairs of NHS Trusts for Yorkshire
and the Humber. Chris Hopson, CEO of the Foundation Trust Network, joined us
and shared information and thoughts about the forward path of current healthcare
thinking. The austerity issues would appear to still dominate government thinking
and they will be putting pressure on Trusts to save more money year on year. There
will be a particular focus on procurement as a way of taking money out of the
business, as Ministers feel that the NHS has not addressed this issue in the same
way as other public sector organisations.
5.3 There has been little comment from the new CEO of the NHS Commissioning Board
but it is expected that we will hear from him at the NHS Confederation conference in
early June, where he will lay out his thoughts on how the NHS should move
forwards.
5.4 On 20th May I attended a procurement summit called by the Department of Health
(DoH), I act as the Non-Executive champion on procurement for the Trust. The
message was firmly put to us that the centre is looking for better procurement deals
from each organisation and has a number of relationships with bigger suppliers to
the NHS that they want Trusts to use to take money out of the cost base of the NHS.
I will be discussing the information I picked up on the day with our Head of
Procurement at the first opportunity. The DoH also expects procurement to be on
the Board agenda, and the delivery of the NHS procurement strategy to be
monitored in each Trust. I will make the necessary arrangements to ensure this is
picked up in our governance review.
5.5 1st May saw the CEO and myself meet with our counterparts in the Clinical
Commissioning Group for our regular monthly discussion. The major part of that as
you would expect was our financial situation and turnround plan. However we did
discuss our service specification and sustainability of those services.
5.6 On 28th May I visited the new Trust contact centre and saw first hand the
improvements that have been made to help our patients get in touch with the Trust
by telephone. We have some excellent equipment available in the Trust and were
assured that plans were being developed to make more use of the technology
available.
6.
BARNSLEY HOSPITAL CHARITY
6.1 This month, as usual, has seen some great developments for the Charity:
• May has been a fantastic month for the Charity with a wave of support from local
businesses and individuals.
• The Alhambra’s activities have started with a sponsored bike ride and golf day
being organised on our behalf.
• Every Sainsbury’s across Barnsley have pledged to support the charity for the
year and in the first 3 weeks have already raised nearly £1000 for us.
BoD June 2014: 13_Chairs report
• The Tiny Hearts Appeal for the Special Care Baby Unit is on target to be
launched this summer and already has gained the support of worldwide mega
star – Louis Tomlinson of One Direction fame, who has agreed to front the One
in a Million campaign for the appeal. We have also gained the support of CBBC
stars Sam and Mark who are recording a charity single for the appeal along with
four local choirs.
• The first ever Rainbow Run was a huge success and saw nearly 600 runners
take part in this fantastic event - the youngest being 8 months old and the oldest
being 83. The community spirit on the day was overwhelming and the event
looks set to reach its £15,000 target as sponsorship starts to come in.
6.2 The Charity Office is moving to Outpatients with a high visibility office located
underneath the escalators and the team has hired a new Fundraising Assistant
following the departure of Janice Starkey. The new Fundraising Assistant has been
volunteering with the charity for nearly a year and comes with some fantastic new
ideas for driving the charity forward.
Stephen Wragg
CHAIRMAN
June 2014
BoD June 2014: 13_Chairs report
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
SUBJECT:
CHIEF EXECUTIVE’S REPORT
DATE:
JUNE 2014
14/06/P-14
Tick as
applicable
PREPARED BY:
For decision/approval
For review
For information

Diane Wake, Chief Executive
SPONSORED BY:
Diane Wake, Chief Executive
PRESENTED BY:
Diane Wake, Chief Executive
PURPOSE:
Tick as
applicable
Assurance
Governance
Strategy
STRATEGIC CONTEXT
2-3 sentences
To report particular events, meetings or publication that the Chief Executive would like
to bring to the Board’s attention.
QUESTION(S) ADDRESSED IN THIS REPORT
CONCLUSION AND RECOMMENDATION(S)
The Board of Directors is asked to receive and note this report.
BoD June 2014: 14_CEO Report New
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD June 2014: 14_CEO Report New
Subject:
1.
CHIEF EXECUTIVE’S REPORT
Ref: 14/06/P-14
INTRODUCTION
1.1 This report is intended to give a brief outline of some of the key activities undertaken
as Chief Executive since last month’s report and highlight a number of items of
interest.
1.2 The items below are not reported in any order of priority.
2.
APPOINTMENTS TO CLINICAL BUSINESS UNIT POSITIONS
2.1 The Chief Executive would like to update the Board of Directors on the progress
towards transforming to six Clinical Business Units (CBUs). Good progress has been
made and appointments have been made to some of the leadership positions within
each CBU. The following appointments have been made:
2.2 Clinical Director Positions
•
•
•
•
•
•
Dr Hughes – Emergencies, Orthopaedics and Care Services CBU
Dr Bowry – Theatres, Anaesthetics and Critical Care CBU
Dr Kapur – General and Specialist Medicine CBU
Mr Shiwani – General and Specialist Surgery CBU
Mr Wickham – Diagnostics and Clinical Support Services CBU
Miss Dass - Women’s Children’s and GUM Services CBU
2.3 General Manager Positions
Arrangements are still underway to finalise the General Manager posts to support the
CBUs. The CBUs will be supported by the existing Deputy Chief Operating Officers
and The Director of Operations.
2.4 Head of Nursing/Midwifery Positions
The Chief Executive would like to inform the Board of Directors that the following
appointment has been made:
•
•
•
•
Josie Foster – Theatres, Anaesthetics and Critical Care Services CBU
Abigail Trainer – General and Specialist Surgery CBU
Andrew Mooraby – General and Specialist Medicine CBU
Sue Gibson – Women’s Children’s and GUM Services CBU
Appointments to the Emergencies, Orthopaedics and Care Services CBU are still in
progress and further updates will be given once the appointments have been made.
3.
WORKING TOGETHER PROGRAMME
3.1 The Director of Human Resources and Organisational Development attended the
monthly Working Together Programme meeting on 12 May 2014 on behalf of the
Chief Executive.
3.2 Good progress overall was reported in terms of establishing the concept of joint
working across the Clinical Commissioning Groups (CCG), however it was noted that
BoD June 2014:CEO Report
Page 1
Mid Yorks and North Derbyshire remained committed to providing local services, and
had not yet been able to fully commit to the principle of joint working.
3.3 Updates were provided on key work streams which were: communication and
engagement, acute cardiology and stroke, children’s services, specialty medicine
collaborative and out of hours working.
3.4 In summary, the children’s services and out of hours working work streams are still to
be developed. Speciality and children’s surgery were reported as progressing well re
data collection and due to report back on work currently being undertaken in July. Any
recommendations on collaborative service provision will require public consultation.
3.5 It was agreed that there was value in the CCG and provider groups working
collaboratively, and that a governance timeline was required to identify where
separation of the two would be required so that any potential anti-competition issues
were avoided
4.
LEADING DEEP CULTURAL CHANGE MASTERCLASS – 20 MAY 2014
4.1 The Chief Executive attending a Leading Deep Cultural Change Masterclass on 20
May 2014.
