summary report abm university health board 5th september 2… · • wrvs • gp out of hours...

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SUMMARY REPORT ABM University Health Board

Health Board Date: 5th September 2013 Agenda item 2(i)

Subject Transfer of the remaining Ward at Cimla Hospital to Neath Port Talbot Hospital

Prepared by Karl Murray, Acting Locality Director

Approved by Paul Stauber, Director of Planning Presented by Paul Stauber, Director of Planning Purpose This report updates the Board on the discussions for the transfer of the remaining ward at Cimla Hospital to Neath Port Talbot Hospital.

Decision Approval √ Information Other

Corporate Objectives Safety Quality Efficiency Workforce Health Governance

√ √ √ √ √ √ Executive Summary This paper outlines the feedback following a period of focussed engagement.

Key Recommendations The remaining ward at Cimla Hospital should transfer to Neath Port Talbot Hospital.

Assurance Framework

Next Steps Subject to Board approval, the Locality will proceed to transfer the remaining ward at Cimla Hospital.

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Corporate Impact Assessment Quality and Safety The Report link to the following standards: -

• 1 – governance and accountability framework.

• 6 – participating in quality improvement initiatives

• 7 – safe and clinically effective care.

Financial Implications

There are no financial implications.

Legal Implications N/A

Equality & Diversity

EqIA will now be undertaken.

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MAIN REPORT ABM University Health Board Health Board Meeting On

5th September 2013

AGENDA ITEM: 2(I)

Subject Transfer of the remaining Ward at Cimla Hospital to Neath Port Talbot Hospital

Prepared by Karl Murray, Acting Locality Director

Approved by Paul Stauber, Director of Planning Presented by Paul Stauber, Director of Planning 1. INTRODUCTION Following the discussion at the Health Board on 4th July 2013, discussions have been held with the Community Health Council and it was agreed that a focused period of engagement would be undertaken between the 24th July 2013 and 7th August 2013 regarding the transfer of the remaining ward at Cimla hospital to Neath Port Talbot Hospital. 2. CONTEXT Our five year strategic plan, Changing for the Better - which was published in 2010 - set out an ambitious programme to improve the quality of the health care services we offer. Modernising hospital care and extending our range of community services are key priorities This means that we have to continually review how we provide care and to consider whether we have the right services, in the right place, and are providing the best care we can. The Health Board recognised that there may be need for more hospital beds with the demographic changes that are, and, will continue to take place over the next 10-15 years. However, the clinical view is that beds should be located on the four main hospital sites and not in isolated community hospitals because this provides better quality of care and improved access to diagnostic and clinical supervision of care. 3. BACKGROUND In September 2012, one of Cimla Hospital’s two wards moved to Neath Port Talbot Hospital following the transfer of acute medicine to the Swansea and Bridgend hospitals. The relocation has been successful for patients who now benefit from the 24/7 medical staffing and diagnostic support. A Consultant in Care of the Elderly, based at Neath Port Talbot Hospital is responsible for the management of patients remaining at Cimla Hospital supported by an Associate Specialist and Nurse Practitioner based at Cimla Hospital.

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Following a review of orthopaedic and general surgical activity at Neath Port Talbot Hospital, the Health Board has been piloting a new service delivery model through the Day Surgery Unit and the current surgical Ward A. The pilot, evaluated at the end of April 2013, indicated that all Neath Port Talbot Hospital’s planned surgical activity, including breast, general and orthopaedic surgery could be undertaken within these areas, which would release Ward B2 for alternative use. These changes were implemented from the 13th July 2013 and Ward B2 is now vacant. It is therefore proposed that given the service and staffing issues to transfer Brynnedd ward from Cimla Hospital to Neath Port Talbot Hospital. All staff, including therapists, will transfer with the in-patient service. 4. ENGAGEMENT PROCESS A focused engagement process was undertaken between the 24th July 2013 – 7th August 2013. The clinical care and rehabilitation services provided at Cimla Hospital have been considered of high quality to date but as indicated above, in 2013, changes in the circumstances within which the local service is being provided indicate that a change is both desirable and necessary. Changes in the services provided at Neath Port Talbot Hospital mean that it will have capacity to accommodate the remaining ward at Cimla Hospital. Transfer of this ward to Neath Port Talbot Hospital would be consistent with the Health Board overall direction of travel in consolidating beds on the four hospital sites. The reasons for the transfer include the following: • Consolidating beds in Neath Port Talbot Hospital would remove the risks of a

stand-alone ward on an isolated hospital site. • Transferring the Ward to Neath Port Talbot Hospital will mean that patients will

benefit from an excellent ward environment. • Patients will also have rapid access to diagnostics and medical advice out of

hours without the need to transfer patients between hospital sites when a patient’s condition requires additional attention.

• Neath Port Talbot Hospital has several dedicated rehabilitation areas, including one attached to Ward C (to which the first Cimla ward transferred) and a larger pool of rehabilitation staff, which will improve patient access and continue to facilitate earlier discharge home, improving patient flow, particularly for stroke patients from Morriston and the Princess of Wales Hospitals.

• Neath Port Talbot Hospital is, however, in a position to meet the vast majority of the needs of patients who have already been diagnosed and treated during the acute phase of their medical illness particularly as the proposed transfer will strengthen the medical workforce at the hospital and provide immediate access and support to senior clinicians for nursing and other health care professionals who will transfer with the service.

• By having all inpatient beds on the Neath Port Talbot Hospital it will enable the consultant workforce to spend their time in Neath Port Talbot Hospital instead of having demands off site.

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• The transfer of the ward to Neath Port Talbot Hospital would strengthen the middle grade cover with the addition of the Associate Specialist position. Similarly there is greater flexibility in covering nurse rosters on a single site and ensuring appropriate staffing levels are maintained on the wards.

• In addition, the out-of-hours medical cover provided by two local general practitioners and the GP Out-of-hours service has become increasingly difficult to maintain at Cimla Hospital due to the inability to recruit locum staff, or, provide cover from Neath Port Talbot Hospital

• Having all beds at Neath Port Talbot Hospital will allow greater flexibility of nursing staff covering absences, gaps in the rota and releasing nursing staff for mandatory and statutory training.

In view of the difficulties from a medical and nursing staff perspective it is recommended that the transfer is made as soon as possible. The nursing and hotel services team will be transferred en bloc to Ward B2. Medical and therapy staff employed to support the Ward will be transferred to Neath Port Talbot Hospital. During the engagement period regular meetings were held with the staff at Cimla Hospital by the Locality and Hotel Services Management Team. In addition, letters have been sent to interested individuals and groups explaining the background and offering meetings or further discussions to clarify any issues. The distribution of letters included:- • Cimla Remodelling Stakeholder Group • Councillor Andrew Jenkins (Neath South) • Neath Town Council • Cimla Hospital League of Friends • WRVS • GP Out of Hours providers for Cimla Hospital • Assembly Members, Mr. David Rees, Mrs. Gwenda Thomas, Ms. Bethan

Jenkins and Mrs. Suzy Davies In addition, there have also been discussions with the Neath Port Talbot Health, Social Care and Well Being Executive Board, the Neath Port Talbot People’s Consultation Forum and the Neath Port Talbot Older People’s Council. 5. OUTCOME OF ENGAGEMENT PROCESS Overall, the principle of moving the remaining ward to Neath Port Talbot Hospital was supported and the following themes were raised during this process:- • Staff understood the reason for the change but were anxious to know when the

move would take place. They were reassured that they were not at risk as far their future employment was concerned.

• Reassurance was sought and given that the current number of beds at Cimla Hospital and associated staffing to be deployed against those bed numbers would be maintained at Neath Port Talbot Hospital.

• The Physiotherapy and Speech & Language Therapy staff sought and received assurance that at Neath Port Talbot hospital they would continue to have access to accommodation close to the ward for provision of the services they

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provided and associated equipment. • A member of the Neath Port Talbot Older People’s Consultation Forum asked if

there would be any loss of beds in the move from Cimla Hospital to Neath Port Talbot Hospital and was assured that the current level of beds was being maintained. No other comments or questions from the Forum or the Older People’s Council were received regarding the transfer of the ward.

• The League of Friends sought and received assurance that commemorative plaques and equipment they had purchased at Cimla Hospital would transfer to Neath Port Talbot Hospital.

County Councillors and officers who have been involved in the Cimla Remodelling Stakeholder Group since early 2013 have continued to express their support with the proposal to transfer the remaining ward whilst stressing their enthusiasm for the site’s redevelopment as a base for integrated health and social care services. The Health Board is committed to developing the site for this purpose. 6. CONCLUSION It was recognised that there were considerable benefits in consolidating the beds on the Neath Port Talbot Hospital and together with the consolidation of community services provide a comprehensive model for the Locality. The Health Board recognises that Cimla Hospital has played an important role in the care of patients, and we are sensitive to the affection many people have for the hospital and its dedicated team of staff. However, the vacated ward at Neath Port Talbot Hospital now provides the opportunity to transfer the remaining at Cimla Hospital and improve the quality of care that those staff and other colleagues in Neath Port Talbot Hospital are able to provide for patients. It is recognised that Cimla Hospital can still provide a very important role for the community and plans are progressing as to how this could be developed as a community resource centre. The Community Health Council has considered the response to the focused engagement and it supports the transfer of the remaining ward from Cimla Hospital to Neath Port Talbot. The Community Health Council accepts the obvious clinical advantages to patients of the move to Neath Port Talbot Hospital. In supporting the move the Community Health Council wishes to continue to work with the Health Board to develop the hospital site as a community resource facility. It is therefore recommended that the Health Board approve the transfer of the remaining ward from Cimla Hospital to Neath Port Talbot Hospital. 7. RECOMMENDATIONS The Health Board is asked to:- • Approve the transfer of the remaining ward from Cimla Hospital to Neath Port

Talbot Hospital; • Continue to develop proposals for the use of Cimla Hospital as a community

resource facility.

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Princess of Wales Health Board 5th Sept 2013

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MAIN REPORT ABM University Health Board Health Board Meeting On

5th September 2013

AGENDA ITEM: 3(I)

Subject Princess of Wales Hospital Report

Prepared by Lesley Bevan, Chief Nurse, Princess of Wales Hospital Hazel Lloyd, Head of Quality Assurance Steve Combe, Board Secretary

Approved & Presented by

Push Mangat, Interim Medical Director

Purpose To set out issues relating to quality & safety at the Princess of Wales Hospital and actions taken to investigate and manage the situation.

Decision Approval Information X Other

PRINCESS OF WALES HOSPITAL REPORT

1. PURPOSE The purpose of this report is set out the actions taken to investigate and manage concerns relating to Quality & Safety which have arisen at the Princess of Wales Hospital.

2. INTRODUCTION The Princess of Wales Hospital (PoWH) is a popular local acute hospital providing, for the most part excellent and well regarded care to thousands of local people. Members will however be aware that a number of issues have been highlighted regarding the quality and safety of some of the services provided at the PoWH. Briefly these are:- • Calculated Risk Adjusted Mortality Index (RAMI) being reported as high. The

RAMI for PoWH has been rebased at the end of March 2013 to 118. An increase is normal for all of Welsh Hospitals as part of the rebasing. As a result the PoWH is no longer an outlier. Whilst this reduction happened prior to any specific actions taken by the Health Board to address these Quality & Safety concerns it gives some comparative assurance – however further detailed work on mortality is required and is being undertaken.

• Reported higher actual mortality in some specialties than might be expected.

• A number of adverse Ombudsman and HM Coroner reports with significant corrective actions mandated.

• The blood glucometry incidents currently under investigation.

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• Difficulty in medical staffing of the Emergency Department (ED). • Discovery that not all deaths of patients who have C.difficile recorded on their

Death Certificates have been reported to Welsh Government (4 out of 11). The Medical Director’s Department has immediately put checks into place in the Mortality review process with the bereavement officers and this has been corrected.

• Increased incidences of Healthcare acquired C.difficile infections within the

Princess of Wales Hospital. These have been managed through the Health Board infection control procedures and cleanliness standards and training compliance has been a theme.

3. ACTION TAKEN Once it became clear that there were a number of issues of concern at the hospital it was decided to tackle these issues collectively rather than individually through standard Board procedures. Since these issues were reported a significant number of actions have been taken and these are summarised below. (i) Quality & Safety Improvement Programme

A PoWH Quality & Safety Improvement Programme has been established overseen by a Steering Group to drive and monitor the progress of improvements in the patient safety, quality and clinical governance issues identified. The Group is chaired by the Chief Executive and the Executive Lead for the Programme is the Interim Medical Director. The Group meets fortnightly. The Steering Group is supported by six workstreams, namely; Patient Safety & Outcomes including

• Advancing Quality Alliance (AQuA) work • Mortality (RAMI & Reviews) • Out of Hours & Hospital at Night (H@N) • Workforce

Standards of Care including

• Clinical standards • Education, training and development • Infection prevention and control • Patient experience

Blood Glucometry Investigation Communications including

• Communications strategy • Managing individual patient & family issues

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Learning from Feedback including • Promoting local ownership of investigations & outcomes • Analysis of complaints, incidents, investigations and outcomes and

promoting local ownership of change • Ensuring arrangements are in place for organisation wide learning

Clinical Leadership & Engagement including

• Improving clinical leadership • Engaging the workforce • Engaging the Medical Staff Advisory Committee

(ii) External expertise, challenge and support

The Advancing Quality Alliance (AQuA) has been invited to provide a “deep dive” quality & safety review. AQuA is an NHS based membership body with more than 60 NHS commissioner and provider member organisations, across the North West of England. They also have strong relationships with Local Authorities and the Third Sector. These relationships mean they can help support transformational change across very large footprints, and can scale up and spread the learning through established networks AQuA has undertaken several Mortality Reviews over the past 24 months which have varied in depth and breadth dependent on member requirements and pre-review diagnostics. However, all reviews have typically taken the 3-phase approach of diagnostics, action planning and organisational roll out. In May 2013, AQuA published their “Reducing In-hospital Mortality: Observations arising from AQuA’s work“, which has been universally well received. The mortality work is centered around five key themes or drivers which have been identified as areas which impact directly on mortality but also on wider quality and safety; namely those of:

• Effective Clinical Care • End of Life Care • Medical Records and Clinical Coding • Leadership • Reliable Care systems

The work of AQuA will involve a significant amount of data analysis and close working with clinicians and managers from the hospital itself. It is anticipated that AQuA will be in a postion to report their findings to the Board in November/December 2013. In addition to this; external support is being provided to the Department of Investigations and Redress and an experienced Complaints Manager has been recruited on a temporary basis to work in the department.

