the shared agenda of group committees in common (cic) papers... · mrs chris mayer cbe,...

Salford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT)

The Shared Agenda ofGroup Committees in Common (CiC)

Monday, 31st July 2017 at 10:00amHumphrey Booth Lecture Theatre, Mayo Building,

Salford Royal, Stott Lane, SALFORD M6 8HD

AGENDA: Part 1

1. Patient Story

2. Chairman’s Opening Remarks Chairman

3. Apologies for Absence Chairman

4. Declarations of Interest All

5. Minutes of Previous Meeting (Part 1) - held on 26th June 2017 Chairman

6. CEO Report, including Chief ExecutiveHigh-level Performance Metrics

7. PAHT Improvement Plan Chief Delivery Officer

8. Patient & Service User Experience Report Chief Nursing Officer

9. Learning From Experiences Report Chief Nursing Officer

10. Staff Engagement Progress Report Chief Strategy & ODOfficer

11. Memorandum of Understanding: SRFT and Centre for Chief Strategy & OD Healthcare Innovation, Singapore Officer

12. SRFT: SCAPE Recommendation Chief Nursing Officer

13. Reports from Standing Committees:

13.1.Group Audit Committee Vice-Chairman meeting held on 29th June 2017

13.2.Group Executive Committees:Risk and Assurance Committee - meeting held on 17th July 2017 Chief Executive

14. Any other business (Part 1)

15. Date and Time of the Next Meeting: Monday, 25th September 2017 from 10amVenue: Humphrey Booth Lecture Theatre, Level 1, Mayo Building, Salford Royal NHS Foundation Trust.

1/2 1/158

Paper For Information

a. Annual Salford HealthWatch Report 2016/17

Resolution: To exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be prejudicial to public interest, by reason of the confidential nature of business. The press and public are requested to leave at this point.

2/2 2/158

Meeting of the Group Committees in CommonDraft Shared Minutes: Part 1Held in PublicMonday 26 June 2017Humphrey Booth Lecture Theatre, Mayo Building, Salford Royal.

Present:Mr Jim Potter, ChairmanSir David Dalton, Group Chief Executive Officer

Mrs Jude Adams, Group Chief Delivery OfficerMr Chris Brookes, Group Chief Medical Officer Mr Damien Finn, Chief Officer North Manchester Care OrganisationMrs Nicola Firth, Oldham Nurse DirectorMrs Elaine Inglesby-Burke CBE, Group Chief Nursing Officer Mr Raj Jain, Group Chief Strategy and Organisational Development OfficerMrs Chris Mayer CBE, Non-Executive DirectorMs Diane Morrison, Salford Finance DirectorMr Ian Moston, Group Chief Finance OfficerDr Chris Reilly, Non-Executive DirectorDr Hamish Stedman, Non-Executive DirectorMr Steve Taylor, Chief Officer Bury & Rochdale Care OrganisationMr John Willis CBE, Vice-ChairmanMrs Jane Burns, Director of Corporate Services and Group SecretaryMrs Rebecca McCarthy, Deputy Group Secretary

Observing:Gareth Griffith, Staff Side Chair, PATVince Hafferty, Intercity Technology GroupChedia Hoolickin, Quality Improvement LeadPaul Hughes, Quality Improvement LeadSiobhan Moran, Assistant Director, Quality ImprovementNicola Kent, Staff GovernorAndrew Lynn, Head of CommunicationsJean O’Donnell, Unison, PATDave Pike, Lead GovernorDaniel Rowbotham, Quality Improvement LeadJackie Schofield, Staff Side Secretary, PATStephen Sutcliffe, Johnson & Johnson

Apologies for Absence: Mrs Diane Brown, Senior Independent Director Mrs Rowena Burns, Non-Executive DirectorMrs Donna McLaughlin, Chief Officer Oldham Care OrganisationMr James Sumner, Chief Officer Salford Care Organisation

1/12 3/158

No. Item Action

1. WelcomeThe Chairman welcomed everyone present to the meeting of the Group Committees in Common and confirmed this was a shared meeting of committees established by the Boards of Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust. The Chairman confirmed that the meeting would be held in two parts: a first part open to members of the public, and a second part in private session for confidential matters.

The Chairman confirmed that the meeting would be followed at 3.30pm by a meeting of the Group Committees in Common (CiC) and the Salford Royal NHS Foundation Trust Council of Governors.

2. Patient StoryThe Group Committees in Common listened to a Patient Story read by the Group Chief Medical Officer.

Opening Matters

3. Chairman’s Opening Remarks

Leadership Event The Chairman informed the Group Committees in Common that a 2 day Leadership Event had been held on 15-16th June, at which senior leaders from across the Group’s Care Organisations met with an eminent leader from the Institute of Health Care Improvement, Jim Reinenston, and considered utilisation of quality improvement methodology to reliably deliver harm free care and drive improvement across all Group objectives.

Group CiC Away Day – 21st June 2017 The Chairman confirmed that the Group CiC Away Day had taken place on 21st June 2017, at which Non-Executive Directors had met in private during the morning session to review Group objectives and the required flow of information to Group CiC. The Chairman added that further review of quality improvement methodology had taken place during the afternoon session with all members of the Group CiC.

4. Apologies for AbsenceThe Group Committees in Common accepted apologies for absence as recorded above.

5. Declarations of Interest The Chairman requested that officers declared any actual or potential conflict of interest relevant to their role as a member of the Group Committees in Common and in particular to any matter being discussed at the meeting. There were no interests declared.

6. Minutes of the Previous Meeting The Chairman confirmed that Part 1 of the previous meeting held on 22nd May 2017 had been open to members of the public. The draft minutes, recorded of

2/12 4/158

No. Item Actionthat session, were reviewed by the Group Committees in Common and approved as a true and correct record.

7. CEO Report including Interim High-Level Performance MetricsThe Chief Executive Officer presented the interim high level key performance indicators and provided further detail on the performance of each Care Organisation, alongside key strategic and operational matters.

7.1 Major Incident - ManchesterThe Chief Executive Officer highlighted the admirable response and professionalism shown by staff across all Care Organisation’s in dealing with the tragic incident at Manchester Arena. He confirmed that additional support had been put in place for both staff and the bereaved families. The Chief Executive Officer highlighted that the observed response to supporting families had been viewed positively, with national interest, and that there had been lessons learnt about the resilience of systems and the organisation of support to families.

The Group Committees in Common formally recorded their appreciation and thanks to all staff involved in the aftermath of the events at Manchester Arena.

7.2 Response to Grenfell Tower The Chief Executive Officer confirmed that, in response to the tragic fire at Grenfell Tower, the Secretary of State had requested a review of arrangements and current position with regards to fire safety. He confirmed that contact with the Fire and Rescue Service had been made to conduct the required full assessment during the course of the week commencing 26th June. The Chief Executive Officer reported that confirmation had been provided to the Secretary of State that no urgent fire safety risks had been identified, and reaffirmed recent action undertaken to improve fire safety by the PFI provider.

7.3 Leadership EventThe Chief Executive Officer summarised the outcome of the 2 day Leadership Event at which clinical and managerial leaders considered, and provided a consensus, for the development of a new single approach to improvement, capable of being used across all Group activities. He added that this approach would be discussed further during the meeting.

7.4 Group CiC Away Day – 21st June 2017 The Chief Executive Officer noted the valuable Group CiC Away Day, at which discussion had taken place regarding the indicators that should be considered to provide intelligence on performance and improvement.

7.5 Financial PositionThe Chief Executive Officer reported that the Group financial position was a net deficit of £12.0m, £2.0m worse than planned. He commented that the position was a reflection, in part, of a control total settlement not having been agreed for Care Organisations in the North East sector. The Chief Executive Officer stated that this matter and a three year view on productivity and efficiency would be discussed further in Part 2 of the meeting.

7.6 Care Organisation ReportThe Chief Executive Officer informed the Group CiC that the Chief Officers’ for

3/12 5/158

No. Item Actioneach Care Organisation were required to submit a monthly Statement of Assurance to the Group Risk and Assurance Committee. Further discussion took place regarding key matters.

7.6.1 Salford: A&E 4 Hour StandardThe Chief Executive Officer provided contextual information regarding the deterioration in performance against this standard in Salford and the challenges experienced, both locally and nationally, during 2016/17. He highlighted the continuing challenge to achieve the performance trajectory target of 90% and stated that the principal reason for this was high levels of bed occupancy. The Chief Executive Officer reconfirmed the agreed action to create additional bed capacity both within the hospital and intermediate care.

The Chief Executive Officer explained that performance in the first two weeks of June had been particularly challenging due to the Manchester Arena incident and reception of 9 major trauma patients on Friday 9th June, disabling the usual patient flow in the following weeks. He added that alongside this was an unprecedented increase in self-referral to the Emergency Department. The Chief Executive Officer iterated the agreed response to create additional bed capacity by the end of June 2017 via ward conversion, and transfer of responsibility for The Limes Care Home to SRFT at the beginning of July 2017. The Chief Executive Officer confirmed the need for additional social work assessment had been recognised, and enacted, to enable patients to be assessed and access appropriate beds in as timely a manner as possible. The Chief Executive Officer added that the inclusion of GP Out of Hours activity within the performance data was being considered and, that as the GP streaming arrangements were implemented from September, it was anticipated that this would further benefit the position. The Chief Executive Officer reported that Salford A&E performance would likely be reviewed as part of a national review, on which the Group CiC would be kept fully informed. He added that this issue had his personal attention and was subject to significant controlled improvement activity by the Salford Care Organisation.

The Vice-Chairman sought further information with regards to the degree of confidence that the actions stated would resolve the issues being faced, and dependent on confidence levels, any further action to be considered and addressed by the Group CiC. The Chief Executive Officer explained that the outcome of all reviews to understand the causal factors of A&E performance, had determined that bed occupancy levels were at such a level that minor fluctuations in patient demand could not be accommodated. He restated the actions being pursued by the Salford Care Organisation to increase bed occupancy levels both on and off site, and described work to develop the Home Safe Service within the Integrated Care Organisation. The Chief Executive Officer provided his full support to the Salford Care Organisation response to create additional bed capacity and therefore lower bed occupancy levels. He expressed his view that it would be appropriate to further consider the rules of reporting the A&E 4 hour standard to include GP Out of Hours activity within the performance data, noting that any timeframe for change to the reporting rules was not yet known. The Chief Executive Officer confirmed that the outcome of internal review on this matter was consistent with the Greater Manchester review, and broader external commentary. In addition, the Chief Executive Officer highlighted the potential adverse consequence to the financial position, as a proportion of funding attributed to achievement of the A&E 4 hour standard would not be available should the performance trajectories not be met. The Vice-Chairman queried further the view of the

4/12 6/158

No. Item ActionSalford Care Organisation regarding constraints, either financial or operational, within which they were operating. The Salford Finance Director expressed her view that there were no financial constraints and that there was clear support from the Executive Directors and Group CiC; she confirmed that the Salford Care Organisation had developed a plan that reflected the complexity of the system and must now be delivered to demonstrate improvement. The Chief Executive Officer relayed his recent discussion with the Salford Care Organisation Chief Officer to establish if any further support was required, and reported that the Salford Care Organisation Chief Officer was confident that the Leadership Team had the required skills and experience to implement the agreed plan. He added that workforce constraints had been highlighted, particularly gaps in middle grade rotas and acute medical services. The Chief Executive Officer confirmed that discussion had also taken place to consider any adverse impact on the quality of patient care. He explained that an assessment of ‘outlying patients’ had been undertaken, and confirmed that there had been between 10-20 outlying patients during the first 2 weeks of June, in comparison to 40-70 outlying patients during the recent winter period. He explained that this assessment confirmed, despite significant patient flow issues, more patients were being treated in the bed and ward/department appropriate to their specialty needs.

The Chief Medical Officer stated that Salford’s A&E performance reflected its position as a Type 1 A&E Department. He further emphasised the workforce challenges being experienced locally and nationally within Emergency Departments, and expressed his view that SRFT must work collectively with Salford CCG to manage increasing demand within the workforce constraints, and in a different way, particularly considering the inclusion of GP Out of Hours. In response to a Non-Executive Director requesting timely and detailed update on this matter, the Chief Executive Officer reported that, in addition to A&E performance, key measures relating to discharge were to be tracked on a daily basis and that regular information would continue to be made available to the Group CiC. A Non-Executive Director referred to Salford Royal’s position as a Type 1 A&E Department and the shortage of middle grade doctors, and queried if potentially a higher number of patients were being admitted due to a lesser experienced workforce. He suggested that it would be of value to have a comparative understanding of the number of patients being admitted at other Type 1 A&E Departments. The Chief Medical Officer confirmed that A&E performance for Type 1 patients only, was largely comparable with other major teaching hospitals in Greater Manchester. He confirmed that data regarding the number of patients admitted was available for Greater Manchester and could be sourced, and acknowledged that there must be consideration of appropriate decision making.

A Non-Executive Director referred to discussions regarding delayed transfers of care in Salford and queried if this was still a significant issue. The Chief Executive Officer confirmed that this matter remained a concern with over 100 patients awaiting discharge to Salford and localities within Greater Manchester or beyond. He reported that the Salford Care Organisation was tracking all patients with a delayed transfer of care, and the reason for this, which included the need for social work assessment or access to a Care Home. He highlighted that discussion had taken place within Greater Manchester, and with NHS Improvement, regarding the need to create a reliable system that facilitated repatriation back to the locality for rehabilitation needs.

In response to the Vice-Chairman seeking confirmation that, although

5/12 7/158

No. Item Actionperformance against the A&E 4 hour standard had shown slippage, the quality of care had been maintained, the Chief Medical Officer confirmed that the quality of care was being maintained and that attention to this was resolute.

The Chief Executive Officer concluded that this matter had the full attention of the Executive Officers and Salford Care Organisation Leadership Team and that the Group CiC would remain fully appraised regarding progress.

7.6.2 Bury & RochdaleThe Chief Executive Officer highlighted that although there remained some instability in achieving the A&E 4 hour standard, that the agreed A&E performance trajectory had been met in April and May. He reported that the financial plan for May 2017 had been achieved with further work to be undertaken relating the Better Care at Lower Cost programme. With respect to quality of care, the Chief Executive Officer reported that there continued to be some risk associated with C Difficile at Fairfield General Hospital and confirmed that an action plan was underway.

7.6.3 OldhamThe Chief Executive Officer highlighted that the Oldham Care Organisation had confirmed its 2017/18 operational targets and that all Care Organisation Directors were now in post, divisional leadership teams appointed and the management board established. He reported that cancer performance remained a key concern, in particular with respect to general surgery, and that work was ongoing to address causal factors. The Chief Executive Officer confirmed that A&E performance had been achieved in May 2017, however the position remained fragile.

7.6.4 North ManchesterThe Chief Executive Officer informed the Group CiC that the North Manchester Care Organisation had confirmed its 2017/18 operational targets and that the Leadership Team was fully established and had commenced a process of deep staff engagement. He highlighted that the 18 week referral to treatment standard had not been achieved during May, and that specialty specific recovery plans and improvement trajectories had been put in place. He added that cancer performance remained a concern.

In response to a Non-Executive Director seeking further information regarding 12 hour trolley waits in the PAT Care Organisations, the Chief Delivery officer confirmed that there had been no 12 hour trolley waits at Bury & Rochdale during May 2017 and a sustained zero position at Oldham during recent months. With respect to North Manchester, the Chief Delivery Officer confirmed significant improvement, less than ten during May 2017, and highlighted that eliminating all 12 hour trolley waits would not be achieved until additional assessment beds were in situ.

In response to a Non-Executive Director seeking further information regarding actions being taken to improve cancer performance, the Chief Delivery Officer expressed her view that performance against the standard for the Urology pathway would be achieved by Quarter 2, noting that due to diagnostic capacity the Upper GI pathway remained fragile. She confirmed that the report commissioned by The Christie had been received, and indicated that a significantly higher number of patients were being tracked across PAT, and therefore additional resource had been provided to ensure focus on the appropriate patients.

6/12 8/158

No. Item Action

7.7 National Inpatient SurveyThe Chief Executive Officer provided contextual information regarding the National Inpatient Survey and confirmed that the national results of the 2016 survey indicated that there had been small, but statistically significant improvements in a number of questions, compared with previous results for Group.

The Chief Executive Officer confirmed that for SRFT, the results highlighted that the Trust (excluding specialist Trusts) was ranked joint 3rd for overall patient experience and for care & treatment of patients and 1st for operations & procedures. The Chief Executive Officer confirmed that the results for PAT remained ‘about the same’ in all grouped sections. He added that the specific responses to all the questions were being analysed to ensure that all Care Organisations could deliver realistic improvements and ensure good practice would be shared. The Chief Nursing Officer commented that the patients who received the survey would have been an inpatient during July 2016; a period of much negative media attention, and that the outcome of the 2017 survey would be a key indicator as to whether patient experience had been improved within the Group structure.

7.8 Strategic Matters

7.8.1 Group Service Strategy The Chief Executive Officer confirmed that work continued to develop the Group Service Strategy, which included reconfiguration of acute services in both the North East sector and across the wider Group footprint to ensure clinical and financial sustainability and develop fully integrated, population health models in each locality. He highlighted that a key area of consideration would be setting the future focus of each site and identification of areas of growth and contraction. He confirmed that a clinical leadership event had been scheduled for 6th July to support the prioritisation process and gain consensus on areas identified as lacking clinical resilience. In response to a Non-Executive Director querying alignment with the Single Hospital Service development, the Chief Executive Officer confirmed that the strategies would be aligned to develop effective and sustainable services, alongside the development of Local/Accountable Care Organisations and commissioner requests for services.

7.8.2 Accountable Care (Integrated Care Organisations/ Local Care Organisations)The Chief Executive Officer confirmed that an assessment had been made of the impact of the North East Sector Local Care Organisation proposals on the PAT Care Organisations. He stated that, at aggregate level, the three locality plans sought to reduce hospital admissions by 20-27% and develop services in primary care. The Chief Executive Officer commented that the associated level of planned disinvestment in acute provision would be £52.9m by 2020/21, and that further work must take place with commissioners in development of the Group Service Strategy to understand the clinical and financial implications. He expressed his view that the Group strategic intent must be to develop a portfolio of both in and out of hospital based services. A Non-Executive Director highlighted the differing skills required in the community and acute workforce and commented that this must be fully considered due to the time required to upskill the workforce. The Chief Executive Officer acknowledged these comments and offered that experience gained in Salford

7/12 9/158

No. Item Actionas Lead Provider of the Integrated Care Organisation would be valuable. The Vice-Chairman expressed his view that the estimated financial disinvestment could be subject to significant change mindful of advances in technologies, and concurred that the financial and political intent was future investment in out of hospital services.

7.9 Group Mission StatementThe Chief Executive Officer reported that the proposed Group Mission Statement had been discussed with clinical and managerial leaders at the Leadership Event, and following key comments revised and agreed as follows:

Saving lives, Improving lives by delivering highly reliable care and services, at scale, which are trusted, connected and pioneering.

Our services will be: Evidence-based and of the highest quality; Highly reliable: high quality whatever the day of the week or hour of the day; At Scale: creating benefits for people through standardisation of best

practice; Trusted: providing safe, effective and compassionate services; Connected: seamlessly delivering what matters most to people and

communities; Pioneering: continuously innovating and improving services.

8. 8.1 PAT Quality Improvement Strategy The Chief Nursing Officer presented the Quality Improvement (QI) Strategy for the PAT Care Organisations, which specifically addressed quality related matters identified from varying diagnostics. She highlighted the key aims:Aim 1: No preventable deathsAim 2: Continuously seek out and reduce patient harmAim 3: Achieve the highest level of reliability for clinical careAim 4: Deliver innovative and integrated care close to home which supports and improves health, wellbeing and independent living

The Chief Nursing Officer emphasised that a Group QI Strategy was being developed, noting that specific projects were already being implemented and led consistently across all Care Organisations. The Chief Nursing Officer commented that the QI Strategy would be aligned to a number of governance and assurance systems and supporting strategies. She highlighted 3 Project Initiation Documents for approval by the Group CiC:− Deteriorating Patient Collaborative− Pressure Ulcers Collaborative− Last 1000 Days/End PJ Paralysis Collaborative (Group wide)

In response to a Non-Executive Director seeking further information regarding the development of the Group QI Strategy, the Chief Nursing Officer confirmed that the SRFT QI Strategy was part way through implementation, and that it was appropriate to complete this work, whilst establishing a QI Strategy at PAT. She commented that proposed Group QI methodology would be discussed later in the meeting. The Non-Executive Director offered his support to the 3 collaborative’s presented. He acknowledged the introduction of a number of different systems and initiatives at PAT and queried the capacity of staff to implement these. The Chief Nursing Officer fully acknowledged the careful management of capacity, and highlighted a future proposal to be

8/12 10/158

No. Item Actionconsidered by the Group CiC that would see the establishment of a Quality and Productivity Division, bringing together the Quality Improvement and Better Care at Lower Cost Department. The Chief Finance Officer offered his view that in improving quality there was invariably an improvement in productivity, and that the latter must also be measured. The Associate Director of Quality Improvement commented that in determining the timeline for projects there had been much consideration of bandwidth and sensitivity in identifying methodology and teams involved.

The Group Committees in Common approved the PAT Quality Improvement Strategy and the Project Initiation Documents and confirmed that, in approving the QI Strategy future Project Initiation Documents did not need to be presented for approval to the Group Committees in Common.

8.2 Care Organisation Quality Improvement (QI) Dashboards- North Manchester- Oldham- Bury & Rochdale- Salford

The Chief Nursing Officer presented headlines from the Care Organisation Quality Improvement Dashboards. She highlighted the difference in falls reporting and confirmed that the Salford QI Dashboard included falls resulting in moderate to serious harm, and the PAT Care Organisation QI Dashboards showed a count of all falls. A Non-Executive Director referred to the Bury & Rochdale QI Dashboard, noting that ‘mortality’ was reported separately for Fairfield General Hospital and Rochdale Infirmary, with all others measures reported jointly, and queried if there was any risk in reporting in this way. The Chief Nursing Officer commented that future QI Dashboards could be presented separately for Fairfield General Hospital and Rochdale Infirmary, ensuring visibility across all sites.

The Group Committees in Common reviewed and confirmed the Care Organisation Quality Improvement Dashboards.

8.3 Quality Improvement as ‘The Method’: Next StepsThe Associate Director of Quality Improvement provided a presentation describing the development of a Group high performance management system including system architecture considering ‘quality control’ and ‘quality improvement’, key steps to high performance and learning system ideas.

The Chief Strategy and Organisational Development Officer expressed his view that staff must initially be able to identify that there is an issue to be improved. The Chief Delivery Officer echoed these comments and offered her view that people need to have a curiosity as to what can be improved and suggested that this was made explicit within the learning systems. The Associate Director of Quality Improvement acknowledged these comments confirming that the learning system must include how to identify what is an issue. A Non-Executive Director expressed her view that the previous PAT QI Strategy and Leadership Strategy had been progressed in silo and encouraged development of future strategies in a combined way. The Chief Strategy and Organisational Development Officer referred to terminology used to categorise ‘middle’ managers, and suggested the term ‘core’ leaders was incorporated. The Chief Nursing Officer also expressed her view that the language used in the organisational and leadership development strategies

Chief Nursing Officer

9/12 11/158

No. Item Actionmust be consistent, ensuring alignment and enabling people to identify the connect between strategies.

The Chief Executive Officer commended the work undertaken to date and asked that the Quality Improvement Directorate, under the leadership of the Associate Director of Improvement, develop a package of support to build capability and competence in the use of quality improvement techniques and methodology, and beginning with the Care Organisation Chief Officers and Senior Leadership Teams, plan to embed this within the Care Organisations.

9. Mortality Review Update ReportThe Chief Medical Officer provided contextual information regarding the trend in Hospital Standardised Mortality Ratio (HSMR) at Pennine Acute Hospitals NHS Trust (PAT) over recent years and provided the current figures in each of the PAT Care Organisations.

The Chief Medical Officer described the work underway to reduce the incidence of avoidable mortality across PAT, including governance and leadership arrangements, and confirmed that each Care Organisation would have its own particular clinical focus for further scrutiny with the main areas of work across PAT encompassing three common domains:− Safe and Reliable Systems − Workforce − Clinical coding

In response to the Vice-Chairman seeking further information regarding rising ‘Elective’ HSMR at Oldham, the Chief Medical Officer referred to deficiencies in General Surgery systems and performance, which had culminated in a Prevention of Future Death warning being issued by HM Coroner. The Chief Medical Officer specifically highlighted poor communication by and between clinicians and confirmed a specific programme of work in the surgical division that dovetailed with the three common domains identified across PAT. A Non-Executive Director welcomed the detailed report and additional assurance provided regarding leadership and governance arrangements, whilst acknowledging the challenge in ensuring a sustained focus. The Chief Executive Officer recognised the challenging trajectories regarding 95% reliability in delivery of harm free care and, mindful of the implementation of the QI Improvement Strategy and bandwidth of staff, requested that the Chief Nursing Officer and Chief Medical Officer ensured alignment and sequencing of workstreams. The Chief Nursing Officer commented that the workstreams were interconnected, acknowledging some difference in terminology, and expressed her view that the systems focused on the delivery of harm free care would be implemented by December 2017, with further testing required to test reliability.

The Group Committees in Common reviewed the work undertaken to understand the PAT position with regards to mortality, and approved the approach to Care Organisation based reporting to an overarching mortality surveillance group, the PAT Mortality Surveillance Group and thereby to the PAT Clinical Effectiveness Committee.

The Group Committees in Common reviewed and confirmed the three domains of improvement.

10/12 12/158

No. Item Action

10. Pennine Acute Hospitals NHS Trust (PAT) Improvement PlanThe Chief Delivery Officer and Chief Nursing Officer presented progress made towards the delivery of the PAT Improvement Plan and specifically highlighted progress made in month across the themes of ‘Improving Quality’ and in fragile services. In addition, the Chief Delivery Officer highlighted that recruitment and workforce availability remained an ongoing risk to the delivery of a number of improvement actions.

The Chief Nursing Officer provided detailed information regarding the process for the follow up inspection at PAT, including timescales. She confirmed that the CQC were working to their new regulatory framework which included a targeted review of up to 4 core services, and that as PAT had 5 defined fragile services (Urgent Care, Maternity, Paediatrics, Critical Care, Medicine), the CQC had established that full review of services across all sites would be required.

The Chairman referred to the significant change in leadership since the previous CQC Inspection and queried if this would be described within the documentation request, as fundamental to the Well-Led assessment. The Chief Nursing Officer confirmed that the Group leadership structures and accountability would be clearly articulated within the narrative provided to the CQC. The Vice-Chairman expressed his view, in light of the workforce challenges, that further discussion was necessary to comprehensively understand agency spend and future plans. In response to the Chief Executive Officer querying progress with respect to the Learning & Development ‘must do’ and ‘should do’s’, the Chief Strategy and Organisational Development Officer confirmed actions remained on plan.

The Group Committees in Common reviewed and confirmed the progress and key risks to the delivery of the CQC and SRFT CQC Diagnostic Improvement Plan.

11. Chairman’s Report from Council of GovernorsThe Chairman provided the Group Committees in Common with a summary of the key issues discussed and the decisions made at the meeting of the Council of Governors on Tuesday, 20th June 2017.

The Group Committees in Common reviewed and confirmed the information provided.

12. Board Composition: Non-Executive Director Skills and Expertise The Chairman reported that Mrs Rowena Burns had decided to stand down from her role as Non-Executive Director on the Salford Royal NHS Foundation Trust (SRFT) Board of Directors, and therefore a member of Group Committees in Common (CiC). The Chairman added that it was for the Group CiC, on behalf of the SRFT Board of Directors, to confirm the skills and expertise required of a new Non-Executive Director, as aligned to the organisation’s strategic direction, and proposed that the specific skills and expertise were set similar to those described during Rowena’s appointment as follows:

− Providing Strategic Business Development guidance and challenge,

11/12 13/158

No. Item Actionespecially in relation to Building Strategic Partnerships with the explicit inclusion within the narrative of understanding/experience of digital transformation strategies and innovative investment strategies.