4.2 The Masterclass launched Advancing Quality Alliance’s (AQuA) 2014/15 programme
for Board, Governing Body and Senior Leader Development. The aim of the
programme was to support members in the improvement, oversight and governance
of quality and patient safety and was led by James Reinertsen M.D.
5.
PRACTICAL ASSESSMENT OF CLINICAL EXAMINATION SKILLS (PACES) COURSE
– 16 AND 17 MAY
5.1 Dr Eltrafi and the Medical Education team hosted a PACES exam preparation course
for 20 delegates from the Yorkshire region. The PACES exam is designed to test the
clinical knowledge and skills of trainee doctors who hope to enter higher specialist
training.
5.2 Over 30 patients were used across the weekend with real clinical conditions to test
the participants’ communication, history, examination and clinical judgement skills.
5.3 The patients were all previous and current patients of Barnsley Hospital and are all
part of the “Patients as Educators” bank which was set up by the Medical Education
team to enable the Trust to use patients to enhance the teaching experience of both
undergraduate and postgraduate doctors on placement at the Trust. It promotes an
active role for patients in the process of medical education and allows the doctor to
gain a patient’s perspective on the management and treatment of their condition.
5.4 One patient who was involved in the course this weekend said “Enjoyed the session
immensely. Very polite doctors who were very easy to talk to. Good to feel I can
‘give something back’ for the help and treatment I have received.”
5.5 The exams will be held in June 2014.
6.
STRATEGIC SERVICES DEVELOPMENT GROUP (SSDG) MEETING – 19 MAY 2014
6.1 The Chief Operating Officer attended the SSDG meeting on 19 May 2014 on behalf of
the Chief Executive. Finances for the Better Care Fund Allocation were briefly
BoD June 2014:CEO Report
Page 2 of 4
discussed and a further meeting was being arranged to discuss the financial strategic
direction in June. This will include consideration of a “refresh” of the SSDG strategy,
to which the Trust is a contributor as a full participating member of the SSDG. The
Trust’s Business Plan will also be referenced to the strategy to show alignment and
support to delivering the overall strategy.
6.2 The Strategy also links with the “One Barnsley” programme and the “Pioneer Status”
accorded to the Barnsley Community in recognition of its integrated working
arrangements.
6.3 Underpinning the strategy is the requirement to consider the Medium Term Financial
Strategy which, linked to the Better Care Fund, will potentially drive service changes
across the Health Community over the next 1- 3 years. The Better Care Fund is a
national requirement to transfer resources from the acute sector via the CCG and the
SSDG to support Local Authority Social Services, in particular to ensure the provision
of services in the community to either prevent or reduce admissions and attendances
at Hospitals, a target of 15% reduction being required over the next three years.
7.
SUPERVISOR OF MIDWIVES ANNUAL LOCAL SUPERVISORY AUDIT (LSA) VISIT –
22 MAY 2014
7.1 The Chief Executive was invited to meet with the LSA Audit Team over lunch
7.2 The audit is undertaken annually and the context of the audit was:
•
•
•
•
8.
Priorities of headlines from regional/national prospective
Presentation by the team including last year’s audit recommendations and action
plan
Success and challenges in supervision (local contest)
LSA audit team verbal feedback session to the Supervisor of Midwives team and
invited guests including the Chief Executive.
JOINT ADVISORY GROUP (JAG) ACCREDITATION
8.1 Following the JAG re-visit to the Endoscopy Unit at the Trust on 8 May 2014, I am
pleased to advise that the Endoscopy Unit at Barnsley Hospital NHS Foundation
Trust met all the required JAG Accreditation standards.
9.
PERSONAL, FAIR AND DIVERSE AWARDS 2014
9.1 The work of Diversity Champions has resulted in the Trust winning a national award
by NHS Employers. The awarded is ‘Highly Commended Winner’ in their Personal,
Fair and Diverse Awards for 2014.
9.2 The Trust has won this accolade because it has demonstrated an on-going
commitment to personalised care through inclusive behaviour which has helped to
improve patient outcomes and create a more inclusive workplace. The Trust has
been seen as going the extra mile to engage and encourage staff in the organisation
to promote the work of Diversity Champions and in turn help further embed the
organisation’s values. The Trust has been invited to attend a Personal, Fair and
Diverse Champion award ceremony along with other winners.
BoD June 2014:CEO Report
Page 3 of 4
10. PASSION FOR COMPASSION CONFERENCE – HEALTHCARE ASSISTANTS 28 MAY
2014
10.1 The Chief Executive and Chairman were invited to attend a Passion for Compassion
Conference at the Trust to celebrate the hard work and dedication of the Health Care
Assistants (HCAs)
10.2 HCAs form a huge part of the nursing team and are often referred to as the bedrock
of the nursing services and provide invaluable support and care to our patients.
10.3 There were a number of presentations including Dementia Care in Hospitals,
Safeguarding and Continence Support, along with facilitated group work.
Diane Wake
Chief Executive
June 2014
BoD June 2014:CEO Report
Page 4 of 4
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
14/06/P-16
SUBJECT:
MONTHLY INTEGRATED TRUST BOARD REPORT –
REPORT PERIOD MONTH 1
DATE:
JUNE 2014
Tick as
applicable
PURPOSE:
For decision/approval
For review
For information


Tick as
applicable
Assurance
Governance
Strategy


PREPARED BY:
SPONSORED BY:
PRESENTED BY:
Stuart Diggles, Interim Director of Finance
David Peverelle, Chief Operating Officer
Heather Mcnair, Director of Nursing & Quality
Hilary Brearley, Director of Human Resources & Organisational
Development
Stuart Diggles, Interim Director of Finance
Heather Mcnair, Director of Nursing & Quality
David Peverelle, Chief Operating Officer
Hilary Brearley, Director of Human Resources & Organisational
Development
STRATEGIC CONTEXT
2-3 sentences
To provide an overview of the Trust’s performance in terms of quality, activity, workforce and
finance for May 2014.
To provide positive assurance against the following Trust business objectives: 1a, 1b, 2c, 3c,
5b.
To provide an update on the Trust’s Emergency Care 4 Hour Pathway Action Plan.
QUESTION(S) ADDRESSED IN THIS REPORT
How has the Trust performed in month 1 and year to date?
Are sufficient actions in place to address any areas of concern?
CONCLUSION AND RECOMMENDATION(S)
The Board of Directors is asked to receive and consider the contents of the report.
BoD June 2014: PP-16 Integrated Board paper_1
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
The report is intended to show progress against delivery of the
Trust’s business plan and highlight any issues of concern.
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
Where applicable, state
resource requirements:
Inherent within the report.