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(iii) Clinical Leadership The Interim Medical Director has taken the Executive lead for the Quality and Safety Improvement Programme and managing the PoWH concerns. He is closely supported by Dr Jonathon Goodfellow as the on site Assistant Medical Director (AMD) and Lesley Bevan as the Chief Nurse for the Hospital. This has ensured that there is clear on site clinical leadership. In addition, • A new Head of Nursing for the Bridgend Locality was appointed on August

7th and will take up post in November. A significant number of changes will be made within the nursing workforce. The Capability Policy is being used in some instances where required. In addition to this, the Chief Nurse is strengthening the clinical leadership role of the Ward Sister/Charge Nurse by ensuring that they are more visible on the ward and that they review each patient at least 3 times per shift. A rota has also been developed to ensure that there is a Ward Sister available every evening within the Bridgend Locality to provide professional support. A new Ward Administrator role has been developed to support the Ward Sister with administrative duties. This role has been advertised and will be piloted for 6 months on Ward 5. If successful it will be rolled out to other wards.

• Ward Sisters and Charge Nurses have had two workshops examining their clinical leadership role and are meeting weekly with the Lead Nurse. They are developing robust training and education plans to include ward based teaching, clinical skills and professional development. Sessions entitled “Professional Accountability” have been arranged for all Band 5 nurses to attend throughout September where they will be asked to develop a portfolio of evidence.

• 31 wte Band 5 nurses have been appointed into the Bridgend Locality and will take up their positions during the first week in September. These appointments will reduce the current over reliance on bank and agency staff and will provide an additional Registered Nurse for each of the Medical Wards at night.

• In addition to the Quality and Safety Steering Group an operational Clinical Quality Forum is also being established which will be jointly chaired by the Assistant Medical Director and Chief Nurse. The aim of the Forum is to focus on the patient experience and improve quality and safety. It will provide a means of direct communication between the Quality and Safety Steering Group and wards and departments within the hospital with a focus on the quality improvement plans.

• With closer clinical leadership engagement the Chief Nurse has found that four wards have had significantly lower numbers of incidents over the past two months and on-going inspection of these areas has revealed good standards of patient care and documentation. However, Ward Sisters in

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these areas are continuing to focus on a number of key areas which will form the basis of their action plans.

• Two of the wards have a high level of incidents and complaints. A

significant management re-structure within these areas should provide an immediate improvement and there has been a substantial investment into training and education over the past two months that will continue across the whole Locality for the foreseeable future.

• The Clinical Decision Unit (CDU) has experienced some adverse

incidents. This could be related to the model of care and a new model for emergency medicine is currently being developed that should further improve quality within this area.

• The AMD will chair a group that will review arrangement in the Emergency Department where a number of issues have been identified.

• A Task and Finish Group is being established to develop a governance

framework for the “Hospital at Night” team. A workforce review has concluded that the Out of Hours Nurse Practitioner Team is experiencing difficulty in managing their site management and clinical duties. The Chief Nurse has met on a number of occasions with the Senior Nurse and a new model is being considered that would separate the clinical team from a new Night Sister role.

• The AMD for Patient Safety, the Clinical Director and General Manager for

the Musculo Skeletal Directorate instigated a detailed review of mortality in patients treated at PoWH with fractured neck of femur. The introduction of ERAS for these patients seems to have led to a reduction in mortality in this group.

• The Head of Information has instigated further work on clinical coding

issues and links with mortality figures.

• All Directorates and Localities have now been required to have minuted Morbidity and Mortality meetings.

• A review of all complaints and incidents over the past 18 months to identify common themes and trends that require remedial action is also underway.

4. RECOMMENDATIONS The Board is requested to consider the contents of this report.

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SUMMARY REPORT ABM University Health Board Health Board Date of Meeting: 5th September

2013 Agenda item 3(ii)a

Subject Health Board Integrated Performance Report

Prepared by Darren Griffiths, Assistant Director of Planning

Approved by Paul Stauber, Director of Planning

Presented by Sara Hayes, Director of Public Health Alexandra Howells, Chief Operating Officer Victoria Franklin, Director of Nursing Services Push Mangat, Interim Medical Director Andrew Phillips, Director of Therapies and Health Sciences Debbie Morgan, Director of Workforce and OD

Purpose This report updates the Health Board on the most recently available performance information for key performance areas.

Decision Approval Information X Other


X X X X Executive Summary The report provides trend based analysis of the Health Board’s performance against key performance measures along with an assessment of their relative level of delivery against national target levels and local target levels where applicable. Key Recommendations The Board is asked to receive the updated performance position across the Health Board and to note the change in approach to the detail available and presentational format of the report.

Assurance Framework The report provides assurance that performance management arrangements are in place for the Health Board.

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Next Steps The performance report will be refined beyond the Tier 1 measures included for the next full health Board meeting as Welsh Government has now published its 2013/04 Delivery Framework which confirms the Tier 1 and Tier 2 requirements. The detail of this publication is set out in a separate report to the Health Board. A web based performance management dash board is being developed to match to the new Tier 1 delivery priorities for 2013/14 and to map to the priorities and objectives set out in the Health Board’s Annual Plan for 2013/14.

Corporate Impact Assessment Quality and Safety The Report link to the following standards: -

• 1 – Governance and accountability framework.

• 6 – participating in quality improvement initiatives

• 7 – Safe and clinically effective care.

Financial Implications

There are no specific resource impacts in preparing this report but delivery of the measures within the report could release resource and increase quality of care.

Legal Implications N/A

Equality & Diversity

N/A

Board Meeting – 5th September 2013 Page 3

Performance Report

MAIN REPORT ABM University Health Board

Health Board Date of Meeting: 5th September 2013

Agenda item 3(ii) a

Subject Health Board Performance Report

Prepared by Darren Griffiths, Assistant Director of Planning

Approved by Paul Stauber, Director of Planning

Presented by Sara Hayes, Director of Public Health Alexandra Howells, Chief Operating Officer Victoria Franklin, Director of Nursing Services Push Mangat, Interim Medical Director Andrew Phillips, Director of Therapies and Health Sciences Debbie Morgan, Director of Workforce and OD

Purpose The aim of this report is to inform the Health Board of the organisation’s position against key performance indicators. In terms of structure, the report will categorise the performance measures to match the Strategic Aims of the Health Board as set out in the Annual Plan for 2013/14 for the rest of 2013/14. These Strategic Aims are the main headings of each section with each performance measure categorised within the sections. For the next Health Board meeting the report will be amended to reflect the recently published Welsh Government Delivery Framework for 2013/14; a document which is subject to a separate Health Board report this month. Attached as Annex A to this narrative report is the usual Performance Statement which is built up to be an aggregate of the Performance Statements of each Directorate and Locality. The narrative section of the report reflects the performance position of the Tier 1 targets included in the Performance Statement. The Performance Statement has been updated to include the revised Tier 1 requirements set out by Welsh Government. O 21st August the Health Board received correspondence from Welsh Government confirming the current escalation status of key tier 1 targets. A copy of this letter is attached as Annex B to this report. A summary of the escalation status is set out below: -

• Unscheduled Care – Level 3 (unchanged) • RTT – Level 1 (reduced from 2) • Cancer – Level 2 (likely to reduce to 1) • Stroke – No escalation (no change) • Finance – Level 2 (no change)

The Welsh Government definitions of the escalation levels are attached as Annex C for the Board’s information. Level 4 is the maximum escalation level.


Performance Report

Summary Following the regular monthly performance review meetings with directorates and localities in July, the following common performance challenges emerged: -

• Unscheduled care delivery • RTT access time delivery • Cancer access time delivery • Sickness absence performance • Stage 1 mortality review form compliance • Discharge summary completeness

All of the above issues along with the work being undertaken to resolve them, are captured in the narratives under each section below as appropriate.


Performance Report

EXCELLENT POPULATION HEALTH 1.1 PUBLIC HEALTH INDICATORS Measurement Definition: various public health indicators. Current escalation status: Nil How are we doing? Uptake of 1 dose MMR at 2nd birthday 94.8%

Uptake of two doses MMR at 5th birthday 89.7% Up-to-date for all immunisations at 4th birthday 83.8% (Wales 83.2%) Uptake HPV at 14 years, after completing the full year programme 88.2% (Wales 86.7%) The Health Board is below target of 95% uptake of two doses of MMR and 95% uptake of the 4-in-1 immunisation for the under 5’s, 90% uptake of HPV for 13 year old girls and 75% uptake of flu for those 65 and over. There is some variation between localities and overall the trend is upwards.

How do we compare with our peers?

The Health Board is below the all-Wales average for MMR II and the 4-in-1 for the last quarter reported. HPV uptake is better than the all-Wales average for the last academic year across ABMU, but flu vaccine uptake in the 65’s and over was lower than the average during the last flu season.

What actions are we taking?

The Immunisation Coordinator post is being reviewed since being made full time. The measles outbreak has been declared over and more than 30,000 doses of MMR have been given to people of all ages through a programme of GP vaccination, open-access outreach clinics, occupational health clinics and vaccination sessions in high schools, colleges and special schools. People in care homes and prisons and the homeless have also been targeted. Work is underway to prepare for the next influenza season. This year children aged 2 and 3 years and those in Year 7 in school will be offered flu vaccination via nasal spray. Table 1 below sets out the uptake rates for key vaccination metrics.


Performance Report

What are the main areas of risk?

Increased numbers of mumps cases are being reported. The key control measures are the same as for measles, namely two doses of MMR, which give good levels of protection against infection. The influenza season is approaching so we need to deliver a strong immunisation campaign to minimise the impact in terms of attack rate in the population and outbreaks in healthcare and care settings.

Table 1 – Vaccination Uptake Rates

No IndicatorAOF

Target

Baseline Set in Sept 2010

Latest Reporting

Time Period Swansea

Neath Port

Talbot Bridgend

Movement since Last

Report Wales

S 92.2% 95.3%NPT 95.1%

B 91.9% 93.8%

S 84.5% 90.6%NPT 89.2%

B 82.7% 88.7%

S89.9% 92.0%NPT 91.2%

B 86.7% 89.2%

33.5%46.4%

59.4%

5 Uptake of seasonal flue aged 55 and over

75% 62.7% As at 12th March 2013

67.8%

Uptake of MMR 2 by age of 5

Uptake of 4 in 1 by age of 5

Uptake of HPV in 13yr girls (all three HPV doses)

Jan - Mar 2013

Jan - Mar 2013

Jan - Mar 2013

65.6%

n/a

1 Uptake of MMR 1 by age of 2

2

3

4 40.8%

92.1%

90.4%

95.1%

89.0%

95%

95%

90%

95%

As at 31st March 2013

Note: measure 4 - HPV doses given to 13 year olds as of 12th March only reflect

performance for the first 2 doses. The third dose is administered later in school year and has not yet been reported.


Performance Report

EXCELLENT PATIENT OUTCOMES 2.1 MORTALITY This section of the Performance Report provides an update on the Health Board In-hospital mortality information, including in-hospital deaths and risk adjusted mortality index. The report will also provide an update on the Health Board mortality review processes. Measurement Definition: two main measures: 1. Actual In-Hospital Mortality - The number of In-Hospital deaths is reported using the

discharge method of the patient recorded on the patient administration system and is not dependant on clinical coding. Therefore this report will include data from April 2009 – June 2013 for actual mortality.

2. Risk Adjusted Mortality Index (RAMI) - The risk adjusted mortality index (RAMI) provided by CHKS is a statistical calculation which assesses the observed deaths in an organisation against the expected deaths, based on the patient record data submitted for the period. The algorithm risk adjusts mortality based on the age, sex, admission method (elective or emergency) and most importantly clinical coding information - Primary diagnosis, secondary diagnoses and procedures. An index value of 100 represents the expected level of mortality for the patients treated during this period; a value above 100 indicates more deaths than expected when compared to the expected norms.

As the algorithm is reliant on clinical coding information in order to risk adjust, RAMI is usually reported 3 months in arrears to ensure high levels of clinical coding completeness. This is imperative as low levels of clinical coding may result in a higher than actual risk adjusted mortality rate as the algorithm will not be able to adjust for the diagnosis, procedure and co-morbidity of patients. The most recently available Health Board data for reporting was submitted to CHKS on the 25th June 2013 and as the minimum level of in-month coding completeness required to report RAMI is 95% the most recent month able to be reported is March 2013 which was 97% complete at the time of submission. Current escalation status: Nil How are we doing? In-Hospital Mortality Information - 2012/13

Actual In-Hospital Mortality The actual number of In-Hospital deaths for the year 2012/13 was 3304, an average of 275 per month. Actual In-hospital deaths in June were 244 (April – June 2013 average 285). The Health Board has continued to use the 2-Stage Mortality Review process that enables all in-hospital deaths to be reviewed by a doctor. The junior doctor who was caring for the patient when they died has the opportunity to use the Stage 1 form to


Performance Report

highlight anything that they think could be improved upon. The forms are reviewed and a sample chosen for a much more detailed review. This Stage 2 review is carried out by a Consultant and aims to draw out thematic and patient-specific lessons that can be shared across the organisation. Following an All Wales meeting in May, led by the Medical Director of Aneurin Bevan Health Board on behalf of Welsh Government, a 2-Stage process already in use in ABMU is being adopted on an all Wales basis. A draft set of questions for each stage has been agreed and organisations have been asked to pilot these on a small scale and feedback findings at the next meeting in September. A pilot of the Stage 1 questions is planned for one week in July at Princess of Wales Hospital (POWH) and individual Consultants are being asked to pilot the Stage 2 form.