The Chairman confirmed that the Council of Governors, at its meeting on 20th June, had agreed the recruitment and appointment process for the Non-Executive Director, subject to final approval of the Job Description and Person Specification at the Group CiC.

The Group Committees in Common reviewed and approved the required skills and expertise for the new Non-Executive Director, including approval of the Job Description and Person Specification.

13. Reports from Standing Committees:

Group Audit Committee – Meeting held on 24 May 2017The Vice-Chairman provided overview of the key matters and decisions made at the meeting on 24th May 2017 and formally thanked all officers involved in the completion of year-end matters.

Group Executive Committees:

Development Committee – Meeting held on 19th June 2017The Chief Executive Officer provided overview of the key matters and decisions made at the meeting on 19th June 2017.

Risk and Assurance Committee – Meeting held on 19th June 2017The Chief Executive Officer provided overview of the key matters and decisions made at the meeting on 19th June 2017.

14. Any Other Business (Part 1)No other business

15. Date and Time of the Next MeetingThe Chairman confirmed that the next meeting would take place on Monday, 31st July 2017 from 10.00 am at Humphrey Booth Lecture Theatre, Mayo Building.

Closure of Part 1 of the Group Committees in Common Meeting

16. Exclusion of the Public

The Group Committees in Common resolved to exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be inappropriate, by reason of the sensitive and confidential nature of business.

Members of the public were requested to leave the meeting room at this point.

12/12 14/158

14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q4

91.7 87.3 85.4 90.1 91.9 80.1 75.1 80.1 86.72 89.29 85.10

90.9 91.1 90.5 90.2 92.6 94.7 99.3 103.3 103.5 103.8 101.6

Salford Royal Foundation Trust

Pennine Acute Hospitals Trust

HSMR - Rolling 12 months

Committee in Common ScorecardSaving Lives, Improving Lives by delivering highly reliable services at scale, which are trusted, connected and pioneering

Highly Reliable & Trusted

Harms

65

70

75

80

85

90

95

100

105

Salford HSMR Rolling 12 Month

Actual Av UCL LCL

+1 Sigma -1 Sigma +2 Sigma -2 Sigma20

30

40

50

60

70

14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3

Rochdale HSMR Rolling 12 Month

80

90

100

110

120

14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3

Fairfield HSMR Rolling 12 Month

80

85

90

95

100

105

110

North Manchester HSMR Rolling 12 Month

Actual Av UCL LCL

+1 Sigma -1 Sigma +2 Sigma -2 Sigma

80

85

90

95

100

105

110

Oldham HSMR Rolling 12 Month

Actual Av UCL LCL


HSMR is a ratio of the observed number of in-hospital deaths to the expected number of in-

hospital deaths for 56 specific Clinical Classification System (CCS) groups. HSMR is risk

adjusted to take into account key risk factorsassociated with mortality.

HSMR for Pennine as a Trust remains above expected levels with Salford remaining below.

HSMR is updated quarterly and therefore these metrics have not changed from the previous

month.

HSMR for the Salford Care Organisation is below the expected

level.

HSMR for Fairfield has shown improvement over a quarter but is still above expected. Rochdale has two quarters out of range but remains statistically low.

HSMR for the North Manchester Care

Organisation continues to be above expected

levels and has plateaued over the last

three quarters.

HSMR for the Oldham Care Organisation has reduced to below expected levels and has been consistent for the last three quarters.

1/19 15/158

14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 16/17 Q3 16/17 Q4

95.02 101.50 97.10 102.92 91.59 83.56 81.10 88.90 86.72 89.29 94.75

105.19 104.50 104.55 100.82 102.19 104.90 107.96 111.54 112.75 103.70 102.17

SHMI - QuarterlySalford Royal Foundation Trust




Harms

SHMI is the ratio between the actual number of patients who die following hospitalisation and the

number that would be expected to die on the basis of average England rates and then risk adjusted to take into account key risk factors

associated with mortality.

Salford's SHMI remains statistically lower than expected whereas Pennine as a Trust has a SHMI

which is statistically higher than expected.

SHMI is updated quarterly and therefore these metrics have not changed from the previous

month.

60

70

80

90

100

110

Salford SHMI Quarterly

Actual Av UCL LCL


SHMI for the Salford Care Organisation is

statistically lower than the expected level.

100

105

110

115

120

125

130

14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2

Fairfield SHMI Quarterly

20

40

60

80

100

14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2

Rochdale SHMI Quarterly

SHMI for Fairfield is above the expected range and is the subject of more detailed review. SHMI at Rochdale remains below expected levels.

80

85

90

95

100

105

110

North Manchester SHMI Quarterly

Actual Av UCL LCL


SHMI for the North Manchester Care

Organisation contines to be above expected

levels but has reduced over the last quarter.

80

85

90

95

100

105

110

115

120

Oldham SHMI Rolling 12 Month

Actual Av UCL LCL


SHMI for the Oldham Care Organisation has reduced to below expected levels and has been consistent for the last three quarters.

2/19 16/158



Clostridium Difficile

0

5

10

15

20

0

5

10

15

20

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Cu

mu

lati

ve

Mo

nth

ly

Salford C.Dif

C-Diff Actual Trajectory

Cumulative Trajectory Cumulative Actual

The Salford Care Organisation is within trajectory for C.Dif.

0

5

10

15

20

0

5

10

15

20

Cu

mu

lati

ve

Mo

nth

ly

Bury & Rochdale C.Dif


Cumulative Actual Cumulative Trajectory

0

5

10

15

20

0

5

10

15

20

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

North Manchester C.Dif



0

5

10

15

20

0

5

10

15

20

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Oldham C.Dif



Trajectories for Clostridium Difficile have been set for each Care Organisation.

This metric forms part of the Single Oversight Framework.

The Bury & RochdaleCare Organisation is within trajectory for

C.Dif.

The North Manchester Care Organisation

remains below trajectory for C.Dif with no occurances in June.

The Oldham Care Organisation is within

its cumulative trajectory for June despite an increase in month.

3/19 17/158



Falls

0

5

10

15

20

25

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Salford Falls

Actual Falls Trajectory

Falls continue to reduce for the Salford Care Organisation

with no instances in June.

0

5

10

15

20

25

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Bury & Rochdale Falls


0

5

10

15

20

25

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

North Manchester Falls


0

5

10

15

20

25

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Oldham Falls


Falls form part of the Safety Thermometer metric. This metric measures falls resulting

in moderate harm and above.

Improvement trajectories are to be set to further reduce occurrences.

The Bury & Rochdale Care Organisation have had no reported falls for June '17.

Falls remain at low levelvs for the North Manchester

Care Organisation.

The Oldham Care Organisation has seen three falls in June '16, which is higher than average.

4/19 18/158



Harms

0

5

10

15

20

25

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Salford Pressure Ulcers

Actual Pressure Ulcers Trajectory

The Salford Care Organisation has seen a

reduction in PressureUlcers for June '17 and has

an improvement trajectory of no more than

five per month.

0

5

10

15

20

25

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Bury & Rochdale Pressure Ulcers


0

5

10

15

20

25

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

North Manchester Pressure Ulcers


0

5

10

15

20

25

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Oldham Pressure Ulcers


Pressure Ulcers form part of the Safety Thermometer metric. This metric

monitors pressure ulcers at Grade 2 and above, including ungraded.

Improvement trajectories have been set with each Care Organisation expected to

deliver a 30% reduction in Pressure Ulcers based on the first quarter of 2017/18.

Pressure Ulcers continue to increase for the Bury & Rochdale Care Organisation.

An improvement trajectory of no more than four per month has been set.

The North Manchester Care Organisation has had eight

pressure ulcers during June. An improvement trajectory

has been set of no more than four falls per month from July

onwards.

The Oldham Care Organisation has seen a continued reduction in Pressure Ulcers. An improvement trajectory of no more than four falls per month has been set.

5/19 19/158

Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17

94.0% 81.8% 90.1% 92.0% 87.6% 80.2% 83.7% 76.7% 77.3% 84.8% 89.9% 82.1% 83.6%

84.8% 81.6% 87.1% 84.7% 81.6% 79.6% 77.8% 76.7% 78.1% 81.3% 80.9% 86.4% 83.5%Pennine Acute Hospitals Trust


Highly Reliable & Connected Care

Urgent Care

A&E 4 Hour Performance


The Salford Care Organisation is below it's improvement

trajectory but has seen improvement in month. The

Care Organisation has an intensive improvement

programme in place.

Waiting times in A&E from arrival to admission, transfer or discharge should be

a maximum of 4hrs for 95% of patients. Improvemnt trajectories have been set for

Care Organisations to ensure deliver of 95% at a Trust level by March '18.

As a Trust, Pennine has achieved it's trajectory for June '17 with an overall

performance of 83.% Salford continues to be behind it's expected trajectory.

The Bury & Rochdale Care Organisation continues to deliver it's improvementtrajectory and is slightly above expected performance for June '17.

The North Manchester Care Organisation has dipped

slightly below it's trajectory for June but remains on

target cumulatively.

The Oldham Care Organisation continues to deliver it's improvement trajectory and is over 5% higher than its expected trajectory for June '17.

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Salford A&E 4 Hour Performance

Actual Trajectory

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Bury & Rochdale A&E 4 Hour Performance

Actual Trajectory

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

North Manchester A&E 4 Hour Performance

Actual Trajectory

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Oldham A&E 4 Hour Performance

Actual Trajectory

6/19 20/158


93.0% 93.0% 92.8% 92.8% 92.9% 92.6% 92.0% 92.7% 92.5% 92.7% 92.4% 93.0% 93.0%

93.3% 92.4% 92.0% 92.1% 92.7% 92.3% 93.1% 92.1% 92.1% 92.2% 92.0% 92.1% 92.2%Pennine Acute Hospitals Trust

RTT Open Performance




Elective Access

The Salford Care Organisation continues to meet the 92%

standard.

Referral to Treatment waiting times for open pathways should not exceed 18 weeks for

92% of patients.

As a whole, Pennine has met the 92% standard for June with a performance of

92.2%.

Bury and Rochdale continue to meet the 92% RTT standard but have seen a deterioration in performance in month.

The North Manchester Care Organisation has improved its

performance in June '17 but is still below the 92%

standard with a performance of 91.40%.

Oldham Care Organisation has seen a slight improvement in performance in June '17 but is still below the 92% standard. with a performance of 91.69%.

There has also been a 52 week waiter in General Surgery

80%

82%

84%

86%

88%

90%

92%

94%

96%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Salford RTT Open Performance

Actual Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Bury & Rochdale RTT Open Performance

Actual Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

North Manchester RTT Open Performance

Actual Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Oldham RTT Open Performance

Actual Target

7/19 21/158

May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17

91.1% 92.4% 90.5% 88.4% 86.0% 97.3% 93.2% 88.9% 89.9% 89.3% 89.8% 88.9% 90.2%

90.9% 77.8% 83.6% 87.7% 84.2% 81.9% 89.0% 87.6% 85.6% 82.4% 76.1% 77.1% 79.9%


89.1% 89.3% 89.2% 87.0% 81.3% 97.3% 90.4% 86.8% 85.0% 88.5% 88.5% 85.4% 87.5%

85.7% 72.6% 79.7% 83.6% 80.1% 77.9% 85.3% 82.9% 82.2% 74.6% 69.1% 72.1% 72.8%


97.1% 96.7% 95.7% 93.0% 96.7% 97.8% 96.4% 96.1% 93.0% 96.9% 92.8% 93.2% 97.0%

94.9% 94.3% 93.5% 93.5% 94.8% 95.8% 97.3% 93.6% 89.4% 94.8% 93.5% 87.4% 95.6%



Cancer Pathways

TWW




62 Day National


62 Day GM



Salford continues to meet the 85% standard and

performance for both the national and GM target have

improved in month.

All patients should receive an inital appointment within 14 days of urgent referral for suspected cancer. Those referred urgently and diagnosed with cancer should begin their

first definitive treatment within 62 days of referral.

Cancer performance is currently reported at Trust level and is two months retrospective.

Greater Manchester (GM) Trusts have a repatriation agreement which may mean

performance against this standard differs to

Performance for Pennine has begun to improve and a recovery plan is in place Achievement of the standard is expected in Quarter Two.

Salford continues to deliver the standard and has

improved in month.

Pennine's two week wait performance has improved in month and the standard has been achieved. This will be positively impact on the delivery of the 62 day standard.

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Salford 62 Day Performance

National GM Target

60%

65%

70%

75%

80%

85%

90%

95%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Pennine 62 Day Performance

National GM Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Salford 2 Week Wait Performance

Actual Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Pennine 2 Week Wait Performance

Actual Target

8/19 22/158


99.2% 99.3% 99.4% 99.4% 99.4% 99.4% 99.1% 99.2% 99.0% 99.0% 99.1% 99.0% 99.1%

95.8% 91.4% 90.8% 94.6% 99.2% 99.3% 99.0% 99.1% 99.6% 99.4% 99.2% 99.1% 97.5%

6 Wk Diagnostic Performance





Diagnostic Access

The Salford Care Organisation continues to

meet the 99% standard.

Key diagnostic tests should to be carried out within 6 weeks of the request for the

test being made for 99% of patients.

As a whole, the Pennine Trust has failed to meet the 99% standard with a

performance of 97.5%.

The Bury & Rochdale Care Organisation continues to deliver 100% performance

for the 6 week diagnostic standard.

The North Manchester Care Organisation has seen a drop

in performance and have failed to deliver the 99%

standard with a performance of 98.69% for June '17.

The Oldham Care Organisation has seen a

continued deterioration of performance with only 97.18% of appplicable

diagnostic tests in June being performed within the 6 week

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Salford Diagnostic 6 Week Performance

Actual Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Bury & Rochdale Diagnostic 6 Week Performance

Actual Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

North Manchester Diagnostic 6 Week Performance

Actual Target

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Oldham Diagnostic 6 Week Performance

Actual Target

9/19 23/158


Connected & At Scale

Workforce

The Salford Care Organisation is above trajectory for sickness

absence although a downwards trend

continues.

Sickness absence is the percentage of sickness in terms of WTEs. This includes both short-term and long-term sickness over a rolling 12 month

period.

Whole time eqivalent numbers represent the number of WTEs in post over a rolling 12 month period. This is not the same as headcount (no.

of staff members).

Sickness absence and WTEs are currently reported at Trust level. Further workforce

productivity metrics for Care Organsations are being developed.

Awaiting Data

Salford has seen another slight increase in WTEs .

The sharp increase at the beginning of the financial

year is due to the inclusion

of all ICO staff groups.

Awaiting Data

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Salford - Sickness Absence

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Pennine - Sickness Absence

5400

5600

5800

6000

6200

6400

6600

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Salford - Whole Time Equivalents in Post

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Mar

-18

Pennine - Whole Time Equivalents in Post

10/19 24/158



Safe Staffing

The Salford Care Organisation continues to

meet the target for care staff at night but is below the standard for all other

shift types .

The Safe Staffing metric compared the actual number of ward shifts filled

compared to the number of expected to be filled. This is split be nursing and care staff

and day and night shifts.

All wards should achieve 95% compliance.

The Bury & Rochdale Care Organisation has acheived

the standard for all shift types.

North Manchester Care Organisation achieved he

standard for Care Staff but is slightly below the 95% target

for nursing shifts

The Oldham Care Organisation acheived the standard for all shift types

with the exception of nurseday shifts.

60%

70%

80%

90%

100%

110%

120%

130%

140%

Salford Safe Staffing Performance

Nurses % - Day Nurses % - Night Care Staff % - Day

Care Staff % - Night Target

60%

70%

80%

90%

100%

110%

120%

Bury & Rochdale Safe Staffing Performance



60%

70%

80%

90%

100%

110%

120%

130%

140%

North Manchester Safe Staffing Performance



60%

70%

80%

90%

100%

110%

120%

Oldham Safe Staffing Performance



11/19 25/158

Ward

Average fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staffWard

Average fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staff

ANU 74.31% 92.99% 79.44% 98.32% AnteNatal Ward 90.60% 85.20% 86.70% 63.30%

ASU 71.67% 86.67% 71.11% 90.35% Childrens 106.80% 40.50% 101.30% 110.00%

B3 69.46% 93.98% 73.11% 100.00% Critical Care 94.10% 103.30% 95.30% 93.30%

B4 67.77% 92.28% 73.03% 105.26% Labour Ward 96.70% 82.50% 100.90% 78.20%

B5 67.65% 87.25% 66.67% 101.27% Neonatal Unit 77.50% 10.30% 76.30% -

B6 87.00% 110.09% 74.15% 139.62% PostNatal Ward 95.70% 117.10% 93.80% 91.70%

B7 75.84% 88.76% 98.88% 92.73% Ward C3 & C4 86.60% 88.50% 94.00% 171.80%

B8 71.02% 87.36% 89.87% 80.14% Ward C5 96.80% 112.40% 100.00% 129.30%

C2 56.47% 82.52% 76.67% 95.33% Ward C6 96.80% 93.90% 100.00% 97.70%

CCU 96.01% 94.33% 131.12% 94.57% Ward CCU G4 87.80% 91.80% 96.70% 103.30%

CPIU 91.03% 76.35% 83.78% 113.64% Ward D5 96.70% 81.70% 101.60% 120.00%

EAU 79.73% 130.92% 85.49% 148.34% Ward D6 131.30% 137.10% 104.70% 125.00%

HAEM 85.80% 83.33% 98.33% 96.67% Ward E1 97.80% 136.40% 102.20% 215.50%

HB1 83.26% 91.81% 71.35% 195.16% Ward E3 101.10% 105.00% 100.00% 153.30%

HB2 84.87% 93.75% 67.78% 235.48% Ward F3 103.80% 112.00% 101.70% 136.40%

HCU 79.48% 106.67% 75.86% 117.24% Ward F5 92.20% 118.40% 104.80% 120.30%

H2 80.34% 96.00% 93.02% 185.71% Ward F6 95.70% 124.50% 103.30% 127.70%

H3 76.19% 107.14% 85.71% 100.00% Ward H3 90.60% 99.20% 84.90% 111.50%

H4 85.29% 90.45% 77.01% 161.76% Ward H4 96.00% 166.90% 102.20% 158.70%

H5 61.15% 95.18% 66.67% 114.00% Ward I5 76.70% 74.20% 100.00% 154.30%

H7 71.53% 66.46% 77.68% 89.07% Ward I6 76.90% 84.90% 88.50% 111.10%

H8 89.01% 96.43% 71.91% 176.67% Ward J3J4 92.70% 100.50% 94.70% 116.70%

L2 71.37% 106.67% 66.67% 340.00% Ward J6 96.10% 108.30% 100.00% 105.00%

L3 78.99% 100.51% 68.89% 231.82% Ward STU 88.30% 91.50% 76.30% 290.00%

L4 80.00% 120.42% 69.51% 242.86%

L5 62.95% 100.55% 69.41% 213.46%

L6 77.22% 104.35% 76.53% 122.99%

M2 75.74% 113.33% 66.67% 122.45%

MA3 94.49% 100.93% 95.00% 89.47%

MAPL 73.30% 86.55% 86.96% 100.00%

NHDU 92.67% 131.25% 97.52% 193.33%

SRU 68.18% 82.16% 100.00% 97.39%

STU 83.15% 91.67% 97.18% 96.55%



Safe Staffing

NightDay

Salford North ManchesterDay Night

12/19 26/158

Hospital Ward

Average fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staffWard

Average fill rate -

registered nurses

Average fill rate -

care staff

Average fill rate -

registered nurses

Average fill rate -

care staff

Fairfield Ward 10 (ITU/HDU) 96.70% 65.00% 96.70% 60.70% A&E Observation Ward 100.00% 101.70% 96.70% 93.30%

Fairfield Ward 11a 92.20% 96.80% 95.60% 127.70% Antenatal Ward 100.00% 101.70% 101.10% 96.70%

Fairfield Ward 11b (Stroke) 95.60% 81.60% 95.60% 114.10% Childrens Unit 90.40% 94.40% 84.40% 36.00%

Fairfield Ward 14 91.10% 87.70% 100.00% 95.30% Critical Care 91.70% 140.00% 96.70% 110.00%

Fairfield Ward 18 95.20% 80.90% 101.70% 139.60% Labour Ward 95.00% 85.00% 90.00% 91.50%

Fairfield Ward 2 CCU 94.20% 65.60% 93.30% 59.20% Neonatal Unit 82.30% 46.70% 84.20% -

Fairfield Ward 20 84.90% 94.30% 97.80% 101.00% Postnatal Ward 97.60% 95.40% 92.50% 85.20%

Fairfield Ward 21 93.90% 84.10% 98.90% 102.40% Ward AMU 88.00% 106.70% 90.40% 126.30%

Fairfield Ward 5 80.00% 107.90% 92.70% 126.70% Ward CCU 100.00% 40.90% 98.30% 50.00%

Fairfield Ward 7 94.60% 92.60% 99.10% 125.80% Ward F1 92.00% 100.80% 96.50% 96.60%



Birch Hill Floyd Unit 106.70% 76.50% 100.00% 93.10% Ward F7 97.10% 101.10% 97.80% 166.70%

Rochdale Clinical Admissions Unit 96.08% 86.67% 96.67% 139.47% Ward F8 82.80% 149.00% 103.30% 111.90%

Rochdale Oasis Unit - RI 101.49% 94.12% 100.00% 103.03% Ward F9 101.70% 94.00% 94.40% 118.40%

Rochdale Wolstenholme Unit - RI 98.89% 95.42% 73.42% 128.57% Ward G1 84.30% 114.20% 93.30% 110.00%

Ward G2 95.60% 108.10% 94.30% 98.50%

Ward T3 81.60% 100.00% 105.10% 104.80%

Ward T4 STU 91.60% 117.10% 98.90% 120.00%

Ward T5 83.90% 96.70% 92.20% 106.70%

Ward T6 82.10% 83.70% 84.00% 92.00%

Ward T7 94.70% 112.40% 107.20% 133.60%

Day Night



Safe Staffing

Day Night

Bury & Rochdale Oldham

13/19 27/158



Finance

The Salford Care Organisation financial

position is £0.06m better than the control total.

Financial performance for care organisation is monitored in terms of alignment with budgetary control totals..

Corporate and Support Services for Pennine care organisations are managed centrally and are not included in

individual care organisation performance. Salford hosted services are also excluded from the Salford Care

Organisation position.

Overall performance for Salford (including hosted services is £0.11m better than the control total. For all Pennine care

organisations plus corporate and support services performance is £0.03m better than the control total.

The Bury & Rochdale Care Organisation financial

position is £0.18m better

than the control total.

North Manchester Care Organisation financial

position is £3.22m worse than the the

control total.

The Oldham Care Organisation financial

position is £2.2m worsethan the control total.

-£0.80

-£0.70

-£0.60

-£0.50

-£0.40

-£0.30

-£0.20

-£0.10

£0.00

£0.10

Ap

r-17

May-17

Jun

-17

Jul-1

7

Au

g-17

Sep-1

7

Oct-1

7

No

v-17

Dec-1

7

Jan-18

Feb-1

8

Mar-18

£m

Salford Finance Performance

Performance vs. Control Total

-£0.20

-£0.15

-£0.10

-£0.05

£0.00

£0.05

£0.10

£0.15

£0.20

£0.25

£0.30

Ap

r-17

May-17

Jun

-17

Jul-1

7

Au

g-17

Sep-1

7

Oct-1

7

No

v-17

Dec-1

7

Jan-18

Feb-1

8

Mar-18

£m

Bury & Rochdale Finance Performance


-£3.50

-£3.00

-£2.50

-£2.00

-£1.50

-£1.00

-£0.50

£0.00 Ap

r-17

May-17

Jun

-17

Jul-1

7

Au

g-17

Sep-1

7

Oct-1

7

No

v-17

Dec-1

7

Jan-18

Feb-1

8

Mar-18

£m

North Manchester Finance Performance


-£2.50

-£2.00

-£1.50

-£1.00

-£0.50

£0.00 Ap

r-17

May-17

Jun

-17

Jul-1

7

Au

g-17

Sep-1

7

Oct-1

7

No

v-17

Dec-1

7

Jan-18

Feb-1

8

Mar-18

£m

Oldham Finance Performance


14/19 28/158

Site Risk Name Principal Risk Risk Lead Action Plan Summary Risk Score

SRFTClinical Staffing

Levels

IF established Trust-wide clinical staffing levels cannot be achieved,

THEN the Trust will remain heavily reliant on non-contracted staff

which may in turn compromise patient care and service delivery

Chief Strategy and

Organisational

Development Officer

• Monthly Workforce Strategy Board in place and focussing on effectively addressing this risk

• Focus on delivery of divisional workforce strategies

• Working with Universities to ensure the Salford Royal job offer is fully understood and we recruit as

many newly qualified nurses as possible

• Full implementation of Trendcare in progress

• Fair and equitable bank rates for all general wards

13

SRFT

Delivering Better

Care @ Lower

Cost

IF the Trust fails to deliver Better Care at Lower Cost target of £28.7m

in 2017/18 THEN the Trust may not achieve the forecast outturn

financial position for 2017/18

Chief Finance Officer Work streams continue to develop for 2017/18. 13

SRFTNon Elective

Capacity

IF demand for emergency admission exceeds non-elective capacity or

specialist teams/diagnostic services do not respond in a timely

manner THEN more than 5% of patients will wait longer than four

hours in A&E, and elective flow and patient care may be

compromised

Chief Delivery Officer

• Please see Clinical Staffing Risk

• Revising Urgent Care Action Plan

• Review of escalation / divert processes across Greater Manchester in progress

13

SRFTVascular

Intervention

IF there is no provision for vascular intervention on site THEN

patients are at increased risk of delays which may lead to higher rates

of mortality and morbidity

(In particular this is in relation to GI bleeds or bleeds as a result of

renal biopsy. SRFT does not have vascular services on site, but is still

required to provide vascular radiology support)

Chief Medical Officer

The risk has been escalated to CEO’s in both organisations which has opened up channels for further

discussion. CMFT are still in discussions around non trauma related vascular radiology at SRFT. Final word

required from Ian Lurcock and Jane Eddlestone at CMFT and a response has been chased.

• SLA produced to cover trauma agreed

• SLA for non-trauma outstanding and awaits feedback

• 6.5 PA's suggested to be paid for this cover but CMFT have failed to recruit into vacant positions to

support this service

12

SRFT

Neuro

Rehabilitation

Pathways

IF the issues of fragmentation, lack of co-ordination, lack of standard

framework for clinical practice, and delays to securing complex

packages of care for neuro-rehabilitation are not resolved across

Greater Manchester, THEN the upstream backlog in terms of

pressure in acute care capacity and hence cost will continue to be

carried by Salford Royal


As part of Trauma Programme of Care SRFT would see itself becoming the lead provider for

neurorehabilitation in Greater Manchester which would assist in facilitating standards of care across the

rehab pathway and co-ordination of care and patient flow.

12

SRFT

Paediatric

Provision and

Support

IF there is not sufficient paediatric provision & support onsite THEN

paediatrics are at increased risk of harm & may lead to increased

mortality and morbidity

(In particular SRFT is a designated Paediatric Trauma Unit and as such

will receive Paediatric Trauma and Paediatric emergencies. These will

require anaesthetic support from the consultant anaesthetists at

SRFT and potentially emergency surgery should there be life

threatening trauma. Further detail included in Datix)


• Clinical Effectiveness Committee to oversee the following actions

• Service review as part of NW sector plans

• SOP being developed

• Meetings planned with NWAS

12

15/19 29/158


SRFT

Increased Number

of Trauma

Admissions

IF the number of trauma admissions continues to increase THEN

there will be a delay to patients accessing theatre/surgery within an

appropriate clinical time period therefore patient outcomes maybe

be adversely affected

Chief Delivery Officer Action plan underway. 12

SRFTRadiology Turn-

Around Times

IF there are insufficient suitably qualified doctors and radiographers

to report images in a timely manner THEN it increases the risk of

delayed diagnosis resulting in higher morbidity and mortality with

resultant increased cost and potential damage to Trust reputation

Chief Strategy and

Organisational

Development Officer

• Update job plans following completion of capacity and demand calculation.