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD June 2014: PP-16 Integrated Board paper_1
= target achieved
= target not achived
Monitor targets
= target achieved
= target not achived
Monitor Exceptions
= target achieved
= target not achived
Performance
= target achieved
= target not achived
= target achieved
= target not achived
Performance Exceptions
= target achieved
= target not achived
Quality
= target achieved
= target not achived
= target achieved
= target not achived
Quality Exceptions
Patient Thermometer Indicators
Workforce
Green
Amber
Red
= on target
Improvement in
performance
= under performance (within 5% of
target)
Deterioration in
performance
= fail (>5% target)
No change in
performance
Page 11 of 25
Workforce Exceptions
Page 14 of 25
REPORT TO THE BOARD OF
BARNSLEY HOSPITAL NHSFT
REF:
Appendix P-16
SUBJECT:
REPORT TO THE BOARD OF BARNSLEY HOSPITAL
NHSFT
DATE:
June 2014
Tick as
applicable
PREPARED BY:
For decision/approval
Assurance
For review
Governance

For information
Strategy
David Peverelle, Chief Operating Officer
SPONSORED BY:
David Peverelle, Chief Operating Officer
PRESENTED BY:
David Peverelle, Chief Operating Officer
PURPOSE:
STRATEGIC CONTEXT
Tick as
applicable
2-3 sentences
The development and transformation of the urgent care pathway is a key Trust objective. This
report provides progress against the range of projects designed to improve the urgent care
patient flow and to deliver the 4 hour target.
QUESTION(S) ADDRESSED IN THIS REPORT
What is the Trust’s progress in delivering against the 4 hour urgent care
pathway?
Are the planned actions coming on line providing an impact as expected?
CONCLUSION AND RECOMMENDATION(S)
The Board of Directors is requested to receive and consider the content of the action plan and
note actions and progress to date.
BoD June 2014: Appendix P_16 Board report - Emergency 4 hour
REFERENCE/CHECKLIST
•
•
Which business plan
objective(s) does this report
relate to?
Objective 1 - To provide high quality and safe services.
Objective 2 - Design healthcare around the needs of our
patients.
Objective 5 - Maintain financial viability and sustainability
Has this report considered the
following stakeholders?
Patients
BCCG
Staff
BMBC
Governors
Monitor
Other
Please state:
Regulators (eg Monitor / CQC)
•
Legal requirements (Acts, HSE, NHS Constitution etc)
Has this report reviewed the
Trust’s compliance with:
Equality, Diversity & Human Rights
The Trust's sustainability strategy
CGC
Yes
•
•
Is this report
supported by a
communications
plan?
Not applicable
To be developed
Has this report
(in draft or during
development) been
reviewed by any
Board or Executive
committees within the
Trust?
NCGRC
Audit Committee
Finance Commitee
ET
•
Where applicable, briefly
identify risk issues (including
any reputation) and cross
reference to risk register and
governance committees
Failure to achieve the national 4 hour urgent care pathway has
resulted in a contributor to the Trust breach of its operating
licence with Monitor.
•
Where applicable, state
resource requirements:
Finance:
Other:
NHS Constitution: In determining this matter, the Board should have regard to the Core
principles contained in the Constitution of:
• Equality of treatment and access to services
• High Standards of excellence and professionalism
• Service user preferences
• Cross community working
• Best Value
• Accountability through local influence and scrutiny
The Board will also have regard to the Trust’s core vision statement:
“Barnsley Hospital: Providing the best healthcare for all”
BoD June 2014: Appendix P_16 Board report - Emergency 4 hour
Subject:
1.
EMERGENCY CARE 4 HOUR PATHWAY ACTION
PLAN
Ref: Appendix P-16
STRATEGIC CONTEXT
1.1 To inform the Board regarding progress in delivering the Trust’s transformation of the
urgent care pathway through the implementation of the external recommendations
received by ECIST and the Trust’s own Transformation Programmes.
2.
INTRODUCTION
2.1 As indicated on the Emergency Department Clinical Indicator Dashboard, (Appendix
1) performance against the 4-hour target in the Emergency Department was achieved
in April (95.03%) and is currently being achieved for May (98.56% as at 26th May).
2.1 Performance throughout April saw a significant improvement in performance, despite
difficulties early in April. This is a result of the range of urgent care programme
initiatives starting to be finally established and having impact as planned and also the
additional input of the new Director of Operations, providing additional focus and
managerial capacity to manage the daily patient flow issues. Also in particular the
continued use of 7 day service levels continues to improve discharge rates notably at
weekends maintaining patient flow and is starting to put pressure on the associated
community services.
2.3 The current urgent care dashboard is re-produced again – however it is planned for
this to be revised to include new programme streams and where new services have
been established and become “business as usual”, and for their outputs and benefits
measured and reported.
2.4
3.
Following the Trust’s performance against the 4 hour target (failing to achieve 5
quarters out of the last 7) and the consequent failure against Monitor’s governance
ratings, the Trust is also required to “refresh” its Urgent Care Programme and to
include a further visit and support from ECIST. Details of this are being finalised with
ECIST with a planned focus on the management of ward rounds to enhance further
patient flow. The Trust is required to agree with Monitor the detail and timing for the
new action plan. In the interim a new trajectory has been submitted and this is
included in the appendices (Appendix 3).
ACTIONS
3.1 The Clinical Decision Unit (CDU) continues to see increasing numbers of patients,
each week, with week ending 6th April 48 admissions, week ending 13th April 51
patients and week ending 20th April 61 patients.
3.2 The GP service based in the Emergency Department is now seeing more patients
following the transfer of the contract to the Trust. The proposed future model of
Primary Care Provision or associated work streams is being finalised between the
Trust and the CCG.
3.3 As reported last month a number of Ambulatory Care Pathways have now been
established in AMU, with referrals being made direct to the Consultant by GPs and are
processing patients avoiding full admission. Activity information is being established.
BoD June 2014: Appendix P_16 Board report - Emergency 4 hour
The National Ambulatory Care Network will be visiting the Trust in June as part of this
work.
3.4 The delayed “Frail Elderly Service” – supporting the ED and AMU has commenced
and is linked to the review of “patient falls services”, this has seen a significant
reduction in the numbers of patients waiting to be seen and increased discharge to
Community Services. Again audits of activity data are commencing.
3.5
The Trust has had confirmation from the CCG of continued funding for some of the
additional initiatives to support weekend working as part of the Marginal Tariff Funds –
although clarity is still required in some areas due those being linked to the separate
bid for 7 day working. Notably the agreed funding to date included the Frail Elderly
Project, Therapy Support and the AMU chaired area (this is expected to be fully
staffed by nursing by September following a repeat recruitment round).
3.6 The governance and programme support arrangements for the Urgent Care
programme and Emergency Pathway Action Plan (EPAP) projects have been
reviewed. In a number of cases, this means projects being devolved to “Business as
usual” whereas other projects will need on-going support. The overall Trust urgent
care programmes will continue to be reviewed by the multi agency programme board
(formerly the Trust Transformation Board) on a monthly basis.
3.7 The weekly multi agency Operational Group (a sub committee of the Health
Community Urgent Care working group), chaired by the Chief Operating Officer,
submitted a business case to the CCG Urgent Care Working Group for the
establishment “sub acute” facility for the health community. This was subsequently
referred to the Health and Well Being “Ageing Well Programme Board”. The outcome
was that the Aging Well Board recommended that in addition to more details regarding
the draft business case, any developments should be considered in relation to the
proposed Health Community review of Intermediate Care Services. The Trust, on
behalf of the Operational Group, has expressed concern that this will delay any
decisions on this proposal, in particular in relation to any anticipated timescales for the
Intermediate care Services Review, the prospect of no perceived benefit of the
proposed “sub acute facility” being available for both the next winter and the Trust’s
plans to review to overall bed capacity and accelerate patient flow and discharge.