• Between April and June 2013, the percentage completion of Stage 1 reviews by hospital site ranged from 26% - 100%. Both NPT and POW hospitals consistently achieved around 90% compliance. The most marked improvement was at Singleton, in June compliance was 96% compared with a peak of 68% last year. This has been achieved by linking up all the administration processes that need to be completed when a patient dies. This was very successful at POWH. The Patient Services Team at Singleton and the Bereavement Officer at POWH have been key to this improvement. Morriston’s compliance is still low (26% in June) but Patient Services there are now adopting the same approach as POWH and Singleton so, if the outcome is the same as in those hospitals, this should improve considerably in the second quarter of 2013/14.

• Between 14% and 64% of Stage 1 responses triggered a Stage 2 review. One reason for this wide variation is the differences in services that are provided at the four hospital sites and the multi-site nature of many of our patient pathways. Work is still ongoing to ensure that admissions are recorded correctly so that unscheduled admissions to one hospital followed by a planned transfer to another site do not trigger as elective admissions. Due to the nature of the services delivered in NPTH, this is a particular issue there. The percentage of Stage 1 reviews that trigger a Stage 2 review in Morriston, POWH & Singleton is between 14% - 40%.

Reviews are providing assurance that the National Early Warning System (NEWS) is fully integrated in to everyday clinical management, that end of life discussions are taking place with


Performance Report

patient and their families and that these are being documented so that decisions are apparent to all those caring for the patient. Table 2 below provides a monthly breakdown of actual in-hospital deaths for the last 4 years which shows that actual number in-hospital deaths have reduced over the period. Risk Adjusted Mortality Index (RAMI) The target for 2012/13 is to reduce the mean ABMU RAMI to less than 100 by the end of the year. RAMI for 2012/13 was 104. This shows that the number of deaths within the Health Board was 4% higher than the expected level, for the type and complexity of cases treated.


Actual In-Hospital Mortality Currently no other Health Board uses this process so no comparative compliance data is available. However, at the All Wales meeting in May the Health Board’s approach to meet the Welsh Government requirement that all in-hospital deaths must be subject to clinical review was commended, and this approach is being adopted across Wales. Consultant engagement is an issue for most other organisations, particularly the other large Health Boards. Risk Adjusted Mortality Index (RAMI) The All Wales index score was 107 for the same period and the Top 40 Hospital Peer group index score was 85.


Actual In-Hospital Mortality • The administration processes have been strengthened,

information from all Stage 1 and Stage 2 forms is now entered on to a database that can be interrogated to provide meaningful and timely feedback to clinicians, as well as more detailed performance data for management teams.

• Linked information from other Health Board systems e.g. Datix, is being provided to Consultants undertaking Stage 2 reviews

Risk Adjusted Mortality Index (RAMI ) • In depth investigation in to the Health Board’s RAMI by

hospital site and specialty indicated that deaths following an emergency admission under the surgical teams at POWH warranted review. A review of 50 cases designated as having a less than 30% risk of death from their CHKS risk profile was undertaken this quarter. It was not possible from this analysis to determine if any of the deaths was amenable to a different outcome or resulted from poor


Performance Report

care or treatment. Poor compliance with the Stage 2 mortality review process and recording of local mortality review meetings needs to be addressed so learning can be gained. The review showed that this group of patients had a higher than expected rate of Global Trigger Tool “harm triggers”, such as healthcare acquired infections, and that complaints, incidents or claims were recorded in 20% of the patients.


• Clinical engagement, in particular completion of Stage 1 forms in Morriston and Stage 2 reviews across the Health Board.

• Feedback of findings and assurance that issues are being addressed appropriately by the right people

• Links with other quality and improvement activities in the Health Board.

Figure 1: ABMU Actual In-hospital Deaths – By Month April 2009 – June 2013


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Table 2: ABMU Actual In-hospital Deaths – by Month

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Monthly Average

2009/10 309 247 262 282 244 261 304 250 344 347 278 308 3436 286

2010/11 250 280 236 250 267 244 293 254 361 354 310 277 3376 281

2011/12 271 319 240 239 237 270 271 275 346 308 302 292 3370 280

2012/13 284 260 248 291 262 260 263 260 303 296 267 310 3304 275

2013/14 322 286 244 285

This table quantifies the number of actual In-hospital deaths for the past four years. This shows that year on year the number of in-hospital deaths has reduced. Figure 2 - ABMU Risk Adjusted Mortality (RAMI 2012) Rolling 12 month trend


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Figure 3 - ABMU RAMI 2012 compared to All Wales Average


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2.2 UNSCHEDULED CARE Work continues to implement the Unscheduled Care and Patient Flow programme which has been developed for 2013/14, overseen by a multi agency Unscheduled Care and Patient Flow Board, chaired by the Chief Executive Officer. This programme is underpinned by 5 key components to deliver improvements in USC performance, namely

• Comprehensive pre-hospital initiatives • Effective Emergency Departments • Improved Patient Flow • Efficient operational management processes • Appropriate hospital and community capacity.

Measurement Definition: There have been 3 main performance measures for Unscheduled Care against which the Health Board’s performance has been measured: 1. Percentage of patients who spend no more than 4 hours in an Emergency Department

(ED) 2. Percentage of patients who spend no more than 8 hours in an Emergency Department 3. Handover of patients from Ambulance service to the Emergency Unit within 15 minutes Whilst performance against these measures has been reported in this report, in July Welsh Government indicated that it also now intends to monitor performance against the following indicators.

• Achieving 8 minute ambulance response times of 65% for Category A patients with increasing frequency

• Continually reducing and rapidly eliminating ambulance handovers >1 hour • Continually reducing and then rapidly eliminating >12 hour waits in Emergency

departments

Future reports will therefore reflect ABMU performance against these additional measures.

Current escalation status: Level 3 How are we doing? At the end of July 2013 the Health Board performed as follows: -

• 90.44% against the 95% 4 hour target (figure 4) • 95.96% against the 98% 8 hour target (figure 5) • 55.2%( unvalidated) against the handover target (figure

6) Within the Health Board the 4 hour performance for July was broken down by hospital site as follows


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4 Hour National Target 95.00% Health Board Position 90.44%

Princess of Wales Hospital 90.65% Neath Port Talbot Hospital 99.22%

Singleton Hospital 97.45% Morriston Hospital 85.42%

The demands on emergency services increased during the month of July. The prolonged hot weather was a possible factor and during the month our Emergency departments and Minor injuries units attended to 17,045 patients – an increase of 5.65% compared to July 2012, and the highest recorded activity since October 2008. The pressures on trauma and orthopaedics, plastic surgery, emergency surgery and acute medicine also increased. The Health Board is in discussion with Welsh Government about what the trajectory for improvement will be in relation to these targets for the remainder of the year. It is anticipated that this will be finalised by the end of August.


The most recently available published comparable information is for the month of June 2013. The all-Wales 4 hour performance was 92.9%, with ABMU Health Board achieving 91.5%. Performance ranged between 91.5% and 96.2% for Health Boards with major EDs and minor injuries units. The all-Wales performance against the 98% 8 hour target in June 2013 was 98.2% with ABMU Health Board achieving 97.51% compliance. Performance ranged between 96.4% and 99.3% for Health Boards with major EDs and minor injuries units. With regard to Ambulance 15 minute handover performance, in June 2013, the ABMU position was 66.0% against an all-Wales position of 66.2%. Performance ranged between 40.5% and 85.6%% for Health Boards with major EDs and minor injuries units.


The Health Board continues to implement the integrated Unscheduled Care and Patient Flow Programme. A further report on this was presented at the Quality and Safety Committee on 22nd August. The Health Board has secured external performance improvement support with effect from September 2013, to provide a fresh perspective on the current plans, identify


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additional areas for development and ensure that the improvement programme leads to sustainable improvements. Work on the Capacity Plan continues, with the focus now shifting to expanding community services and changing pathways of care, given the physical limitations on ward/bed capacity. The original demand assumptions for 13/14 will be reviewed now that we are nearly mid way through the year to ensure that the plan is still fit for purpose. Closely linked to this, during July “ward flow bundles” were implemented as part of the Patient Flow Plan – these are key to improving quality and safety throughout the unscheduled care system, by reducing delays and waste and ensuring that patients do not stay in hospital any longer than is necessary. These are now being rolled out across the Health Board over the next few months. The Unscheduled Care Board has agreed an initial work programme for collection and consideration of patient experience information, starting with the Emergency Departments. The Unscheduled care board has also agreed a communications plan to ensure that all partner organisations understand the scale of the programme and their contribution to it. Many of these actions are underway and the first bulletin has been published. The first meeting of the multi agency Seasonal Planning Group was also held at the end of July and a checklist of actions has been developed to assist with the planning and preparations to ensure sustainability of services during the winter months. This will inform a national meeting on 10 September with the Welsh Government.


The main area of risk remains the implementation of the capacity and patient flow components of the plan in order to achieve lower occupancy levels in hospital beds. There are some physical and workforce related issues that need to be addressed to achieve this which have a lead in time. In addition medical staffing arrangements in Emergency Departments are stretched due to ongoing difficulties in recruitment.


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Figure 4 – Patients waiting less than 4 hours in an Emergency Department

Figure 5 – patients waiting less than 8 hours in an Emergency Department


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Figure 6 – Handover of patients from Ambulance service to the Emergency Department within 15 minutes


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2.3 STROKE SERVICES Set out below ABMU’s position in respect of the 4 key acute stroke service bundles by both stroke admitting hospitals. Measurement definition: Compliance with Acute Stroke Bundles: 1. First 3 Hours – Rapid diagnosis using a recognised tool, e.g. the Recognition of Stroke in

the Emergency Room (ROSIER) tool and confirmation of diagnosis by an experienced clinician

2. First 24 Hours – CT scan, admission to stroke unit, swallow screen, nutritional screening, prescription of aspirin if appropriate

3. First 3 Days – Physiological monitoring, manual handling assessment, specialist review, physiotherapy assessment, got out of bed

4. First 7 Days – OT assessment, full assessment of impairments, MDT goals set, information sharing and estimated discharge date discussed

Princess of Wales Hospital Performance on First 3 hours, First 3 days and First 7 days bundles has been consistently close to or above 95% compliance with Tier 1 acute stroke targets. In July, 2 patients missed the ROSIER score within the first hours, 1 patient had CT scan over 24 hours and 2 patients admitted on a Friday did not have senior specialist review until the Monday morning.

Current escalation status: Nil How are we doing? Compliance with first 3 days and first 7 days bundles are

consistently close to or above the 95% target. Achievement of targets can be significantly affected by the overall pressures in the Emergency Department (ED). The Bridgend Locality has ring-fenced an acute stroke bed. This is subject to review as and when pressures in ED reappear to ensure best use of resources across all acutely unwell patients. CT scanning affects compliance with the first 24 hour bundle but prompt admission to the Stroke Unit facilitates compliance with all elements in bundles 2, 3 and 4. Compliance with bundle 3 and 4 is consistently met.


The performance against the four bundles is consistently at the upper level of the all Wales performance. Unscheduled care pressures in all Health Boards have significantly affected compliance with bundle 2.


The Stroke Steering Group has identified actions required to meet the new Royal College of Physicians (RCP) guidelines (CT scanning within 12 hours, admission to the Stroke Unit within 4hours, swallow screening and nutritional screening within 4hours, all currently within 24hours) and the SSNAP (Sentinel Stroke National Audit Programme) Organisational Audit Report


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(staffing levels, direct admission to the Stroke Unit, 7 day working, Psychology and Early Supported Discharge). Bridgend Locality is in the process of implementing a plan to achieve bundle compliance by swapping stroke ward 2 to ward 5 and ring fencing stroke bed. This will also give access to therapy space denied when surge capacity is used in Ward 2.


Care is compromised for stroke patients not admitted rapidly to the Acute Stroke Unit. Rapid admission requires stroke beds to be ring fenced and this policy is reviewed when there are pressures from acutely unwell patients. SSNAP was due to replace the current Intelligent Targets (AWSSIC) from July 2013. However, there have been issues in data definition and extraction that are being resolved by Welsh Government

Figure 7 - % Compliance with First Hour Bundle


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Figure 8 - % Compliance with First Day Bundle

Figure 9 - % Compliance with First 3 Days Bundle


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Figure 10 - % Compliance with First 7 Days Bundle

Morriston Hospital Data is not available currently for June or July due to issues in moving to the SSNAP database. Before June 2013, performance was stable across three of the four bundles. The first day bundle was not being achieved due to difficulties with getting patients admitted to the Stroke Unit within 24hrs, the main area of concern. This was due in part to the overall bed pressures across the Health Board, medical patients being cared for on the Stroke Unit and inability to be able to move patients along the pathway to Singleton Hosp: due to bed capacity issues and discharge delays. A number of ring fenced stroke beds have been reintroduced. This is subject to review as and when pressures in ED reappear to ensure best use of resources across all acutely unwell patients. How are we doing? Prior to June 2013, the Swansea Locality

was consistently meeting the first hours bundle, but there were challenges in meeting the first 24hrs bundle, mainly due to timely admission to the Acute Stroke Unit within 24hrs. Compliance with bundle 3 and 4 was consistent, although timely admission to the Stroke unit affected these bundles. Around 20% of patients are being thrombolysed with excellent outcomes.


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This is excellent performance and is helping to reduce disability in stroke survivors with many more patients regaining independent living.

How do we compare with our peers? The Locality performance against the four bundles prior to June 2013 was at the upper range of all Wales performance. All Health Boards are experiencing pressure in achieving bundle 2.

What actions are we taking? The Stroke Steering Group has identified a number of actions as part of the Royal College of Physicians (RCP) stroke audit, in order to improve our overall performance for next year. These include seven day working by MDT members, ensuring patients are admitted to the Stroke unit within 24hrs at present, this will be changing to 4hrs following recent RCP guidance and scoping the possibilities of a Stroke ESD service. Locality bed management have ring fenced beds on the Acute Stroke Unit to help facilitate the pathway.

What are the main areas of risk? Stroke patients’ care is compromised when they are not admitted to a Stroke Unit within 24hrs. The Swansea Locality has agreed to reintroduce a ring fenced stroke bed to facilitate rapid admission. However, it is likely that this policy will be reviewed when there are pressures from acutely unwell patients.