• MSK Radiologist appointments being considered12

SRFT

Capital

Requirements for

Major Trauma

and Healthier

Together

IF the Trust fails to secure agreement around capital requirement for

Major Trauma and Healthier Together in a timely manner THEN there

is a significant risk to the implementation timetable for these

important strategic developments

Chief Strategy and

Organisational

Development Officer

Development of Major Trauma and Healthier Together mobilisation plans, pending capital approval. 12

SRFTTransformation

Funding

IF the Trust fails to secure the appropriate transformation funding for

PAHT THEN SRFT will withdraw its offer to incorporate PAHT in the

SRFT Group

Chief Strategy and

Organisational

Development Officer

• SRFT to prepare exit strategy in preparedness of system failure

• Further submission to GM HSCP for additional transformation funding

• Ongoing talks with national bodies

12

SRFTActivity and

Income Levels

IF the planned activity and income levels are not achieved and/or

expenditure controls are exceeded leading to a NHSI Use of

Resources Rating lower than planned in 2017/18, THEN this will

increase regulatory investigation and intervention

Chief Finance Officer Financial Plan for 2017/18 approved by Board of Directors December 2016. 12

SRFT

Capacity Plans for

Increasing

Demand

IF specialities do not have robust capacity plans in place to meet

demand / increasing demand and standardised systems in place to

effectively manage the open/incomplete referral to treatment time

standard THEN more than 8% of patients will not receive their

treatment within 18 weeks


Task and Finish Group ongoing to review the systems and processes in place to ensure standardisation

across the organisation and systemize patient activity recording processes.

Revised Recovery Plan in place.

12

SRFT

Compliance with

the Capped

Agency Rate

IF the Trust does not comply with the capped agency rates (from Nov

16) and cannot provide adequate explanation for breaches, THEN this

may adversely affect the Trust’s Single Oversight Framework rating

Chief Strategy and

Organisational

Development Officer

Director of OD and Medical Director to meet with counterparts at CMFT to reach agreement on

compliance. 12

SRFTOperational

Estate Capacity

IF the Trust cannot secure sufficient and operational estate capacity

THEN future service developments may be at risk

Chief Strategy and

Organisational

Development Officer

Better Care at Lower Cost Programme underway to improve bed capacity and utilisation. Stage 1 works to

provide additional beds are underway.

Review of future service requirements underway in conjunction with HT and MTC.

12

16/19 30/158


PAHTRecruiting to

Establishment

IF evidenced based budgeted establishment levels are not

maintained THEN the quality of care will be compromised and cost

reduction targets not met


and Chief Medical

Officer

• Engagement plan 2017/18 at Board in May 2017

• Omni recruitment review complete and implementation plan being developed

• New Care Organisation Management Teams in place

• OD plan phase 1 mobilised

• Corporate Services Review to report in June

• Re-engineering Workforce Directorate implemented in Q2

13

PAHT

Stabilising the

Workforce in ED

and AMU

IF the Trust is unable to stabilise and sustain the medical and nursing

workforce to support ED and AMU THEN there is a risk that the Trust

could not provide high quality, timely 24/7 emergency care


and Chief Medical

Officer

• Continue to implement Improvement Plan (timelines outlined within plan)

• Recruitment against approved funding for consultants appointment within 17/18 financial plan (Dec

2017)

• Appoint to existing gaps in NMGH new Divisional and Directorate structures (July 2017)

• Work with UHSM to strengthen acute physician input into AMU (July 2017)

• Deliver against plan to expand AMU Beds (July 17)

• Transition to NHSP and recruit to nursing workforce gaps (Sept 2017)

13

PAHT

Achieving the 62

Day National

Cancer Target

IF Capacity and Demand is not matched for challenged specialities

THEN patients may not be treated within required timescales

resulting in potential harm to patients, poor experience and failure of

Cancer 62 day National Standards


• Review Consultant leave Policies (July 2017)

• Training in place for bowel screening (July 2017)

• Continue Private sector capacity Gastro and recruit to business plan (review July 2017)

• Pathway review with CMFT for urology (July 2017)

• Review colorectal / General surgical pathways and capacity

• Procure Capacity / demand tool and training and standardise model (August 2017)

• Transition plan to be progressed

• Re-establishment of Divisional Performance and Assurance systems

13

PAHTClinisys Lab

Systems

IF the supplier support and licenses for the (known) end of life

Clinisys lab system is completely withdrawn THEN the Trust will lose

its results reporting capability which will severely affect patient care

and lead to adverse clinical incidents, slower patient flows, additional

expense for results reporting, patient complaints and reputational

damage

Chief Strategy and

Organisational

Development Officer

The Trust must urgently agree a strategy for replacing the existing Lab centre solution that recognises the

greater Manchester pathology service redesign work.13

PAHT

Caring for the

Deteriorating

Patient

IF processes are not in place and/or followed to reliably recognise a

deteriorating patient, THEN patient care may be compromised


and Chief Medical

Officer

• 2nd learning session took place 01/03/2017- good attendance by both medics and nursing

• E-Obs project planned rollout planned for mid-May 2017

• Third learning session to take place in Q2

• NEWS audit process to commence in July 2017

12

PAHTCaring for Patients

with Sepsis

IF processes are not in place and/or followed when caring for

patients with Sepsis, THEN patient care may be compromised


and Chief Medical

Officer

• Policy and procedure to be reviewed and refreshed

• Develop metrics aligned to SRFT

• To achieve quarterly CQUIN targets notes reviewed retrospectively until 50 patients with potential sepsis

are found

• Development of measurements/proxy measurements - completed

• Roll out of NEWS chart

• Sepsis steering group now established

• Sepsis clinical leadership now in place for each Care Organisation

• Sepsis Toolkit finalised at Sepsis steering group

12

17/19 31/158


PAHT Learning Lessons

IF lessons learnt are not effectively identified and acted upon THEN

system failures could affect the quality of patient care delivered and

regulatory involvement and reputational damage could occur


and Chief Medical

Officer

• DATIX system implementation from June 2017

• Development of risk registers and BAFs at NE Sector CO level in SRFT format

• BAFs to be reviewed at PRAGS, and to be presented to GRAC in June.

• Quality Control of process for Serious Incident Investigations. (High level review of completed

investigations).

• Improve communication and feedback process between Group and HM Coroners

• Learning Framework Report to be presented to Group CiC

• Comprehensive Action Plan to be presented to GRAC in June 2017

12

PAHT

Learning Lessons

from the

Diagnostic Review

IF lessons learnt are not acted upon following the Diagnostic review

THEN system failures could affect the quality of patient care

delivered and regulatory involvement and reputational damage could

occur


and Chief Medical

Officer

• Missed diagnosis e-learning programme launched December 2016

• Radiology Reporting Policy Protocols and Procedures policy reviewed and updated. Draft considered at

Diagnostic Review Group in Feb 2017 reported to the Audit Committee by Chief Medical Officer May 2017

and agenda item at Clinical Effectiveness Committee in My 2017

• EPR system to control and manage diagnostic requests to be implemented April 2017

• CRIS Communicator pilots to be commenced on all four sites

12

PAHT

Delivering an

Effective Quality

Improvement

Strategy

IF the Trust fails to deliver an effective Quality Improvement Strategy

THEN the Trust may fail to save and improve lives through reliable

care

Chief Nursing Officer · Final version of Quality Improvement Strategy to be approved by Group CiC. 12

PAHT

Delivering the

Cost

Improvement

Programme

Target

IF the Trust fails to deliver its Cost Improvement Programme target in

17/18 THEN the Trust may not achieve the forecast outturn financial

positon for 2017/18

Chief Finance Officer

• GROUP Productivity strategy to be developed via executive development and delivery committee

• Establishment of QPID across group to ensure opportunities for quality and productivity improvements

are identified and delivered in Care Organisations

12

PAHT

Putting Clinical

Leadership in

Place

IF effective, clinical leadership is not in place across the Trust THEN

Clinical variation may continue potentially leading to patient harm

Chief Strategy and

Organisational

Development Officer

Work being undertaken to develop a Leadership model for CDs to include the development of assurance

mechanisms. 12

PAHTRegaining JAG

Accreditation

IF the Trust fails to regain JAG Endoscopy accreditation THEN this

could lead to financial contract penalties and reputational issuesChief Delivery Officer

• On-going recruitment to permanent consultant posts (on-going)

• Deliver on action plan to meet JAG standards (May 2017)

• Complete estates, equipment and training risk assessments

12

PAHT

Achieving Planned

Activity and

Income Levels

IF the planned activity and income levels are not achieved and or

expenditure controls are exceeded leading to NHSI use of resources

rating lower than planned in 2017/18 THEN this will increase

regulatory investigation and intervention

Chief Finance Officer 2017/18 financial plan forecast to be achieved. 12

PAHT

Retrieving Clinical

Notes

Electronically

(Evolve)

IF the system for digitisation of clinical notes (Evolve) does not

deliver timely accessible and reliable retrieval of clinical notes THEN

care and communications with partners will be compromised


Agreed, robust staff training plan to strengthen and standardise records management and retrieval

practice/skills across all areas of the Trust and regular provision of assurance against plan provided into

PAT EARC .

12

18/19 32/158


PAHTCyber Security

Threat

IF the available cyber security expert advice or the Trust preventative

measures do not prevent emerging threats THEN this may lead to the

unavailability of key ICT systems/ infrastructure/records which would

significantly impact the Trust's ability to deliver safe patient care and

its ability to function as a care organisation

Chief Strategy and

Organisational

Development Officer

1.Review roles and responsibilities to ensure to address current and future cyber security threats (June

2017)

2. Increase Trust staff awareness of cyber security (December 2017)

3. Establish a task and finish group to implement recommendations from recent audits (May 2017)

4. Established a internal processes to review and maintain security controls and procedures (September

2017)

5. Plan further external reviews for assurance (September 2017)

12

PAHTImproving Patient

Flow

IF the Trust is unable to improve patient flow and ensure capacity to

meet demand through all sites with emergency departments THEN

the national standards for access will not be met and patient care will

be compromised


• Delivery of PAHT improvement plan projects (timelines outlined within plan)

• plan to support acute assess / ambulatory expansion at NMGH (July 2017)

• Trusted assessor and single line management of all IDT (July 2017)

• Agree ambulatory codes, counting and recurrent financial investment to enable recruitment and

expansion – all sites (July 2017)

12

PAHT

Patient Tracking

and Booking

System

IF effective systems and process are not in place to assure patient

tracking, booking and to ensure data quality THEN patient

treatments may be delayed, data submissions, and data used for

assurance and governance processes may be compromised


• Complete final validation of PTLs –(July 2017)

• Develop robust BI tools and systems to ensure data is viable, timely and accurate for operational teams

July 2017 Symphony upgrade (June 2017)

• PAS upgrade (October 2017)

• Deliver against actions in B&S improvement plan (October 2017)

• Establish new Divisional performance and assurance systems (August 2017)

• Review of cancer tracking and performance management arrangements (June 2017)

12

PAHT

National Referral

To Treatment

standards

IF Capacity and Demand is not matched for challenged specialities

THEN patients may not be treated within required timescales

resulting in potential harm to patients, poor experience and failure of

National Referral to Treatment standards


• Capacity and demand analysis to be completed for all specialities (August 2017)

• Improvement plans outlined and delivered – On-going

• Resolve process for inclusion of AHP activity (July 2017)

• Implement new CO performance and assurance structures and processes (August 2017)

• Recruit to workforce gaps (September 2017)

• Deliver final PTL and validation work (July 2017)

• Transition plan to be progressed

• Re-establishment of Divisional Performance and Assurance systems

12

PAHT

Completing Staff

Personal

Development

Reviews

IF staff do not participate in a good quality PDR THEN staff retention

may reduce and the workforce capabilities of Trust to deliver high

performance and improvement may be compromised

Chief Strategy and

Organisational

Development Officer

• Develop and implement a PDR quality monitoring system with which to improve the effectiveness of the

conversation. Site based reporting being developed

• Divisional Directors and Divisional HR BP have been requested to submit assurance plans to confirm

required target will be met – Plans submitted and monitored weekly

12

PAHTThe Estate at

NMGH

IF lack if investment in NMGH estate continues due to national

shortage of public dividend capital or business case not approved at

Greater Manchester or treasury levels THEN temporary work to allow

patient care in current facilities will need to continue

Chief Strategy and

Organisational

Development Officer

• Review underway of first elements of site investment of NM and TROH

• Developing Capital programme to bring forward some infrastructure and demolition

• Expectation of approval of infrastructure works

• Full premises assurance model survey for all sites within next 12 months

• Full Trust participation in regular meetings with CCG and GM on site redesign

12

PAHTIM&T Clinical

Systems

IF the Trust fails to achieve a coherent range of IM&T clinical systems

THEN there will be a lack of interoperability and sub optimal support

for clinical decision making and recording

Chief Strategy and

Organisational

Development Officer

• SOC incl high level IM&T plan shared with NHSI 12/12/2016, identifying £25m for EPR / PAS / healthview

• Clarify and establish the JEPR Board or similar

• Maintain current direction of travel and all controls as we work closely with Salford and GM

12

19/19 33/158

1


Meeting Group Committees in Common

Author Jude Adams, Chief Delivery OfficerJayne Downey Director of Governance,

Presented by Jude Adams Chief Delivery Officer Elaine Inglesby- Burke, Chief Nurse

Date 31st July 2017

Executive Summary

The Patient Information Request (PIR) was submitted to the CQC on 10th July. Along with multiple data and information requests the Trust is required to self-assess its services both at CO level and Trust wide. A quality summary outlining key improvements, weaknesses and challenges is also included in the PIR document.

Progress on the improvement plan continues to be made and a number of improvements sustained. Key risks continue to be workforce availability and a new risk relating to available funding to support the improvement plan following the inability to reach the desired settlement with NHSI.

Annual Plan Objective

Pursuing Quality Improvement to assure safe, reliable and compassionate care

Principal Associated Risks

Saving Lives, reducing harm and CQC quality improvements

Recommendations The Group Committees in Common is asked to review and confirm the current progress and associated risks.

Public and/or Patient Involvement (Including equality related impacts)N/A

CommunicationTo be discussed through NES CO Quality Improvement Meetings and Team Brief

Freedom of InformationPlease indicate appropriate box below

A – This document is for full publication

B – This document contains FoIA exempt information

C – This whole document is exempt under the FoIA

If you have chosen B above, highlight the information that is to be redacted within the document for subsequent removal.

Confirm to the Group Secretary which applicable exemptions apply to the whole document or to highlighted sections.

Title of Report PAHT Improvement Plan

x

1/9 34/158

2

1.0 Purpose

To outline for the Group Committees in Common the progress and key risks in delivering the Pennine Improvement Plan.

2.0 CQC Update

The PIR was completed and uploaded to the CQC on 10th July, within the identified timescale. The data required included universal information; medicines management, governance and risk management systems, mandatory training acute and community level information.

The information was verified by Group Executives and senior governance and patient safety leads, along with Care Organisation senior leadership teams. A Trust-wide and Care Organisation level self-assessment was undertaken against each of the 5 Domains, these are included in Appendix 1.The CQC has requested further information since the submission, which was to provide the performance dashboards, and these were supplied.

A number of areas were identified that require attention prior to the CQC assessment and these are being actioned through local and trust-wide CQC meetings and include:

Non-clinical ward moves Observation audits of WHO checklist Tracking children not admitted to the children’s ward Consent

As part of the PIR submission the trust was asked to identify areas of significant improvement, our weaker areas and areas of biggest challenge which are listed below.

Improvements made include:

Progress made against the improvement plan in particular the fragile services Introduction of the NEWS observation process Launch of the Quality Strategy and progress against collaboratives Introduction of NAAS Development of the visions and values Staff engagement Improved Governance and risk systems Falls End of Life care Waiting times for planned patients

Weaker areas include:

Performance against cancer standards (access, pathway coordination, capacity and demand) Pathology (leadership and governance, outcomes, conduct) Urgent care (ability to manage non-elective demand within the workforce / capacity constraints) Medical services (ability to provide specialist response reliably in the first 48 hours of care) Colo-rectal surgery (quality and safety) General surgery (capacity and demand) NAAS outcomes highlighting the need for reliable deployment of systems by ward teams

Biggest challenges include:

Recruitment to vacancies; and high reliance on bank, agency, and locum staff. Embedding a learning system

2/9 35/158

3

Organisational culture - embedding the values and behaviours of high reliability. Quality of some ward environments at North Manchester. Reliability and quality of IT systems Access to capital to enable reconfiguration of services to

support the Clinical Strategy

The CQC will meet on 14th August to discuss the process of inspection and identify resources required to undertake the inspection. It is anticipated an initial unannounced visit sometime in September, will take place across all sites which will include either some or all of the fragile services. At this time, a date will be agreed (within 2 weeks) for a further announced visit to be undertaken in order to review the remaining services and a date will be agreed for the announced well-led review.

It was clarified that based on the findings an up dated rating will be applied to Pennine

The weekly senior Executive meetings continue, along with care organisation and Trust-wide review of all services, reviewing up dated actions within the improvement plan and ‘must and should do’ documents.

3.0 Overall Improvement Plan Progress

Since the previous report further progress has been made towards delivery of the Improvement Plan, with the following ratings applied in month, previous month in (xx)

Overview of progress:

BRAG Blue Green Amber/Green Amber Amber/Red Red

Actions 46 (41) 19 (17) 11 (11) 17 (15) 8 1

As reported at the June Board the projects that are rated amber/red and red are largely driven by workforce constraints and are unlikely to see considerable shift ahead of the CQC inspection.

Medicines management is the exception to this and attention will be given to this by the Chief Pharmacist and Directors of Nursing over the coming weeks with a focused medicines safety audit to be undertaken across all CO over the next week. The PAHT Improvement Board has requested a more detailed assessment and review of the key risks and actions relating to medicines management.

Another emerging risk is the fragility of maintaining the critical care unit consultant cover at FGH, this in turn impacts upon the ROH workforce solution to stabilize HDU. There are currently 4wte vacancies (post HDU investment), these gaps in cover are over and above gaps in the on-call rota that have emerged as a result of medical adjustments and on the advice of occupational health. Solutions are being sought for safety in the immediate term but the impact on the remaining team is not sustainable.

The expansion to the acute medical beds at NMGH will be delivered in phases due to the availability of staffing – both medical and nursing. The Delayed Transfers of Care (DTOC) have not decreased at the rate required to release staff to support the additional assessment beds. A challenge has been set by the Chair of the PAHT Improvement Board to both Bury and City of Manchester LA’s to place a focused effort in meeting the required reduction over the next few weeks. Acute physician medical leadership support from University Hospital South Manchester is agreed in principle to support medical wards but not yet quantified or start dates agreed, this is being pursued actively by the Directors at NMGH. Quality improvement support into the AMU at NMGH is underway with tests of change focusing on the Society of Acute Medicine (SAM) guidelines.

3/9 36/158

4

Two quality collaboratives have been launched over the past month – Last 1000 days and Pressure Ulcers.

The good progress on IP&C clearly requires a sustained focus, a cluster of CDiff infections at the ROH are awaiting root cause and themed analysis to ascertain what additional measures need to be put in place or require greater focus.

4.0 Key Risks

4.1 As reported to the last CiC Board by the Chief Financial Officer a satisfactory financial agreement by all parties to support the improvement plan at Pennine has not been reached. The revised financial solution proposed to the June Committees in Common (CiC) Board has now been agreed between CCG commissioners CiC executives. In summary:

PAHT to improve its projections by £3.5m by utilising budgets held to manage risk, including those associated with loss of STF funding linked to delivery of performance standards.

NE sector CCG to allow PAHT to utilise slippage against stabilisation funding towards closing the gap. Current plans require a 10% slippage to reduce planned spend from £22.7m to £20.5m. It is proposed that a further £3.5m slippage is targeted setting a cap of £17m.

Appendix 2 sets out the revision to the investment plan and potential quality and performance impact along with any mitigation, were identifiable, of the revised financial settlement for PAHT.

This proposal was set out at the PAHT Improvement Board and whilst accepted was recognised to be sub-optimal and poses risk to the continued improvement projects and plans set out in 2016/17.

PAHT CiC executive directors and CCG quality leads have agreed that monitoring the quality and performance impact of this revised plan will be undertaken by the Clinical Quality Leads contract meeting which forms part of the governance arrangements between PAHT and commissioners. This group also has an additional reporting line through to the PAHT Improvement Board.

4.2 As reported in previous reports to the Board recruitment and workforce availability remains an ongoing risk to the delivery of a number of improvement actions. A detailed and expert review of our recruitment plans and strategy has been completed. The report identifies a numbers of areas for improvement and an implementation plan has been developed to be delivered by April 2018. The anticipated impact being:

• Increasing number of actual hires• Improved candidate and hiring manager experience• Improved candidate conversion rates• Increasing number of returners• Reduced turnover rates in staff with less than 24 months

4.3 General surgical service has been identified as a key risk through the Trust’s governance and assurance systems. There are a range of issues across quality, delivery and people, which the ROH senior leadership teams are addressing as the host of general surgery across the NES CO’s.

All Must and Should do’s, the fragile services and PIR issues are now being discussed and actioned through the Care Organisation and Trust-wide meetings.

Appendix 1

4/9 37/158

5

Pennine Wide

Acute Hospitals

Safe Effective Caring Responsive Well-led Comments

Provider wide Requires Improvement Good Good Requires

Improvement Good

AcuteSafe Effective Caring Responsive Well-led Comments

Urgent and emergency services Requires Improvement Good Good Requires

ImprovementRequires

ImprovementMedical care (including older people's care)

Requires Improvement

Requires Improvement Good Requires

Improvement Good

Surgery Requires Improvement Good Good Requires

Improvement Good

Critical care Good Good Good Requires Improvement Good

Maternity Requires Improvement Good Good Requires

Improvement Good

Gynaecology Good Requires Improvement Good Requires

Improvement Good

Services for children and young people Requires Improvement Good Good Requires

Improvement Good

End of life care Good Good Outstanding Good Good Based on the trust-wide end-of-life and bereavement models, service and team

Diagnostics Requires Improvement Good Good Good Good

Outpatients Good Good Good Requires Improvement Good

(Additional service - please describe)

Community

CommunitySafe Effective Caring Responsive Well-led Comments

Community inpatients Good Good Outstanding Good GoodAdults community Good Good Good Good GoodChildren, young people and families Good Good Good Good GoodEnd of life care Good Good Outstanding Good GoodCommunity dentalSexual health(Additional service - please describe)

NMGH

5/9 38/158

6


Provider wide Requires Improvement


Improvement Good


Urgent and emergency services Requires Improvement


ImprovementRequires

ImprovementMedical care (including older people's care)



ImprovementRequires

Improvement

Surgery Requires Improvement Good Good Requires

ImprovementRequires

ImprovementCritical care Good Good Good Good Good


Improvement Good


Improvement Good

Services for children and young people

Requires Improvement Good Good Requires

Improvement Good

End of life care Good Good Good Good Good





Community inpatients Good Good Good Good GoodAdults community Good Good Good Good Good

Children, young people and families Good Good Good Good Good

End of life care Good Good Outstanding Good GoodCommunity dentalSexual health(Additional service - please describe)

ROH



Improvement Good


Urgent and emergency services Good Good Good Requires

ImprovementRequires

ImprovementMedical care (including older people's care) Good Requires

Improvement Good Requires Improvement Good

Surgery Requires Improvement


Improvement Good

Critical care Requires Improvement Good Good Requires

Improvement Good


Improvement Good


Improvement Good

Services for children and young people

Requires Improvement Good Good Requires

Improvement Good

End of life care Good Good Good Good Good




FGH

6/9 39/158

7



Improvement Good


Urgent and emergency services Good Good Good Requires Improvement


Medical care (including older people's care)



Improvement Good

Surgery Good Requires Improvement Good Good Good

Critical care Requires Improvement Good Good Requires

Improvement Good

Maternity GynaecologyServices for children and young peopleEnd of life care Good Good Good Good Good




RI

Safe Effective Caring Responsive Well-led CommentsProvider wide Good Good Good Good Good

AcuteSafe Effective Caring Responsive Well-led

Urgent and emergency services Requires Improvement

Requires Improvement Good Good Good

Medical care (including older people's care) Good Good Outstanding Good Good

Surgery Good Good Outstanding Good GoodCritical careMaternity GynaecologyServices for children and young peopleEnd of life care Good Good Good Good Good





Community inpatients Outstanding Outstanding Outstanding Good OutstandingAdults community Good Good Good Outstanding GoodChildren, young people and familiesEnd of life care Good Good Good Good GoodCommunity dentalSexual health


7/9 40/158

Appendix 2

Workstream2017/18 Plan Revised Spend Impact Risks to Quality and

PerformanceMitigations

Critical Care £4,000,000 £2,500,000(-£1,500,000)

No investment in critical care outreach teamSlippage and revised investment in AHP and pharmacy supportSlippage and delay in recruitment to supernummary nurse co-ordinators

Failure to provide timely care and escalation/rescue of critically unwell

QI Project - Deteriorating Patient Collaborative

Matron appointments and prioritise 1:1 nursing care

Divisional Clinical Director appointment (strengthened leadership from anaesthesia)

Maternity Care £600,000 £400,000(-£200,000)

Revised support plan from CMFT. Limited to consultant Pas and HOM support

Improvement work does not continue at the pace needed

Investment in NMGH site leadership teams, Divisional and service structures

Continue to deliver improvement plans and activities already developed and in progress

Workstream 2017/18 Plan Revised Spend Impact Risks to Quality and Performance

Mitigations

Urgent Care £1,000,000 £850,000(-£150,000)

Reduction in spend on medical staffing due to permanent recruitment to consultant post and reduced medical remuneration costs

Safe staffing (nursing) £6,500,000 £4,000,000 Slippage in recruitment to nurse Impact on ability to safely staff all Prioritise urgent care demand

8/9 41/158

(-£2,500,000) staffing beds and meet activity and care demand – 18 week RTT impact, flow and quality of care

at expense of planned elective

Use NAAS to guide and put support into most vulnerable & priority areas

Site leadership and Divisional leadership investment

Further CCG deflections and OOH patient management

Trendcare and PAS £425,000 £225,000(-£200,000)

Revenue to capital transfer Value engineer NMGH and ROH capital enabling works

Data quality systems and processes

£500,000 £300,000(-£200,000)

Reduction in ability to improve DQ at pace

Ability to have real time good quality data to drive continuous quality improvement and identify productivity opportunities (Better care lower cost impact)

Leadership Development £750,000 £300,000(-£450,000)

Limitations to achieve scale and ‘reach’ of clinical leadership development

Fail to secure the cultural and leadership changes required to deliver improvement

Quality Improvement projects

£590,000 £540,000(-£50,000)

Slippage on recruitment Slippage to some timelines in improvement projects

Identify priority areas

Total £14,365,000 £9,115 ,000(-£5.25m)

9/9 42/158

Summary of the CQC and SRFT Diagnostic Improvement PlanBLUE Milestone successfully achieved

GREENSuccessful delivery of the project is on track and seems highly likely to remain so, and there are no major outstanding issues that appear to threaten delivery significantly.

AMBER/GREEN Successful delivery appears probable however constant attention will be needed to ensure risks do not materialise into issues threatening delivery.

AMBERSuccessful delivery appears feasible but significant issues already exist requiring management attention. These appear resolvable at this stage and if addressed promptly, should not cause the project to overrun.

AMBER/REDSuccessful delivery is in doubt with major risks or issues apparent in a number of key areas. Urgent action is needed to ensure these are addressed, and to determine whether resolution is feasible.

RED

Successful delivery appears to be unachievable. There are major issues on project definition, with project delivery and its associated benefits appearing highly unlikely, which at this stage do not appear to be resolvable.

Version Version 7.8Date 25/7/17

1/32 43/158

PENNINE ACUTE HOSPITALS TRUST – SAVING LIVES, IMPROVING LIVES OUR IMPROVEMENT PLAN AND OUR PROGRESS

2 k1fxjys4.5xu

What and why we need to improve

During February 2016 the CQC inspected services at PAHT. On 1st March 2016 Ms. Ann Ford, Head of Hospitals Inspection CQC, wrote to confirm immediate patient safety concerns that had been discovered as a result of the inspection. The concerns that required decisive immediate actions to stabilise services and assure patient safety were across 4 main service areas Maternity, Children, Urgent Care and Critical Care.