3.8 The Patient Flow Project that was presented to the Board in May, was also presented
and received at the Health Community Urgent Care Working Group at its meeting May
as this programme of work will also require actions across the Health Community to
deliver the range of changes to care pathways. The Patient Flow Project will also form
a key element of the revised urgent care programme.
3.9 Through the work of the weekly Health Community Operational Group, revisions have
been made to the referral processes for the Independent Living At Home Service,
where currently the take up has only been approximately 50%. The service provides 3
tiers of service provision; to provide facilitated discharge, with short term intervention
support in the home; short term support for those who would not normally qualify for
adult social care services and support provided 24/7 through the use of assistive
technologies. Referrals to these services are possible directly through the Trusts
nursing and therapist services. This is a “6 month pilot” to assess the benefits of
extending these services and enhanced referral processes.
BoD June 2014: Appendix P_16 Board report - Emergency 4 hour
3.10 Whilst staffing for ED Middle Grades remains challenging the situation is slightly more
optimistic with the possibility of additional trainees being available, if only on a short
term basis.
4.
CURRENT PERFORMANCE
4.1 The performance for April was 95.03% with 6,743 patients attending the Emergency
Department. This is achieving the 95% threshold but just below the required trajectory.
4.2 As at 26th May there have been 5,781 attendances with performance at 98.56%.
4.3 At 26th May, the waiting time performance for Q1 is 96.66%.
5.
COMPLETED ACTIONS AND NEXT STEPS
5.1 The Action Plan will continue to be closely monitored with a focus on assurance and
progress to ensure that actions are being taken and that the impact is being felt.
5.2 The key focus for June is to sustain the levels of improved performance along with the
newly configured Clinical Business Units, and continue to “embed” the developing
pathways, and to revise the urgent care pathway with external support from ECIST,
and to develop the revised performance dashboard.
6.
CONCLUSION
6.1
Good progress has been made in March, April and May against the 4 hour urgent care
pathway, this needs to be sustained and the momentum continued throughout the rest
of the year. This will be delivered by continuing to “embed” the new service models
and continue to develop and refine other pathways, and with the newly established and
enhanced Clinical Business Units, not only to ensure delivery against the 4 hour target,
but also for the Trust to achieve its challenging reconfiguration of services across the
Health Community.
BoD June 2014: Appendix P_16 Board report - Emergency 4 hour
Appendices:
•
Appendix 1 – ED Weekly Performance
•
Appendix 2 – ED Clinical Indicators
•
Appendix 3 – Waiting time Trajectory 2014-15
•
Appendix 4 – Urgent Care and EPAP
•
Appendix 5 – AMU Direct Discharges and Frail Elderly patients
BoD June 2014: Appendix P_16 Board report - Emergency 4 hour
Appendix One: ED Daily Performance
BoD May 2014: Appendix P_19 Board report - Emergency 4 hour
10/03/2014
17/03/2014
24/03/2014
31/03/2014
07/04/2014
14/04/2014
21/04/2014
28/04/2014
05/05/2014
12/05/2014
19/05/2014
Indicator
Total Attendances
Total Time in ED - 4 hours or less
Total Time in ED - 95th Percentile
ED - Unplanned Re-attendance Rate
ED - Left Without Being Seen
ED - Admitted Patients- 95th Percentile
ED - Admitted Patients- Median
ED - Admitted Patients - Single Longest Wait
ED - Non Admitted Patients- 95th Percentile
ED - Non Admitted Patients- Median
ED - Non Admitted Patients - Single Longest Wait
Emergency Ambulance Arrivals - 95th Percentile
Emergency Ambulance Arrivals - Median
Emergency Ambulance Arrivals - Single Longest Wait
ED - Time to treatment Decision - 95th Percentile
ED - Time to treatment Decision - Median Wait
ED - Time to treatment Decision - Single Longest Wait
03/03/2014
Appendix Two: ED Clinical Indicators
1,592
91.5%
309
1.57%
2.32%
366
120
574
279
120
596
213
68
406
1,600
97.6%
237
1.25%
0.94%
239
202
555
230
118
432
153
59
277
1,562
97.6%
238
2.43%
1.98%
289
212
566
226
121
371
158
65
239
1,486
95.0%
240
2.42%
1.41%
345
204
641
236
113
364
169
49
281
1,607
92.0%
326
2.36%
2.67%
456
228
639
234
122
838
162
56
236
1,558
91.9%
346
1.98%
2.31%
465
217
626
228
109
414
155
51
431
1,550
97.0%
239
2.51%
1.41%
257
218
583
234
125
438
181
55
274
1,585
97.6%
238
2.34%
1.73%
240
213
529
230
127
609
165
57
278
1,552
99.5%
229
2.25%
1.61%
236
188
573
213
109
274
135
50
207
1,553
97.8%
236
2.12%
1.03%
286
202
517
225
115
797
158
53
227
1,513
99.1%
235
1.52%
1.05%
238
208
426
223
123
426
150
53
236
1,596
97.9%
238
2.00%
1.75%
264
214
485
230
132
485
175
67
236
Appendix Three: Waiting time Trajectory 2014-15
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
95.05%
95.03%
6,743
335
11.2
95.73%
96.07%
96.36%
96.32%
96.47%
96.40%
96.46%
95.03%
95.20%
96.10%
96.41%
BHNFT ED Waiting Times Trajectory: 2014/15
100%
7,000
98%
6,800
96%
6,600
94%
6,400
92%
6,200
90%
6,000
ED Attendances
88%
5,800
Waiting time: Trajectory
86%
Waiting time: Actual
5,600
84%
5,400
82%
Apr-14
BoD June
95.97%
95.03%
6,743
335
11.2
Appendix P_19 Board report
May-14
Jun-14
4
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Waiting Times Performance
Attendances
7,200
2014/15 Avg
May-14
Waiting time: Trajectory
Waiting time: Actual
ED Attendances
Breaches
Average breaches per day
Apr-14
2014/15 Trajectory
Appendix Four: Urgent Care and EPAP
Urgent Care Programme
Transforming Urgent Care
Expa ns i on of the Res us uni t
Tra ns formi ng Devel opment of a 10 bedded CDU
Urgent
Ca re: Pha s e 1
Pri ma ry Ca re work s trea m
Tra ns formi ng
Urgent Ca re:
Pha s e 2
AMU Cha i red Area
AEC Network
Milestone
Current Milestone date
Moni tori ng
Eva l ua ti on
Monitoring: Ongoi ng
Evaluation: Ma rch 2014
Tel econference
Servi ce revi ew meeti ng:
2014/15 Propos a l :
December 2013
Ja n 2014
31s t Ma rch 2014
Pa rti a l expa ns i on
ful l expa ns i on
Partial: 9th December 2013
Full: 6th Ja nua ry 2014
Il l us tra ted a nd documented
pa thwa ys , i ncl udi ng CSU l evel
pl a ns .
22nd Ja nua ry 2014
Emergency Pathways
Milestone
Current Milestone date
Emergency
Pa thwa y
Thera py
Support
Pa rti a l Impl ementa ti on
Devel opment of a Phys i o a nd OT tea m
Ful l s ervi ce
Partial: 9th December 2013,
Full: 6th Ja nua ry 2013
ED Pa ti ent
Fl ow
Assi sta nts
A&C Tea m to focus on Pa ti ent Fl ow
wi thi n ED.