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2.4 CANCER ACCESS The Health Board continues to experience significant challenges in the delivery of the Urgent Suspected Cancer referral target in particular. Detail is provided below. Measurement Definition: there are two measures for cancer performance: - 1. Percentage of patients referred as Non Urgent Suspected Cancer (NUSC) who are seen

within 31 days 2. Percentage of patients referred as Urgent Suspected Cancer (USC) who are seen within

62 days Current escalation status: Level 2 How are we doing? The figures for the month of July 2013 are as follows: -

• 97% of patients were treated within 31 days for the NUSC target. (figure 11)

• 87% of patients were treated within 62 days for the USC target. (figure 12)

ABMU has been working to reduce the number of patients waiting beyond their target treatment date in order to move towards sustainable delivery of the target. A profile has been submitted to Welsh Government and agreed which will see tumour site performance achieve target levels over the next 4 months. See actions section below. Performance levels in July have improved as a result of the delivery of the actions. In a recent telephone with Welsh Government we understand that the escalation level for cancer will reduce from 2 to 1 as a result of the improvement in performance. During August, it has emerged through the weekly monitoring meetings that the Urology tumour site is under pressure and has slipped by 1 month outside of the agreed profile. The specific actions in respect of Urology are set out below.


The most recently available published national figures are for the end of June reporting position. For the 31 day target, only two Health Boards in Wales achieved the target in month (Aneurin Bevan – 98.5% and Betsi Cadwaladr – 98.7%). All other Health Boards were outside of the target level. ABMU was the lowest performing Health Board at 92.5% For the 62 day target, no Health Board in Wales achieved the target in June. ABMU was one from bottom at 75% although this


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has improved to 87% in July.


Weekly meetings remain in place chaired by either the Director of Planning or the Chief Operating Officer to actively manage cancer patients through the system. These meetings continue to discuss in detail every patient reported on a cancer pathway. These Executive-led weekly meetings will continue as routine practice for managing cancer access times improvement. With regard to Urology, the matter has been escalated to the Chief Executive and a meeting has been held with the Clinical Director and the Directorate General Manager. Welsh Government has also been informed and a detailed action plan specifically addressing Urology pressures has been submitted and agreed with Welsh Government. The plan describes the actions to achieve target level performance in Urology as a tumour site by the end of September with the while Health Board being at target levels for October.


The main area of risk to the delivery of these targets now centres on the delivery of the Urology action plan. Significant progress has been made with the removal of backlog in all other tumour sites and Urology remains an outlier. Additionally, cancer patients are afforded high priority for access to beds but pressures on the unscheduled care system will need to be carefully managed to ensure that flows of cancer patients through elective beds are maintained as pressures increase.

Figure 11 – Non Urgent Suspected Cancer (NUSC) Performance


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Figure 12 – Urgent Suspected Cancer (USC) Performance


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2.5 RTT The Health Board has had a challenging 2 months in respect of Referral to Treatment access times delivery. Further detail is supplied below. Measurement Definition: 3 main national measures: 1. Total numbers of patients waiting longer than 52 weeks 2. Total numbers of patients waiting longer than 36 weeks 3. Percentage of patients waiting less than 26 weeks One local measure: 1. Number of patients waiting over 26 weeks for their first outpatient consultation Current escalation status: 1 How are we doing? At the end of July the Health Board performed as follows: -

• 86 patients waiting over 52 weeks • 993 patients waiting over 36 weeks (figure 13) • 92.5% against the 95% 26 week target (figure 14) • 500 patients waiting over 26 weeks for first outpatient

attendance (figure 15) General RTT performance improved in July 2013. As a result of this improvement and Welsh Government’s confidence in the Health Board’s RTT plans, the escalation level for RTT has been reduced from level 2 to level 1. The Health Board has a trajectory to deliver no patients waiting over 36 weeks by the end of March 2014 and focus must continue to the end of the year to achieve this. Discussions are ongoing with WHSSC around the plan for Cardiac Surgery delivery in 2013/14 and at the time of writing no final plan is in place. However a significant amount of modelling to improve to Cardiac Surgery waiting times is being carried out jointly with Cardiff and Vale Health Board to enable WHSSC to develop a waiting times improvement plan in partnership with Health Boards.


The most recent nationally available published figures for RTT are the end of June 2013 figures. At this point of reference ABMU remained the best performing Health Board in Wales in respect of RTT access times with the exception of Powys Teaching Health Board and Hywel Dda Health Board. ABMU was the only Health Board in Wales to reduce its numbers of patients waiting over 36 weeks in the month of July with all other Health Board increasing their breach numbers.


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As previously advised the Health Board has developed an outline RTT access time improvement plan which sets out trajectories by specialty for the delivery of access times within available resources and not through the application of initiative funding. RTT performance improvement is being managed through the implementation of these plans. Performance is managed trough the monthly performance review meetings with directorates and localities. RTT delivery is also linked to the Health Board’s broader plan to increase bed capacity and to develop alternative care schemes to move towards an 85% bed occupancy level for medical beds. The delivery of this plan will reduce unscheduled medicine pressure on surgical wards and is complementary to the planning around scheduled care flow.


The main area of risk remains access to beds, both critical care and ward beds as a result of the unscheduled care pressures which remain high into April. The actions set out in the above section of this table are the actions being developed to mitigate this risk.

Figure 13 – Total number of patients waiting over 36 weeks at the end of each month


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Figure 14 – Percentage of patients waiting less than 26 weeks at the end of each month

Figure 15 – Number of patients waiting over 26 weeks for first new Outpatient appointment


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2.6 HEALTHCARE ACQUIRED INFECTIONS (HAIs) Measurement Definition: There are 3 headline measures for HAIs, which are the number of cases of: 1. Clostridium difficile (C.difficile) 2. Methicillin-resistant Staphylococcus aureus (MRSA) and; 3. Methicillin-sensitive Staphylococcus aureus (MSSA). Current escalation status: Nil

How are we doing? The Health Board is working towards a zero tolerance to all Healthcare acquired infections and is working to further reduce healthcare acquired infection rates. The Health Board has continued to see a reduction in Healthcare acquired C. difficile infections. A 31% reduction was achieved for 2012-2013 compared with 2011-2012 (161 cases). For the first four months of this year the Health Board is no longer on target to achieve a further 20% reduction (58 cases). There were 21 more cases than would be required to be able to remain on target for a 20% reduction. Between April to July 2013, there had been a 26% increase in the number of healthcare associated C. difficile cases in the over 66 age group compared to the same period in 2012. There had been a 31% increase in the number of cases in the 2years and over age group compared to the same period in 2012. However, in May 2013, the Public Health Wales laboratory changed its testing method for detection of C. difficile toxin to a more sensitive test. This may have had an unquantifiable impact on the increased number of cases reported. Identified through localised surveillance programmes, there have been five cases of healthcare acquired MRSA bacteraemia between April and July 2013. Identified through localised surveillance programmes, there have been 20 cases of healthcare acquired MSSA bacteraemia cases up to July 2013. This was one more case than for the same period in 2012.


Numbers of healthcare acquired C. difficile Infections across the whole of NHS Wales up to the end of July 2013 have increased by 1.3% compared to same period in 2012. There were three Health Boards in Wales whose cases of C. difficile had increased by July 2013. Three other Health Boards are currently achieving reductions.


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The numbers of MRSA bacteraemias (community & healthcare acquired) across NHS Wales up to the end of July 2013, as published in the Public Health Wales monthly report, have demonstrated a 1.7% increase compared to the same period last year.. For the first quarter of this financial year, there were 6 reported cases if MRSA bacteraemia within the Health Board (a 50% reduction in reported cases compared to the same period in 2012). However, three of these cases were identified in non-inpatients. The 6 monthly rate report Oct 2011-Sept 2012 (received March 2013) demonstrated that the MRSA bacteraemia rate for the Health Board was 5/100,000 bed days which equates to the all Wales total. Healthcare acquired MRSA bacteraemias have reduced since April 2012. The publication of the Public Health Wales report for October 2012 to March 2013 has been delayed. Numbers of MSSA bacteraemias (community & healthcare acquired) across NHS Wales up to the end of July 2013, as published in the Public Health Wales monthly report, continue with an upward trend. Numbers of cases across the NHS in Wales are 18% higher than the same period in 2012. The numbers of cases have risen in all organisations except one Health Board. The number of cases in the Health Board to July 2013 is one more than for the same period in 2012. There were 52 reported cases of MSSA bacteraemia between April to July 2013; 17 of these occurred in non-inpatients; additionally, a proportion of those cases identified in inpatients were from those who had been admitted to hospital for treatment of these infections. The 6 monthly rate report Oct 2011-Sept 2012 (received March 2013) demonstrated that the MSSA bacteraemia rate for the Health Board was 22/100,000 bed days (compared with Wales total of 19/100,000 bed days). The publication of the Public Health Wales report for October 2012 to March 2013 has been delayed.


The Infection Prevention Board continues and since April 2013 has enhanced further its monthly ward by ward monitoring against agreed process standards that impact on healthcare acquired infections. The compliance with core care bundles is now reported as well as cleanliness standards, training compliance, audit compliance and infection rates. Targeted actions are being taken forward by the Board to:


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• Achieve full compliance with IC training requirements • Achieve full compliance with ward / unit cleaning lists & %

items clean when checked • Achieve full compliance with antimicrobial bundle and policy

requirements • Achieve full compliance with hand hygiene standards • Implementation of chloraprep • Progression of a Community Infection control / surveillance

business plan • Enhancement of cleaning hours to meet minimum frequency

outlined in Welsh Government national standards of cleanliness (2011)

• Prioritised estates work programme which is well underway


The main areas of risk are: • The increasing capacity and acuity of patients • Lack of sufficient single rooms • Addressing Community acquired infections

Figure 16 Numbers of Clostridium difficile in inpatients in ABM University Health

Board for the period 01/04/2013 to 31/07/2013 - progress against baseline year (April 2012 - March 2013)


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Figure 17 Numbers of Clostridium difficile in inpatients aged 66+ in ABM University

Health Board for the period 01/04/2013 to 31/07/2013 - progress against baseline year (April 2012 - March 2013)

Figure 18 Numbers of MRSA bacteraemias in ABM University Health Board for the

period 01/04/2013 to 31/07/2013 - progress against baseline year (April 2012 - March 2013)


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Figure 19 Numbers of Healthcare acquired MRSA bacteraemia’s within ABMUHB April

2011- July 2013 (source- ABMUHB Infection Control surveillance system)

Figure 20 Numbers of MSSA bacteraemias in ABM University Health Board for the

period 01/04/2013 to 31/07/2013 - progress against baseline year (April 2012 - March 2013)


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Figure 21 Numbers of Healthcare acquired MSSA bacteraemia’s within ABMUHB April

2011- July 2013 (source- ABMUHB Infection Control surveillance system)

Source: Observational audit Reports ABMUHB Figure 22 Average Staff hand hygiene compliance by month June 2010 to July 2013


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2.7 PRIMARY CARE INDICATORS Measurement Definition: Set out below are measures around access to primary care services. These will be developed over coming months in line with the work being undertaken to develop the web based performance system. Current escalation status: Nil How are we doing? Access to General Medical Services

Improving access to GP surgeries is a key Welsh Programme for Government commitment. The Minister announced a three phase approach to improving access. In phase 1, the focus was around redistributing appointments towards the latter part of the day, between 5pm and 6.30pm, and a reduction in the number of practices with half day or lunchtime closing. The second phase focussed on later evening appointments, after 6.30pm and the 3rd phase will look at the provision of planned appointments at weekends. The Delivery Framework for 2013-14 includes 2 new indicators: % of GP practices offering appointments between 5pm and 6.30pm on at least 2 nights per week and % of GP practices open during daily core hours; or within one hour of the daily core hours. Welsh Government has asked Health Boards to coordinate an update on opening times and appointment times and this was submitted in June. A local system to capture information on a quarterly basis is being developed. The position shows that 90% of practices in ABMU offer an appointment after 5pm and before 6.30pm on at least 2 days per week; a slight increase from 2012. Data on opening times is likely to be published showing the number of practices open each day across the core hours period or within an hour of core hours; and also on a weekly basis. The current position indicates that 71% of practices are open for at least 90% of core hours across the week i.e. open for a minimum of 47 ½ hours against a maximum of 52 ½ hours. Within ABM, Neath Port Talbot and Bridgend areas are broadly comparable, but Swansea has a very high number of practices offering appointments after 5pm but a poorer compliance in terms of overall opening times. Recent visits to discuss access arrangements have taken place on a targeted basis within individual localities and it is believe that the update due at the end of quarter 2 will show a further improvement. Access to General Dental Services


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Annual Measure: % of population treated As a measure of dental access, the Health Board is able to review the % of adults and children that have received NHS dental treatment in or out of hours. We are anticipating the release of annual data for 2012/13 on the 17th September 2013 GP Out of Hours Services The ABMU Out of Hours service has been operational since July 2011, with call handling provided by Primecare and clinical services provided by an in house team of clinicians. The service also provides clinical care to patients in Cimla Hospital and patients resident with Ystradgynlais Medical Practice, as well as services to HMP Swansea and the minor injury and acute GP units in Singleton Hospital. In the first year of the service July 2011 to July 2012) there were 84,181 patient contacts, and in the 10 month period from July 2012 to April 2013, there have been 75,326 contacts, representing a 9.7% increase over the same period in 2011/12. Demand from patients has risen month on month, with the biggest growth in demand in the Swansea area [13%] , with the profile for Bridgend and NPT localities at a level of 5% and 8% respectively. The increase in demand is significant at weekends and includes an overall 3% increase in home visits.