In April, following the interim appointment of Sir David Dalton as CEO, a team of senior health executives, supplemented by external support constructed and conducted a diagnostic review of the causes of risk to patient safety and care sustainability.

The diagnostic focus was to identify areas for improvement that impacted on patient safety. It was not a full investigation into all aspects of operations of the trust. Nor was it a full due diligence of the trust. The diagnostic was informed by the immediate concerns raised by the CQC.

The key areas for improvement identified in addition to the fragile services were: Patient safety, harm and outcomes Systems of assurance and governance arrangements Operational management and data quality Workforce capacity and capability Leadership and external relations

2/32 44/158


3 k1fxjys4.5xu

The CQC report has now been published (August 2016). The CQC identified 77 ‘Must Dos’ and 144 ‘Should Dos’ to ensure sustainable improvement to care delivered across the Pennine Trust services. The full report corroborates the findings of SRFT’s diagnostic.

The full CQC report has established evidence that PAHT, overall, is rated Inadequate.

All of the CQC ‘must dos’ and ‘should dos’ have been mapped across to the themes for improvement identified in the SRFT Diagnostic.

This improvement plan sets out the immediate (first 9 months) improvement actions – this is to ensure we are getting the basics right, stabilising services and creating the right conditions upon which we can continue to improve and ultimately transform care delivery across Pennine.

Our quality improvement strategy ‘Saving Lives, Improving Lives’, aims to go beyond the immediate concerns raised by the CQC report, we will engage our staff in a quality improvement strategy that will result in our services to be rated good or outstanding by regulators, that our staff would rate as a good place to work and a good place for their relatives to be cared for.

Who is responsible?

NHS Improvement (NHSi), in conjunction with GM Health & Social Care Partnership (coordinating the response of Bury, Oldham, HMR and North Manchester CCGs), invited Salford Royal NHS Foundation Trust (SRFT), to provide interim leadership support to PAHT from 1st April 2016 the Chair, Mr. Jim Potter and the CEO, Sir David Dalton, were appointed to interim positions of Chair and CEO of PAHT.

3/32 45/158


4 k1fxjys4.5xu

The Trust Chief Executive Sir David Dalton is ultimately responsible for implementing the actions in this document, the Trust executive team will provide the leadership to ensure we identify the right improvement actions that will tackle some of the long standing issues the Trust has faced and create the right conditions to deliver the changes required.

Our site leadership teams, divisional triumvirates and clinical leaders across the Trust will be key to delivering the actions that will ensure service sustainability and transformation. The high level deliverables articulated in this plan are underpinned by weekly improvement actions that clinical and management teams have developed and own. These weekly actions and evidence of delivery will be managed via an integration management office; teams will be supported to deliver changes at scale and pace with access to the SRFT standard operating model.

The GM Improvement Board will bring together parts of the local health and care economies to ensure there is a shared understanding and collective commitment to the delivery of the improvement plan, including resources that need to be made available to enable the changes to happen.

It is evident that the Trust has many thousands of staff trying to deliver good standards of care to patients. However, we need to create a culture of continuous improvement supported by robust governance and accountability arrangements from Board to ward which ensures leaders are focused on the key risks to the delivery of excellent care.

4/32 46/158


5 k1fxjys4.5xu

How will we measure our improvement?

Measurement of our improvements will be fundamental to ensuring sustainability and the reliability of our care. We will develop a high level assurance dashboard against our key themes that measures our progress. We need to ensure that our improvement actions and activities are translating to improvement in outcomes for patients using a small number of key performance indicators.

We will assure our improvement plan through our Trust board and Executive assurance committees

How will we communicate progress?

Internal Communication to staff within the Trust will utilise the full range of existing communication channels and our new leadership arrangements to listen, update and engage staff in the delivery of the improvement plan.

We will utilise a weekly message circulated to all staff, site notice boards; monthly face to face Team Talk sessions led by an Executive Director; regular briefings with the staff side representatives and direct engagement sessions between the Executive team and senior managers with a particular focus on meeting with the Clinical Directors.

Briefing of key issues through the line management structure; use of dedicated pages on the Trust intranet and articles on our improvement journey will feature in the monthly Pennine News magazine. Any matters which require immediate communication will be sent through an all user email.

5/32 47/158


6 k1fxjys4.5xu

There are multiple routes for staff to feed-back comments including the dedicated [email protected] email address; raising issues at face to face sessions with their line managers or at Team Talk sessions; contributing through the staff engagement programme; if necessary using the Speak in Confidence system to raise matters anonymously directly with senior managers.

Working in partnership with the multi-agency communications group we will: • Ensure the clear, consistent and integrated delivery of all internal and external communications including staff,

patients, families and carers, commissioners, GPs;• Ensure the public/patients are informed and reassured that services are safe;• Ensure that all key partners and stakeholders are kept up to date and informed about developments, decisions and

any service changes that are required and their impact;• Ensure all related media enquiries are co-ordinated and managed effectively, to ensure clear and consistent

messages and to ensure media coverage is accurate;• Work together to manage and protect the reputation of the NHS and social care in Greater Manchester and the

services provided across the local healthcare economy; • Ensure any subsequent operational or service changes are communicated effectively across PAT and the local

healthcare system to staff, GPs, the public and externally.

6/32 48/158


7 k1fxjys4.5xu

Improvement Theme

Summary of actions required Agreed timescale

Assurance and external support

RAG Status Executive and Operational Leadership

Revised deadline if required

BAF

Improving fragile services

Urgent Care

Establish clear leadership for the urgent care services and EDs in line with site based leadership model

Ensure adequate stabilisation of consultant and middle grade cover in ED at NMGH to meet the agreed service model requirements.

Assess the options for the Urgent Care service model for North Manchester

1.12.16

12.9.16

1.4 17

External – GM Improvement Board CCGsGM providers

Internal – Care Board and Quality Assurance Committee

All appointments made and commence in post June – SeptGREEN

Stability of consultant cover. Middle grade to be kept under review from a stability perspectiveAMBER

Options assessed and recommendation made to GMHSCP. COMPLETE

Chris BrookesChief Medical Officer

June for Division

1.3.17 for reviewRevised30.9.17

31.7.17

7/32 49/158


8 k1fxjys4.5xu

Have in place a nursing, ENP, ANP workforce to meet the demand of patients across EDs

Have in place a nursing, ANP, AHP workforce to meet the demand of patients across AMU’s

Develop and deliver primary care offer within ED at NMGH (including streaming)

Develop integrated ambulatory pathways and frailty model at NMG

31.3.17

1.9.17

30.9.16

31.3.17

ROH vacancies = no vacancies from SeptNMGH vacancies = 14 current, none from SeptAMBER GREEN

ROH= 14 RN vacancies from Sept post new recruitsNMGH =3 RNs current but 28RNs post expansion, 11 in pipelineAMBER

New Primary Care front end model outlined and tests of change underway AMBER GREEN

Model agreed, capital bid against NHSi funding submitted. Frailty offer will be included within phase 2 of the AMU expansion. Workforce recruitment remains risk to expansion AMBER

Chief Nurse



Chief Medical

ongoing

Ongoing

1.9.17

31.7.171.10.17

8/32 50/158


9 k1fxjys4.5xu

Ensure best practice patient pathways within the ED and time to assessment, treatment and transfers are well understood and delivered in order to manage risks to patient safety and improve care

Ensure the pathways/escalation response for medical, surgical and paediatrics and the speciality services capacity to respond to urgent and emergency care is developed in place.

Have in place an extended crisis response service for North Manchester, 8am – 10pm, 7 days

31.3.17

31.3.17

31.12.16

Improvement actions underway at all CO with weekly tests of change. Workforce & bed capacity remains key risk. Indicators stabilised or improving. ROH delivery risk increased.AMBER

Speciality solution not yet reliable but improving. DTAs at NMGH significantly improved. ROH delivery risk increasedAMBER

COMPLETED

Officer


31.7.17

ongoing

30.6.17

Go live Feb 17

9/32 51/158


10 k1fxjys4.5xu

Maternity Care

Put in place the senior management and clinical leadership to develop and drive forward the maternity improvement plan

Have in place robust workforce plans and available staff to deliver maternity services, including medical, nursing and support posts.

Establish comprehensive risk and governance arrangements which includes learning from incidents, complaints, auditing practice and improving incident and risk management systems and processes. Embed learning culture

30.9.16

1.1.17

19.12.16

External – GM Improvement BoardCCGsCMFT/RBH


COMPLETE

Midwife to births ratio improving. New recruits Sept. Interview dates for ROH consultant appointments 25/7 (17 candidates for 6 posts). NMGH – 5 posts advertised after RCOG approval, interviews Sept 6thGREEN

Systems and processes in place. COMPLETED

Chief Nurse/ Chief Medical Officer

Chief Nurse/Chief Medical Officer

1.12.16

Phase 2 30.6.17 appointsIn post 30.9.17

On-going

On-

10/32 52/158


11 k1fxjys4.5xu

Ensure all staff are trained and developed specific to their job roles

Ensure the engagement of all staff in the improvement plan, developing a culture of continuous quality improvement

31.3.17

31.3.17

Indicators improving with CTG training at 93%. GREEN

Continuous engagement on-goingGREEN

going

On-going

Paediatric Care

Ensure adequate numbers of trained paediatric nurses are in place to meet the demand and ensure safe care

Develop and deliver on the new model to stabilise paediatric urgent care for FGH

31.3.17

30.9.16

1.12.16

External – GM Improvement Board CCGs CMFT/RBH


HDU beds reliably staffed. Beds flexed to daily staffing to maintain safe ratios. Recruitment ongoing. Reduction in transfer out remains stable at reduced rateAMBER

COMPLETED

Chief Nurse


Chief Nurse

1.9.17

11/32 53/158


12 k1fxjys4.5xu

Ensure all staff are trained and competent to manage the critically ill child and have in place a 24hr/7 day rota for APLS/PLS trained staff.

Ensure the capacity to treat and care for children requiring elective treatment is in place sustainably

Develop and deliver on the new models of care to receive, assess and treat paediatrics at all sites

1.3.17

30.6.17

COMPLETED

Oral surgery wait list re-opened with agreement from NHSI. Capacity in place to reliably deliver 20 cases/mthGREEN

23Hr unit in place at NMGH. Gaps in workforce cap/demand at ROH and ANP role introducedAMBER/GREEN


Chief Delivery officer

1.9.17

Critical Care

Ensure sufficient consultant and middle grade cover to the HDU at ROH

30.9.16External – GM Improvement Board CCGs CMFT/RBH


HDU cover maintained at agreed levels and middle grade recruitment progressed. Risks to sustainability due to emerging consultant gaps at FGH and ROH cover required.AMBER

Chris BrookesChief Officer

Chief Nurse

31.1.1731.3.171.8.17

12/32 54/158


13 k1fxjys4.5xu

Ensure that the required nursing/AHP workforce across the critical care units is determined and in place

Determine the requirements for critical care outreach and safe response at night and weekends

1.6.17

1.6.17

Nursing gap closing to enable delivery against agreed plan. AHP plan to be reviewed in line with benchmark and funding revisionAMBER

Review post QI-Deteriorating patient

1.9.17

Develop and Ignite our QI Strategy

Develop PAHT QI strategy

Engagement and launch of Strategy with CO staff

1.9.16

31.4.17

External – GM Improvement Board CCGs COMPLETED

COMPLETED

Chief Nurse14.11.1612.12.1631.01.17

ongoing

Improving Quality

Improving Safety

QI Collaborative on deteriorating patients and managing sepsis

Engagement of staff 30.9.16


COMPLETED Chief nurse/Chief Medical Officer

13/32 55/158


14 k1fxjys4.5xu

Development of QI faculty

Commence collaborative

Test of change being undertaken and QI learning being embedded

Develop change package and scale up and spread

21.10.16

18.11.17

31.7.17

31.12.17

COMPLETED

COMPLETED

UnderwayGREEN

To be develop following completion of collaborative

31.7.17

Improving Safety 90 day improvement

cycles for pressure ulcers, falls, CAUTI

Have in place reliable data

Develop ward improvement goals

(Mar-Jun17)

1.3.17

1.6.17

Internal – Care Board and Quality Assurance Committee Pressure Ulcer data

correct, falls data correct, CAUTI under review but using STGREEN

Falls continues to improve, and P Ulcer collaborative launchedGREEN

Chief Nurse/Chief Medical Officer

ongoing

1.8.17

14/32 56/158


15 k1fxjys4.5xu

Improving Safety 90 day improvement cycle

reducing hospital acquired C.Diff

Have in place reliable data

Develop ward improvement goals and plans

Review and improve the Trust antibiotic polices and antimicrobial stewardship

Review and improve hand hygiene practices

(Oct-Dec)

1.10.16

1.1.17

30.9.17

30.9.17


COMPLETED-local action plans developed

COMPLETED

Policies reviewed by IP&C. Fundamentals of care programme led by CMOGREEN

CO medical directors assuring compliance but system not yet reliable.AMBER


Dec-Feb

Mar 17

Improving Safety

Implement NAAS System to ensure core nursing standards are met

Mobilise team and engage senior 9.9.16

Internal – Care Board and Quality Assurance Committee COMPLETED

Chief Nurse

15/32 57/158


16 k1fxjys4.5xu

nurse leaders in NAAS model

Undertake desktop assessment

Identify data collections methods and priority areas (pilot wards)

Baseline assessment of all priority wards and improvement plans developed

Completion of all wards

50% of all wards to achieve Green status

30.9.16

14.10.16

31.3.17

30.6.17

1.3.18

COMPLETED

COMPLETED

COMPLETED

On track – 15 wards outstanding

GREEN

Red wards improved in month 40% to 34% (now amber), green unchanged (24%)AMBER

28.10.16

1.9.17

Improving Safety Implement patient

support systemDeploy a support system to support vulnerable patients and families

Commence 1.10.16Complete 31.12.16


COMPLETED

Chief Nurse 31.3.17

16/32 58/158


17 k1fxjys4.5xu

Evaluation of support system 1.9.17

Improving Effectiveness

Reducing mortality

Outline methodology

Undertake Trust wide mortality review

Determine CO/Service level improvement actions using review data and Dr Foster intelligence

Ensure reliable system for M&M reviews and learning from avoidable factors

1.9.16

1.3.17

1.11.16

30.4.17

External – GM Improvement Board CCGs


COMPLETED

COMPLETED

COMPLETED

Maturity of system seen at FGH. Roll out to other CO under MD leadershipAMBER GREEN


31.12.1631.1.17

30.4.1630.6.17

30.6.1730.9.17

Improving patient experience

Improving End of Life Care

Undertake a baseline assessment of bereavement care

30.9.16


Internal – Care Board and

COMPLETED

Elaine Inglesby-Burke

Site Nurse Directors and Medical Directors

17/32 59/158


18 k1fxjys4.5xu

Work with wards and departments to agree the plan

Roll out the Royals Alliance bereavement model

1.12.16

31.3.17

Quality Assurance Committee

COMPLETED

COMPLETED

Improving patient experience

Implement ‘what matters most to me’

Undertake baseline assessment of Patient Experience and determine other key improvement actions

Develop QI Collaborative on last 1000 days and PJ Paralysis

Undertake tests of change

Commence 1.4.17Complete 1.9.17

30.4.17

CommenceJune 17.Conclude 30.11.17July-Nov

Project to form part of last 1000 days

Ongoing improvement actions relating to FFT continueGREEN

COMPLETED

CommencedGREEN

Chief Nurse

ongoing

18/32 60/158


19 k1fxjys4.5xu

Develop change package and spread

Nov-Dec

Ensure safe medicines management

Develop plans derived from core standards and audits

Deliver on improvements to:- CD/RD checks- Fridge ambient temps- Crossing out/signatories

Revise Medicines Safety Group

31.10.16

31.7.17

31.7.17

COMPLETED

Some improvement in June Duthie audits. Comprehensive unannounced medicines afety audit to be undertaken in July by senior nurse leaders. Re-evaluate post auditAMBER-RED

First meeting of revised group to take place in AugustAMBER-RED


30.4.17

19/32 61/158


20 k1fxjys4.5xu

Complete MIAA audit actions 31.8.17 Plans in place to address actions AMBER-RED

Improving Risk and Governance

Implement new risks and governance arrangement across the Trust

Undertake comprehensive assessment of governance arrangements and develop work plan focussing initially on 4 priority areas:complaints, claims, serious incidents and coroners inquests

Implement new risk and governance framework

Put in place new Board Assurance Framework

Ensure risk and governance arrangements during Transition to new CO and once new CO are

31.11.16

1.8.17

31.12.16

31.10.16

1.9.17


Internal – Care Board Executive Risk Assurance Committee

Assessment and early improvement actions determinedCOMPLETED. Month on month improvements continueComplaints backlog trajectory agreed real time response to be in place by November 17GREEN

COMPLETED

COMPLETED

New Transition Board established. Clear project planAMBER- GREEN

Chief Nurse

30.11.17

20/32 62/158


21 k1fxjys4.5xu

established remain robust

Roll out risk training for all staff

Phase 2 training to be delivered for new Divisional leaders once established

Implement new Datix system

31.3.17

CommenceJuly

31.4.17

COMPLETED for phase 1.

Additional training procured and starts SeptGREEN

Implementation August, training completed AMBER GREEN

1.6.171.7.171.8.17

Review all safeguarding

Deliver on level 3 children’s safeguarding training to agreed standard

Undertake gap analysis for MCA DOLs and deliver on agreed action plan

31.11.16

31.2.17

External – GM Improvement Board CCGs Local Authorities

Internal – Executive Quality Assurance Committee

New Head of Safeguarding in post, training compliance maintained for high risk areasGREEN

Gap analysis completed. Plans in place to develop staff knowledge and applicationAMBER/GREEN

Chief Nurse

31.3.17On-going

On-going

21/32 63/158


22 k1fxjys4.5xu

Improving Operations and Performance

Ensure improvement to patient flow

Implement SAFER model across all wards

Improving reliability of SAFER

Commence QI project on Reliable ward rounds

Commence QI project on standard work for bed managers

Ensure flow/bed requirements are driven by agreed clinical pathways of care, are modelled and delivered

16.12.16

31.7.17

Start 1.7.17

Start 1.7.17

1.4.17

External – GM Improvement Board CCGs Local AuthoritiesCommunity providers

Internal – Executive Operations and Performance Committee

COMPLETED

See refresh below

Tests on 2-3 wards per CO to identify bottlenecks

NMGH AMU work underway. AMBER

CO wide meeting 2nd August to review FOCUS model and agree 90 day improvement planAMBER

AMU/ambulatory pathways modelled. GREENAgreements with Commissioners on recurrent ambulatory funding. Workforce risks to NMGH AMU expansionAMBER/RED


1.9.17

Revised date1.9.17

22/32 64/158


23 k1fxjys4.5xu

Have in place systems and processes for the management and escalation of patient flow across the acute sites to ensure patients are care for in the right place

Put in place and deliver against agreed standards which ensure medically optimised patients are transferred safely and appropriately

1.4.17

1.6.17

Trust escalation systems revised to include OPEL. COMPLETE

IDT teams in place. Needs agreed timeliness standards across NES & TA. Agreed DTOC levels not achievedAMBER

1.9.17

Ensure data quality systems and processes are robust to deliver on operational performance

Reduce PAS open registrations by completing data cleanse exercise and put in place systems and process for access control

Create business intelligent patient tracking list and tools to support operational staff in managing stages of treatment for patients

28.10.16

1.1.17


Internal – Care Board and Executive Operations and Performance Committee

Open registration closure commencedAMBER GREEN

RTT and FU PTLs live in July/AugAMBER GREEN

Chief Delivery Officer 14.11.16

14.2.1716.4.1730.6.1731.8.17

30.6.1731.7.17

23/32 65/158


24 k1fxjys4.5xu

Ensure all identified staff groups have access to and are trained and assessed on referral to treatment rules and PAS functionality

Ensure booking and scheduling functions and resources are in place to meet the standards required and are structured to support operational delivery and the best patient experience.

Put in place systems and processes to ensure clinical input into validation of ED breaches and non breaches

Ensure ED symphony system is utilised and optimised in patient tracking and clinical pathway management.

Ensure ED patient tracker roles are developed and supported across all EDs

1.1.17

31.3.17

1.10.16

1.12.16

31.12.16

Core systems trainers appointed. Training on-goingGREEN

Draft KPIs developed and clinical and operational policies/processes under review. Engagement sessions planned with teamsAMBER

COMPLETED

Continued delays with technical solutionAMBER RED

COMPLETED

On-going

1.6.1730.9.17

31.3.1731.5.1727.6.1731.8.17

24/32 66/158


25 k1fxjys4.5xu

Undertake self-assessment against audit commission standards on DQ, develop action plans to address gaps.

1.6.17 Reviewing DQ kite marking for all corporate data and actions plans TBD based on level of riskAMBER

ongoing

Workforce and safe staffing

Undertake baseline safe staffing review of nursing

Assess all wards and departments against Salford Nursing Standards commencing with high risks areas

Agree and develop workforce plan to address shortfalls

Have in place systems and processes to report and close workforce gaps to achieve safe reliable staffing (90% standard)

30.9.16

31.10.16

30.6.17


Internal – Care Board and Executive Quality Assurance Committee

COMPLETED

Blended workforce solutions outlined in principle but require strategic and operational plan to deliver AMBER RED

Fill rates achieved with reliance on temporary staff due to recruitment challenges. NHSP gone liveAMBER RED

Chief Nurse 14.11.16

30.11.161.5.17Ongoing

Ongoing

25/32 67/158


26 k1fxjys4.5xu

Undertake baseline safe staffing assessment for medical staff

Understand vacancies against funded establishment

Assess fragile services against national standards and clinical service need.

Develop plans for resolution of gaps

Close all critical medical workforce gaps on sustainable base

31.8.16

31.12.16

31.6.17

External – GM Improvement Board CCGs, GMTU

Internal – Care Board and Executive Workforce Assurance Committee

COMPLETED

Assessment COMPLETE

Agreed initial investment 12.5 WTE Consultants across the three CO’s to support general internal medicineCOMPLETED

Progress on stabilisation. Sustainable solution at risk – timescale and cost Overseas recruitment underway with circa 10-14 MGs in pipelineRED


1.12.17

26/32 68/158


27 k1fxjys4.5xu

Implement new model for recruitment

Identify hard to recruit groups

Outline model and strategy for recruitment for fragile services

Evaluation of strategy

30.9.16

30.9.16

1.9.17

COMPLETED

COMPLETED – plan revised following exec discussion

COMPLETED – revised action plan developed

31.11.16

Deliver on staff ‘Happy Health Here’ programme

Promote and improve the health, wellbeing and engagement of the workforce

Improve availability of the workforce and reduce reliance on temporary staffing

31.3.17

31.3.17



Sickness absence in month at 4.97%Engagement strategy approved and underway with launch of 1000 voicesAMBER GREEN

Temporary staffing spend remains high. Staff appointments in pipeline for Sept startsAMBER/RED

Chief of Strategy and Organisational Development

On-going

On-going

27/32 69/158


28 k1fxjys4.5xu

Develop new PDR offer and ensure staff have opportunity to engage in performance development discussions.

Meet 90% PDR standard

Ensure all staff have access to and complete mandatory training

Meet 90% standard

31.3.17

31.3.17

31.3.17

New offer developed. COMPLETED

PDRs at 71% DQ issues being addressed. AMBER

Current performance marginally below target at 86% against 90% standard AMBER-GREEN

On-going

On-going

On-going

Improving Leadership and strategic relations

Development of Group

Transition from interim executive Chair and CEO arrangement to permanent solution

Finalise group structure and governance arrangements

1.8.16

31.3.17

External – NHSi, NHSE, GM Improvement Board CCGs

COMPLETED

COMPLETED

Chief Executive 30.11.16

31.3.17

28/32 70/158


29 k1fxjys4.5xu

Implement Site Leadership model

Agree model and for site leadership and management of services

Recruit to site leadership teams

Develop site improvement plans and accountability framework

31.10.16

Commence 1.9.16Conclude 1.4.17

1.12.16



COMPLETED

COMPLETED

COMPLETED

Jon LenneyExecutive Director of HR &OD

1.4.17

Develop and deliver on clinical leadership programmes

Design, commission and deliver joint clinical leadership programmes with Chief Nurse, PAHT MD and Salford Head of Leadership (post TFL programme)

Design 1.10.16

Delivery commence 1.12.16

Develop

QI and Leadership programmes developed and delivery underway. GREEN

Chief of Strategy and Organisational Development

1.4.17

31.6.17Ongoing delivery

29/32 71/158


30 k1fxjys4.5xu

Develop and deliver a range of leadership workshops for non-clinical leaders with SRFT Head of Leadership and Executive Sponsor(s)

31.10.16

Delivery commence 1.11.17

Plans developed with CO and underway

GREEN

1.4.17

31.6.17On-going

30/32 72/158


31 k1fxjys4.5xu

Requirements to support improvement action

Timescale for implementation

Owner Progress against timescale Revised deadline if required

Agreement of management contract with SRFT 31.10.16 Raj Jain Complete 31.11.16

31.3.17Financial settlement agreed to support improvement plans and delivery on LTFM in 16/17 and projections for 17/18 30.9.16 Damien

Finn/CCGsComplete 31.11.16

Agreed specification and plans from commissioners on model of care for ‘primary care front end’

1.12.16 CCGs Requires finalisation in all localities 30.4.17Engagement with and support from CCGs and LA to deliver on site and locality clinical service strategies 31.3.17 CCG/LAs

Joint Transformation Board in place. LCO plans in various stages of development

Requires revised deadline

Engagement and contribution to system wide UC improvement & safety workshop led respectively by ECIP and Charles Vincent

31.1.17 CCG/LAs and PAHT

Commenced

Review of clinical quality and performance arrangements with commissioners to ensure robust assurance and safety systems in place

1.12.16 CCGs and PAHT

Contributions to CQC inspections by Commissioners

Establishment of IMO to manage integration and co-ordinate improvement activities/synergies with SRFT 31.9.16 Jude

AdamsIn place

Support from GM transformation unit and GM providers to develop and contribute where appropriate to new models of care for frail services

30.9.16 GMTU In place

31/32 73/158


32 k1fxjys4.5xu

SALFORD STANDARD OPERATING MODEL

32/32 74/158

1



Author Linda Izquierdo Associate Director of Nursing, Patient Experience

Presented by Elaine Inglesby- Burke, Chief Nursing Officer

Date 31st July 2017

Executive Summary

The purpose of this paper is to provide the Committee in Common (CiC) with an update on; the progress and effectiveness of systems and processes for the collection, analysis, learning, implementing and monitoring improvements across the 4 Care Organisations based on patient/service user feedback. To highlight areas that demonstrate good practice and themes across the 4 Care Organisations which are receiving attention to improve patient/ service user and staff experience and satisfaction.


Pursuing Quality Improvement to assure safe, reliable and compassionate care


Saving Lives, Reducing harm and CQC quality improvements Possible failure to demonstrate meaningful engagement and subsequent improvement to patient experience may harm the reputation of the Group and/or Care Organisation, and negatively raise the Trust’s profile with the CQC, Commissioners and other stakeholders.

Inefficacy in obtaining and utilising the patient experience as an additional indicator for patient safety could potentially compromise the quality and safety of patient care.

Recommendations The Group Committees in Common is asked to review and confirm the content of the report and provide any further recommendations to the proposed actions to be taken.

Public and/or Patient Involvement Patient feedback forms the basis of the report.

Communication







Title of Report Patient and Service User Experience Progress Report - April to June 2017

X

1/7 75/158

2

1.0 Introduction

1.1 The purpose of this paper is to provide the Group Committees in Common (CiC) with an update on; The progress and effectiveness of systems and processes for the collection, analysis, learning,

implementing and monitoring improvements across the 4 Care Organisations based on patient/service user feedback.

To highlight areas that demonstrate good practice and themes across the 4 Care Organisations which are receiving attention to improve patient/ service user experience and satisfaction.

1.2 Patient/ service user experience is well established as a measure of quality and referred to by theCQC as one of the key indicators of a well led organisation. Patient/ service user feedback data is available from a variety of sources at both a local and national level from people who use the services of the 4 Care Organisations.

1.3 It is critical to understand what patients/service users think about the care and treatment they receive to enable the organisations to improve or maintain a high level of quality, safe care with good patient/service users experience and outcomes.