Partial: 9th December 2013
Full: 6th Ja nua ry 2013
ED Pa ti ent
Support
Assi sta nts
Hous e Keeper/ED a s s i s ta nt to provi deImpl ementa ti on
Impl ementa ti on
Clinical Pathways
Expa ns i on of the Vi rtua l Wa rd to
Vi rtua l Wa rd ca s e ma na ge pa ti ents a t a hi gh ri s k
of rea dmi s s i on or fa i l ed di s cha rge
Bus i nes s ca s e for communi ty
s ol uti on. Query Communi ty or
Communi ty AND Trus t s ol uti on.
Milestone
Current Milestone date
Fra i l El derl y Speci a l ty Doctors
Appoi ntment: 3rd round
Q4 2013/14
Res pi ra tory Hub
Impl ementa ti on
3rd Ma rch 2014
ARAS (Acute Respi ra tory Ass ess ment
Impl ementa ti on
Servi ce - Communi ty l ed)
Li ve
In-rea ch
Ongoi ng; pendi ng eva l ua ti on
Pi l ot
Lead
Dyfri g Hughes
Da vi d
Subha s h Ra na
Peverel l e
Executive
Lead
Da vi d
Peverel l e
Executive
Lead
BoD June 2014: Appendix P_19 Board report - Emergency 4 hour
Executive
Lead
Project Manager/
contact
Status
CSU Servi ce Ma na ger
(Ni cki Doherty i nteri m)
Recurrent/ 201415 funding
required
No
Key Benefit
Ma i nta i ng s ta ffi ng l evel s .
Improved pul l of pa ti ents the ED,
reduced IP a dmi s s i ons .
Ni cki Doherty
Options to be
explored,
including s ite
vis its
No
Loui s e Sha rp
Dela yed due to
opera tiona l
recruitment
£110,000
CSU Servi ce Ma na ger
(Ni cki Doherty i nteri m)
Key Risks
Propos a l to be devel oped
Recrui tment ongoi ng.
No
Ongoing Governance arrangements
Phi l l pa Moreno
£232,000
Assumption: Reduced Emergency
Admi s s i ons a nd Rea dmi s s i ons for
fra i l el derl y pa ti ents .
Dyfri g Hughes
Debbi e Fi rth
£105,000
Hel p to ma i nta i n focus on wa i ti ng
ti me performa nce a nd ED qua l i ty
i ndi ca tors .
Dyfri g Hughes
Debbi e Fi rth
Lead
Project Manager/
Owner
Lead
Project Manager/
Owner
Sus i e Orme
Da vi d
Peverel l e
Ja mi l
Muha mmed
Lee Ta rren
Benefit
£260, 000
Status
Del a yed due
to recrui tment
Deni s e Ta te
Andrea Da ri us
Deni s e Ta te
Fundi ng requi red i f key
el ements not requi red by
communi ty s ol uti on.
Reduced emergency rea dmi s s i ons ,
i mproved pa ti ent experi ence.
Benefit
£368,000
No
Business as usual: Fortni ghtl y proj ect meeti ngs unti l
Ma rch 31s t; es s enti a l l y ma na ged wi thi n the CSU.
Moni tori ng of key metri c i ncorpora ted i nto the CSU
performa nce revi ew.
Business as Usual: moni tored a nd ma na ged by the
CSU. Bus i nes s Ca s e cover needed to upda te on
progres s a nd pl a n for next yea r.
Improved pa ti ent ca re a nd experi ence.
Status
Ja mi l Muha mmed/
Deni s e Ta te
Ka ren Sha rpe
Da vi d
Peverel l e
£150,000
Business as Usual: Uti l i s a ti on a nd opera ti ona l
cha nges 2013/14 ma na ged by CSU. 2014/15
Devel opment overs een by DCOO (ND).
Benefit
Hel en Di xon/
Phi l l i pa
Moreno
Key Risks
Business as Usual: Ongoi ng moni tori ng a nd
Eva l ua ti on a t 3 months , 6 months a nd 12 months .
Ma na ged a s Bus i nes s a s us ua l vi a the CSU.
Project Managed within CSU: Ma na ged by the AMAC
Proj ect Group; overs een by the CSU Ma na gement
tea m a nd moni tored by the weekl y Emergency
Pa thwa y Exec meeti ng. Li nk wi th other CSUs .
Project Manager/
Owner
Status
Ongoing Governance arrangements
Improved pul l from the ED, reduced IP
Admi s s i ons . Defl ecti on of GP
Emergency Admi s s i ons . Reduced
Emergency Admi s s i ons .
Lead
Da vi d
Da vi d Ra ms a y
Peverel l e
Feb: 2014
Ma rch: 2014
El derl y Ca re Nurs e Speci a l i s ts
COPD
Current Milestone date
Pa rti a l i mpl ementa ti on
Ful l i mpl ementa ti on
Fra i l El derl y
Da vi d
Peverel l e
Partial: 9th December 2013
Full: 6th Ja nua ry 2013
Milestone
Clinical Pathways
Executive
Lead
Sl ow recrui tment; ba ckfi l l i s
requi red to free up the key For Frail Elderly: di rect a dmi s s i ons
nurs i ng tea m. On 3rd round from ED, reduced Emergency
a dmi s s i ons a nd rea dmi s s i ons .
of Medi ca l recrui tment,
l ooki ng a t a l terna ti ves .
For COPD: reduced Emergency
Sl ow recrui tment
Admi s s i ons a nd Rea dmi s s i ons .
Res ource for communi ty
For COPD: reduced ED a ttenda nces ,
l i nk.
Emergency a dmi s s i ons /rea dmi s s i ons
For COPD: reduced emergency bed
Res ource for eva l ua ti on
da ys ; s upports Ambul a tory Pa thwa ys .
Ongoing Governance arrangements
Business as usual: ma na ged by the CSU i n
conj uncti on wi th SWYPHT.
Ongoing Governance arrangements
Business as Usual: recrui tment a nd procedures
ma na ged by CSU; overs een a nd s upported by DCOO.
Business as Usual: In-rea ch up a nd runni ng; moni tor
a nd cl os e. ARAS: bei ng l ed by communi ty.
Res pi ra tory hub: devel oped by CSU. Benefi ts
moni tored wi thi n Performa nce Fra mework.
Emergency Pathway Action Plan
Patient Pathways
Wa rd Pa ti ent
Pra cti ti oners
Di s cha rge
Uni t
Milestone
Pra cti ti oner tea m to s upport wa rds
rounds a nd pa ti ent fl ow.
Devel opment of a di s cha rge uni t;
opened Aug. 2013.
Impl ementa ti on
Pendi ng recrui tment
Go l i ve
Eva l ua ti on
Augus t 2013
31s t Ja nua ry 2014
Emergency Flow
START
ED Front
Entra nce
Sta ffi ng Model
Current Milestone date
Milestone
Current Milestone date
Executive
Lead
Hea ther
McNa i r
Hea ther
McNa i r
Executive
Lead
Lead
Andrew
Moora by
Andrew
Moora by
Lead
Project Manager/
Owner
Status
Andrew Moora by
Recrui tment
Andrew Moora by
Project Manager/
Owner
Eva l ua ti on of START pi l ot.