GP Access Although there have been some improvements in access arrangements in 2012, compared to 2011, there are a number of areas where the Health Board's performance is worse than peers. The areas where we need to focus attention are:

• Increasing the number of practices who offer appointments between 5pm and 6.30pm on at least 2 days per week

• Increasing the number of practices who offer appointments between 6pm and 6.30pm

• Reducing the percentages of practices who are open for less than 80% of the standard contract hours in the week

ABMU remains the highest in Wales for offering extended hours, and appointments after 6.30pm Dental Access Our position in terms of the % of population treated; as compared to other health boards in Wales will be published by


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Welsh Government on the 17th September 2013. The needs assessment carried out in 2011/12 is also being updated by Public Health Wales and the Dental Reference Service, to inform the development of Local Oral Health Plans which all health boards have been asked to develop. GP Out of Hours There is no national dataset to enable comparisons to be made. A review of GP out of hours services across Wales was undertaken in 2011-12, and a sub group has been established to take forward the recommendations, one of which related to the need to have revised performance standards and comparative performance information available.


GP Access Actions taken this quarter to improve performance

• New access guidance has been agreed with the LMC • Each locality is beginning a series of visits with practices

where there is evidence that there are issues with access arrangements

• The enhanced service offering appointments after 6.30pm has been reviewed

• The CHC will be visiting 12 practices in June to August to test patient experience.

In the next quarter we will:

• Establish an automated system for capturing data on access arrangements on a routine basis

• Feedback on performance against the Tier 1 targets following the submission of data to Welsh Government

• Have feedback on key issues arising from the CHC and individual practice visits

• Review information on OOH usage at an individual practice level, looking at the period 6.30pm to 7.30pm

• Finalise arrangements for commissioning extended hours. Dental Access We will continue to monitor access levels to test that the additional activity that has been commissioned in 2012/13 is improving dental access. Over 26,000 units of dental activity were commissioned across the Health Board in the areas of greatest need. Annual dental contract review visits are being carried out during August and September 2013


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There has been a recent agreement to extend the Dental Training Unit and this will increase result in the number of trainees at the Unit doubling; which will have a positive impact on access arrangements. Proposals have been developed to improve in hours access arrangements and OOH’s emergency services and planned changes should be implemented in 2014. Progress is being made on the development of the Oral Health Plan. GP Out of Hours The Health Board is participating in the national work to consider the introduction of the 111 non emergency number in Wales, and it is anticipated that this will determine the way forward in respect of the call handling model for GP OOH services. This work is progressing and there will be an update once the national group has confirmed its preferred service model.


GP Access The workload pressures within primary care are increasing, and morale within the primary care workforce is low. This may impact on the discussions with practices and may make it challenging to negotiate more stringent access guidance. The contractual levers are very limited. Dental Access The key risk is ensuring that arrangements for managing in hours emergency access sessions and OOHs emergency activity are effective meet patients’ needs. GP Out of Hour The increasing workload and complexity of patients who are presenting out of hours has put the service under pressure, particularly during bank holidays, and has led to longer call back times for patients. The management and support structure is under review, to ensure that there is sufficient clinical and managerial support available at peak times. There are general risks around the sustainability of services in the light of workload pressures, and an ageing GP workforce. These are not isolated to ABMU, and the workforce requirements around OOH will be brought into the overall workforce plan for primary care which is being developed over the summer period.


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The Health Board needs to consider its preferred way forward in commissioning the call handling element of the service, and is involved in the national work to consider the roll out of the non emergency 111 number in Wales. A draft 111/OOH national service model is under discussion and an update will provided to the November Health Board meeting for discussion.


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EXCELLENT PEOPLE 3.1 SICKNESS ABSENCE How are we doing? The rolling 12 month sick absence rate for ABMU, as at May

2013, is 6.08%. This is significantly above the 5.08% target set by Welsh Government. Figure 23 shows that there has been a month on month increase over the last year and this reflects an increased trend in sickness absence levels across all Health Boards The figure is the highest of all the Health Boards in Wales. This is a major concern.


Since 2006 ABMU has always had a sickness absence rate above the NHS Wales average. This high starting position reflects in part the population demographics and health status. A higher % of ABMU residents assess their health status as bad or very bad (Figure 25). As our staff are largely drawn from the local population this underlying health status will impact on the higher levels of sick absence experienced by our staff compared to other Health Boards. This is reflected in the ABMU improvement target set by Welsh Government at 5.08%. Another issue which will undoubtedly have increased the overall figure is the amount of organisational change experienced by staff since 2008. Figure 24 shows that NHS Wales’ average sickness has increased each year since May 2011 although ABMU is showing the greatest increase.


In support of the actions already taken and set out in the last report to the Health Board - the Health Board has developed an improvement project plan that is being implemented with immediate effect. The key focus of the plan will be to

• Ensure a consistent way of capturing and analysing data • Focus on hot spot areas ( high numbers of staff with high

levels of absence) with targeted interventions • Immediate focus on policy compliance and auditing • Improved governance arrangements and performance

management • Focused occupational health and well being interventions • Improved support mechanisms for line managers • Deliver a sustainable reduction in sickness absence

through improved people management skills. • Monitor progress monthly by the Executive Team

Three staff groups are showing absence levels above the ABMU


Performance Report

target and this has been the position for some time. Whilst the increase in absence rates is reflected in most staff groups it is the relative size of these three large groups which effectively means our absence rate is driven by them. These groups are Nursing and Midwifery; Estates and Ancillary staff; Additional Clinical Services ( Health care Support Workers) Important factors in implementing the improvement plan will be ownership of this issue by directorates and localities; staff side engagement and taking account of the views expressed in the recent staff survey. An overarching objective will be to improve people management skills as this will give us a sustainable reduction in absence levels. Many of the targeted interventions will be behavioural as this will drive improvement in performance. The Welsh Audit Office is currently undertaking a review of sickness absence management in the Health Board and the recommendations will also inform the improvement plan. The Workforce & OD Committee will continue to receive performance data and updates on progress.


Without concerted management action sickness absence rates may continue to rise. This could have a direct affect on costs in terms of bank, agency and overtime costs. Increasing levels of sick absence increases pressure on those staff who remain at work. This can therefore be a downward spiral which ultimately affects the quality of patient care.


Performance Report

Figure 23 – Rolling 12 month sickness percentage trend Jan 2011 to May 2013

The rolling 12 month sickness absence rate has risen month on month over the last year. This reflects a trend in increases in absence levels seen across Welsh Health Boards. Figure 24 - Comparative Data Sick Absence 2008 – Sept 2012 (data from Stats Wales)


Performance Report

Figure 25 - Percentage of all Welsh residents who assess their general health status as bad or very bad, Wales and local authorities, March 2011

Produced by Public Health Wales Observatory, using Census 2011 (ONS)

The data above illustrates that the ABMU area has a higher % of residents whose Health Status is assessed as bad or very bad. This illustrates that the ABMU area in general has poor underlying sick absence and given our staff are drawn as residents of this area this may account for the higher levels of sick absence within our staff when compared to other areas.

ANNEX A

HCS Ref

Target

Type

Current

Month

TargetTolerance Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 YTD Max

Score Score Commentary

EMERGENCY DEPARTMENT

A&E WAITING TIMES1 % waiting < 4 Hour Wait - Major Tier 1 95% 95% 83.1% 87.9% 83.9% 82.7% 80.8% 81.9% 81.5% 80.6% 77.9% 80.4% 87.7% 89.3% 87.8%1 % waiting < 4 Hour Wait - Minor Tier 1 95% 95% 94.0% 95.6% 99.6% 99.7% 99.6% 99.1% 99.6% 99.4% 99.3% 99.7% 99.5% 99.4% 99.2%

1 % waiting < 4 Hour Wait ABMU Tier 1 95% 95% 85.7% 89.5% 87.0% 86.1% 84.5% 85.3% 85.2% 84.5% 82.8% 84.9% 90.6% 91.7% 90.4%

1 % waiting < 8 Hour Wait - Major 99% 99% 94.4% 97.0% 94.6% 94.1% 91.7% 91.1% 89.7% 91.1% 87.9% 90.6% 95.7% 96.9% 94.9%1 % waiting < 8 Hour Wait - Minor 99% 99% 98.8% 99.2% 99.8% 99.8% 99.9% 99.7% 99.9% 99.8% 99.9% 99.9% 99.9% 99.9% 99.9%

1 % waiting < 8 Hour Wait ABMU 99% 99% 95.5% 97.5% 95.6% 95.2% 93.3% 92.8% 91.8% 92.9% 90.6% 92.8% 96.7% 97.6% 96.1%

1 % waiting <12 Hour Wait ABMU Tier 1 100% 0% 98.5% 99.4% 98.5% 98.3% 97.4% 96.5% 96.0% 96.8% 95.3% 96.5% 99.1% 99.5% 98.3%

AMBULANCE HANDOVER TIMES1, 6 No. transferred < 15 mins Tier 2 100% 95% 60.2% 63.7% 50.7% 51.6% 46.0% 52.8% 47.0% 47.2% 39.0% 43.2% 58.8% 66.0% 55.2%

1, 6 No. transferred < 30 mins Local 100% 100% 83.2% 87.9% 75.9% 74.4% 69.9% 77.3% 74.0% 72.5% 64.1% 69.3% 86.1% 89.3% 82.0%

REFERRAL TO TREATMENT WAITING TIMES% Waiting less than 26 weeks

1 All Specialties Tier 1 100% 95% 93.9% 92.9% 93.0% 92.9% 92.7% 92.2% 92.4% 93.2% 92.8% 91.5% 91.9% 92.2% 92.5%

Number waiting over 36 weeks

1 All Specialties Tier 1 0 0 302 287 322 305 340 388 513 423 378 690 840 1002 993

Number of Stage 1 waiting over 26 weeks

1 All Specialties Local 0 0 161 729 444 499 420 432 224 119 4 208 568 425 500

CANCELLED OP's

% of procedures cancelled on more than one occasion by hospital

with less than eight days notice subsequently carried out within 14

days

Tier 1

Changes required to

National PAS for this

indicator

ENDOSCOPY% Waiting < 8 weeks

1 All Specialties Tier 2 100% 100% 64.2% 62.7% 58.5% 60.9% 61.6% 53.9% 49.6% 59.8% 58.2% 50.6% 48.5% 49.9% 54.5%

Number waiting >= 8 Weeks

1 All Specialties Tier 2 0 0 838 853 999 962 940 1152 1162 962 1016 1209 1269 1146 1024

DIAGNOSTIC WAITING TIMES

% Waiting < 8 Weeks

1 All Procedures AQF 100% 100% 96.0% 92.6% 92.8% 96.0% 95.0% 91.6% 88.6% 91.8% 93.0% 92.8% 92.4% 87.8% 91.8%


1 All Procedures AQF 0 0 335 594 578 338 437 747 1002 764 624 666 715 1184 802

THERAPY WAITING TIMES

% Waiting < 14 Weeks

1 All Therapies AQF 100% 100% 95.3% 95.5% 97.4% 98.3% 96.9% 98.0% 97.6% 98.1% 98.2% 98.8% 99.6% 99.4% 98.8%


1 All Therapies AQF 0 0 234 158 117 73 128 78 84 69 66 47 18 26 49

CANCER WAITING TIMES 31 Days from Diagnosis to treatment

1 All Tumour Sites Tier 1 98% 98% 94.3% 95.7% 93.8% 94.5% 96.0% 94.0% 89.0% 98.0% 94.0% 90.0% 95.0% 93.0% 97.0%

62 Days - Screening Refs to 1st Treatment

1 All Tumour Sites Tier 1 95% 95% 75.5% 73.1% 77.0% 67.6% 78.0% 70.0% 71.0% 69.0% 69.0% 73.0% 77.0% 75.0% 87.0%

DTOC - Based on Residence1, 6 Non Mental Health Patients Tier 2 Reduce Reduce 33 28 32 26 20 17 20 18 15 18 25 41 33

1, 6 Non Mental Health Days Delayed Tier 2 Reduce Reduce 1,416 1,309 950 822 1,949 876 1,015 1,019 837 588 865 1,396 1,318

1, 6 Mental Health Patients Tier 2 Reduce Reduce 22 22 20 24 30 15 16 16 13 18 19 20 22

1, 6 Mental Health Days Delayed Tier 2 Reduce Reduce 3,233 1,952 1,939 1,841 1,226 1,390 1,686 978 890 1,220 1,320 871 1,294

DTOC - Based on Hospital1, 6 Non Mental Health Patients - Based on Hospital Tier 2 Reduce Reduce 39 32 40 29 34 22 25 20 19 22 27 43 34

1, 6 Non Mental Health Days Delayed - Based on Hospital Tier 2 Reduce Reduce 2,840 1,807 1,813 1,216 1,731 509 1,679 1,297 1,191 976 1,237 1,838 1,401

1, 6 Mental Health Patients - Based on Hospital Tier 2 Reduce Reduce 23 23 19 26 23 18 16 17 14 19 20 22 26

1, 6 Mental Health Days Delayed - Based on Hospital Tier 2 Reduce Reduce 3,813 2,560 1,973 2,130 2,028 481 1,686 994 904 1,262 1,347 906 1,406

CARE AND TREATMENT THROUGH CPA

6, 7 Enhanced CPA must have an agreed care plan AOF 100% 100%

6, 7 Standard CPA must have an agreed care plan AOF 95% 95%

6, 7

Appropriate patients on Enhanced CPA will receive an assessment

from AO service AOF 95% 95%

Abertawe Bro Morgannwg University Health Board

ACCESS

SEPTEMBER 2013 HEALTH BOARD MEETING

Current Month score

Under Development

5th Sepembert 2013 Page 1 Health Board Performance Statement

HCS Ref

Target Type

Current

Month

Target

Tolerance Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Max

Score

Score Source

STATUTORY & MANDATORY TRAINING

Infection Protection Control

% staff up to date with infection control standard precautions training in last 12mths Tier 2 90% 85% 79% 79% 80% 79% 84% 84.7% 87% 83% 84% 86% 87%Completed ward based Nursing Care Metric

aggregated up to HB level

% of staff up to date with Hand Hygiene training in last 12mths Statutory 90% 85% 89% 91% 90% 91% 94% 92% 95% 90% 91% 91% 92%Completed ward based Nursing Care Metric


Health & Safety

% of staff up to date with manual handling training for mth TBC TBC 80% 83% 76% 76% 79% 77% 77% 71% 59% 63% 60%Completed ward based Nursing Care Metric


% of staff up to date with fire training for mth TBC TBC 76% 76% 77% 76% 81% 80% 80% 83% 84% 85% 88%Completed ward based Nursing Care Metric


% of staff up to date with V&A training for mth TBC TBC 74% 75% 74% 74% 79% 78% 74% 80% 80% 80% 80%Completed ward based Nursing Care Metric


Women & Child Health

% of staff up to date with Neonatal life support training for mth TBC TBC 73% 63% 67% 82% 47% 57% 72% 99% 94% 94% 99%Completed ward based Nursing Care Metric


% of staff up to date with NLS training for mth TBC TBC 99% 99% 92% 91% 94% 94% 100%Completed ward based Nursing Care Metric


% of staff up to date with Paediatric life support training for mth TBC TBC 96% 94% 94% 90% 95% 91% 89% 50% 53% 54% 58%Completed ward based Nursing Care Metric


% of staff up to date with ILS training for mth TBC TBC 97% 64% 64% 65% 95% 68% 63% 65% 66% 68% 88%Completed ward based Nursing Care Metric


Safeguarding Vulnerable Groups

% of staff up to date with Child protection training for mth TBC TBC 56% 54% 56% 55% 59% 55% 47% 69% 71% 72% 71%Completed ward based Nursing Care Metric


% of staff up to date with POVA training for mth TBC TBC 67% 59% 66% 62% 66% 63% 51% 71% 71% 72% 77%Completed ward based Nursing Care Metric


% of staff up to date with MCA/Dols Training for mth TBC TBC 65% 66% 67% 66% 68% 62% 45% 72% 69% 72% 75%Completed ward based Nursing Care Metric


% of staff with CTG training for mth TBC TBC 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Completed ward based Nursing Care Metric


APPRAISALS

24Non-Medical Appraisals completed against Headcount Statutory 100% 95%

ABMU LEAN Paper-based process based on

Locality/Directorate completed returns.