1.4 The aim in presenting this data is to provide assurance to the Committee, patients, services users, and other stakeholders of the current measures in place and action being taken to support future development and improvement.

1.5 It should be noted that due both the national surveys categorisation of organisations as Acute Hospital or Combined Acute hospital and Community services and the variation in current systems and processes across the 4 Care Organisations for the collection, analysis and presentation of data used in this report is not always comparable. This issue is currently being scoped with the relevant support services to identify potential solutions and timeframes to provide comparable and meaningful data to assist with performance monitoring in the future.

1.6 This paper focuses upon the feedback gained from: The Annual Care Quality Commission (CQC) Inpatient Survey 2016 The Family and Friends Test (FFT) Near Real Time and Real Time feedback Nursing Accreditation and Assessment Scheme (NAAS) Community Assessment and Accreditation Scheme(CAAS)

2.0 Summary April 2017 to June 2017

2.1 Annual Care Quality Commission (CQC) Inpatient Survey 2016 result highlights.

2.1.1 The national CQC inpatient survey is designed to reflect the patient journey and eligibility for participation in the 2016 survey was based on patients who are 16 years or older, that had spent at least one night in hospital and were not admitted to maternity or psychiatric units, between August 2016 and January 2017.

2.1.2 Salford Royal NHS Foundation Trust (SRFT) results showed ‘About the Same’ on 10/11 section scoredwhen compared to all other Trusts including specialist Trusts and ‘Better’ on section 8 of the survey - operations & procedures.

2.1.3 Excluding specialist Trust’s:

SRFT score ranked joint 3rd for overall patient experience (7 other Trust’s) SRFT score ranked joint 3rd for section score on care & treatment (7 other Trust’s) SRFT score ranked 1st for section score on Operations & Procedures

2.1.4 Areas where SRFT scores declined compared to 2015 are: From the time you arrived in hospital, did you feel that you had to wait long to get a bed on a ward?

2/7 76/158

3

Were you offered a choice of food? In your opinion, were there enough nurses on duty to care for you in hospital? Did you feel involved in your decisions about your discharge from hospital? Did hospital staff take your family or home situation into account when planning your discharge?

2.1.5 Pennine Acute Hospitals Trust (PAHT) results indicated ‘About the Same’ on all section scores when compared to all other Trust. Although the Trust’s overall rating for Section 8 of the survey- operations and procedures section was average, the question about ‘receiving an explanation they could understand about how they would be put to sleep or their pain controlled’ has for the past 3 years seen a year on year increase in score for the question in this section. This indicates this is ‘Better’ than other comparable Trusts.

2.1.6 Areas where scores declined compared to 2015 are: Did you get enough help from staff to eat meals? Were you told how you could expect to feel after you had the operation or procedure? Did a member of staff tell you about medication side effects to watch for when you went home?

2.1.7 CQC National Inpatient survey results scores are reported at a Trust level with some elements of scores for questions reported by individual hospital site.

2.1.8 A review of the scores for the North Manchester General Hospital (NMGH), Fairfield General Hospital (FOH) and Royal Oldham Hospital (ROH) highlight the following;

NMGH consistently received the highest negative ratings in respect of treating some patients with a lack of dignity, patients not feeling well looked after, overall poor patient experience, and providing information as to how to complain.

Fairfield General Hospital registered the highest percentage score for not seeking patients views on the quality of care received. They did however perform better for overall rating in providing good patient experience, and treating patients with respect or dignity than the Picker average. (See Table 1)

Table 1

Royal Oldham Hospital received ratings marginally better than the PAHT average in respect of treating patients with dignity and respect and providing a good patient experience. Whilst it was found to be weaker, obtaining patients views of their care, informing patients on how to complain and not making patients feel well looked after.

Rochdale Hospital did not receive specific feedback as only 9 responses to the National inpatient survey were received.

2.1.9 All Care Organisations have received and reviewed the results of the survey for consideration and triangulation with other key sources of data including; complaints, Pals, other survey responses and FFT feedback. This will assist in identifying common themes and high impact outcomes, to initiate improvements that will be

Aspect of Care FGH Trust

Q16. Hospital: bothered by noise at night from staff 11% 21%

Q18+. Hospital: toilets not very or not at all clean 1% 6%

Q22+ Hospital: food was fair or poor 26% 38%

Q23 Hospital: not offered a choice of food 17% 27%

Q26 Doctors: did not always have confidence and trust 15% 24%

3/7 77/158

4

incorporated into the over-arching and individual Care Organisation/Trust quality, patient safety and patient and service user experience improvement plans.

2.1.10 Patient/ service user engagement with local communities and stakeholders including Healthwatch and Care Organisations is being progressed by the patient experience team to promote involvement in shared solutions were appropriate.

2.1.11 Initial common themes from the inpatient surveys, across the 4 Care Organisations for consideration of actionsfor improvement include;

Themes Actions Poor meal choice and insufficient food Review and improve nutrition and hydration system and

process to ensure patients/ service users dietary needs are met

Lack of discharge planning and patient/service user involvement in decisions about their discharge from hospital, taking family or home situation into account when planning discharge

Review and improve discharge planning and implementation in association with relevant partner organisations.

Lack of information regarding information regarding medication including side effects to watch for when discharged

Review and improve patient information and guidance regarding medication including expected side effects to be watch for including when discharged.

Ensuring privacy and dignity is maintained across all aspects of care and stages of the patient/service user journey

Build on existing good practice and learning to improve and sustain patient/service user privacy and dignity across all aspects of care and all stages of their journey.

2.2 The Family and Friends Test (FFT)

2.2.1 This is mandated by NHS England and which both PAHT and SRFT implement through a third party provider (HealthCare Communications).

2.2.2 PAHT overall response rate in May 2017 for emergency departments, inpatient and day-case areas showed a low Response Rate of 19%, 7042 (88%) patient/service users, would recommend and 449 (6%) patient/service users would not recommend. FFT performance data are now illustrated and monitored via a SPC Chart format for PAHT.

84

86

88

90

92

94

96

98

Inpatient - Friends and FamilyPatient Experience - % Recommend

Actual Av UCL LCL

+1 Sigma -1 Sigma -2 Sigma +2 Sigma

2.2.3 A comprehensive programme of work is currently underway to strengthen staff’s understanding and promotion of FFT to gain feedback regarding the care received by the patient or service user, as an additional indicator for patient safety and quality. This includes representation, input and shared learning across the 4 care organisations in the form of a time limited task and finish group to improve FFT performance and the use of patient/service user feedback by staff to improve care.

2.2.4 Key work streams and actions include; Increasing patient participation through highlighting the FFT in both hospital and community areas and

improving awareness to staff and patients of the Friends and Family test including non- clinical staff for example reception and appointment staff.

4/7 78/158

5

Working with key staff to identify the most appropriate methods for feedback dependent of the patient or service user groups. This will include SMS, Text, Cards, including bespoke cards to the area for example ‘Tops and Pants’ in Children’s wards and inclusivity cards for those whom English is not their first language or who have communication difficulties.

Data cleansing and action to address the failure rate in contacting patients including clarification of hierarchy codes for improved individual Care Organisation reporting and the implementation of robust processes to disseminate accurate information and improve and increase staff’s receptiveness and actions taken on FFT feedback.

2.2.5 SRFT has recently refreshed the response rate for community and outpatients as the current calculation as required by NHS England was for inpatients/A&E only and this was significantly impacting on the response rates. The calculation is now based on the responses from actual number of surveys sent rather than the total number of eligible patients, due to survey fatigue, user excluded from the survey if they have received a survey in the last 30 days. For example for overall response rate for May 2017 has increased from 15% to 31% for outpatients, local FFT data sent out to divisions will now show both calculation rates.

2.2.6 A review comparing FFT rates with comparable Trusts (acute/community and data collection methods), is due to be undertaken to prevent significant impacts on performance depending on the type or organisation and the method of data collection.

2.2.7 SRFT and PAHT are working with Healthcare Communications (HCC) to identify best practice to collect user data for example from the Panda unit and also undertake a deep dive of the data from community services to identify key areas for improvement.

3.0 Real time and Near Real Time Feedback

3.1. Systems and processes to gather real-time and near real patient/service user feedback give the ability to capture, review and act on individual experiences of care to improve quality safety and patient/service user experiences and can lead to rapid improved learning and shared good practice were appropriate.

3.2 SRFT local surveys supported by Picker are embedded and provide a rich source of data and are collected both electronically (through the hospedia TV system on ward areas) and paper based collection.

3.3 Patient/service user feedback is discussed by staff at ward, community or outpatient level. These discussions with staff take place in a variety of different ways: utilising daily safety huddles, staff emails, ward meetings or patient experience notice boards. By using various methods of highlighting patient feedback, this ensures that staff are very aware of what patients say about their care and use this to make improvements.

3.4 Similarly work is taking place across NMGH, ROH, FGH and RH Care Organisations to utilise these and other methods to review, act on and ensure shared learning from patient/service user feedback to improve care supported by the patient experience team.

3.5 A deep dive of methods for capturing data and working to improve data collection and reporting of this information is being undertaken by SRFT, to ensure that it is accurate and reflective of the current organisation. The business performance & information team will be working with divisions to cleanse this information to ensure it is captured and presented accurately.

3.6 Women’s and Children’s Division are exploring a number of methods to gather information and act on that information to enhance both care and facilities to improve patient experience. The Division has a pilot project at the ROH supported by Care Opinion (an independent non-profit feedback platform for health and social care), to highlight and respond to posting specific to their services. This method gives the opportunity for changes to feedback to be clearly highlighted as part of the feedback process.

3.7 A recent example of a change that has recently been implemented at the ROH Maternity Unit is that a card will be left in the mother’s room to indicate that it has been cleaned. This has the potential to be developed and rolled out across the care organisations to improve and maintain cleanliness of patient/ service areas.

5/7 79/158

6

3.8 End of life and Bereavement services following the identification of common themes from real time feedback from patients/service users regarding their experience have implemented a number of changes across NMGH, ROH, FGH and RH Care Organisations. These include;

SWAN facilities to ensure the family can stay with their loved ones who is in the last days of their life Easy reference multi faith care of the dying guidance in partnership with faith leaders and the

chaplaincy team for staff to assist them meet the needs of patients/service users

4.0 Nursing Accreditation and Assessment Scheme (NAAS)

4.1 The NAAS is designed to support nurses in practice to understand how they deliver care, identify what works well and where further improvements are needed.

4.2 Current Performance

4.2.1 SRFT

4.2.2 To date, there are 32 wards that are SCAPE status (safe, clean and personal every time). One ward (B6) is deferred till a SCAPE Panel later this year, following their review at December’s 2016 SCAPE Panel.

4.2.3 With recent ward reconfigurations there are currently 44 areas in total to be assessed with two new areas requiring assessment which are The Pendleton Suite and M2.

4.2.4 The current results to date show:

4.2.5 PAHT

4.2.6 A total of 53 areas have now been identified as requiring a NAAS assessment, including the 3 A&E departments and critical care areas. This number has reduced from the initial 59 areas as several wards have been assessed together if they have the same Ward Manager eg.C5 and 6 at NMGH and wards 4and 5 at FGH.

4.2.7 To date: 38 ‘first’ NAAS assessments have been undertaken 9 assessments as part of the pilot and 13 re-assessments

34%

42%

24%

Red wards Amber wards Green wards

Across all 4 sites 53 areas in total to be assessed

38 undertaken15 outstanding

56%19%25%

Red wards Amber wards Green wards

NMGH20 areas in total to

be assessed16 undertaken4 outstanding

Red Level 00

Amber Level 10

Green Level 210

Blue Level 332

6/7 80/158

7

23%

54%

23%Red ward Amber ward Green ward

TROH16 areas in total to be assessed

11 undertaken5 outstanding

4.2.8 The date for completion of all ‘first’ NAAS assessments is September 2017; this is later than the initial date

identified of July 2017 due to the number of reassessment which was not anticipated. 4.6 SRFT CAAS (Community Assessment and Accreditation System)

4.6.1 There are currently 42 areas that require assessment (this number might change due to service reconfiguration).

4.6.2 To date, 41 areas have been assessed with 1 team needing assessment. Results are as follows:

4.7. OPAAS (Outpatients Assessment and Accreditation System)

5.0 Conclusion

5.1 Further understanding and triangulation of patient and service user feedback mechanisms is required including survey results, FFT and Real-time feedback with clear improvement actions and learning identified.

5.2 Integrated data and performance monitoring IT solutions to support data collection and analysis.

5.3 Development of a Group performance dashboard for patient experience assurance and governance.

5.4 Development, engagement and launch of the Group Patient/User Experience and Involvement strategy linked tothe Quality Improvement Strategy.

Red Level 0 Amber Level 11

Green Level 232

Blue Level 35

Red Level 0 Amber Level 1 Green Level 29

Blue Level 33

9%

55%

36%

Red ward Amber ward

FGH / RI17 areas in total to be assessed

11 undertaken 6 outstanding

7/7 81/158

1



Author

Josh Hennighan – Incident CoordinatorAlison Dooley – Inquest ManagerLynne Logan – Complaints ManagerCraig Wood – Datix Project Manager

Paul Downes – Director of Patient Safety

Presented by Chief Nursing Officer

Date 31st July 2017

Executive Summary

This report provides governance data for the period 1st April 2017 – 30th June 2017 (Q1). The data provides insight into incident reporting, coronial activity, litigation and complaint management. Lesson learning from each category is provided within the report, together with key areas of improvement and areas of risk. Where the latter is described, a narrative is provided to provide assurance as to how the risk is being managed.



Recommendations Group Committees in Common is asked to:

Confirm the progress in the monitoring and management of governance assurance systems and consider any associated risk.

Public and/or Patient Involvement (Including equality related impacts)N/A

Communication The Learning from Experience Report will become a public document through the publication of the Group CiC meeting papers.

Title of Report Learning from Experiences Report

1/44 82/158

2







IntroductionThis paper combines both Pennine Acute Hospitals NHS Trust and Salford Royal NHS Foundation Trust data to create the first Group Learning from Experience Report (LFE) report. The period described relates to Quarter 1, 2017-18 and it is based on data submitted to the Safeguard Risk Management Database at Pennine Acute Trust and the Datix Management System at Salford Royal. The purpose of the report is to advise Board members of governance reporting activity, learn from incidents, coronial inquests, complaints and PALs information, and to identify themes and share learning, which will lead to improved patient safety.

Incident reporting

Incidents reported between 01/04/2016 and 30/06/2017 by Care Organisation

Patient Safety Incident?

Patient Safety Incident?

No YesGrand Total

No YesGrand TotalCare

Organisation

Actual number of reported incidents Percentage reported of Group’s total

North Manchester 495 1500 1995 5% 16% 22%

Rochdale and Bury 497 971 1468 5% 10% 16%

Royal Oldham 547 1541 2088 6% 17% 23%

Salford Royal 483 3049 3532 5% 33% 38%

N/A* 107 71 178 1% 1% 2%

Grand Total 2129 7132 9261 23% 77% 100%

*Due to the historic inclusion on Pennine’s Safeguard of miscellaneous locations and generic (such as “All Sites”) not all reported incidents can be transposed into the Care Organisation format

X

2/44 83/158

3

Group – All Incidents reported per month Group – Patient Safety Incidents per month

0

500

1000

1500

2000

2500

3000

3500

4000

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6 0

500

1000

1500

2000

2500

3000

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Incident reporting has seen an increase over the Group with all Care Organisations demonstrating a collective 10% increase in reporting over the last 12 months. NMGH is the highest reporter of adverse incidents within the Pennine Trust and also demonstrates the lowest number of harm events. The highest individual Care Organisations reporter of incidents for Q1, 2017/18 is Salford Royal, with 3532 (38%) of the Group’s 9261 reported incidents. Salford Royal also continuously sees the highest year on year improvement in terms of number of incidents reported. Organisations with higher incident reporting numbers are associated with a positive culture of being open and staff confidence in learning when incidents are submitted. Salford Royal’s significantly higher reporting data demonstrates a current positive difference in staff perception of transparency.

Late, or non-submission of incidents which relate to a patient harm event negatively impact on reliable lesson learning, early relationship building with patients/families and robust preparation for coronial inquests. Each Care Organisation within Pennine Acute Trust is currently reviewing their own methods for raising the profile of incident reporting and the details of these methods will be reported within Q2’s Learning from Experience report.

Furthermore, Pennine Acute is launching a Datix risk management system, which will replace Safeguard, as the reporting and management system on 1st August 2017. The design of the application has been based upon learning from the good aspects of both Pennine’s Safeguard and Salford’s Datix to make a system more robust, user friendly and provide more accurate outcomes than either previous systems.

As part of the Datix project, user feedback as to why front line staff do not feel engaged with the incident database has been collated, and Datix has been built to accommodate these views. A common theme identified is that staff do not feel the value of submitting an incident due to lack of feedback. Whilst Safeguard has a feedback option it is difficult to use, therefore feedback return rates are low. Datix’s automatic feedback option will address this issue.

North Manchester – All Incidents reported per month North Manchester – Patient Safety Incidents per month

0

100

200

300

400

500

600

700

800

900

1000

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

0

100

200

300

400

500

600

700

800

900

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Rochdale and Bury– All Incidents reported per month Rochdale and Bury– Patient Safety Incidents per

3/44 84/158

4

month

0

100

200

300

400

500

600

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

0

50

100

150

200

250

300

350

400

450

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

ROH – All Incidents reported per month ROH – Patient Safety Incidents per month

0

100

200

300

400

500

600

700

800

900

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

0

100

200

300

400

500

600

700

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

SRFT – All Incidents reported per month SRFT – Patient Safety Incidents per month

0

200

400

600

800

1000

1200

1400

1600

1800

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

0

200

400

600

800

1000

1200

1400

1600

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

4/44 85/158

5

Top 5 themes of incident type reportedCommentary and actions are currently managed separately by the relevant PAHT or SRFT teams, therefore analysis in this section will be by Trust. Additionally, the incident categories in use at PAHT and SRFT are not directly comparable; however some similarities can be drawn.

Top 5 Categories at each Care Organisation in Q1 2017/18 CountNorth Manchester

Patient Accident / Incident 427Maternity 243Falls 199Patient/staff Accident Incident 148Medication 80

Rochdale and BuryPatient Accident / Incident 711Falls 181Patient/staff Accident Incident 105Medication 100Pressure Ulcers 64

Royal OldhamPatient Accident / Incident 413Patient/staff Accident Incident 221Maternity 187Falls 142Violence 121

SalfordPressure ulcer or other skin lesion 506Fall, slip or trip 262General communication 218Medicine related incident 214Other category 179

Falls – Patient harm events

0

50

100

150

200

250

300

350

400

450

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Group - Patient Falls with Harm

5/44 86/158

6

The total number of patient harm events from falls remains stable with a gradual decline over the last 2 years. As falls at PAHT and SRFT is currently managed by different specialist teams, the below commentary is split by Trust.

0

50

100

150

200

250

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Pennine Acute Hospitals - Patient Falls with Harm

The Falls Team is now working with the Group Quality Improvement Team to identify the Quality Improvement Project for falls as part of PAHT Quality Improvement Strategy. This will include revision of the Fallsafe Process/Policy to be re-launched around October/November 2017.

The National Falls Audit took place in May 2017, the outcome of this report should be provided in autumn this year, main areas of concern highlighted across Pennine Acute Hospitals at the point of audit were, medications not being reviewed when patient identified as being a risk of falls and lying and standing blood pressure not being completed on admission. This will be included in the Quality Improvement Project for falls.

On-going work around lessons learned from a Coroner’s Inquest is being carried out at FGH in relation to falls. The lessons learned were identified as Incorrect Risk Assessments, Risk Assessments not being repeated if a patient experiences a change in condition and escalation of observation if a patient becomes a higher risk of falls.

Lack of re-assessment of the falls risk is a common theme amongst 72hr reviews and investigations completed. It is therefore required all staff are compliant with completing Falls Awareness Training to gain a baseline knowledge around the risks associated with patients falls, all staff patient facing need to have completed the training by 1st September 2017. This can be accessed by e-learning or face to face training.

Themes of patients falling following the issuing of standardised Pyjamas were identified in Quarter 1 at both RoH and FGH Care organisations. Both organisations only had Pyjamas available in large and x-large sizes and 6 harm events (bone fractures) were noted through patients falling over elongated trouser legs. RoH are working with their laundry services to provide cuffed bottoms Pyjamas and FGH are presently undertaking a ‘test of change’ around the use of ¾ length trousers. Both trials are being monitored by the Falls Team who are preparing a related alert to the wards of NMGH and SRFT.

The falls team currently do not have any questions relating to pyjama usage in the falls questionnaire completed after every hospital fall. This document will be amended in August 2017 to address this so that the collation of more comprehensive data can be obtained.

6/44 87/158

7

0

20

40

60

80

100

120

140

160

180

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Salford - Patient Falls with Harm

Pressure UlcersThe Trust’s pressure ulcer reduction agenda remains a key focus of quality improvement for staff across the organisation. 59% of registered nurses and 56% of Health Care Support Workers have undertaken pressure ulcer essential job related training. This is a significant achievement given the staffing pressures experienced by many departments in the last 12 months. Over 90 staff attended a pressure ulcer conference in November 2016 as part of the World Wide Stop the Pressure Awareness Day. The clinical incident reporting process has been made more rigorous to improve data quality. This has involved greater scrutiny and validation of pressure ulcer data on an on-going basis ensuring pressure ulcers identified are assigned to the correct organisation. The challenge and scrutiny created by the Monthly Pressure Ulcer Panel Review meetings has resulted in more timely completion of root cause analyses and more meaningful action planning / lesson learning.

The Trust now operates an online dynamic mattress ordering system which promotes greater efficiency and timeliness in the delivery of high risk pressure relieving equipment. An intentional rounding tool has been developed and is currently being rolled out. One of the components of this tool is to safeguard vulnerable patients at risk of pressure ulcers. In an effort to reduce the incidence of heel pressure damage, mirrors have been distributed to all clinical areas involved in the assessment of skin.

Between 01/04/2017 and 30/06/2017 there were 792 pressure ulcer incidents reported within Pennine Acute Hospitals. Following validation 281 (35%) of these incidents have been attributed to Pennine Acute Hospitals, with the rest being validated as non PAHT harm.

The tissue viability validation process plays an important role in ensuring that we have a clear picture of where Hospital Acquired Pressure Ulcers occur and enables appropriate investigation. During the Quarter 1 17/18 there has been a retrospective validation of pressure ulcers dating back to October 2016 and a new set of incident codes has been agreed to provide clarity on the source of the tissue damage and initiate investigation by the correct teams. The validation process is on-going and data can be expected to shift between categories as the process continues.

7/44 88/158

8

Delays in diagnosis and treatment

0

10

20

30

40

50

60

70

80

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Pennine - Delays in Diagnosis and Treatment

Detail of incidents in the 5 categories of diagnostic incidents have been sent to the Diagnostics Improvement Group (DIG) for their consideration. Following a review of these incidents the group (chaired by the deputy Medical Director – NMGH) found that the categories assigned to incidents did not always truly reflect the incident and as the Trust moves to the Datix Incident Reporting system the categories used for such incidents will be revised. These categories have changed considerably on Datix.

The review has also found several Root Cause Analysis reports (RCAs) from serious incidents and moderate harm events are inappropriately themed and the actions plans are not as strong as the Group would like to be able to confidently provide assurance the risk of re-occurrence will be mitigated. DIG are feeding recommendations of how to strengthen existing and future action plans to Governance Managers and the DIG will be changing its role to monitor and challenge RCAs (when appropriate) to provide assurance of learning.

A&E 12hr Breaches

The reporting of A&E 12 hour breaches as serious incidents ceased (April 2017). On review the process in place was not valuable in terms of learning lessons and placed a heavy demand on resources which can now be invested in other areas to improve patient care. The Trust will continue to log incidents and escalate through the serious incident process in the event of any high harm incidents related to A&E breaches. The CCG will continue to receive assurance of improvement plans and updated performance results via the Medical Division and Trust performance data and are working with Medical Division to obtain assurance for any issues thought to be outstanding.

Patient Watch (Security)Pennine Acute records incidents as Patient Watch (Security) Incidents. These incidents are reported where the Trust’s Security Guards are called to assist the ward; this is usually where the patients’ behaviour is adversely affecting other patients on the ward, or where there is a risk of harm to self, other patients or staff. These are not incidents; they are the outcome of an incident or risk, therefore Safeguard is not accurately recording the source of the issue e.g. violence to others. Security are using the incident database as a job tracker, so even if an incident has not actually occurred, an incident is still being logged. Learning from this, Datix will not allow an incident to be categorised as Patient Watch (Security).

Patient Accident/ Incident and Patient/staff Accident Incident

Pennine currently has 2 generic “Cause Groups” which contain the miscellaneous categories; therefore data can be difficult to extract thematically what the incidents were. Both of these cause groups appear in all 3 Pennine Acute Care Organisations top 5 incident “Cause Groups”. These cause groups often result in incidents being incorrectly reported and additional administration is then required to correct. Going forward, Datix has been designed so categories and sub-categories of incidents flow more logically, mitigating incorrect pathways of incident management.

8/44 89/158

9

Medication Incidents

Whilst Medications is in the top 5 for both Rochdale and Bury and North Manchester in Q1 17/18, comparatively compared to Salford, all Pennine Acute hospitals are reporting low numbers of medication incidents. As part of the Datix implementation the categories and sub-categories have been updated in line with Salford’s model.

0

2

4

6

8

10

12

14

16

18

20

2015- 7

2015- 8

2015- 9

2015- 10

2015- 11

2015- 12

2016- 1

2016- 2

2016- 3

2016- 4

2016- 5

2016- 6

2016- 7

2016- 8

2016- 9

2016- 10

2016- 11

2016- 12

2017- 1

2017- 2

2017- 3

2017- 4

2017- 5

2017- 6

Medication Incidents with Harm - By Care Organisation

North Manchester

Rochdale and Bury

Royal Oldham

Salford

However when medications incidents with harm are compared across Care Organisations, the numbers are similar across all 4 care organisations, implying Pennine Acute does requires improvement in reporting of no harm or near miss medication events to be able to develop learning.

VTE/PE incidentsPennine Acute is currently reviewing the process for identification and reporting of VTE incidents which is slow to identify genuine incidents attributable to Pennine Acute and can result in delayed discharge of Duty of Candour for confirmed cases. The delays in the current process also result in a falsely high number of severe harm incidents being reported to the National Reporting and Learning System (NRLS). The Care Organisation Medical Director for FGH will have oversight of the VTE Committee going forward and it is anticipated that much of the issues associated with process will be resolved, enabling focus on confirmed hospital acquired VTE incidents, improved trend analysis and feedback leading to quality improvement. All reported incidents from 01/04/2017 are reported as no harm, until otherwise validated, to ensure genuine harm cases are managed appropriately.

9/44 90/158

10

Serious Incidents (SIs)

This section excludes A&E 12 hour decision to admit breaches in charts.

Serious Incidents declared by month

0

5

10

15

20

25

30

35

4020

15 -

7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Group - Serious Incidents declared per month

As a Group, the average number of serious incidents declared in Q1 remains within normal variation. Site Directors are now responsible for each serious incident declared in their Care Organisation. The average number of deaths elating to SI’s has decreased from 4 per month in 2016, to 3 per month in 2017.

Time to declare serious incidentsThe delays to declare a serious incident is vastly improving. In Q1 2017/18 the time to declare an SI investigation on average fell from 41 days in May 2017 to 6.1 in June 2017. There are still improvements to make to achieve the 48 hour serious incident decision target and this will be achieved now all CO Divisional Directors of Nursing are in post.