Pi l ot
Eva l ua ti on
Compl ete
Da vi d
Peverel l e
Dyfri g Hughes
Ni cki Doherty
El ectroni c s i gna ge a nd pa ti ent
i nforma ti on
Ins ta l l a ti on
Ja n-14
Da vi d
Peverel l e
Dyfri g Hughes
Li z Ba xter
Nurs i ng; pi l ot of 12 hour s hi fts
12 hour s hi ft pa tterns
Da vi d
Peverel l e
Dyfri g Hughes
Jugnu
Ma ha j a n
Da vi d
Peverel l e
Medi ca l
AMU 12/7 Cons ul ta nt Cover
Speci a l i ty In-rea ch
Pa ti ent fl ow
model s
Short Sta y
9th September 2013
Tel econferenece wi th Pl ymouth
Ja n '14
Impl ementa ti on
Eva l ua ti on
2/9/2013
31/01/2014
Res pi ra tory
Ca rdi ol ogy
Ca re of the El derl y
Aug-13
28/02/2014
28/02/2014
Thera pi es
03/02/2014
Endocri nol ogy
Interna l Profes s i ona l
Sta nda rds
Agree model
Li ve
Internal Professional Standards:
30th November 2013
Agreed model
Ways of working
Milestone
Current Milestone date
Dyfri g Hughes
Dyfri g Hughes /
Subha s h Ra na
£450,000
Debbi e Horne
Cl i ni ca l Di rectors
Jugnu
Jugnu Ma ha j a n
Ma ha j a n
Executive
Lead
Lead
Dyfri g Hughes
Exec.
Project Manager/
Owner
Stewa rt Ya tes Da vi d Houghton
Wa ys of
worki ng
Winter Plan
Loca l Opera ti ona l pl a ns
Ta cti ca l res pons e (BHNFT)
Ta cti ca l Res pons e (CCG)
Wi nter Es ca l a ti on Area
6th December 2013
Acti ons Ca rds
Acti on Ca rds : Pendi ng
SOP: 14/11/2013
Assurance Report: 19/9/2013
Update: 28/11/2013
As s ura nce report
Loca l i ty opera ti ona l forum
02/12/2013
CCG As s ura nce report
30/09/2013
Overvi ew
Ongoi ng moni tori ng
NHS Engl a nd As s ura nce report 6th Ja nua ry 2014
BoD June 2014: Appendix P_19 Board report - Emergency 4 hour
Sus i e Orme/
Ni cki Doherty
Ja cki e Howa rth
Status
Benefit
Morni ng di s cha rges , uti l i s i ng
EDD/PDD
Free up IP beds ea rl i er i n the da y;
i mproves Pt fl ow.
Benefit
Improved wa i ti ng ti mes i n ED;
Improved performa nce a ga i ns t ED
Qua l i ty Indi ca tors .
Improve s i gnpos ti ng for pa ti ent ma y
decrea s e a ttenda nces .
Improved s ta ffi ng pa tterns ma tched to
dema nd.
Improved weekend di s cha rges ,
reduced LOS, Improved Fl ow
Ongoing Governance arrangements
Business as Usual: Overs een by ADN; reported
Business as Usual: Proj ect Cl os ed; overs een by ADN.
Ongoing Governance arrangements
Business as Usual: Moni tored vi a CSU Performa nce
Fra mework.
Business as usual: Cl os ed by end of Ja n.
Business as usual: Cl os ed
Business as Usual: ma na ged by CD, s upported by
DCOO
Business as usual: ma na ged by CSU Ma na gement
tea m a nd moni tored wi thi n Performa nce
Fra mework. Overs een by Coj ns i s tency i n Ca re.
Cl i ni ca l Res ources ,
ma na gement s upport
Reduced LOS/bed da ys , Reduced IP
Emergency Admi s s i ons , reduced
Rea dmi s s i ons . Al s o s upport
a mbul a tory pa thwa ys .
Business as Usual: ma na ged by the CSU a nd
moni tored by Performa nce Fra mework.
Ma na gement s upport
Abi l i ty to moni tor CSU Performa nce
a ga i ns t a gree s ta nda rds .
Business as Usual: ma na ged wi thi n CSU, Overs een by
MD.
No
14th October 2013
28/02/2014
Res ource ti me,
depa rtmenta l enga gement
Res ource to dri ve
i mpl ementa ti on
Pos ters in ED.
Kios ks ordered
No
24/7 Di a gnos ti c Support
Propos a l
No
Ni cki Doherty
Dyfri g Hughes Dyfri g Hughes
Refres h of exi s ti ng pl a ns
Key Risks
No
Nov-13
Ma s s pa ti ent pl a ns
Abi l ty to recrui t to a ful l
compl i ment.
No
Status
Debbi e Fi rth
Ful l Ca pa ci ty Protocol devel opment
Si gn off
a nd s i gn off
Long Sta y Protocol
Key Risks
£700,000
Key Risks
Benefit
Key a cti on to ma na ge pa ti ent fl ow
when performa nce i s l i kel y to drop.
Ongoing Governance arrangements
Business as usual: overs een by COO a nd DCOO
Business as Usual: Ma na ged by CSU.
Del a ys i n Fra i l
El derl y
Reduced LOS/Emergency Bed da ys for
cohort of pa ti ents
Business as Usual: Ma na ged by CSU.
Mi ke Lees
Da vi d
Peverel l e
No
Ni cki Doherty
John
Ca rtwri ght
Ma na gement res ource
Cl ea r, s ucci nct, documenta ti on of
a cti ons to ta ke duri ng ei ther a ma s s
ca s ua l ty pl a n or, more l i kel y, bed
Business as usual: overs een by COO a nd DCOO
pres s ures wi l l ena bl e a better
res pons e a nd a s horter recovery ti me
for the trus t a nd CCG.