24Medical Revalidation Statutory 100% 95%

Reporting mechanism for this measure is under

development

Leadership*

24 % of Staff who have participated in Leadership Development Programmes TBC TBC

ABSENCE MANAGEMENT

24 Sickness Rate - In-month TBC TBC 6.01% 5.90% 5.89% 6.34% 6.61% 6.71% 6.84% 6.38% 6.27% 6.11% 5.90%

24 Sickness Rate - Rolling 12 Month Tier 1 5.08% 5.08% 5.73% 5.76% 5.78% 5.82% 5.86% 5.91% 5.99% 6.00% 6.04% 6.08% 6.08%

n/a Percentage that is long term sick - In-month TBC TBC 3.20% 3.34% 3.15% 3.39% 3.34% 3.76% 3.30% 2.85% 2.78% 3.22% 3.42%

n/a Percentage that is long term sick Local TBC TBC 2.89% 2.91% 2.93% 2.96% 2.97% 2.99% 3.03% 3.04% 3.07% 3.08% 3.09%

National ESR system using multiple processes to

capture Sickness Absence, resulting in reporting

delays

Note: Current reported Statutory and Mandatory Training compliance at ABMU level is sourced using the Nursing Care Metric until national developments within ESR and its OLM component begin to take effect. Directorates/Localities have established their own manual reporting mechanisms to monitor compliance, which forms part of the

HBs performance review process and action agreed where necessary.



WORKFORCE

Current Month score

57.0% 71.0%48.0%

Under Development

Under Development

89.0% 98.0%

5th September 2013 Page 2 Health Board Performance Statement

HCS RefTarget type

Current

Month

TargetTolerance Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Max

Score Score Commentary/Source

Six Key Safety CommitmentsClean hands

13Hand Hygiene Audits - compliance with WHO 5 moments AQF 100% 95% 84.1% 86.1% 84.6% 89.6% 89.4% 90.4% 93.1% 94.6% 94.2% 89.9% 90.9% 90.4% 91.8% Source: Care Metrics

Acting upon patient observations that raise

concerns

13

% Patients with Completed NEWS Score and Appropriate

Responses Actioned Local 100% 100% 94.3% 96.1% 95.8% 94.1% 93.7% 92.3% 97.1% 93.5% 94.7% 96.6% 97.6% 97.9% 94.3% Source: Care Metrics

Communicating patient information on patient

discharge

n/a Discharge Summary Completeness Tier 1 100% TBA 36.1% 36.8% 37.3% 36.6% 39.5% 36.8% 40.3% 46.8% 40.6% 45.7% 42.9% 43.8% 37.5%

% Patients where the GP has received a minimum standard

(Diagnosis, FUP & Med) within 24hrs of Discharge Tier 1100% TBA 39.0% 39.1% 40.1% 42.3% 43.2% 40.1% 45.5% 47.6% 41.3% 45.8% 48.5% 47.0% 41.4%

Sentinel Events

1, 5, 23 % Stage 1 forms completed Local 100% 100% 31% 31% 39% 41% 43% 70% 65% 69% 71% 64% 72% 69%

Thrombo-prophylaxis risk assessment

Measure to be agreed Tier 1

Decision makers reviewing patients daily

Measure to be agreed

Annula rolling reduction in Sepsis mortality reate for ICU unitsTier 1

RISK

1, 22, 25 No of risk score > 20 Local Reduce Reduce 31 33 40 32 32 35 36 40 32 30 29 30 28

CONCERNS

Incidents:

23 Number of Never Events Local 0 0 0 0 0 1 2 1 0 1 0 1 0 0 1

23 Number of incidents reported Local Reduce Reduce 1271(1288) 1210(1230) 1201(1209) 1438 1330 1217 1215 1198 1373 1361 1377 1332 1526

23 Number of Serious Incidents reported Local 4 9 8 4 4 3 5 4 4 4 9

23 Number of incidents remaining not approved Local 0 0 0(0) 0(0) 0(0) 0(0) 1(1) 4(4) 3(3) 5(5) 5(6) 9(13) 7(15) 6(86) 112

23 Number of incidents reported with harm (patient / staff) Local Reduce Reduce 115(118) 113(115) 109(110) 137(138) 132(133) 103(107) 102(106) 102(105) 117(118) 123(128) 115(120) 137(144) 112

23 % of investigated incidents with harm (patient / staff) Local 100% 100% 64%(61%) 71%(66%) 68%(60%) 56%(50%) 52%(48%) 60%(52%) 62%(55%) 56%48%) 58%(51%) 52%(45%) 53%(45%) 46%(29%) 36%

23 Number of incidents resulting in harm to (patient / staff) Local 0 0 27 (26) 16(15) 24(22) 19(18) 16(17) 22(21) 17(14) 15(11) 21(19) 19(18) 15(15) 9(9) 10

23POVA - Attributed to Health Board or Health Board Staff Statutory 0 0 6 9 8 13 3 11 8 11 9 9 10 16 5

23 Inpatient Falls Local Reduce Reduce 218 211 202 222 220 203 200 183 118 209 282 282 256 Source: Care Metrics

Complaints:

1, 5, 23 Number of complaints received Tier 2 Monitor Monitor 144(146) 137(141) 138(132) 163 129 107 121 142(144) 161 136 136(137) 113 130

1, 5, 23 Number of complaints received (green and yellow only) Tier 2 Monitor Monitor 128(129) 124(129) 123(118) 148(150) 111(113) 95(93) 105(109) 127(130) 148 124(127) 118 106 115

1, 5, 23

Number of responses sent within 30 working days

(green/yellow graded concerns) Tier 2 Monitor Monitor 88(86) 92 90 100 69 53 73 85 97 83 79

1, 5, 23 Percentage if Complaints Closed Within Timeframe Tier 2 100% 90% 69%(67%) 74% 73% 67% 62% 56% 70% 67% 66% 66% 67%

Patient Experience

Number of Patient Responses Local 458 322 602 399 343 300 325 674 85 235 250 201 801

Average Patient Satisfaction Percentage Local 95% 95% 91% 91% 93% 90% 92% 89% 88% 91% 95% 92% 90% 95% 90%

MORTALITY

6 Actual in-hospital deaths Tier 1 N/A N/A 291 263 261 264 260 303 297 270 310 324 287 244 246

6 Risk Adjusted Mortality Index rolling 12 months (RAMI 2012) Tier 1100 TBA 108 108 107 105 105 104 104 103 104 105

Only reported when coding > 95%

Cancer mortality rate under 75 years per 100.000 Tier 1 N/A N/A

CONDITION SPECIFIC INDICATORS

Stroke:

Compliance with Stroke Bundles

6 1st Hour Tier 1 95% 95% 99% 94% 93% 87% 95% 94.8% 85% 98% 94% 98% 94% 92%

6 1st Day Tier 1 95% 95% 81% 89% 72% 71% 79% 74% 77% 67% 62% 81% 66% 63%

6 3 Days Tier 1 95% 95% 100% 97% 96% 98% 98% 98% 92% 98% 94% 97% 96% 100%

6 7 Days Tier 1 95% 95% 97% 97% 100% 100% 100% 97% 97% 100% 99% 100% 97% 99%

6 Stroke Mortality (actual in-hospital) Tier 1 N/A N/A 11 24 13 18 8 13 15 11 9 14 13 15 8

6

% Discharged to usual place of residence (within 56 days of

Admission) AQFIncrease Increase 66.2% 45.8% 40.4% 43.3% 60.3% 56.9% 53.6% 51.0% 50.0% 65.3% 67.7%

6 Number of stroke admissions Local N/A N/A 72 66 52 63 62 58 66 76 69 58 68 75

Myocardial infarction:

6 Call to Balloon Times <150 mins AQF TBA TBA 73.2% 67.6% 57.2% 73.1% 67.9% 66.7% 68.0% 75.0% 66.6% 56.8% 58.8% 65.6% 80.0%

Under Development

Under Development

Under Development

SSNAP data collection from July

2013. DSU are currently working

towards a reporting solution.


End of month figures 30 working

days in arrears. Future populated

SAFETY & QUALITY


Under Development

Current Month score


HCS RefTarget type

Current

Month

TargetTolerance Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Max

Score Score Commentary/Source

Six Key Safety Commitments


SAFETY & QUALITY


Current Month score

6 MI Mortality (actual in-hospital) AQF N/A N/A 9 2 9 4 7 7 15 4 6 5 6 6 3

Fractured Neck of Femur

6 # Neck of Femur - % within 24 hrs AQF 90% 90% 82.4% 79.4% 77.1% 88.2% 79.1% 76.7% 78.8% 83.6% 85.0% 94.0% 69.0% 66.0% 52.0%

6 # NOF Mortality (actual in-hospital) Tier 1 Reduce Reduce 7 10 4 9 1 8 8 8 6 6 5 3 3

6 % Discharged to usual place of residence AQF Increase Increase 43.1% 42.4% 36.2% 33.3% 43.9% 41.2% 33.3% 50.8% 44.8% 27.9% 36.4%

6 Number of #NOF Admissions Local N/A N/A 56 54 47 45 53 46 63 46 73 70 60 58 33 Acute Only

INFECTION CONTROL

13

Healthcare Attributed MRSA Bacteraemia (Community &

Healthcare Acquired)Tier 1 Reduce Reduce 4 3 4 0 2 3 1 1 1 3 0 2 1

13

Healthcare Attributed MSSA Bacteraemia (Community &

Healthcare Acquired)Tier 1 Reduce Reduce 15 11 20 10 14 15 19 13 16 8 12 16 1

13 Healthcare Attributed C-Diff (Inpatients aged 66+) Tier 1 Reduce Reduce 8 13 18 19 7 20 11 16 11 13 11 12 22

13 Monthly Infection Control Environmental Audit Score Local 85% 75% 92.2% 91.5% 91.9% 91.0% 91.8% 93.4% 92.3% 92.3% 92.8% 90.1% 91.4% 91.8% 92.1%

Anti-microbial Audit

13 % indication documented 95% 58.7% 61.0% 73.5% 66.6% 70.4% 68.2% 68.1%

13 % stop/review date documented 95% 49.5% 54.7% 59.2% 54.6% 64.6% 58.4% 60.1%

13 % sticker used 95% 49.1% 49.6% 57.3% 55.3% 60.9% 62.7% 64.0%

Surgical Site Infections6 C-Section SSI Rate AQF TBA TBA 5.9% 6.1%

6 Hip Arthroplasty SSI Rate AQF TBA TBA 1.5% 1.7% 2.2%

6 Knee Arthroplasty SSI rate AQF TBA TBA 2.9% 2.5% 0.0%

PATIENT OBSERVATION &

DETERIORATION

QUALITY

6 Incidents of Healthcare Acquired Pressure Ulcer Tier 1 0 0 14 9 9 6 10 2 7 10 13 11 15 18 8 Source: Care Metrics

n/a % Clinical Coding Completeness Local 95% 95% 99.2% 99.1% 99.2% 99.1% 99.0% 99.0% 99.0% 98.8% 98.4% 93.2% 80.1%

95% In month completeness within 12 weeks of discharge Tier 1 95% 95%

98% rolling 12 month completeness within 12 weeks of

discharge Tier 198% 98%

1 Readmissions within 28 Days Local 5% 5% 6.8% 6.7% 6.6% 6.8% 7.0% 7.4% 6.6% 6.4% 6.6% 7.0% 6.2%

CLINICAL AUDITTotal Audits Planned 2012/13 326 326 326 323 322 320 307 305 306 306

Number in progress 44.0% 45.0% 45.0% 40.0% 41.0% 42.0% 37.0% 35.0% 35.0% 34.0%

Total Planned Completed 7.0% 8.0% 10.0% 20.0% 22.0% 29.0% 0.0% 3.0% 4.0% 5.0%

Number of Follow Ups over target date:

1 All Specialties Local Reduce Reduce 34,502 35,811 36,355 36,118 35,548 39,321 40,131 41,647 44,265 40,804 41,346 38,984 41,655 Data being validated

VACCINATIONS & IMMUNISATIONS

PH% coverage level of MMR at age 2

Tier 195% 90%

PH% coverage level of MMR at age 5 (1 dose)

Tier 195% 90%

PH% coverage level of MMR at age 5 (2 doses)