5

10

1516

21

26

2928

32 3230 30

2728

29

25

2220

1918

20

2423

21

13

4

79

1012

14

22

25 2526

2220

19 1917

12 1211

1415

17

13

6

9 911

14 1415

2322

2422

24

32

29

26

2122

2021

15

2019

20

14

2 2

7 75

8

1314

11 1112

810

12

16

2325

22

2830

36

40

46

53

Open Serious Incident Investigations by Care Organisation as of the beginning of each monthNorth Manchester Rochdale and Bury Royal Oldham Salford

10/44 91/158

11

5

7

11 1110

1211

14

1718

1918

14

1112

10

13 1314

8

1

3 34

2

5

8

12

18

1617

12 12 12

8 8

6

2 2

4

67

45

9

7

9

13

16

19

16

14 14 14

1112

89

87

1 1

45 5

4

65

3

5

8 8

12 1213

17

1920

25

31

Breached Serious Incident Investigations by Care Organisation as of the beginning of each month

North Manchester Rochdale and Bury Royal Oldham Salford

Open and Breached Serious Incident Investigations by month – Care Organisations comparisonThe above comparative charts show that Pennine Acute Hospitals have made significant improvements within the last 12 months in regards to the number of open serious incident investigations at any one time, with all 3 Care Organizations making progress in decreasing the number of open SI’s from 87 to 57. This is as a result of the appointment of CO Divisional Directors of Nursing who are the responsible officers for serious incidents, weekly serious incident meetings and greater top down engagement of the serious incident processes by Care Organisation leadership.

Group – Open serious incidents investigations by month

Group – Breached Serious Incidents at the beginning of each month

0

20

40

60

80

100

120

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

10

20

30

40

50

60

70

80

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

Salford’s data however, is showing that since August 2016 both total number of serious incident investigations open and serious incident investigations breached are increasing month on month. This is a similar theme across serious incidents, SIARCs and duty of candour. On individual review, this appears to be the omission of coding being applied to the events rather than the function itself not being completed. Actions have been initiated for members of the Pennine Acute Trust Risk team to assist SRFT in addressing this technical issue, so that coding data is corrected.

11/44 92/158

12

Pennine Acute Hospitals Only – Open serious incidents investigations by month

0

10

20

30

40

50

60

Apr

-15

May

-15

Jun-

15

Jul-1

5

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Jul-1

7

Data

Time Period

Open Breached Serious Incidents Total

12/44 93/158

13

Work continues to have all serious incidents completed within the 60 day timescales, and the weekly serious incident meeting at Pennine Acute Hospitals is refocusing to proactively monitor and mitigate issues which may cause breaches, rather than reactively fixing issues once a deadline has been breached. In August 2016, just in under half (44%) of all SI’s declared would breach their 60 day investigation period. June sees this figure drop to 29%, however this remains a key focus of the central risk team to ensure that all SI investigations are completed within the allocated timeframe. Specific SI monitoring arrangements have been installed into each Care Organisation with the aim of addressing investigation breaches and reducing the review time period to 45 days before the end of the calendar year.

Investigation tools, templates and training

In Q1 2017/18 the Root Cause Analysis (RCA) template has been extensively reviewed using feedback from governance management staff and a review of the positive aspects of both the Pennine and Salford RCA templates, to develop a new RCA template for use at Pennine. This will make reports easier to write, eliminate duplication and mitigates confusion. There will be only one template for comprehensive and concise investigations and has been designed to be as useful and informative to the patient/ family as opposed to traditional corporate objectives. This template is now in use for all RCAs. The template also introduces a Lessons Learned Proforma to allow key lessons to be extracted and easily distrusted to all staff and will be shared cross-divisionally and cross-organisationally.

To maximise learning from all serious incidents and SIARC events, Pennine will be making all new investigation reports available on the intranet for all staff to be able to access at any time.

Root Cause Analysis (RCA) training for senior staff remains on-going with every session at full capacity. 187 members of staff ranging from Matrons to Consultants have been trained to date. The RCA/duty Candour sessions have been well received by all divisions and the incident team will continue to deliver these sessions with a further 3 sessions planned in the coming months

A training needs analysis was completed by the Inquest Manager and the Divisional Governance Managers, to ensure the staff who are booked onto the training sessions are currently investigating officers who require RCA training; or will become investigating officer following completion of the training. The sessions were fairly disseminated between each care organisation to ensure an equal amount of staff are up skilled in each area.

Pennine Acute Hospitals – Top 5 SIs (excluding A&E 12 hour decision to admit breaches)

Categories of incidents are not comparable due to two different databases as Salford and Pennine, the below is North Manchester, Royal Oldham and Rochdale and Bury combined.

Pennine - Top Serious Incident Causes in last 12 months 2016/17 - Q2 2016/17 - Q3 2016/17 - Q4 2017/18 - Q1

Total for last 12 months

Death - Unanticipated/unexpected 7 3 5 3 18

Delay In Diagnosis/Treatment (Cancer) 3 4 7 2 16Found on Floor 4 2 3 6 15Failure To Rescue 0 1 3 2 6Slip, trip Or Fall On Same Level 1 1 0 3 5Delay In Treatment/Care 2 1 1 1 5

13/44 94/158

14

North Manchester Serious Incidents

0

2

4

6

8

10

12

14

16

2015

- 7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

North Manchester - Serious Incidents declared per month

North Manchester – Open serious incidents at the beginning of each month

North Manchester – Breached Serious Incidents at the beginning of each month

0

5

10

15

20

25

30

35

40

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

5

10

15

20

25N

ov-1

5

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

North Manchester - Top Serious Incident Causes in last 12 months 2016/17 - Q2 2016/17 - Q3 2016/17 - Q4 2017/18 - Q1



Delay In Diagnosis/Treatment (Cancer) 0 1 2 1 4Found on Floor 1 0 0 2 3Radiology Issue 2 0 1 0 3

Slip, trip Or Fall On Same Level 1 1 0 1 3Stillbirth > 500g 1 2 0 0 3

Delay In Diagnosis/Treatment (Fracture) 1 1 0 1 3

Below are some examples of lessons learned from serious incidents at this care organisation.

14/44 95/158

15

Location Incident Number/ Coroner ref

Incident description Learning

NMGH 259475 The patient was admitted with abdominal pains and had subsequent surgery. She was discharged home where she sadly died a month after. Family concerns were received and an investigation commenced to review the care given to her whilst an inpatient.

In complex cases, there needs to be an adequate handover between the parent consultant and the receiving consultant (who may be covering an absent colleague or may be undertaking an 8on-call shift). The handover must involve a discussion around anticipated investigations/treatment which may need to be delivered by a covering consultant. The anticipated plan of care should also be clearly documented in the case notes with a clear mention of which consultant will be responsible for the patient.

Awareness amongst the clinical team of the need for a protocol based system to manage cases of intestinal obstruction in order to minimise variation in practice.

The psychological support of patients’ needs to be addressed alongside their clinical needs.

Rochdale and Bury Serious Incidents

0

1

2

3

4

5

6

7

8

9

10

2015

- 7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Rochdale and Bury - Serious Incidents declared per month

Rochdale and Bury– Open serious incidents at the beginning of each month

Rochdale and Bury– Breached Serious Incidents at the beginning of each month

0

5

10

15

20

25

30

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

5

10

15

20

25

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

15/44 96/158

16

Rochdale and Bury- Top Serious Incident Causes in last 12 months 2016/17 - Q2 2016/17 - Q3 2016/17 - Q4 2017/18 - Q1


Delay In Diagnosis/Treatment (Cancer) 1 0 4 0 5Found on Floor 1 0 3 0 4Complication Of Surgery 0 0 1 1 2Failure To Rescue 0 0 1 1 2

The above lists the top 4 (only) incidents from Rochdale and Bury as there were 20 other incident types with only 1 serious incident reported, suggesting that Rochdale and Bury are able to mitigate re-occurrence of serious incidents once one occurs.




FGH Theatres

266701 During entry onto the National Register it was noted that a 32mm femoral head implant had been used with a 28mm acetabula cup.

As this incident was picked up 7 months after the even and there had been a similar event at the ROH theatre at a similar time to this much of the learning from the ROH event had already been embedded.

Boxes from prosthesis, which are colour coded to be used as additional verification process.

Second time-out process should be documented in patient’s notes, which should note what has been verified and by whom.

If there is a change in decision for a different prosthesis/implant size after the second time-out has been performed, then the second time-out process needs to be repeated to verify the new size.

A review of the existing training by Zimmer Biomet to improve the way proficiency in skills and knowledge in products is determined for staff and extend learning to other new or legacy products training requirements.

FGH Theatres

266689 A patient was listed for Manipulation of knee under general anaesthetic and was to have an anaesthetic knee block.

Initially the block was given in the wrong side.

Up to the point at which the incident occurred, staff had followed Trust policy and WHO patient safety protocols.

Trust staff need to be aware of and follow Trust Policies at all stages of the patient’s peri operative journey.

If staff had followed the Trust Policy it is highly unlikely that the incorrect block would have occurred. Guidance has been distributed to all Anaesthetic staff formally and ‘Stop Before you Block’ Posters have been displayed in all Anaesthetic rooms

Consider additional support from within the theatre

16/44 97/158

17



team where they are available to assist the anaesthetic practitioner when there are two anaesthetists present carrying out additional interventions.

Royal Oldham Serious Incidents

0

2

4

6

8

10

12

2015

- 7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Royal Oldham - Serious Incidents declared per month

ROH – Open serious incidents at the beginning of each month

ROH – Breached Serious Incidents at the beginning of each month

0

5

10

15

20

25

30

35

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

2

4

6

8

10

12

14

16

18

20

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

ROH - Top Serious Incident Causes in last 12 months 2016/17 - Q2 2016/17 - Q3 2016/17 - Q4 2017/18 - Q1


Found on Floor 2 2 0 4 8Delay In Diagnosis/Treatment (Cancer) 2 3 1 1 7


Patient Incident/injury During Treatment/Care 1 0 2 1 4

Pulmonary Embolism (Hospital Acquired) 0 3 0 0 3


17/44 98/158

18



ROH 246759 Orthopedic patient with unstable diabetes went into DKA but sadly became more critical and suffered a myocardial infarction.

Transferred to HDU but passed away 2 days later.

Communication between the different specialist clinical teams was poor.

Clinical staff and nursing staff demonstrated gaps in knowledge in how to manage a patient with unstable diabetes and the early recognition of DKA.

Guidance and advice offered by specialist nursing and medical teams was not strictly adhered to.

Consideration to how other problems encountered by the patient, such as the acute kidney injury and vomiting, and how these would affect the diabetes and its management was not made by the team caring for her, neither were the consequence of vomiting and onset of DKA.

Documentation of management plans and patient observations, and escalation of concerns were inconsistent and not to the required standard.

ROH Theatres

254837 Patient attended theatre for a right total knee replacement. This is inserted in three parts, two parts were checked and inserted correctly. Third component checked and inserted size 7 x 8mm instead of size 8 x 7mm.The numbers were transposed.

The mistake was noted once the patient was discharged from theatre.

New systems or procedures not to be introduced without full communication to, and necessary training for, all staff involved.

Staff to be familiar with the equipment they work with.

Staff to ensure that they know what they are checking during checking procedures.

Location of supplies within workplaces should support efficient working processes.

ROH 243376 Patient diagnosed with bowel perforation, listed for laparotomy. Clinical decision changed to conservative management, patient deteriorated and taken to theatre 6 days later, perforation and faecal peritonitis. Sadly the patient died after a 6 week admission to ICU.

Communication between clinical teams, patients and their families need to be improved.

Documentation of management plans and escalations were not to the required standards.

Emergency surgery guidelines should be adhered to.

Documentation of discussions between clinicians, patients and families need to be improved.

18/44 99/158

19



ROH 254703 The patient had a cardiac arrest during the surgical procedure, the investigation showed that there had been the potential to recognise the deterioration and treat the patient at an earlier opportunity.

Communication and documentation between clinical teams, patients and their families need to be improved.

Documentation of management plans and escalations were not to the required standards, both nursing and medical.

Improvement in the care of the deteriorating patient.

Less over reliance on tools such as the EWS and more clinical judgment.

Repeat tests and act upon the results accordingly.

Recognition of timely diagnostic tests and treatment.

Salford Royal Serious Incidents

0

1

2

3

4

5

6

2015

- 7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Salford - Serious Incidents declared per month

Salford – Open serious incidents at the beginning of each month

Salford – Breached Serious Incidents at the beginning of each month

0

5

10

15

20

25

30

35

40

45

50

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

5

10

15

20

25

30

35

40

45

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

19/44 100/158

20

Salford - Top Serious Incident Causes in last 12 months 2016/17 - Q2 2016/17 - Q3 2016/17 - Q4 2017/18 - Q1


Other 1 3 4 3 11Misdiagnosis general 4 3 2 1 10Wrong site surgery 0 0 0 2 2Prescribing error 0 2 0 0 2Identified in hospital (SRFT) 0 0 0 2 2Identified in the community (SRFT) 1 1 0 0 2

SIARC eventsSIARC events are incidents which are not declared as serious incidents (SI’s), but are deemed to have either caused patient harm which requires further investigation and/or evidences a risk to patient safety and should be investigated to mitigate future risk. These incidents and investigations are monitored via the weekly SIARC meeting at both Pennine and Salford.

In Q1 17/18 Pennine Acute Hospital started the SIARC weekly meeting, attended by Governance Managers and chaired by the Risk Manager.

0

10

20

30

40

50

60

70

2015

- 7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Group - SIARCS declared per month

0 0 0 0 13 4

13

20

34

47

55

63

7068

61

71

7678

82 81

8588

84

0 0 0 0 0 1 14

9

15 15 16

21 22 2224

32 31 31 3032 33

3941

02 2 3

57 8

13

22

29

35

4143

4951

43

54

63 6265 65 64

7174

5

10

1719 18

20

29

33 33

2826

3330

2624

29

40 41 40

54

6057

65

71

Open SIARC by Care Organisation as of the beginning of each monthNorth Manchester Rochdale and Bury Royal Oldham Salford

20/44 101/158

21

0 0 0 13 3

9

17

26

36

47

5860 60 60

66

7376

7880

7779

0 0 0 0 1 13

7

13 1215

1821 20 20

27 28 2830 31 31

34

2 2 35

7 8

13

19

27

33 3436

46

38 38

48

5659

63 64

5961

4 5

911

14 13

20 20

14

18

14 15

119

13

22

28 2831

42

52 51

Open SIARC by Care Organisation as of the beginning of each monthNorth Manchester Rochdale and Bury Royal Oldham Salford

Open and Breached SIARC events by Month - Care Organisation comparison

At Pennine Acute Hospitals there are 213 open and historic concise/ SIARC, RCAs, which are being reviewed for themes by the Governance Managers. Once themed, these incidents will be presented to an executive committee to determine future actions in regards to closure and/or management of these incidents. Themes and lessons learned will be in greater detail in the next learning from experience report.

Whilst the total number of open and breached SIARC events has increased, the rate of growth has decreased significantly. There were 19 new concise RCAs commenced and 17 finalised in June 2017. Compared to June 2016 the Trust opened 22 new RCAs and finalised 10. Since 2015 the Trust has never closed as many SIARC/ concise investigations as it has opened in any one month, June 17 is the closest the Trust has achieved to date. As with serious incidents and Duty of Candour, Salford’s record keeping on Datix makes their performance appear higher than actual, with a high numbers of open and breached SIARCs. This will be addressed by the Pennine Risk team assisting SRFT colleagues.

Group – Open SIARC events at the beginning of the month

Group – Breached SIARC events at the beginning of each month

0

50

100

150

200

250

300

350

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

50

100

150

200

250

300

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

Categories of incidents are not comparable due to two different databases as Salford and Pennine, the below is North Manchester, Royal Oldham and Rochdale and Bury combined.

21/44 102/158

22

Pennine - Top SIARC events in last 12 months

2016/17 - Q2

2016/17 - Q3

2016/17 - Q4

2017/18 - Q1


Slip, trip Or Fall On Same Level 5 3 2 3 13Delay In Treatment/Care 3 3 2 4 12

Hospital Acquired Colonisation/Infection 4 4 1 2 11Found on Floor 1 3 3 3 10

Patient Incident/injury During Treatment/Care 0 2 3 4 9Delay In Diagnosis 3 2 1 2 8

North Manchester SIARC events

0

2

4

6

8

10

12

14

16

18

20

2015

- 7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

NM - SIARCS declared per month

North Manchester – Open SIARC events by month North Manchester – Breached SIARC events by month

0

20

40

60

80

100

120

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

10

20

30

40

50

60

70

80

90

100

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

22/44 103/158

23

North Manchester - Top SIARC events in last 12 months 2016/17 - Q2 2016/17 - Q3 2016/17 - Q4 2017/18 - Q1


Slip, trip Or Fall On Same Level 2 0 2 2 6

Unexpected Transfer To Neonatal Unit 3 1 0 0 4Delay In Treatment/Care 1 1 1 1 4

Hospital Acquired Colonisation/Infection 0 3 1 0 4Found on Floor 0 1 2 0 3Transfer Issue 0 1 1 1 3Stillbirth > 500g 1 0 2 0 3Delay In Diagnosis 2 1 0 0 3

Delay In Diagnosis/Treatment (Cancer) 0 0 1 2 3

Post Partum Haemorrhage > 1000 Mls 1 1 0 1 3

Patient Incident/injury During Treatment/Care 0 0 1 2 3

Rochdale and Bury SIARC events

0

2

4

6

8

10

12

14

2015

- 7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

R&B - SIARCS declared per month

Rochdale and Bury– Open SIARC events by month Rochdale and Bury– Breached SIARC events by month

0

5

10

15

20

25

30

35

40

45

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

5

10

15

20

25

30

35

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

23/44 104/158

24

Rochdale and Bury- Top SIARC events in last 12 months 2016/17 - Q2 2016/17 - Q3 2016/17 - Q4 2017/18 - Q1


Found on Floor 1 1 1 2 5Slip, trip Or Fall On Same Level 1 3 0 1 5Delay In Diagnosis 1 1 0 2 4Delay In Treatment/Care 1 1 0 1 3

Failure To Follow Infection Control Policy/Guidance 0 2 0 1 3

Incorrect/Inappropriate Procedure Performed 2 0 0 0 2Delay In Diagnosis/Treatment (Cancer) 0 1 1 0 2

Medication Prescribed - Not Given To Patient 0 1 0 1 2

Royal Oldham SIARC events

0

2

4

6

8

10

12

14

16

2015

- 7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

ROH - SIARCS declared per month

ROH – Open SIARC events at the beginning by month ROH – Breached SIARC events by month

0

10

20

30

40

50

60

70

80

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

10

20

30

40

50

60

70

80

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

24/44 105/158

25

ROH - Top SIARC events in last 12 months 2016/17 - Q2 2016/17 - Q3 2016/17 - Q4 2017/18 - Q1


Hospital Acquired Colonisation/Infection 4 1 0 2 7

Patient Incident/injury During Treatment/Care 0 2 2 1 5Delay In Treatment/Care 1 1 1 2 5Pathology Issue 1 2 0 1 4

Failure To Follow Guideline/protocol/policy 1 2 0 1 4


Post Partum Haemorrhage > 1000 Mls 0 1 0 2 3

Failure To Recognise Or Escalate Acute Illness 0 0 1 2 3Failure To Rescue 1 0 1 1 3

Salford Royal SIARC events

0

2

4

6

8

10

12

14

16

2015

- 7

2015

- 8

2015

- 9

2015

-10

2015

-11

2015

-12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

-10

2016

-11

2016

-12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Salford - SIARCS declared per month

Salford – Open SIARC events by month Salford – Breached SIARC events by month

0

10

20

30

40

50

60

70

80

90

100

Aug

-15

Sep-

15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

0

10

20

30

40

50

60

70

80

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

25/44 106/158

26

Salford - Top 5 SIARC events in last 12 months 2016/17 - Q2 2016/17 - Q3 2016/17 - Q4 2017/18 - Q1


Other 5 8 5 10 28Misdiagnosis general 2 4 3 3 12Found on floor/un-witnessed 2 3 2 0 7Fall from bed 0 3 2 0 5Communication breakdown within immediate team 0 2 0 2 4Identified in the community (SRFT) 1 1 2 0 4Identified in hospital (SRFT) 1 0 2 1 4

Duty of CandourThis section includes documented details of where initial contact with the patient and/or family has been achieved to deliver an apology where appropriate, provide assurance that lesson learning will occur and that the patient/family will receive feedback of all related investigations. Duty of Candour is now monitored weekly for performance at both the SI and SIARC weekly meetings. This is to provide assurance that Duty of Candour is accurately discharged in a timely manner, and that any delays or issues can be speedily escalated effectively.

As with serious incidents and SIARCs, electronic record keeping is making Salford Royal appear as a low complier. Whilst assurance has been provided locally that this is an electronic related deficiency, the central risk team have a planned visit to the review the Salford Royal system to qualify the DoC assurance provided.

Serious Incidents – Duty of CandourGroup – Serious incident Duty of Candour

compliance by monthPennine Acute Only – Serious incident Duty of

Candour compliance by month

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Group - Serious Incidents - Duty of Candour - Percentage Complaint

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

0

0.2

0.4

0.6

0.8

1

1.2

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

North Manchester - Serious Incidents - Duty of Candour -Percentage Complaint

0

0.2

0.4

0.6

0.8

1

1.2

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Rochdale and Bury - Serious Incidents - Duty of Candour -Percentage Complaint

26/44 107/158

27

0

0.2

0.4

0.6

0.8

1

1.2

2015

- 7

2015

- 8

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Royal Oldham - Serious Incidents - Duty of Candour - Percentage Complaint

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2015

- 7

2015

- 9

2015

- 10

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Salford - Serious Incidents - Duty of Candour - Percentage Complaint

Duty of Candour for Serious Incidents in Q1 2017/18 at Pennine Acute Hospitals is 100%. Learning from how this has been achieved will be applied to SIARC events in Q2 2017/18.

SIARC events – Duty of CandourGroup – SIARC Duty of Candour compliance by

monthPennine Acute Only – SIARC Duty of Candour

compliance by month

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Group - SIARC - Duty of Candour - Percentage Complaint

0

0.2

0.4

0.6

0.8

1

1.2

1.4Ju

l-15

Aug

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb-

16

Mar

-16

Apr

-16

May

-16

Jun-

16

Jul-1

6

Aug

-16

Sep-

16

Oct

-16

Nov

-16

Dec

-16

Jan-

17

Feb-

17

Mar

-17

Apr

-17

May

-17

Jun-

17

Data

Time Period

SIARC events - Relevant Person Contacted Percentage

0

0.5

1

1.5

2

2.5

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

North Manchester - SIARC - Duty of Candour - Percentage Complaint

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

2015

- 12

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Rochdale & Bury - SIARC - Duty of Candour - Percentage Complaint

27/44 108/158

28

0

0.5

1

1.5

2

2.5

3

3.5

2015

- 8

2015

- 10

2015

- 11

2015

- 12

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2016

- 8

2016

- 9

2016

- 10

2016

- 11

2016

- 12

2017

- 1

2017

- 2

2017

- 5

2017

- 6

Data

Time Period

Royal Oldham - SIARC - Duty of Candour - Percentage Complaint

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2015

- 7

2015

- 8

2015

- 9

2015

- 10

2015

- 11

2015

- 12

2016

- 1

2016

- 2

2016

- 3

2016

- 4

2016

- 5

2016

- 6

2016

- 7

2017

- 2

2017

- 3

2017

- 4

2017

- 5

2017

- 6

Data

Time Period

Salford - SIARC - Duty of Candour - Percentage Complaint

28/44 109/158

29

Inquests

As noted in the incident section both Pennine Acute Hospital and Salford Royal inquest data has been combined to create the first Group report. The two organisations use different databases (Safeguard and Datix) to record inquests and this has proved difficult when comparing the learning from experience elements of inquests.

Inquests per month

The number of inquests reported across all four care organisation are within normal variation.

29/44 110/158

30

Themes identified from inquests

Nursing C

are/h

andove

rFa

lls

Communicatio

n

Treatment D

elayPolicy VTE

Consent

Safegu

arding

Surgi

cal

Medical E

quipment/devic

es

PFD Iss

ued

Medicatio

nAudit

Mis-Man

agement O

f Diab

etes0

1

2

3

4

5

6

7

8

Medicine

Integrated & Community Service

Human Resources

Anaesthesia & Surgery

The inquest team have introduced a robust mechanism for monitoring themes that arise following inquests to assist with aggregated learning. The above chart shows that there are 38 themes identified (21 Medicine, 1 Community, 15 surgery and 1 HR (policy). Reoccurring themes are feedback from the Inquest Team to the divisions to ensure actions are taken.

There has been a review of the most common themes across the three Care Organisations (communication and nursing care) and concerns have been noted around the Evolve system. A piece of work is being undertaken by the Inquest Manager and the Associate Director of Bereavement to embed a new process; whereby, the medical records are kept following the death of a patient until notification has been received that no inquest is required. This new process will ensure the divisions do not receive criticism at inquest around lack of communication/handover. Example below:

Mr xx notes were scanned onto evolve; however, pages where incomplete or missing. The Doctor was unable to say whether the nursing handover was recorded or if it is an error due to the way in which notes were scanned onto evolve. The Coroner did not issue a PFD; however, the Trust has been warned that she would issue a Regulation 28 in future if this happened again.

Although there are none recorded at present, the team are aware of a number of inquests due to conclude; which show alcohol pathway misuse as a reoccurring theme. The Inquest Manager is currently monitoring the theme around alcohol withdrawal pathway and plans have been made to meet with the alcohol team on 24 July 2017 to discuss “hotspot” areas.

Unfortunately, Salford Care Organisation do not have the facility on the Datix system to record themes; however, this has been identified as a learning point by the Inquest Manager and Pennine’s new Datix system, which is due to be launched in August 2017, will include a section for recording themes, following inquests. Once the new system is implemented, the inquest team across all four Care Organisations will thematically review completed inquests, to allow the data to become richer and to allow the team to monitor learning.

30/44 111/158

31

Prevent Future Death reports (PFDs)

The number of days between PFD has increased at Pennine between August 2016 and April 2017. 1 PFD was awarded against the organization in April 2017, which was the first the Trust had received since August 2016. Prior to this, the Trust received 5 in the calendar year of 2016. This development is largely due to the number of improvements being made into transparency with families, the CO Divisions leadership amendments, developing robust SMART action plans which are shared with the coroner pre-inquest to provide assurance that lessons have been learnt.

Salford Care Organisation received 2 PFD’s within Q1, which were in addition to the 3 PFD’s received in Q4 of the previous year and a further 2 PFD’s in Q3. As shown in the table above there has been a steady decline in the number of days between PFD being received. The increased number of PFD’s received at SRFT will be addressed by a Group leadership arrangement for the management of coronial inquests. Salford Care Organisation does not currently record the learning from the PFD on their system, therefore for the Q2 report there will be a separate action plan produced to show actions and learning following PFD issued.

Unlisted inquests

4270

5

4273

6

4276

7

4279

5

4282

6

4285

6

4288

7

0

50

100

150

200

250

300

Unlisted inquests per month

Dat

a

There has been a significant improvement in the number of unlisted inquests open on the safeguard system. This positive decline is due to the Inquest Team completing a “look back” exercise, to ensure the number of unlisted inquests open on the system was a true reflection of the work that is being undertaken. The reduction in the number of unlisted has enabled the Inquest Team to produce concise accurate reports the divisions.

31/44 112/158

32

Unfortunately, unlisted inquests are not comparable for Salford Care Organisation due to two different databases and the way in which unlisted inquests are recorded.

Legal Representation

Prior to January 2017 no records were obtained with regards to the number of inquest files where legal representation was commissioned. When records were initiated in January 2017, 44% of coronial inquests received external legal representation. In June 2017, this number has been reduced to 5%. No financial figure has been calculated for this improvement; however a retrospective PID is being developed.

Unfortunately, legal representation data is not recorded for Salford Care Organisation at present; however, it will be available for the Q2 report.

TrainingIn addition to the RCA and Duty of Candour training listed above; arrangements have been made for an “away day” training session for the Inquest Staff, Bereavement Staff and the Coroner Office for the end of September. The training day will enable the teams to look at ways to improve the service and share best practice. The Senior Coroner and Coroner for Heywood will also be there to give a talk on expectations they have around statements and attendance in court. This away day will improve working relationships between Pennine and the Coroner office and the learning will be disseminated to all staff in the inquest training, which will commence from October 2017.

32/44 113/158

33

Complaints

Quarter One - 2017/18:

The complaints department at Pennine Acute Hospitals Trust received 228 formal complaints in Q1. This represents a decrease of 5% against the 240 complaints received in Q4.