Da vi d Peverel l e
El a i ne Jeffers
CCG
Andy Moora by
Recrui tment
Appendix Five: AMU Direct Discharges and Frail Elderly patients
w/c
05/08/2013
12/08/2013
19/08/2013
26/08/2013
02/09/2013
09/09/2013
16/09/2013
23/09/2013
30/09/2013
07/10/2013
14/10/2013
21/10/2013
28/10/2013
04/11/2013
11/11/2013
18/11/2013
25/11/2013
02/12/2013
09/12/2013
16/12/2013
23/12/2013
30/12/2013
06/01/2014
13/01/2014
20/01/2014
27/01/2014
03/02/2014
10/02/2014
17/02/2014
24/02/2014
03/03/2014
10/03/2014
17/03/2014
24/03/2014
31/03/2014
07/04/2014
14/04/2014
21/04/2014
28/04/2014
05/05/2014
12/05/2014
ED
ED
ED
ED
Attendances Attendances Attendances Age
(total)
(avg/day)
(maximum) 75+
4 hour %
96.84%
93.97%
96.46%
95.30%
96.49%
95.39%
95.20%
92.89%
95.93%
95.32%
92.29%
92.57%
96.25%
96.22%
96.64%
96.92%
95.66%
91.16%
89.91%
93.86%
96.78%
88.38%
93.61%
93.92%
93.48%
96.29%
96.26%
96.02%
93.56%
84.69%
91.52%
97.56%
97.57%
95.02%
92.03%
91.91%
97.03%
97.60%
99.55%
97.81%
99.14%
e Conversion Admissions
dmissions
dmissions
1,489
1,508
1,553
1,512
1,481
1,497
1,541
1,632
1,500
1,495
1,557
1,547
1,385
1,482
1,487
1,494
1,497
1,505
1,527
1,564
1,430
1,489
1,377
1,431
1,411
1,484
1,551
1,484
1,506
1,470
1,592
1,600
1,562
1,486
1,607
1,558
1,550
1,585
1,552
1,553
1,513
213
215
222
216
212
214
220
233
214
214
222
221
198
212
212
213
214
215
218
223
204
213
197
204
202
212
222
212
215
210
227
229
223
212
230
223
221
226
222
222
216
233
233
240
244
236
249
244
266
260
284
259
249
248
247
245
243
250
254
255
256
233
239
211
229
228
246
264
249
238
247
241
267
288
249
257
242
256
263
248
253
228
176
199
228
194
187
188
201
202
188
202
201
187
183
209
201
202
198
211
208
200
229
233
188
222
194
187
190
195
210
218
205
177
195
189
204
181
205
237
199
199
211
Adm
issio
ns
ED
Age
85+
60
73
76
65
72
75
65
70
78
79
76
75
71
88
78
75
77
84
93
84
73
85
74
88
72
76
70
79
89
68
72
63
76
81
86
81
74
95
81
64
81
All 15
All 15 day+
LOS
ED
AMU
AMU
All NEL
All NEL
All NEL
AMU
AMU Direct day+ LOS
Patients
ED Ambulance Conversion Admissions Admissions Admissions Admissions Admissions Admissions Discharges Patients
(avg/day) (maximum)
Rate
(total)
(avg/day) (maximum)
(total)
(avg/day)
(maximum)
%
Arrivals
403
453
460
411
438
423
463
484
451
450
488
506
452
496
440
486
463
464
484
474
516
494
460
502
489
475
471
445
456
443
474
439
441
409
467
428
442
471
462
436
451
Adm Admissions
issio
ns
23%
25%
24%
25%
25%
24%
25%
25%
24%
25%
24%
24%
27%
26%
25%
25%
26%
26%
30%
27%
32%
30%
30%
30%
30%
27%
29%
29%
28%
30%
27%
27%
28%
28%
26%
27%
28%
27%
28%
28%
29%
459
488
503
491
514
486
493
512
480
501
503
481
507
498
511
524
537
536
622
532
531
573
542
527
588
527
584
580
560
554
561
558
556
535
544
556
560
550
559
527
604
66
70
72
70
73
69
70
73
69
72
72
69
72
71
73
75
77
77
89
76
76
82
77
75
84
75
83
83
80
79
80
80
79
76
78
79
80
79
80
75
86
Discharges
Patients
82
87
94
89
86
79
85
83
90
97
94
88
85
88
89
103
101
96
104
100
93
104
92
95
102
93
103
101
106
92
98
96
102
91
86
94
101
87
103
90
108
Patients
244
265
283
276
251
258
286
271
253
275
264
257
252
290
251
254
281
268
284
224
254
296
272
254
303
254
283
261
279
270
264
263
251
262
274
267
271
261
279
259
274
35
38
40
39
36
37
41
39
36
39
38
37
36
41
36
36
40
38
41
32
36
42
39
36
43
36
40
37
40
39
38
38
36
37
39
38
39
37
40
37
39
47
48
49
49
43
42
51
44
50
47
51
45
44
52
41
52
52
48
48
43
45
60
45
45
53
47
53
46
55
47
44
47
50
51
43
51
51
44
48
41
47
46.72%
40.75%
42.76%
41.30%
42.63%
45.74%
42.31%
42.44%
50.20%
43.64%
41.67%
38.13%
46.03%
40.00%
34.66%
41.73%
32.38%
31.72%
32.39%
27.68%
33.46%
37.16%
29.41%
33.86%
34.98%
34.25%
29.68%
37.55%
27.24%
35.93%
39.77%
34.22%
33.86%
34.73%
30.66%
35.58%
35.06%
33.72%
34.05%
35.52%
39.42%
69
71
54
52
57
58
64
64
66
61
55
52
53
55
50
60
56
50
54
46
50
57
60
61
42
41
44
51
61
57
55
59
58
58
60
49
48
50
45
52
46
78
82
64
54
64
66
70
68
71
69
62
57
59
61
57
69
68
58
59
55
60
71
73
64
53
45
50
57
63
59
61
62
63
62
65
55
53
53
50
54
53
REFERENCE SECTION
BoD: XX Reference - June 2014
BoD: XX Reference - June 2014
SCHEDULE OF ACRONYMS
Additional acronyms may be added as appropriate/on request
A
A&E
A4C / AfC
ACCEA
ACE
ACS
AEC
AHP
AHSN
AMU
ANP
AOA
AQuA
ARCP
AUP
B
BAEM
BBE
BCCG
BHNFT
BMA
BMBC
BMJ
BoD
BWCC
C
CAP
CASU
CAUTI
CBU
CCG
CCU
C. diff
CDU
CE / CEO
CEMACH
CHAI
CHD
CHI
CHKS
CIP
CLAHRC
CLAUDE
CMO
CMT
CNST
COG
COO
COPD
Accident and Emergency
Agenda for Change
Awards Committee for Clinical
Excellence Awards
Acute Care of the Eldery
Additional Clinical Services
Ambulatory Emergency Care
Allied Health Professions
Academic Health Science Network
Acute Medical Unit
Advance Nurse Practitioner
Annual Organisational Audit
Advancing Quality Alliance
Annual Review of Competence
Progression
Acceptable Use Policy
British Association of Emergency
Medicines
Bare below the elbows
Barnsley Clinical Commissioning Group
Barnsley Hospital NHS Foundation
Trust
British Medical Association
Barnsley Metropolitan Borough Council
British Medical Journal
Board of Directors
Barnsley Women and Children’s Centre
Community Acquired Pneumonia
Controls Assurance Support Unit
Catheter-Associated Urinary Tract
Infection
Clinical Business Unit
Clinical Commissioning Group
Coronary Care Unit
Clostridium Difficile
Clinical Decision Unit
Chief Executive / Chief Executive Officer
Confidential Enquiry into Maternal and
Child Health
Commission for Health Audit and
Improvement
Coronary Heart Disease
Commission for Health Improvement
CHKS – name of company providing
statistical/benchmarking data
Cost Improvement Programme (also
known as efficiency programme)
Collaboration for Leadership in Applied
Health Research and Care
Clinical Audit Data Base
Chief Medical Officer
Clinical Management Team
Clinical Negligence Scheme for Trusts
Council of Governors
Chief Operating Officer
Chronic Obstructive Pulmonary Disease
BoD:XX Reference - June 2014
COSHH
CPA
CPE
CPEC
CPMS
CPT
CQC
CQUIN
CRS
CSSD
CSU
D
DB
DDA
Do ICT
DoH
DoHR&OD
Do N&Q
DHSC
DH / DoH
DIPC
DMD
DNA
DNAR
DPM
DNR
DSEU
E
EBITDA
ECIST
ECN
ED
EDD
EDS2
ENT
EPAP
EPR
EqIA
ET
EWS
EWTR
F
FABULOS
FBC
FCE/FCSE
FFCE
FFT
FT
FTN
G
GMC
Control of Substances Hazardous to
Health
Clinical Pathology Accreditation