Tier 195% 90%

PH % coverage level of 5 in 1 vaccine at age 1 Tier 1 95% 90%

Influenza

65 & over, under 65 at risk groups, pregnant women Tier 1 75% 75%

Health care workers Tier 1 50% 50%

Smoking Cessaton ServicesSmokers quit attempt via Cessation Services Tier 1 5% 5%

CO validated quit rate at 4 weeks Tier 1 40% 40%

Reported Quarterly

Source: Care Metrics

Pharmacy

Source: Public Health Wales Report

Under development

Under development

BGD - 95.5% NPT - 95.6% SWA -

96.2%

BGD - 88.7% NPT - 89.2% SWA -

90.6%

BGD - 93.8% NPT - 94.1% SWA - 93.4%

BGD - 85.6% NPT - 87.5% SWA - 86.3%

BGD - 92.8% NPT - 93.0% SWA -

94.6%

BGD - 96.3% NPT - 97.0% SWA -

96.2%

BGD - 87.6% NPT - 88.4% SWA -

90.8%

BGD - 95.5% NPT - 91.9% SWA - 93.2%BGD - 93.8% NPT - 95.1% SWA -

95.3%

Weekly during flu season

(Sep - Mar)

BGD - 96.4% NPT - 97.3% SWA - 97.4% BGD - 98.5% NPT - 96.8% SWA - 96.0

%

BGD - 97.7% NPT - 97.0% SWA -

96.9%


HCS Ref

Target Type

Current

Month

TargetTolerance Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 YTD

Max Score Score Commentary

INPATIENTSAverage Length of Stay: Elective

1, 6 General Surgery AQF 3.3 3.3 3.9 4.1 3.7 3.7 3.32 4.5 3.7 4.8 3.0 4.0 4.4 3.4 3.7 3.9 Provided by NWIS,

1, 6 Urology AQF 2.2 2.2 2.3 1.8 1.9 2.0 3.2 2.4 2.5 2.2 2.4 2.1 2.1 2.1 2.3 2.17 reported 1 month in

1, 6 Trauma & Orthopaedics AQF 3.2 3.2 3.6 4.2 3.7 4.0 4.0 3.9 3.7 3.5 4.5 4.2 3.7 3.9 3.7 3.8 arrears

1, 6 ENT AQF 0.9 0.9 1.6 1.6 1.1 1.3 1.5 1.2 1.4 1.9 1.2 1.5 1.3 1.3 1.2 1.3

1, 6 Plastic Surgery AQF 3.2 3.2 3.0 3.7 3.8 3.2 4.4 4.2 3.1 3.5 3.7 4.1 2.7 3.2 3.6 3.3

1, 6 Gynaecology AQF 2.4 2.4 3.5 2.6 2.9 3.0 3.2 3.0 2.5 3.0 2.9 2.8 2.4 3.3 2.4 2.7

Average Casemix Length of Stay: Elective

1, 6 Hip Replacements AQF 6.1 6.1 5.9 7.0 5.5 6.3 5.9 4.3 5.8 5.0 6.0 5.6 4.7 4.9 4.9

1, 6 Knee Replacement AQF 6.5 6.5 4.3 5.0 4.5 4.7 4.6 4.2 4.5 4.2 5.2 5.7 5.4 5.1 5.4

1, 6 Upper Genital Tract - Major AQF 4.0 4.0 4.6 4.1 4.4 4.7 4.1 4.6 4.2 5.4 3.8 5.1 3.4 4.0 4.11, 6 Large Intestine - Very Major AQF 9.7 9.7 8.0 9.8 9.1 9.9 9.5 12.4 10.6 11.0 7.8 9.8 12.3 7.5 10.7

Average Length of Stay: Emergency

1, 6 General Surgery Tier 1 6.0 6.0 7.1 6.0 6.9 6.5 6.5 6.6 6.0 7.0 7.0 7.0 7.7 6.6 7.5 7.2

1, 6 Urology Tier 1 3.2 3.2 3.6 2.4 3.6 2.7 3.3 3.0 2.8 4.0 2.9 1.9 2.5 2.6 2.9 2.5

1, 6 Trauma & Orthopaedics Tier 1 10.0 10.0 10.9 10.4 11.1 11.3 10.3 10.1 11.2 12.4 10.3 14.0 9.6 9.1 10.3 10.7

1, 6 Plastic Surgery Tier 1 2.3 2.3 1.9 2.6 1.8 1.8 2.1 1.9 1.4 1.8 2.2 2.2 1.7 2.3 2.6 2.2

1, 6 Gynaecology Tier 1 2.2 2.2 0.9 1.6 1.4 1.1 1.2 1.1 1.0 0.9 1.0 1.2 1.2 1.4 1.3 1.3

1, 6 Combined Medicine Tier 1 9.9 9.9 11.0 10.1 10.5 11.1 10.7 11.4 11.2 11.4 11.5 12.1 11.2 10.9 11.4 11.4

Average Casemix Length of Stay: Emergency

1, 6 Respiratory AQF 7.4 7.4 7.8 5.9 7.2 6.3 6.5 8.1 6.9 8.8 8.8 9.8 7.2 8.9 8.6

1, 6 Cardiovascular AQF 9.2 9.2 11.9 10.4 9.4 11.7 15.7 14.7 13.4 14.7 13.8 11.2 12.3 16.6 12.5

1, 6 Musculoskeletal AQF 9.1 9.1 11.2 7.9 7.8 10.7 8.3 6.8 9.3 10.9 7.0 8.7 9.4 10.9 9.5

1, 6 Diabetes AQF 6.9 6.9 8.9 8.1 8.1 7.9 8.3 8.2 4.1 8.8 3.9 11.3 16.7 10.1 12.6

1, 6 CVA AQF 17.3 17.3 18.7 18.2 12.5 19.5 14.6 15.1 19.6 20.7 18.7 17.4 18.9 16.4 17.8

1, 6 Atrial Fibrillation AQF 6.1 6.1 5.4 6.4 6.6 8.5 10.9 5.7 9.7 6.8 15.4 5.6 7.4 3.3 5.7

1, 6 Fracture Neck of Femur AQF 24.7 24.7 29.2 26.1 25.0 31.0 34.5 26.7 27.3 26.5 29.9 29.6 29.4 36.3 31.1

Elective Admissions With No Procedure

1, 6 Day Cases Tier 1 3.8% 3.8% 4.6% 4.8% 4.3% 5.7% 3.7% 4.3% 3.7% 3.8% 5.4% 3.9% 3.6% 3.0% 3.5%

1, 6 Inpatients Tier 1 2.7% 2.7% 6.41% 5.3% 5.0% 4.4% 6.6% 6.25% 6.5% 6.2% 5.9% 4.7% 3.0% 1.5% 3.0%

Electives Undertaken As A Day Case

1, 6 General Surgery Tier 1 55% 52.3% 47.5% 43.3% 44.1% 47.5% 49.2% 47.2% 47.8% 52.1% 53.4% 53.0% 45.1% 48.0% 48.8%

1, 6 Urology Tier 1 81% 77.0% 73.9% 78.6% 77.4% 76.2% 80.9% 79.5% 82.3% 75.3% 80.0% 79.8% 77.6% 75.7% 77.8%

1, 6 Trauma & Orthopaedics Tier 1 56% 53.2% 52.8% 53.2% 51.9% 51.8% 49.6% 51.6% 50.0% 50.2% 53.8% 59.7% 51.7% 51.0% 54.1%

1, 6 ENT Tier 1 47% 44.7% 51.1% 40.1% 41.2% 50.2% 40.9% 44.5% 42.5% 40.7% 49.3% 44.8% 32.2% 31.0% 35.7%

1, 6 Ophthalmology Tier 1 100% 95.0% 93.8% 96.5% 93.9% 95.4% 94.3% 94.8% 92.7% 95.2% 95.5% 94.5% 95.1% 94.3% 94.6%

1, 6 Oral/Maxillo Facial Surgery Tier 1 90% 85.5% 50.8% 41.7% 50.5% 40.4% 50.8% 51.5% 54.2% 51.0% 54.8% 57.9% 49.5% 38.8% 50.5%

1, 6 Gynaecology Tier 1 72% 68.4% 74.7% 74.8% 72.9% 71.7% 77.0% 75.2% 70.7% 72.2% 74.6% 72.9% 67.5% 69.2% 69.9%

1, 6 BADS 50 Tier 1 80% 76.0% 79.8% 77.3% 76.2% 78.7% 78.0% 79.1% 77.4% 76.7% 80.4% 84.1% 80.6% 84.0% 82.8%

Operations On The Day of Admission

1, 6 General Surgery Tier 1 62% 58.9% 52.7% 56.5% 56.0% 61.1% 61.2% 64.8% 57.5% 50.7% 65.7% 61.8% 66.4% 74.4% 66.8%

1, 6 Urology Tier 1 75% 71.3% 76.2% 74.4% 66.9% 76.7% 76.5% 78.0% 71.3% 70.4% 73.2% 73.0% 84.9% 77.2% 78.8%

1, 6 Trauma & Orthopaedics Tier 1 64% 60.8% 77.3% 76.1% 76.2% 75.3% 79.6% 77.0% 75.5% 74.8% 63.9% 69.3% 75.4% 71.8% 72.3%

1, 6 ENT Tier 1 96% 91.2% 93.4% 92.7% 91.5% 94.9% 95.4% 96.3% 93.9% 95.7% 97.3% 95.5% 94.6% 100.0% 96.1%

1, 6 Ophthalmology Tier 1 87% 82.7% 13.0% 50.0% 29.2% 30.4% 57.7% 35.3% 42.9% 52.4% 28.6% 45.8% 29.4% 41.2% 39.7%

1, 6 Oral/Maxillo Facial Surgery Tier 1 83% 78.9% 20.8% 28.3% 28.0% 26.6% 34.5% 44.4% 30.0% 27.5% 17.1% 44.7% 30.6% 42.9% 39.0%

1, 6 Gynaecology Tier 1 76% 72.2% 80.3% 76.4% 79.8% 80.6% 71.7% 73.9% 75.0% 77.5% 77.7% 75.5% 83.3% 78.2% 79.2%

Short Stay Basket of Procedures

1, 6 Anterior Colporrhaphy Tier 1 80% 76.0% 80.0% 100.0% 94.7% 85.0% 78.6% 87.5% 93.3% 91.7% 100.0% 100.0% 87.5% 90.9% 90.3%

1, 6 Arthroscopy of Knee Tier 1 90% 85.5% 78.4% 72.8% 79.8% 78.8% 79.7% 73.6% 75.6% 77.9% 83.3% 80.9% 88.0% 90.1% 86.5%

1, 6 Bunion Operation Tier 1 90% 85.5% 70.0% 86.4% 85.7% 80.0% 88.2% 75.0% 77.8% 100.0% 93.3% 75.0% 87.5% 95.0% 86.5%

1, 6 Circumcision Tier 1 90% 85.5% 87.5% 86.7% 94.7% 85.7% 94.7% 75.0% 89.7% 88.9% 84.2% 85.7% 86.7% 92.9% 88.0%

1, 6 Combined Procedures Tier 1 100% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 85.7% 100.0% 83.3% 100.0% 100.0% 100.0% 100.0% 100.0%

1, 6 Combined Varicose Veins Procedures Tier 1 90% 85.5% 89.3% 80.0% 92.9% 52.6% 86.4% 100.0% 92.9% 82.4% 100.0% 83.3% 100.0% 95.2% 93.3%

1, 6 Diagnostic Laparoscopy Tier 1 85% 80.8% 92.9% 77.8% 57.1% 58.3% 79.0% 75.0% 90.0% 72.7% 93.3% 63.6% 78.6% 75.0% 72.4%

1, 6 Endoscopic Resection of Prostate Tier 1 80% 76.0% 80.0% 88.2% 78.6% 95.5% 71.4% 90.9% 60.0% 80.0% 60.0% 81.8% 75.0% 50.0% 74.1%

1, 6 Endoscopic Resection/Lesion of Bladder Tier 1 75% 71.3% 77.1% 63.9% 65.8% 73.3% 76.7% 60.9% 81.8% 66.7% 71.0% 63.6% 61.7% 75.9% 66.3%

1, 6 Laparoscopy and Therapeutic Procedures Tier 1 70% 66.5% 66.7% 68.8% 79.0% 90.9% 81.3% 77.8% 50.0% 71.4% 79.2% 81.8% 66.7% 75.0% 73.3%

1, 6 Laparascopic Cholecystectomy Tier 1 85% 80.8% 79.6% 75.0% 74.5% 90.6% 77.1% 93.3% 94.6% 75.0% 79.6% 94.1% 72.7% 81.8% 82.0%

1, 6 Operations to Manage Female Incontinence Tier 1 85% 80.8% 81.8% 77.8% 80.0% 93.3% 68.8% 80.0% 100.0% 100.0% 100.0% 80.0% 100.0% 100.0% 85.7%

1, 6 Primary Repair of Inguinal Hernia Tier 1 85% 80.8% 65.9% 63.2% 76.7% 64.4% 59.3% 69.7% 69.4% 78.4% 77.3% 93.5% 66.7% 80.6% 80.0%

1, 6 Repair of Umbilical Hernia Tier 1 80% 76.0% 71.4% 88.2% 76.9% 82.6% 80.0% 69.2% 93.8% 81.8% 100.0% 100.0% 72.2% 75.0% 81.6%

1, 6 Septoplasty of Nose Tier 1 95% 90.3% 85.7% 90.0% 100.0% 92.3% 87.5% 83.3% 77.8% 66.7% 100.0% 100.0% 100.0% 100.0% 100.0%

1, 6 Simple Mastectomy Tier 1 75% 71.3% 71.4% 66.7% 82.6% 70.0% 66.7% 66.7% 80.8% 81.3% 84.2% 70.0% 68.8% 78.3% 72.9%

1, 6 Tonsillectomy Tier 1 100% 95.0% 95.5% 91.5% 95.4% 89.2% 90.0% 98.0% 91.5% 89.9% 100.0% 100.0% 91.7% 88.9% 93.9%

1, 6 Therapeutic operation On The Uterus Tier 1 90% 85.5% 96.2% 85.7% 94.12% 92.50% 86.3% 88.5% 95.45% 92.59% 85.37% 88.64% 94.29% 95.83% 92.2%