Over the last 6 months there has been a gradual increase in the number of formal complaints received. The monthly average over this time is 77. The dip in figures is as expected in December and during the holiday season.

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

0

20

40

60

80

100

120Complaints Received by Month

Time Period

Dat

a

The graph below details the numbers of complaints received by site for each quarter.

N.M.G.H.

R.O.H.

Fairfi

eld R.I.

Community

All Site

s

(blank)

HMR Integra

ted Community

Servi

Birch Hill

Tudor Court,

Heywood

0102030405060708090

2016-17 (1) 2016-17 (2) 2016-17 (3) 2016-17 (4) 2017-18 (1)

33/44 114/158

34

Number of Complaints Received Q1

NMGH TROH FGH/RI SALFORD

Apr-17 22 25 21 18

May-17 28 36 20 23

Jun-17 28 23 25 30

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

0

20

40

60

80

100

120

140Complaints Closed by Month

Time Period

Dat

a

.

The spikes in activity during Dec 15 – June 16 relates to staff working overtime and additional staff employed to specifically work on backlog complaints

Number of Complaints Closed Q1


Apr-17 17 22 17 39

May-17 22 26 17 44

Jun-17 25 18 22 25

34/44 115/158

35

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

0

10

20

30

40

50

60% Complaints Responded to Within Timescale by Month

Time Period

Dat

a

The Trust has agreed with the CCG’s a trajectory of compliance against the 25 and 60 working day targets. This runs from April 17 to January 2018.

Response Times

Threshold 90% Apr-17 May-17 Jun-17 Jul-17 Aug-

17 Sep-17 Oct-17

Nov-17

Dec-17

Jan-18

Target 45% 50% 55% 60% 65% 70% 75% 80% 85% 90%

Actual 34%

The compliance for March 2017 was 25% which demonstrates there has been an improvement in turnaround times in April 2017.

Risk Grading

Upon receipt of a complaint a risk grade is applied. Any case graded as HIGH risk is sent to the Division and an Urgent Clinical Review is undertaken by clinical staff to establish if the case has been an incident or is deemed to be HIGH risk therefore warranting a 60 days response time to allow for a detailed investigation to take place.

The peak in February 2017 corresponds with the increased number of complaints received at that time.

35/44 116/158

36

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

05

10152025303540

Number of RED Complaints by Month

Time Period

Dat

a

Number of RED Complaints Received Q1


Apr-17 5 10 2 1

May-17 4 8 7 0

Jun-17 5 9 7 0

36/44 117/158

37

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

0

5

10

15

20

25

30Number of PHSO Referrals by Month

Time Period

Dat

a

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

0

5

10

15

20

25

30PHSO - Upheld/Partially Upheld

of Those Received By Month

Time Period

Dat

a

The zero return reported from November 2016 to June 2017 is mainly due to the cases still being open

37/44 118/158

38

Top Five Themes for Complaints – 1 July 2016 to 340 June 2017

Total number of complaints: 819

Category Type Number Received % of Total ReceivedClinical Treatment 331 40%Communication 89 11%Values and Behaviour (staff) 78 9%Patient Care 70 8%Appointments 58 7%

There has been a recurrent theme within complaints in relation to the medical workforce. Whilst the top category of complaint is Clinical Treatment, there is a trend relating to poor communication and behaviour, unfortunately medical staff are often cited within complaints for their poor attitude and handling of consultations.

Learning systems used in Complaints Management.

Currently upon resolution of a complaint, any action taken or learning from the investigation is captured and recorded on Safeguard. The intention is to use aggregated learning from Complaints and PALs and disseminate this to Care Organisation for discussion at their Clinical Governance meetings.At the moment, Case Handlers assigned to Care Organisations, attend the DON’s weekly Governance meetings. Any significant learning is shared at these meetings.

It is planned to co-ordinate all themes and trends across all Care Organisations from Complaints, PALS, Litigation and SI’s to provide a ‘heat map’ identifying hot spots and areas of concern. In addition a fully aggregated report can be formulated to identify learning which can be promulgated across the Trust through the Governance Framework.

Some specific examples of learning or actions taken as a direct result of complaints management:

AMU now has a standardised handover sheet so there is less chance of conflicting information being given to the patient/relatives.

Ward H4 is in the process of creating a designated family room, where family members can be given information about loved ones in a more suitable environment.

The Trust’s Training and Implementation Team are amending their training documentation for the Healthviews Systems to ensure that staff members are explicitly informed about the colour change feature for deceased patients.

We Identified areas of risk in charts on the Wards for Phototherapy. They have now all been individually coloured and re labelled. There has also been a box added on to the charts where staff are required to input the gestation at birth which is an added safety feature to ensure correct chart's been used.

38/44 119/158

39

Patient Advice and Liaison Service

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

050

100150200250300350400

Number of PALS Cases by Month

Time Period

Dat

a

Prior to January 2016 the PALS service was limited to 1 PALS Officer for the whole Trust. The Trust now has a PALS presence on each site, capturing more enquiries.

Number of PALS Enquiries Received Q1


Apr-17 73 110 99 207

May-17 85 126 102 227

Jun-17 73 104 87 195

Number of PALS Enquiries Closed Q1


Apr-17 90 130 111 185

May-17 84 117 102 191

Jun-17 79 118 90 172

39/44 120/158

40

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

0

5

10

15

20

25

30Complaints referred from PALS by month

Time Period

Dat

a

Prior to a PALs case being converted to a formal complaint, all efforts are made to try and resolve the patients /families/carers concerns. However, if the PALs Officer feels that PALs intervention will be unable to provide resolution, or the enquirer insists on making a complaint, then the concern is referred to the Complaints Department

This data has not been recorded prior to July 2016

Top Five themes for PALS – 1 July 2016 to 30 June 2017

Total number of enquiries: 3610

Category Type Number Received % of Total ReceivedCommunication 619 17%Appointments 426 12%Positive Feedback 409 11%Request for Information 409 11%Clinical Treatment 246 7%

40/44 121/158

41

Clinical Negligence and Employers and Public Liability Claims42

186

4221

742

248

4227

842

309

4233

942

370

4240

142

430

4246

142

491

4252

242

552

4258

342

614

4264

442

675

4270

542

736

4276

742

795

4282

642

856

4288

7

0

5

10

15

20

25

30Total New Claims

Time Period

Dat

a

The Trust has been notified of 291 new claims in the last 24 months. The highest numbers were received in February 2016 and March 2016. However, this was then followed by a drop of claims until July 2016.The last three months have seen a steady stream of claims with 12 received in April and then 11 in both May and June.

Breakdown of Letters of Claim received by Care Organisation over the last quarter

NMGH ROH Bury and Rochdale

Salford

April May June April May June April May June April May JuneClinical Negligence

5 4 2 6 2 6 3 6 4 3 5 7

Employers Liability/Public Liability

0 4 0 2 1 1 0 0 1 3 1 3

41/44 122/158

42

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

0

5

10

15

20

25

30Bury and Rochdale New Claims

Time Period

Dat

a

81 new claims have been received for Bury and Rochdale Care Organisation in the last 24 months. The most claims were received in February and March 2016 which is consistent with the total claims received. No claims were received in November 2015. This may be due to the fact that claimant’s solicitors are looking to settle their on-going claims ahead of the Christmas period.

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

0

5

10

15

20

25

30Royal Oldham New Claims

Time Period

Dat

a

90 new claims were received for Royal Oldham Care Organisation in the last 24 months. The highest number was received in April 2017 with 8 new claims being received. However, this was then followed by a decrease in May 2017 with only 3 new claims being received.

42/44 123/158

43

4218

642

217

4224

842

278

4230

942

339

4237

042

401

4243

042

461

4249

142

522

4255

242

583

4261

442

644

4267

542

705

4273

642

767

4279

542

826

4285

642

887

0

5

10

15

20

25

30N.M.G.H New Claims

Time Period

Dat

a

The above graph represents the claims we have received over the past 24 months against North Manchester General Hospital. We saw an increase in the claims received over February and May before the end of the financial year. This could be in relation to the claimant solicitors aiming to have their claims served before a more beneficial funding arrangement came to an end in April 2016. We also see an increase in claims in January following the Christmas period. This would coincide with the claimant solicitors wishing to meet their own targets following the quietened down period over Christmas and remains consistent with what the NHS Resolution have reported over the same period of time.

Aggregated learning from Governance systems

A historic review of coronial activity which concluded in ‘neglect’ verdicts, together with of an analysis of Serious Incidents relating to preventable deaths highlighted that the General Surgical Service at Pennine Acute Trust was as an outlying concern. 12 Neglect verdicts were issued to Pennine Acute Trust within the last 12 months (none issued at Salford Royal). 3 of these 12 were awarded against General Surgery. One PFD was issued against Pennine Acute Trust in Q1 and this also related to General Surgery.

The following immediate actions were implemented to address this concern:

Directorate constructed an operational policy which clarifies expectations of medical staff when undertaking patient reviews during ward round and handover. The key headings are summarised below:

Delivery of High Quality Ward Rounds Quality of Documentation in Case Notes Handover of Care Prior to Weekend On-Call Weekend On Call Review Responsibility in Relation to Instructions Given/Investigations Requested

Monitoring of compliance of the newly constructed operational policy is being undertaken by the specialties Clinical Director, who has also developed a more robust Morbidity and Mortality system. General surgical colleagues from Salford Royal attended the first meeting in June 2017 as a critical friend, together with CO Medical Directors and the Chief Medical Director.

43/44 124/158

44

44/44 125/158



Author Lynda Spaven, Lead for Staff Engagement/Assistant Director L&D Raj Jain, Chief Strategy and Organisational Development Officer

Presented by Chief Strategy and Organisational Development Officer

Date 31st July 2017

Executive Summary

This paper provides an update on the Go Engage model for staff engagement approved by the Group Committees in Common on 22nd May 2017. It outlines the progress to date of three main strands; 1000 Voices Events, Pioneer Programme Rollout and Q1 Pulse Check Survey Results for NE sector Care Organisations. It highlights challenges to be address over the next 3 months.



Recommendations The Group Committees in Common is asked to review the progress to date and support actions to address challenge.

Public and/or Patient Involvement (Including equality related impacts)

Communication







Title of Report Staff Engagement Update

X

1/6 126/158

1. Introduction

1.1 At the 22nd May 2017 CiC the Boards of SRFT and PAT approved the use of the Go Engaged model as a framework for improving staff engagement.

1.2 The framework provides a single and unified approach to mobilisation, whilst providing flexibility in recognising that Care Organisations (CO) are at different places in relation to levels of staff engagement.

1.3 This report provides an update on the progress of three main strands of the Go Engage model:

1000 Voices Engagement Events Pioneers Programme Roll Out Quarter 1 Pulse Check Survey results

2. 1000 Voices Engagement Events

2.1 Three days of events for each care organisation focusing on one of the three dimensions of the Group Staff Engagement Model

i. Day 1 (May/June)– Our Future: clarity, trust & mind-setii. Day 2 (August) – My Team: work relationships, resources, perceived fairnessiii. Day 3 (November) – My Contribution: Influence, recognition, personal development

2.2 Day one events Our Future took place throughout June and early July with high levels of engagement from the CO leadership teams.

2.3 North Manchester CO delayed their pre-planned date until 3rd July. This was in order to provide greater clarity to staff following the outcomes of several key meetings regarding single hospitals service in June.

2.4 Bury & Rochdale CO required 3 separate events for each site plus community services. This was identified due to the variance in staff engagement levels and issues between the three areas.

2.5 Events were publicised through the communication systems; in addition the staff engagement team hand delivered posters to wards and departments to engage with staff and encourage attendance. Staff side promoted the events to their members through their networks.

2.6 Collectively approximately 150 staff attended the day 1 events including admin and clerical, clinical and medical staff. Many brought with them the views of colleagues; in addition a number of staff emailed in their responses to the questions posed. There was poor representation from estates and facilities staff; these groups will be targeted for future events.

2/6 127/158

2.7 There was excellent engagement at the events with valuable feedback for the CO leadership teams. This feedback has been themed and returned to the CO teams to develop local plans for action.

2.8 Some of the key themes, many of them common to each CO, were:

2.8.1 Oldham:- No time for self-development, lack of teaching and training; senior staff needs training and awareness; lack of respect and appreciation, undervalued, more celebrating success; expectations that staff will go beyond their competencies; excessive number of initiatives and too many dashboards; rapid changes, knee jerk reactions.

2.8.2 Bury & Rochdale:- Improve communication – use of digital/multi-media and greater access to directors and managers; recognition – feeling valued; greater staff engagement – being listened and fed back too; better access to, and improved, learning and development; staff space; improved policies.

2.8.3 North Manchester:- Greater clarity around services and single hospital; environment – run down; complexity of patients –makes jobs harder; better security; being done to instead of with – lack of influence; some consistency in leadership; better access to learning and development; too much bureaucracy – improved service delivery e.g. how clinics/theatres/units are run; improved communication – social media/digital.

2.8.4 Staff from all CO identified out of date IT systems as being barriers to work; car parking was identified as a big issue for staff and service users. All raised the need for transparent communication and the use of digital/social/multi-media to enable this.

2.8.5 There was a sense of optimism for the future and all attendees were committed to improving services to provide high quality health and social care.

2.9 Providing feedback to staff on how their contribution is being actioned is vital; several of the CO have decided to adjust the time frames by utilising the August dates as feedback sessions, with Day 2 taking place in November and Day 3 being planned for Feb/Mar 2018.

3. Pioneers Programme Roll Out

3.1 The Pioneers Programme aims to embed staff engagement at team level and provides the tools and techniques to allow bottom-up improvement initiatives designed and delivered by local teams.

3.2 Approximately 70 wards and units are in scope for participating in the roll out at scale within the NE sector CO. A number of in scope teams had already commenced on the programme in cohorts 1 & 2.

3.3 Identification of teams in scope who are ready for the programme has taken place in partnership with NASS team, CO Directors of Nursing & AD Workforce.

3/6 128/158

3.4 Some teams who would benefit significantly from the programme have had to delay their start date due to high vacancy levels and reliance on bank and agency staff.

3.5 Roll out commenced in June 2017 with cohorts of pioneers from a maximum of 15 ‘in scope’ teams being trained up each month on the concepts of staff engagement, tools and techniques to improve this in their own teams. The team diagnostic undertaken at the beginning of the 6 month programme informs the action plan development.

3.6 To date 26 in scope teams have commenced on programme; 13 teams will be starting at the end of July (39 in total by 31st July) with the remainder of teams commencing across August, September & October.

3.7 To sustain this roll out the pioneers support faculty has been expanded. Ten staff from across workforce, NASS and QI are receiving training on 17th July to equip them with the knowledge and skills for this role; a further ten staff members, including SRFT staff, will be trained in August/September. These people will play a key role in helping pioneers succeed in improving staff engagement and service improvement in their teams; each member of the faculty is allocated a number of teams to enable this.

3.8 Director level sponsorship from each CO has been request as a further support mechanism and names have been received; this group will evolve over the next few months.

3.9 Examples of the improvements current teams are making include: Implementing local staff recognition schemes Introducing Team Charters to improve working relationships Utilising visual management to improve communication and priorities Improving clinical profile and recruitment opportunities Review of shift patterns for newly qualified staff Identification and equipping a staff room in clinical area

3.10 Awareness raising training for clinical managers through existing meetings is being planned.

4. Pulse Check Survey (Q1 May 2017)

4.1 The survey was sent to a third of NE sector care organisation staff (3291) in May 2017. The response rate was 9% with 291 staff completing the survey; this low response rate was partly as a result of the global cyberattack which caused restrictions to external emails, hyperlinks and external websites. This resulted in an extension whilst systems were restored.

4.2 Overall most areas have improved significantly over the last twelve months although some caution should be adopted in the interpretation of the results due to the low response rate.

4/6 129/158

4.3 The overall engagement score for the Trust is reported as 3.91 against a score of 3.77 in February 2017. For the first time the survey has focused on individual CO. Their individual scores are: North Manchester 4.01 out of 5.0 (105 responses) Oldham 3.82 out of 5.0 (106 responses) Rochdale 4.01 out of 5.0 (27 responses) Bury 3.85 out of 5.0 (53 responses)

4.4 Friends and Family Test has shown a marked increase over the last twelve months; 63.92% of staff would recommend the Trust for care or treatment compared to 52.88% in March 2016 and 56.36% would recommend it as a place to work compared to 45.51% in March 2016.

4.5 Trust and working relationships remain the highest scoring enablers scoring 4.08 and 3.88 respectively – this continues to be an area of strength.

4.6 Recognition remains the lowest scoring enabler however trend data suggests that staff feeling satisfied with the extent the Trust values their work has significantly improved over the last 12 months. Staff at North Manchester reported most highly (3.59) on this enabler whilst Oldham staff reported the lowest (3.26).

4.7 The enabler mindset is still reporting moderately at 3.52, staff confidence in the future of the organisation, is beginning to report more positively (3.08 from 2.58) as is the item staff feeling able to achieve their work objectives (3.63).

4.8 Mindset needs to be an area of prioritisation; staff comments indicate concerns regarding increased administration work which is impacting on patient care, absenteeism and sickness rates. This correlates with feedback from 1000 Voices Events; further action could include staff forums, enhancing the offer of resilience training or wellbeing interventions.

4.9 Bury is reporting a significantly lower score (3.18) than the Trust norm (3.37) for perceived fairness and comments indicate a dissatisfaction with policies relating to recruitment, promotion, sickness and development. This correlates with feedback at the 1000 voices event and warrants further action.

4.10 The survey results are currently being used to update the staff engagement dashboards for each CO.

5. Challenges to Address

5.1 Getting the feedback right; staff will quickly become disengaged if there isn’t clear evidence of CO acting upon their feedback. It is vital that systems and processes are quickly established within CO to facilitate timely feedback.

5.2 Exploration and investment in digital means to communicate more effectively with staff.

5/6 130/158

5.3 Work in each CO is required to promote the completion of the pulse and National Staff Survey to ensure reliable data to monitor progress of staff engagement interventions. This will require identification of administrative support to enable a mixed mode completion method; currently the survey is sent out electronically except to a small number of staff who do not possess a Trust email address.

5.4 Strengthen director level sponsorship within each CO to support the success of the pioneer teams.

5.5 Awareness raising sessions for managers across Group as interest for the programme is increasing

5.6 Identification of teams at SRFT who would benefit from participation in the Pioneers Programme

6/6 131/158


Meeting Group Committees in CommonAuthor Abigail Harrison, Director of Innovation, Haelo

Presented by Raj Jain, Group Chief Strategy and Organisational Development Officer

Date 31st July 2017

Executive Summary

Salford Royal and Haelo have been invited to join a co learning network with global thought leaders in improvement and innovation lead by the Centre for Healthcare Innovation (CHI) in Singapore. The proposed areas of collaboration are clearly linked to our strategic agenda and bring the opportunity for significant learning. This paper outlines a proposed MoU and explores the benefits and associated risks.

Annual Plan Objective Principal Associated Risks

Recommendations The Group Committees in Common is asked to:

− Consider the proposed collaboration including benefits and risks and comment

− Review the MoU

Public and/or Patient Involvement (Including equality related impacts)N/ACommunicationCommunications to be disseminated via committee structure described.Freedom of InformationPlease indicate appropriate box below




1. Background

1.1. Salford Royal has long understood the value of learning from other health systems in supporting our commitment to continuous improvement and we recognise the benefits of working in partnership to encourage innovation and develop our thinking. Haelo, Salford’s Innovation and Improvement science

Title of Paper Proposed MoU with the Centre for Healthcare Innovation, Singapore

X

1/3 132/158

centre, plays an important role in connecting the Salford health system to thought leaders across the world and in seeking opportunities to learn from others.

1.2. The Centre for Healthcare Innovation (CHI) is hosted by Tan Tock Seng, Singapore, and acts as a hub for healthcare innovation. The CHI host a co learning network including Tan Tock Seng, Singapore, Jonkoping, Sweden (Qulturum), Counties Manukau, Middlemore Hospital, NZ (Ko Awatea) and Siriraj Hospital, Mahidol University, Thailand (R2R). Key leaders from the CHI visited Salford in March, facilitated by Haelo. They met with clinicians and leaders from Salford Royal, the ICO and Haelo and all involved found the exchange of ideas and learning of value.

2. Purpose2.1. This paper outlines the proposed approach to collaboration with the CHI, provides key details of a

proposed Memorandum of Understanding (MoU) and considers benefits and risks. The full MoU can be found as an appendix.

3. Proposed Collaboration3.1. SRFT / Haelo and the CHI have identified potential value in a partnership agreement focussed on the

sharing of learning about healthcare and population health improvement. The CHI have invited Salford Royal, as represented by Haelo, to join their co learning network and have put forward a MoU to support collaboration.

3.2. The Co learning network has three key objectives: To build thought leadership in healthcare innovation and improvement through a co-learning network To drive workforce transformation, both formal and informal, focusing on productivity and creating value

for our patients; and To enable healthcare training through new pedagogies, aiming to develop healthcare leaders of the

future

3.3. It is proposed that SRFT, through Haelo, build the governance and infrastructure required to capture learnings that can be rapidly applied to organisational objectives. At this early phase of the relationship we are aware of potential collaborations, for example Tan Tok Seng achievements in using digital and workforce redesign to improve productivity. Haelo will seek to quickly determine priorities for the CiC Executive to consider for deployment.

3.4. To secure the proposed relationship, a Memorandum of Understanding has been developed (attached).

4. Memorandum of Understanding4.1. The proposed MoU has a broad range of possible synergies that may be worked on for mutual benefit.

Focus and priorities will be developed through a discovery phase of exploring member capabilities and priorities. The possible areas of work may include: Contribution to thought leadership through the CHI Co-Learning Network as a CHI Council member Building capability through co-developing pedagogies to drive healthcare innovation Enhancing co-learning, communications, knowledge sharing and management through the use of

digital platforms Facilitating benchmarking and ideation for areas in population health strategies, digital strategies,

management of patient flow and development of an Accountable Care Organisation Supporting joint training and learning opportunities such as a fellowship exchange programme and

secondments between organisations

2/3 133/158

Providing accessibility for coaching and mentorship Actively participate in the annual retreat of the CHI Council (as members of the CHI Co-Learning

network) to foster collaborative dialogue, reflection and renewal of strategic objectives for the learning network in relation to innovation and improvement. The key areas of focus for CHI Co-Learning Network anchored by different co-learning network partners collectively include:

o Workforce transformationo Leadership and organization developmento Improvement methodology and Training pedagogyo Capability buildingo Quality and safetyo Clinical engagemento Benchmarkingo Health Services and Population Researcho Knowledge managemento Design Thinking and Innovation; ando Ethnographic Research

5. Benefits and risks5.1. The ambition is to share knowledge with global leaders on designated focus areas relevant to our

strategic agenda. We will assess each opportunity and validate, using business cases where appropriate, such opportunities for deployment in the group. Along side these every specific and focussed benefits we hope to inspire and support staff to connect with others across the world to increase the pace of innovation and learning.

5.2. The key risk is that there is failure to spread innovation & learning. i.e. knowledge is left with a few people. This is the classic issue with innovation. The mitigation is the use of a discovery phase that produces a PID with clear actions, requirements and benefit realisation. The PID will be hard wired into the appropriate organisational strategy and subject to the performance management arrangements of that strategy. For example, Better Care at Lower Cost, the digital programme, the workforce transformation plan etc. In this way, projects will not sit in isolation, whether they go forward or not will be determined by an assessment against other opportunities for improvement and they will be performance managed so that the required ROI is delivered.

6. Recommendation6.1. It is proposed that the MoU is signed at the conference in November, covering a period of three years,

effective from 8 November 2017. Raj Jain will take the lead to establish the partnership, supported by Abigail Harrison, Haelo Associate Director.

3/3 134/158

MEMORANDUM OF UNDERSTANDING

BETWEEN

TAN TOCK SENG HOSPITAL PTE LTD,AS REPRESENTED BY ITS

CENTRE FOR HEALTHCARE INNOVATION 11 JALAN TAN TOCK SENG

SINGAPORE 308433

AND

SALFORD ROYAL NHS FOUNDATION TRUST AS REPRESENTED BY HAELO, INNOVATION AND IMPROVEMENT SCIENCE CENTRE

HAELO THE VICTORIA, HARBOUR CITY

MEDIACITYUK, SALFORD QUAYS M50 3SP

1/15 135/158

of 13

MEMORANDUM OF UNDERSTANDING

This Memorandum of Understanding (“MOU”) dated 21 October 2016 is entered into between:

1. Tan Tock Seng Hospital Pte Ltd (“TTSH”), as represented by its Centre for Healthcare Innovation (“CHI”), a restructured hospital incorporated in the Republic of Singapore and having its registered address at 11 Jalan Tan Tock Seng, Singapore 308433; and

2. Salford Royal NHS Foundation Trust (SRFT), as represented by HaeloHaelo (“HAELOSRFT”), an Innovation and Improvement Science Centre, as a joint venture between Salford Royal NHS Foundation Trust, Salford Clinical Commissioning Group and Salford City Council, having its registered address at The Victoria, Harbour City, MediaCityUK, Salford Quays, M50 3SP

for a period of three [3] years, effective from 8 November 2017 up to and including 7 November 2020.

WHEREAS:

The Parties would like to collaborate to promote co-learning in healthcare innovation and workforce transformation between the Parties on the basis of equality and mutual benefit.

IT IS HEREBY AGREED as follows:

1. The Principles of this Memorandum

1.1 Both parties shall encourage the following activities to expand and promote their mutual interests to include but is not limited to:

(i) Contribution to thought leadership in healthcare innovation and workforce transformation through the CHI Co-Learning Network as a CHI Council member.

(ii) Building capability through co-developing pedagogies to drive healthcare innovation, using innovation and improvement science, as equal partners within the CHI Co-Learning Network.

(iii) Enhancing co-learning, communications, knowledge sharing and management through the use of digital platforms.

(iv) Facilitating benchmarking and ideation for areas in population health strategies, digital strategies, management of patient flow and development of an Accountable Care Organisation.

2/15 136/158

of 13

(v) Support joint training and learning opportunities such as a fellowship exchange programme and secondments between organisations. projects, programmes, fellowships and attachments for students and staff.

(vi) Provide accessibility for coaching and mentorship on projects identified and agreed upon by representatives of both parties during the period of MOU.

(vii) Actively participate in the annual retreat of the CHI Council (from CHI Co-Learning network) to foster collaborative dialogue, reflection and renewal of strategic objectives for the learning network in relation to innovation and improvement. The key areas of focus for CHI Co-Learning Network anchored by different co-learning network partners collectively include:

(a) Workforce transformation;(b) Leadership and organization development;(c) Improvement methodology;(d) Training pedagogy;(e) Capability building;(f) Quality and safety;(g) Clinical engagement; (h) Benchmarking; (i) Health Services and Population Research;(j) Knowledge management;(k) Design Thinking and Innovation; and (l) Ethnographic Research.

2. Mutual Obligations

2.1 To nominate one [1] representative from each party for the CHI Co-Learning Network as a CHI Council member to oversee the identification and facilitation of suitable projects and relevant performance measures, management of resources, intellectual property, data and knowledge management.

2.2 To undertake the above activities, all expenses during the collaboration shall be borne by the respective Parties, unless otherwise stipulated in the individual programme or activity.

3. Confidentiality

3.1 The parties acknowledge the obligation that the Confidential Information provided by any party to the other party pursuant to this MOU is the sole property of the Disclosing Party and all title, rights and interests in the Confidential Information remain vested in the Disclosing Party.