Clinical Performance & Effectiveness
Clinical Performance & Effectiveness
Committee
Central Portfolio Management System
Capital Planning Team
Care Quality Commission
Commissioning for Quality and
Innovation
Commissioner Requested Services
Central Sterile Services Department
Clinical Service Units
Designated Body
Disability Discrimination Act
Director of ICT
Department of Health
Director of Human Resourses and
Organisational Development
Director of Nursing and Quality
Directorate of Health & Social Care
Department of Health
Director of Infection Prevention &
Control
Divisional Medical Director
Did Not Attend
Do Not Attempt Resusitation
Department of Psychological Medicine
Do Not Resusitate
Day Surgery & Endoscopy Unit
Earnings before interest, taxes,
depreciation and amortisation
Emergency Care Intensive Support
Team
Emergency Care Network
Emergency Department
Estimated Date of Discharge
Equality Delivery System
Ear, Nose & Throat
Emergency Pathway Action Plan
Electronic Patient Records
Equality Impact Assessment
Executive Team
Early Warning Score
European Working Time Regulation
Fluids, Antibiotics, Blood Cultures,
Urine, Lactate, Oxygen, Sepsis Six
Full Business Case
Finished Consultant Episode
First Finished Consultant Episode
Friends and Family Testing
Foundation Trust
Foundation Trust Network
General Medical Council
GP
GUM /
GU Med
H
HAPPY
HCA
HES
HSE
H&S
HDU
HR
HRG
HSC
HSMR
I
I&E
ICU
IFRS
IIP
IHP
IPC
IR1
IRMER
ISS
IT
ITU
IV
IWL
J
JNCC
JTUC
KL
KPI
LA
LCRN
LAC
LDP
LHC
LIFT
LINks
LOS
LPMS
LRC
LTC
M
M&S
MAG
MDA
MDT
ME
MHRA
MINAP
MRI
MTAS
General Practitioner
N
Genito-Urinary Medicine
NCEPOD
Harmonised Approval Process Pan
Yorkshire
Health Care Assistant
Hospital Episode Statistics
Health & Safety Executive
Health & Safety
High Dependency Unit
Human Resources
Health Resource Group (finance)
Health Service Circular
Hospital Standardised Mortality Ratio
Income and Expenditure
Intensive Care Unit (also known as ITU)
International Financial Reporting
Standards
Investors in People
Improving Hospital Partnerships
Infection Prevention & Contr
Incident Reporting form
Ionising Radiation - Medical Exposure
Regulations
ISS Mediclean – cleaning contractors at
the Trust
Information Technology
Intensive Therapy Unit (also known as
ICU)
Intravenous
Improving Working Lives
Joint Negotiating and Consultation
Committee
Joint Trade Union Committee
Key Performance Indicator
Local Authority
Local Clinical Research Network
Local Awards Committee
Local Development Plan
Local Health Community
Local Improvement Finance Trust
Local Involvement Networks
Length of Stay
Local Portfolio Management System
Learning and Resource Centre
Long Term Conditions
Medical & Surgical
Model Appraisal Guide
Medical Devices Agency
Multi-Disciplinary Team
Management Executive
Medicines &Medical Healthcare
Regulatory Agency
Myocardial Infarction National Audit
Programme
Magnetic Resonance Imaging
Medical Training Application Service
NED
NEWS
NHS
NHSE
NHSE
NHSLA
NORCOM
NCISH
NICE
NIMG
NIHR
NPAT
NPSA
NRLS
NSF
O
OBC
OH
OJEC
OPERA
OPT
OT
PQ
PA
PACS
PALS
PAS
PBR / PbR
PCT
PEAT
PGME
PIU
PLACE
PMG
PPG
PPI
PR
PROMS
PSM
PTS
QA
QIPP
QSIEB
R
R&D
RAF
RATS
RCPCH
RCP
Bod: XX Reference - June 2014
National Confidential Enquiry into
Perioperative Deaths
Non Executive Director
National Early Warning Score
National Health Service
National Health Service England
National Health & Safety Executive
National Health Service Litigation
Authority
North Derbyshire, South Yorkshire and
Bassetlaw Commissioning Consortium
National Confidential Inquiry into Suicide
and Homicide
National Institute for Clinical Excellence
NICE Initiation and Monitoring Group
National Institute for Health Research
National Patients Access Team
National Patient Safety Agency
National Reporting & Learning System
National Service Framework
Outline Business Case
Occupational Health
Official Journal of the European
Communities
Older Persons Early Rehabilitation
Assessment
Operational Performance Team
Occupatinal Therapy
Professional Activities (4 hours)
Picture Archiving & Communications
Systems
Patient Advice & Liaison Services
Patient Administration System
Payment by results (tariff system)
Primary Care Trust
Patient Environment Action Team
Post Graduate Medical Education
Planned Investigation Unit
Patient Led Assessment of the Care
Environment
Performance Management Group
Patient Participation Group
Public & Patient Involvement
Public Relations
Patient Reported Outcome Measures
Patient Services Manager
Patient transport services
Quality Assurance
Quality Innovation Prevention &
Productivity
Quality and Safety Improvement &
Effectiveness Board
Research and Development
Risk Assessment Framework
Remuneration and Terms of Service
Royal College of Paediatrics and Child
Health
Royal College of Physicians
RFT
ROCA
RPST
RST
RTT
S
SABS
SALT
SAS
SAU
SCH
SDA
SHA
SHMI
SHO
SI
SIFT
SLA /
SLAM
SOA
SUI
SoS
Rotherham Hospital NHS Foundation
Trust
Register of Controls Assurance
Risk Pooling Assessment for Trusts
Revalidation Support Team
Referral to Treatment
Safety Alert Broadcast System
Speech and Language Therapy
Staff and Associate Specialist
Surgical Administration Unit
Sheffield Children’s Hospital NHS
Foundation Trust
Surgical Decision Area
Strategic Health Authority
Standardise Hospital Mortality Indicators
Senior House Officer
Serious Incident
Service Increment for Training
Service Level Agreements / Service
Level Agreement Monitoring
Strategic Options Analysis
Serious Untoward Incident
Secretary of State
Bod: XX Reference - June 2014
SPC
SpR
SSD
STH
STEIS
SYSHA
SWYPFT
Statistical Process Control
Specialist Registrar
Sterile Services Department
Sheffield Teaching Hospitals NHS
Foundation Trust
Strategic Health Authority Executive
Information System
South Yorkshire Strategic Health
Authority
South West Yorkshire Partnership
Foundation Trust
TUV
TIGER
TWWMIB
VDI
VTE
WXYZ
WCA
WLI
Wte
Y&H
YTD
The Information Governance Education
Recognition Award
Together We Will Make It Better
Virtual Desktop Infrastructure
VenousThrombo-Embolism
Wider Controls Assurance
Waiting List Initiative
whole time equivalent
Yorkshire & the Humber
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