THEATRES1 Late Starts Tier 1 13.5% 13.5% 20.8% 22.2% 25.2% 19.4% 23.3% 27.8% 31.4% 24.9% 30.3% 29.6% 27.9% 38.5% 37.3%

1 Early finishes Tier 1 20.6% 20.6% 27.2% 25.4% 26.5% 25.9% 28.3% 37.2% 36.1% 31.1% 38.1% 36.5% 32.7% 38.0% 34.0%

Theatre Turn-around Times Tier 1 DSU 1000 lives

Uptake of ERAS Tier 1 Dave Murphy

Current Month score


EFFICIENCY & PRODUCTIVITY


Under Development


HCS RefJul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13

Max

Score Score Commentary

PERFORMANCE AGAINST BUDGETCUMULATIVE VARIANCE

n/a Non Contract Income 465 536 844 779 799 975 1,043 1,044 1,882 36 (143) (222) (290)

n/a Pay 1,489 1,751 1,861 2,259 2,747 2,831 3,023 2,849 3,332 264 1,027 1,561 1,906

n/a Non Pay (3,798) (4,998) (6,449) (7,524) (9,140) (18,514) (20,930) (25,457) (31,039) (834) (946) (773) (108)

n/a CIPs 9,311 11,360 13,485 15,259 10,754 19,613 21,736 23,966 25,683 3,148 5,795 8,382 10,897

VARIANCE TOTAL 7,467 8,649 9,741 10,773 5,160 4,905 4,872 2,402 (142) 2,614 5,733 8,948 12,405 0

WORKFORCE COSTSn/a Pay -Basic 44,246 44,022 43,641 44,103 44,330 44,105 44,723 44,359 45,015 43,686 44,834 43,707 43,736

24 Pay - Bank 500 535 526 622 661 530 591 576 660 554 539 488 481

24 Pay - Overtime 300 312 260 248 347 340 435 352 438 444 587 418 419

24 Pay - Agency 453 427 437 435 548 564 510 475 875 599 716 834 919

24 Pay - Other Variable Pay 623 710 667 480 394 254 454 522 821 341 368 630 489

TOTAL PAY COSTS 46,122 46,006 45,531 45,888 46,280 45,793 46,713 46,284 47,809 45,624 47,044 46,077 46,044

CIPsn/a Plan 5,381 6,970 8,772 11,727 14,075 16,517 18,735 24,400 24,400 957 2,040 3,169

n/a Actual 4,377 5,871 7,491 10,089 12,019 14,220 16,288 21,327 21,431 743 1,730 2,889

Variance (1,004) (1,099) (1,281) (1,638) (2,056) (2,297) (2,447) (3,073) (2,969) (215) (311) (279)

% Variance -18.7% -15.8% -14.6% -14.0% -14.6% -13.9% -13.1% -12.6% -12.2% -1.2% -15.2% -8.8%

CIP

Plan

Actual

Workforce

Plan

Basic

Bank

Overtime

Agency

Other Variable

Total



FINANCE

ANNUAL

PLAN

Current Month score

44000

44500

45000

45500

46000

46500

47000

47500

48000

TOTAL MONTHLY PAY SPEND

Plan Actual

0

100

200

300

400

500

600

700

800

900

1000

Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13

PAY BY TYPE

Pay - Bank Pay - Overtime Pay - Agency Pay - Other Variable Pay

0

20000

40000

60000

80000

100000

120000

NON PAY

Plan Actual

5th September 2013 Page 5 Abertawe Bro Morgannwg University Health Board

Yr Adran Iechyd, Gwasanaethau Cymdeithasol a PhlantDepartment for Health, Social Services and Children

Parc Cathays ● Cathays ParkCaerdydd ● Cardiff

CF10 3NQ

Ffôn ● Tel 02920 82 6335 [email protected]

Gwefan ● website: www.wales.gov.uk

Paul RobertsChief Executive ABM University Health BoardHealth Board HeadquartersOne Talbot GatewayBaglan Energy ParkPort TalbotSA12 7BR

KF/13/128/A5655499

21st August 2013

Dear Paul

I wrote to you in May 2013 outlining the approach to the agreement of recovery plans and your escalation status.

There has been a general recovery across the system and, whilst performance in a number of areas is below target, the situation has improved. As we discussed in relation to your Health Board, the unscheduled care recovery plan that has been submitted, does not currently provide the required assurance that performance in this area will improve, as per the nationally agreed parameters.

From your various submissions and recent conversations with you, we have agreed the following in relation to your escalation levels:

Unscheduled Care: Level 3

RTT: Level 1

Cancer: Level 2

Stroke: No escalation

Finance: Level 2*

*N.B: The finance status is based on Quarter 1. A more formal review with you will be undertaken following month 4.

www.wales.gov.uk

As discussed, the level noted above against Cancer performance, assume’s you are able to provide the assurance required on the following issue:

1) Urology Cancer Backlog Recovery as per my letter dated 14th August 2013, to which a response is due by Wednesday 21st August 2013

If the requested response is unable to provide the necessary assurance that the agreed position for October 2013 will be delivered, we will need to consider escalating your Health Board to level 3 in this area also.

Other areas where assurance is being monitored:

Long O/P waits

Mortality (relating to isolated incident at PoW)

Serious Incident closure report backlog

On this basis and our assessment of your general level of risk, we can confirm your overall escalation status is level 3. This is driven by the risk and concerns we share around unscheduled care performance delivery.

In relation to the frequency of Quality and Delivery Meetings, and in recognition of your broader performance, we are proposing to hold those meetings on a bi-monthly basis whilst you continue to deliver your agreed recovery plans. Given the concerns around unscheduled care however, we propose supplementing the bi-monthly Quality and Delivery Meeting with a monthly meeting to review progress in this specific area.

Should you show signs of significant deviation from these plans we will review your escalation status and meeting frequency as part of the agreement of further recovery action.

I must stress the importance of delivering a sustained recovery from here on, and the elimination of >1hr handovers, 12 hour waits and the 62 day cancer wait backlog, as well as a continued improvement against the 4 hour target and reduction in over 36 week RTT waits by March 2014.

You will be contacted to agree your meeting dates for the remainder of the year. In the meantime I will arrange a monthly meeting or telephone call with you to discuss delivery matters generally.

As all these standards relate to quality and safety issues, your Board must continue to satisfy themselves that quality and safety risks are being appropriately managed. It is important that you provide assurance that this is the case.

I trust the above is clear but if you have any queries please do not hesitate to contact me.

Yours sincerely

Kevin FlynnCyfarwyddwr Cyflenwi/Dirprwy Brif Weithredwr, GIG CymruDirector of Delivery/Deputy Chief Executive, NHS Wales

cc: David SisslingAndrew Carruthers

1

SUMMARY REPORT ABM University Health Board

Health Board Date 5th September 2013 Agenda item 3(ii)b

Subject FINANCIAL REPORT – MONTH 4 Prepared by Samantha Lewis, Assistant Director of Finance

Eifion Williams, Director of Finance Approved by Eifion Williams, Director of Finance

Presented by Eifion Williams, Director of Finance Purpose To advise Board members of the overall financial position of ABMU Health Board as at 31st July 2013.

Decision Approval Information x Other


X Executive Summary The report provides the Health Board with the following updates:-

i. the financial position of the Health Board to 31st July 2013 ii. an update of the Capital programme current position iii. the Performance against the PSPP 30 day target iv. the Debtors Position as at 31st July 2013 v. the Cash Position as at 31st July 2013 and year end forecast

Key Recommendations The Health Board is asked to note:-

i. The Financial Position of Health Board to 31st July and the actions required to improve financial performance

ii. The forecast position of the capital programme for 2013/14 iii. The Performance against the P.S.P.P 30 day target and the achievement of the Welsh

Government PSPP target iv. The Debtors Position as at 31st July2013; and v. The Cash Position as at 31st July 2013.

__________________________________________________________________________________________ 2

1 PURPOSE 1.1 To advise Board Members of the overall financial position of ABMU Health Board as

at 31st July 2013. The report provides an update of the following:- (i) the Financial Position of the Health Board to 31st July 2013; (ii) the Capital Programme outturn position ; (iii) the Performance against the P.S.P.P. 30 day target; (iv) the Debtor’s Position as at 31st July 2013; and (v) the Cash Position as at 31st July 2013 and year end forecast.

2 REVENUE FINANCIAL POSITION 2.1 The financial plan of the Health Board identified unfunded costs for 2013/14 of some

£56.5m, against which savings and cost avoidance measures of £24m had been identified prior to the commencement of the year.

2.2 The Health Board has reported an overspend of £12.4m to the end of July, which is

above that which would be the expected at this point in the financial year, given the shortfall in saving schemes.

2.3 The Health Board has experienced service challenges during the first four months of

2013/14, which include significant price increases across a range of drugs, and pressures on staffing resources to meet capacity requirements.

2.4 The identification and delivery of further savings schemes are critical to the Health

Board in order to improve the financial performance and outlook. To achieve this goal, a series of meetings have been held with Directorates and Localities to discuss opportunities and monitor progress in the delivery of the savings target established. This ongoing work has resulted in a further £3.5m of savings schemes being identified to add to the £24m already being progressed. These are currently being reviewed to ensure that they are deliverable in this financial year.

2.5 Containing the operational budget overspend is essential in order for the Health

Board to deliver to its financial plan. Operational Control Measures have been agreed and opportunities to reduce premium costs for some of the additional staff that are currently being used have also been highlighted.

2.6 The Health Board has received in July an additional £1.8m of funding announced by

the Welsh Government to meet the cost of additional nursing staff employed to improve staffing levels in key ward areas.

3 CAPITAL FORECAST FINANCIAL PLAN 2012-13 3.1 Performance to Month 4

The financial position to month 4 is showing an over performance of £0.198m against a plan of £8m spend to date. Within individual schemes, there are a small number of variances to plan, which at this stage are not anticipated to affect the estimated spend on these schemes during this year.

MAIN REPORT ABM University Health Board

Health Board Agenda item 3(ii)b

Subject Financial Report – Month 4 Prepared by Samantha Lewis, Assistant Director of Finance Approved by Eifion Williams, Director of Finance Presented by Eifion Williams, Director of Finance

__________________________________________________________________________________________ 3

3.2 Forecast Financial Plan 2013-14 The Health Board has a Capital Plan which projects expenditure within the current year of some £40.6m. The forecast for the Capital Financial Plan for 2013-14 shows an over commitment of £0.857m. This is being offset by anticipated income of £1m from Welsh Government for resources committed on schemes currently subject to Business Cases. This leaves a remaining balance of £0.144m to be committed during the remainder of this year.

Table 1 – Capital Plan Forecast Outturn 2013-14

Forecast Outturn

'£000

Income 39,723

Expenditure 40,581

Cumulative Planned -Under / Over Commitment 857

Add Anticipated Funding Not Yet Received for Committed Spend

Office Accommodation OBC Fees -105

Low Secure FBC Enabling Package & FBC Fees -871

Asceptic Suite OBC Fees -25

Sub Total -1,001

Adjusted Cumulative Planned -Under / Over Commitment -144

The capital funding needed to support replacing equipment and maintaining the fabric of the estate, is continuing to put pressure on the Capital Programme. Opportunities to access additional funding are being explored by the Planning and Finance Directorates.

4 PUBLIC SECTOR PAYMENT POLICY 4.1 The Health Board has achieved a cumulative Public Sector Payment Policy

compliance level to the end of July of 96.39% of supplier invoices paid within the 30 day target, with an in-month compliance of 96.35%. This represents a key achievement and confirms compliance with the Welsh Government PSPP target of 95%.

5 DEBTOR’S POSITION 5.1 The position on debtors across the Health Board as at 31st July 2013 is set out in the

table below. The movement on debtor balances, compared to the equivalent figures for the previous month is also shown.

Type

Position At

Total

Outstanding (£)

Current Month

To 30 Days Past Due (£)

31 - 90

Days (£)

91 Days

and Over (£)

NHS 31st July 30th June

9,678,766 8,414,627

8,218,321 6,414,426

1,236,969 1,868,217

223,477 131,984

Non-NHS

31st July 30th June

3,171,427 2,907,084

2,329,580 2,157,711

297,712 294,233

545,135 455,139

5.2 The Health Board’s debt has increased by £1.528m between 30th June and 31st July.

NHS debts have increased by £1.264m whilst non NHS debts have increased by £0.264m. The increase in both NHS and non NHS debtors was anticipated and are due to invoices being raised in June and July for services provided during the first quarter. It is forecast that the outstanding debts will reduce in August when these invoices are paid.

__________________________________________________________________________________________ 4

5.3 Between June and July there was a decrease of £0.631m in NHS debts outstanding for more than 30 days. There continues to be robust debt follow up in respect of all invoices. The £0.545m of non NHS debts outstanding for more than 90 days, as at the end of July, are either being paid in instalments or are being managed by the Health Board’s debt collection agency CCI.

6. CASH POSITION 6.1 The Welsh Government has set a best practice cash balance figure for Health Boards

to achieve at the end of each month, of 1/300th of the combined revenue and capital resource limits. For July 2013 this figure was £3,080m, with the Health Board being within this target with a closing cash balance of £2.496m.

6.2 At the end of July a further detailed review of the LHB cash forecast was undertaken,

utilising actual cash payments and receipts for the first quarter, comparisons with actual data from 2012/13, known and anticipated cash allocations from Welsh Government and anticipated movements in working capital balances.

6.3 The Health Board’s cash forecast is updated with actual figures on a daily basis and

is reviewed monthly through the Finance Team Corporate Review Process via the Cash Monitoring Group, and is reported regularly to Welsh Government through the monthly Monitoring Returns.

7 RECOMMENDATION 7.1 The Health Board is asked to note: -

(i) The Financial Position of the Health Board to 31st July2013 and the actions to improve financial performance;

(ii) the current position of the Capital Programme; (iii) the Performance against the PSPP 30 day target (iv) the Debtors Position as at 31st July 2013; and (v) the Cash Position as at 31st July 2013.

summary report abm university health board 5th september 2… · • wrvs • gp out of hours...

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