3.2 Both parties agree to treat as confidential all information received from the other party which the latter has indicated in writing or labelled to be “Confidential”, “Proprietary Information” or with any other comparable legend to similar effect, at the time of disclosure [or if disclosed orally, confirmed in writing by the Disclosing

3/15 137/158

of 13

Party as such within thirty (30) days after its disclosure], including but without any limitation whatsoever:

(a) all commercial, marketing and business information, strategic and development plans, intentions, any matter concerning HAELOSRFT and/or TTSH and/or CHI, its affairs, business, operations, shareholders, directors, officers, business associates, clients or any other person or entity having dealings with HAELOSRFT and/or TTSH and/or CHI;

(b) information relating to the financial condition of HAELOSRFT and/or TTSH and/or CHI, its accounts, audited or otherwise, notes, memoranda, documents and/or records in any form whatsoever, whether electronic or otherwise; and

(c) scientific, technical, intellectual or other information in any form whatsoever, whether electronic or otherwise, relating to methods, processes, formulae, compositions, systems, techniques, product information, inventions, know-how, trade secrets, design rights, machines, computer programs, software, development codes and research projects; business plans, co-developer/collaborator identities, data, business records of every nature, customer lists and client database, pricing data, project records, market reports, sources of supply, employee lists, business manuals, policies and procedures, information relating to technologies or theory, and all other information which may be disclosed by HAELOSRFT and/or TTSH and/or CHI, whether stored electronically or otherwise; and all copies, reproductions and extracts thereof, in any format or manner of storage, whether in whole or in part, together with any other property of HAELOSRFT and/or TTSH and/or CHI made or acquired by the other party or coming into their possession or control in any manner whatsoever.

3.3 The Confidential Information shall be and remain the sole property of the Disclosing Party and shall be returned to the Disclosing Party forthwith on demand at any time or without demand upon the expiry or termination of this MOU.

3.4 HAELOSRFT shall ensure that none of the patients of TTSH can be identified in any reports, submissions and publications of HAELOSRFT, which shall be deemed to be confidential information of TTSH within the meaning of this clause.

3.5 Both parties shall use all reasonable steps to ensure that any information marked as confidential or proprietary to TTSH and/or CHI and/or HAELOSRFT shall not be disclosed, whether directly or indirectly, to third (3rd) parties without the prior written consent of the other party, which consent shall not be unreasonably withheld, except:-

(a) for the purposes contemplated, pursuant to and in accordance with the terms of this MOU; or

(b) with the consent of the other party and then only to the extent specified in such consent;

4/15 138/158

of 13

(c) to the extent as may be required by law or in accordance with the order of a court of competent jurisdiction, regulation, effective government policy or by any regulatory authority arising out of this MOU or relating to or in connection with the other party, provided that the party so required must give the other party prompt written notice and make a reasonable effort to obtain a protective order.

3.6 The restrictions on disclosure of Confidential Information described in Clauses 3.1 to 3.5 above do not extend to any information that (a) already exists in the public domain at the time of its disclosure; (b) is already in HAELOSRFT’s or TTSH’s and/or CHI’s possession; (c) is independently developed by HAELOSRFT or TTSH and/or CHI outside the scope of this MOU; or (d) is rightfully obtained from third (3rd) parties.

3.7 Each party hereby agrees that it shall take all reasonably necessary steps to limit access to the Confidential Information of the other party to those principals, directors, officers, agents, employees, bankers, financial advisors, consultants and legal or other advisors, whose duties require them to possess such information or who are directly concerned with the purposes contemplated by this MOU and are made aware of its confidential status, to the extent reasonably required for the performance of this MOU, and ensure that they do not disclose or make public or authorise any disclosure or publication of any Confidential Information in violation of this MOU.

3.8 Each party must promptly inform the other party about any unauthorised disclosure of the other party’s Confidential Information.

3.9 Subject to the foregoing, each party’s confidentiality obligations under this clause shall survive the expiry or termination of this MOU.

4. Personal Data Protection

4.1 Any personal data provided by one Party (the “Disclosing Party”) to the other Party (the “Receiving Party”) and used by the Receiving Party directly or indirectly in the performance of this Agreement shall remain at all times the property of the Disclosing Party. It shall be identified, clearly marked and recorded as such by the Receiving Party on all media and in all documentation. Save as aforesaid, the parties shall ensure that only anonymised information relating, directly or indirectly, to patients shall be disclosed.

4.2 The Receiving Party shall take all reasonable precautions and adequate measures to preserve the integrity and prevent any corruption or loss, damage or destruction of the Disclosing Party’s personal data. In the event of termination of this Agreement, the Receiving Party shall when directed to do so by the Disclosing Party, instruct all its agents and sub-contractors to erase all personal data provided by the Disclosing Party and all copies of any part of the personal data provided by the Disclosing Party from the Receiving party’s systems and magnetic/storage data.

4.3 All personal data acquired by the Receiving Party from the Disclosing Party shall

5/15 139/158

of 13

only be used for the purposes of this Agreement and shall not be further processed or disclosed without the prior consent of the Disclosing Party.

4.4 The personal data will not be transferred or made available to any Third (3rd) Party without the prior written consent of the Disclosing Party. The Receiving party shall not use any personal data provided by the Disclosing Party, or any substance that is replicated or derived therefrom for any commercial or profit-generating purpose, or in the conduct of research that is subject to consulting, licensing or other similar legal or commercial obligations to another institution, corporation or business entity, unless the provider provides its prior written consent. Upon the expiry or earlier termination of this Agreement, the personal data will be either returned to the Disclosing Party or disposed of under the Receiving party’s supervision in accordance with the applicable laws and regulations, and the written instructions of the Disclosing Party.

4.5 Both Parties shall comply at all times with the Personal Data Protection Act 2012 (Act 26 of 2012) and its regulations made thereunder.

5. Effectiveness

5.1. Except for Clauses 3, 4, 6 to 9, 11 to 20 and 22, which are intended to be legally binding, and shall so bind the parties, this MOU is not intended to be legally binding nor does it represent a complete summary of the contractual or commercial aims of the parties but their current desires and understandings. This MOU shall form the basis of negotiations for a definitive agreement or agreements and save in respect of the paragraphs aforesaid, neither party is obliged to the other unless and until such a definitive agreement or agreements is signed by both parties and has become effective in accordance with its terms.

6. Further Assurance

6.1 This MOU does not give rise to an exclusive arrangement between the parties. Neither party shall be precluded from entering into similar agreements with third (3rd) parties, subject to the observance of the obligations on confidentiality set out in this MOU.

7. Expenses

7.1 HAELOSRFT and TTSH agree that each party will be responsible for its own legal and all other costs and expenses associated with evaluating and executing the contemplated transaction and/or arising out of and in connection with the preparation of this MOU.

8. Termination

8.1 This MOU may be terminated:-

6/15 140/158

of 13

(a) by either party forthwith on giving notice in writing to the other party if the other party commits a material breach of any provision of this MOU and shall have failed to remedy the breach within thirty (30) days after receipt of a request in writing to do so;

(b) in the event of a non-compliance by the other Party with any license, regulatory or legal requirement(s) applicable to that Party’s performance of its obligations under the Agreement;

(c) if either party, being a company or limited liability partnership, shall pass a resolution to go into liquidation, or the courts shall make an order that the company be compulsorily wound up (otherwise than for the purpose of reconstruction or amalgamation) or the company is subject to the supervision of the court, either involuntarily or otherwise, or the company enters into an arrangement with or compounds or convenes a meeting of its creditors or has a receiver, manager, judicial manager or an administrator appointed on behalf of a creditor over all or a substantial part of its properties or assets or ceases for any reason whatsoever to carry on its business or is deemed unable to pay its debts within the meaning of section 254(2) of the Companies Act (Cap. 50) or takes or suffers any similar action as a consequence of debt;

(d) if any event occurs, or proceeding is taken, with respect to the other party in any jurisdiction to which it is subject that has an effect equivalent or similar to any of the events mentioned in Clause 8.1(c) above; or

(e) if there is a change of control of the other Party. For the purposes of this clause, “control” means the power of a person to secure, directly or indirectly (whether by holding of shares, possession of voting rights or by virtue of any other power conferred by the articles of association, constitution, partnership deed or other documents regulating another person or otherwise) that the affairs of such other person are conducted in accordance with his or its wishes.

8.2 Any termination of this MOU by either party howsoever caused shall not affect:

(i) any rights or remedies of either party which have accrued prior to the date of termination; or

(ii) either Party’s past and future obligations and liabilities arising under the surviving provisions of the MOU as set out in Clause 8.4.

8.3 TTSH and HAELOSRFT may terminate this MOU without cause upon giving thirty (30) days’ prior written notice to each other.

8.3 Any provision of this MOU which expressly or by implication is intended to come into or continue in force on or after termination of this Agreement [including Clauses 3, 4, 6 to 9, 11 to 20 and 22] shall remain in full force and effect.

9. Advertisement and Publication

7/15 141/158

of 13

9.1 Both parties agree not to use any name or description in connection with its activities or make any public statements or disclosures in respect of this MOU or the areas of cooperation contemplated herein without the express written consent of the other party, which consent shall not be unreasonably withheld. The Parties shall submit such pamphlets, advertisement or other promotional material to the other Party for approval prior to such pamphlets, advertisement or other promotional material being published in the various media.

9.2 Clause 9.1 does not give both Parties any editorial rights over the contents of the pamphlets, advertisement or other promotional material, other than to ensure that the goodwill or reputation of the other Party is not being jeopardized by such pamphlets, advertisement or other promotional material and/or that the public is not being confused, misled or deceived by such pamphlets, advertisement or other promotional material.

9.3 Both Parties also undertake that it shall not use in any way commercial information derived from the other Party arising out of this cooperation work without prior written permission.

9.4 Notwithstanding the generality of the above, the parties may notify third (3rd) parties of the fact that this MOU is in effect.

10. Notice

10.1 Except as otherwise provided in this MOU, notices which are required to be given under or permitted by this MOU shall be made in writing (unless expressly stated otherwise) and sent to the fax number or address or electronic mail (“email”) of the recipient set out in this MOU. All notices may be sent by facsimile to the number as specified in this MOU or such other number as the party may later specify, or by email or by hand or by AR Registered post or certified mail, return receipt requested, postage prepaid and properly addressed to the offices of the parties as specified in this MOU or to such other address or email address as the party may later specify.

10.2 Every notice or communication so sent shall be deemed to have been properly served and validly made, if by facsimile on the next working day after transmission, but only if a transmission report is generated by the sender’s fax machine recording a message from the recipient’s fax machine, confirming that the fax was sent to the number indicated and confirming that all pages were successfully transmitted, or if by hand when delivered to the recipient’s address or if sent by AR Registered post two (2) days after posting if posted to an address within Singapore and eight (8) days after posting, if posted to an address outside Singapore, notwithstanding the fact that the letter may be returned by the Post Office undelivered. Notice given by email shall be deemed delivered when transmitted electronically to the intended recipient’s email address, provided no transmission error message is generated by the transmitting device.

8/15 142/158

of 13

CHIRepresentatives & Notice Address

HaeloHAELORepresentatives & Notice Address

Name: Mr. David DhevarajuluTitle: Executive Director, CHI Mailing address: Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng Singapore 308433 Phone: +65 6359 6794 Fax: +65 6256 2261 (CEO Office fax)Email: [email protected]

Name:Raj Jain Title: Chief strategy and organizational development directorMailing address:The Victoria, Media City UK, Salford Quays M50 3SP

Phone: Fax: - Email: [email protected]

11. No Partnership

11.1 Nothing contained in or relating to this MOU shall be deemed to constitute a partnership or a principal-agent relationship between the parties and no party shall have any authority to act for or assume any obligation or responsibility of any kind, express or implied on behalf of the other party or bind or commit the other party for any purpose in any way whatsoever.

12. Variation

12.1 No amendment, modification of or addition to any provisions of this MOU shall be effective unless made in writing and signed by the duly authorized representatives of both parties.

13. Limitation of Liabilities

13.1 In carrying out their respective obligations under this MOU, HAELOSRFT and TTSH shall comply with all laws and regulations applicable thereto but save for deliberate breaches, wilful acts, default or gross negligence on their respective parts, neither party shall be liable to the other party for any indirect, incidental, special, punitive, financial or consequential damages however caused, including any loss of profits, loss of goodwill, loss of business, loss of business opportunities, loss of anticipated savings, loss or corruption of data or information or business interruption costs and under any theory of liability, including but not limited to contract, strict liability and negligence or for breach of statutory duty or misrepresentation; whether or not the other party has been advised of the possibility of such damage.

14. Assignment

9/15 143/158

mailto:[email protected]

of 13

14.1 Subject to the other provisions of this MOU, all the terms and conditions of this MOU shall be binding upon and inure to the benefit of the parties and their respective permitted assigns and successors-in-title except that:-

(a) neither party to this MOU shall transfer or assign all or any of its rights, obligations or benefits hereunder in whole or in part to any third (3rd) party without the prior written consent of the other party, which consent shall not be unreasonably withheld;

(b) any permitted assignee or transferee shall agree in writing to comply with all terms and conditions of this MOU; and

(c) any assignment shall not exceed the existing scope of this MOU.

15. Severability

15.1 In the event that any term, condition or provision contained in this MOU or the application of any such term, condition or provision shall be held by a court of competent jurisdiction to be wholly or partly illegal, invalid, unenforceable or a violation of any applicable law, statute or regulation of any jurisdiction, the same shall be deemed to be deleted from this MOU and shall be of no force and effect; whereas the remaining terms, conditions or provisions of this MOU shall remain in full force and effect as if such term, condition and provision had not originally been contained in this MOU, unless the severed provisions render the continuing performance of this MOU impossible, or materially change either party’s rights or obligations under this MOU; in which event such party may give written notice of its intent to terminate this MOU to the other party.

15.2 Notwithstanding the aforesaid, in the event of such deletion, the parties hereto shall negotiate in good faith in order to agree to terms of mutually acceptable and satisfactory alternative provisions in place of the provision(s) so deleted.

16. Waiver

16.1 No waiver of any breach of any covenant, condition, stipulation, obligation or provision contained or implied in this MOU shall operate or be interpreted as a waiver of another breach of the same or of any covenant, condition, stipulation, obligation or provision in this MOU.

16.2 Any time or other indulgence granted by either Party under this MOU shall be without prejudice to and shall not be taken as a waiver of that Party’s rights under this MOU nor shall it prejudice or in any way limit or affect any statutory rights or powers from time to time vested in or exercisable by the Parties.

17. Dispute Resolution

10/15 144/158

of 13

17.1 In the event of any dispute or difference arising out of or in connection with or in relation to this MOU, including any question regarding the existence, validity, termination, application or interpretation of this MOU or any of its provisions, or any claim, disagreement or dispute arising out of or relating to this MOU or the breach thereof of any of its provisions, both parties shall use their best endeavours to settle the dispute informally by agreement between the parties. Both parties shall always act in good faith and co-operate with each other to resolve any disputes.

17.2 Notwithstanding anything in this MOU, if the dispute is not settled informally in accordance with Clause 17.1, no party shall proceed to litigation or any other form of dispute resolution unless the parties have made reasonable efforts to resolve the same through mediation, in accordance with the mediation rules of the Singapore Mediation Centre. A party who receives a notice for mediation from the other party shall consent and participate in the mediation process in good faith in accordance with this clause. The parties undertake to abide by the terms of any settlement reached. Failure to comply with this clause shall be deemed to be a breach of this MOU.

17.3 In the event that mediation is unsuccessful, the dispute shall be resolved either by reference to arbitration or by court proceedings as elected by either party, by way of a written notice to the other party, which shall state the specific dispute to be resolved and the nature of such dispute. Should the Parties fail to agree to refer the dispute to arbitration, either party may institute an action in court; the Parties agree, in such event, to submit irrevocably to the non-exclusive jurisdiction of the Courts of the Republic of Singapore to settle any and all disputes in connection with this Agreement.

17.4 Any reference to arbitration in Singapore shall be a submission to arbitration within the meaning of the Arbitration Act (Cap. 10) for the time being in force in Singapore. Such arbitration shall be conducted in the English language in accordance with the Arbitration Rules of the Singapore International Arbitration Centre (“SIAC Rules”) for the time being in force, which rules are deemed to be incorporated by reference into this clause, except in so far as such Rules conflict with the express provisions of this clause, in which event the provisions of this clause will prevail.

17.5 The arbitral tribunal shall consist of one (1) arbitrator to be appointed by mutual agreement between the parties. Either party may propose to the other the name or names of one (1) or more persons, one (1) of whom would serve as the arbitrator. If no agreement is reached within thirty (30) days after receipt by one (1) party of such a proposal from the other, the arbitrator shall be appointed by the Appointing Authority.

17.6 The Appointing Authority shall be the Chairman of SIAC.

17.7 The arbitrator must not be a present or former employee or agent of, or consultant or counsel to, either party or any related corporation [as defined in Section 6 of the Companies Act (Cap 50)] of either party.

11/15 145/158

of 13

17.8 Any decision or award of an arbitral tribunal appointed pursuant to this clause will be final and binding on the parties and the execution thereof may be entered into any court having jurisdiction.

17.9 Interest at the annual rate of six per cent (6%) per annum will be due and payable to the party in receipt of an arbitration award from such date as the arbitration tribunal may decide until the date of payment to such party.

17.10 The parties hereto undertake to keep the arbitration proceedings and all information, pleadings, documents, evidence and all matters relating thereto confidential.

17.11 The application of Part II of the International Arbitration Act (Cap. 143A) and the Model Law referred to therein, to this MOU is hereby excluded.

17.12 For the avoidance of doubt, it is agreed that nothing in this clause shall prevent a party from seeking urgent equitable relief before any appropriate court and the commencement of any dispute resolution proceedings shall in no way affect the continual performance of the parties’ obligations under this MOU.

18. Entire Agreement

18.1 The parties expressly acknowledge that they have read this MOU and understood its provisions. The parties agree that this MOU and all Schedules annexed to the same constitute the entire agreement between them with respect to the subject matter of this MOU and that it supersedes all prior or contemporaneous proposals, agreements, negotiations, representations, warranties, understandings, correspondence and all other communications (whether written or oral, express or implied) or arrangements entered into between the parties prior to this MOU in respect of the matters dealt with in it.

18.2 No promise, inducement, representation or agreement other than as expressly set forth in this MOU has been made to or by the parties.

19. No Third (3rd) Party Beneficiaries

19.1 Nothing contained in this MOU is intended to confer upon any person (other than the parties hereto) any rights, benefits or remedies of any kind or character whatsoever or any right to enforce the terms of this MOU under the Contracts (Rights of Third Parties) Act (Cap. 53B), and no person shall be deemed to be a third (3rd) party beneficiary under or by reason of this MOU.

20. Governing Law

20.1 This MOU shall be deemed to be made in Singapore, subject to, governed by and construed in all respects in accordance with the laws of the Republic of Singapore for every intent and purpose.

12/15 146/158

of 13

21. Execution in Counterparts

21.1 This MOU may be executed in one (1) or more counterparts by the duly authorised representatives of the parties, each of which when so executed shall be deemed to be an original and all of which taken together shall constitute one (1) and the same agreement provided that this MOU shall be of no force and effect until the counterparts are exchanged.

22. Miscellaneous

22.1 Words incorporating the masculine gender only shall include the feminine and/or neuter genders and vice versa and words incorporating the singular meaning shall include the plural meaning and vice versa and words denoting natural persons shall include bodies corporate, incorporate, associated partnerships, firms, trusts, associations, joint ventures, governments, governmental agencies or departments or any other entity, and all such words shall be construed interchangeably in that manner.

22.2 The clauses, paragraph or clause headings and marginal notes in this MOU are inserted for ease of reference and convenience only and do not form part of this MOU. They shall not be deemed to define, limit, construe or describe the scope or intent of the clauses hereof nor shall they in any way affect the interpretation of this MOU.

22.3 References to clauses, schedules and annexes shall be references to Clauses of and the Schedules and Annexes to this MOU. The Schedules and Annexes are to have effect and be construed as an integral part of, and shall be deemed to be incorporated into, this MOU.

22.4 References to statutory provisions shall be construed as references to those provisions as respectively amended, consolidated, extended or re-enacted from time to time and all statutory instruments or orders made pursuant to them.

22.5 Any reference to “day” shall mean a period of twenty-four (24) hours, ending at twelve (12) midnight.

22.6 If any period of time is specified from a given day, or the day of a given act or event, it is to be calculated exclusive of that day. Where expressed by reference to a person in Singapore, business day means any day other than a Saturday, a Sunday or a day on which licensed banks are authorised or required to be closed in Singapore and, where expressed by reference to the jurisdiction of a person other than Singapore, means any day other than a Saturday, a Sunday or a day on which licensed banks are authorised or required to be closed in the jurisdiction of that person, then that time limit is deemed to only expire on the next business day.

22.7 References in this MOU to anything which any party is required to do or not to do shall include its acts, default and omissions, whether direct or indirect, on its own

13/15 147/158

of 13

account, or for or through any other person and those which it permits or suffers to be done or not done by any other person.

14/15 148/158

of 13

IN WITNESS WHEREOF the parties hereto have caused this MOU to be executed by their duly authorised representatives as at the date first set forth above.

Tan Tock Seng Hospital Pte Ltd HaeloSRFT

_______________________________Dr Eugene Fidelis SohChief Executive Officer

_______________________________Professor Maxine PowersSir David DaltonChief Executive Officer

In the presence of:

_______________________________Mr. David Dhevarajulu Executive DirectorCentre for Healthcare Innovation

_______________________________

15/15 149/158


Meeting Group Committees in CommonAuthor Charlotte Towell, Corporate Matron

Presented by Chief Nursing Officer

Date 31st July 2017

Executive Summary

This paper provides a recommendation to the Group Committees in Common regarding two community teams attending SCAPE Panel on the 13th July 2017.



Recommendations The Group Committees in Common is asked to review the following recommendations:

Approve SCAPE accreditation status for:

The Bladder and Bowel Service

Defer SCAPE accreditation status for:

The Community Intermediate Rehabilitation and Supportive Discharge service

Public and/or Patient Involvement (Including equality related impacts)N/ACommunicationOutcome will be communicated via NAAS/CAAS section of intranet.







Title of Report SRFT: SCAPE Panel Recommendations

X

1/3 150/158

1. Introduction

1.1 The CAAS (Community Assessment and Accreditation System) is used on all community areas to highlight best practices as well as deficiencies in practice, patient safety, education and management. This system has been in operation since late 2013.

1.2 The aim is for all community services to achieve SCAPE (safe clean and personal every time) status. Once services are consistently assessed as ‘green’ they may apply for SCAPE and further rigorous assessments continue.

1.3 SCAPE goes beyond nursing care and therapy; services being considered must demonstrate multidisciplinary working on improvement and safety. SCAPE is a reward for achievement of quality standards as well as being a Trust leader in patient safety.

2. SCAPE Panel

2.1 On the 13th July 2017 the Panel sat to review the Bladder and Bowel Service and the Community Intermediate Rehabilitation and Supportive Discharge Service SCAPE applications. These are the fourth group of community teams to attend SCAPE Panel. The Community Rehabilitation and Supportive Discharge service is the first AHP team to apply for SCAPE accreditation.

2.2 The Panel consisted of the Director of Nursing, Medical Director, Managing Director, Non-Executive Director, Deputy Divisional Director of Nursing, ADNS, Lead Nurse, and a patient representative from the Trust Membership.

2.3 The Panel process involved reviewing background information supplied by the teams. The panel split into two teams and one team attended the Bladder and Bowel Service team base in the morning and shadowed staff performing a home visits and a clinic at Eccles Gateway. The second team attended the Community Intermediate Rehabilitation and Supportive Discharge Service Team base and attended home visits with team members and a residential care home to shadow staff undertaking assessments and therapy. Panel members also spoke to staff that were completing referral screening, spoke with teams who work alongside the teams presenting, and had discussions with staff at each of the team’s bases. The panel regrouped and spent the afternoon listening to the team’s presentations and engaged in an in-depth question and answer session with the teams.

3. Recommendations

3.1 The Group Committees in Common is recommended to approve SCAPE status for:

The Bladder and Bowel Service

3.2 The team will be given recommendations from the SCAPE Panel to achieve and be reviewed and discussed again at their SCAPE Review Panel in approx. 12 months

3.3 The Panel is recommending deferment for:

The Community Intermediate Rehabilitation and Supportive Discharge service

2/3 151/158

3.4 The Panel felt the team failed to convey innovation within the team to sustain SCAPE status, they will be invited to present again in approx. 6 months’ time in order for the team to compile sufficient data and evidence to support their application for SCAPE accreditation.

3.5 If approved the total number of SCAPE community services will stand at 6. (Walkden District Nurses, West Health Visitors and School Nurses; Childrens Diana Nursing team, Irlam District Nurses, South Health visitors and School nurses, Bladder and Bowel Service)

3.6 One further Community team is currently deferred (Broughton district Nursing team) who will present to panel again in early 2018

3.7 The total number of wards achieving SCAPE status in the Trust is 33

3.8 The next SCAPE Panel is scheduled for 14th September 2017.

3/3 152/158


Meeting Group Committees in CommonAuthor Rebecca McCarthy, Deputy Trust Secretary

Presented by John Willis, Chairman of Audit Committee

Date 31st July 2017

Executive Summary

A summary is provided for the Group Committees in Common of the key matters and decisions from the Group Audit Committee meeting on 29th June 2017.



N/A

Recommendations The Group Committees in Common is asked to review the summary of the meeting and the agreed actions.


N/ACommunication

N/AFreedom of InformationPlease indicate appropriate box below






Title of Report Report from Group Audit Committee – 29th June 2017

X

1/2 153/158

1. Review of arrangements by which staff can raise issues or concerns – Confirmed arrangements were in place for the proportionate and independent investigation of issues and concerns.

2. Chief Medical Officer Report including Response to Internal Audit Limited Assurance Reports:

− Medical Job Planning − Medicines Management − Working Time Arrangements for Coronial Post Mortems

Key actions to be implemented, including timescales, in response to recommendations made in the above Internal Audit limited assurance reports reviewed and confirmed. Audit Committee emphasised the importance of accountability with regards to the implementation of agreed actions.

3. Chief Nursing Officer Report: Group CQC Corporate Assurance Review Programme – Reviewed and confirmed the proposed programme for Group wide CQC Corporate Assurance Review Programme.

4. Chief Finance Officer Report – Reviewed and approved including confirmation of the post Annual Accounts Sustainability and Transformation Funding adjustment at both PAT and SRFT, and approval of the Losses and Special payments covering the period 1st April 2017 to 31st May 2017.

5. Group Governance Framework Manual – Review and confirmed, noting further review in November 2017.

6. Internal Audit Plans – Group and Care Organisation – Reviewed and approved approach, including reporting, for agreed Internal Audit Plans 2017/18 in a Group and Care Organisation structure.

7. Discussion: Group Audit Committee – Discussion took place regarding the development of Group Audit Committee work plan and key reports/issues to be included for review.

2/2 154/158


Meeting Group Committees in CommonAuthor Stuart Logan, Assurance Framework Manager

Presented by Sir David Dalton, Chief Executive Officer

Date 31st July 2017

Executive Summary

A summary is provided for the Group Committees in Common of the key matters considered at the Group Risk and Assurance Committee held on 17th July 2017.

Annual Plan Objective N/A


Risks presented via the Care Organisation Statements of Assurance which are triangulated with the Care Organisation Board Assurance Frameworks/Risk Registers.

Recommendations The Group Committees in Common is asked to note the summary of the matters considered.


N/A

CommunicationKey matters for action disseminated to Care Organisations.Freedom of InformationPlease indicate appropriate box below

A – This document is for full publication B – This document contains FoIA exempt information C – This whole document is exempt under the FoIA If you have chosen B above, highlight the information that is to be redacted within the document for subsequent removal.Confirm to the Group Secretary which applicable exemptions apply to the whole document or to highlighted sections.

Title of Report Report from Group Risk and Assurance Committee – 17th July 2017

X

1/4 155/158

Group Risk and Assurance Committee (GRAC)

Key Matters Considered:

1. Cladding Review ReportAn update was provided to the committee by the Director of Capital, Estates and Facilities. Over the past month, special investigations have taken place across the Group’s estate to assess compliance with both building and fire regulations with respect of the cladding that is in place following the Grenfell Tower disaster. The GRAC received a report indicating that the Group’s estate is legally compliant. The Director of Capital, Estates and Facilities advised that the Group will be in a position to satisfy the return required by NHS Improvement on Wednesday 19th July. In addition to the NHS Improvement Return, the Director of Capital, Estates and Facilities agreed to write to the landlords of buildings which the Trust use under contract to seek assurance that they are also compliant with fire legislation.

2. Report from PAT Executive Assurance and Risk CommitteeThe key matters from the Pennine Executive Assurance and Risk Committee were conveyed to the committee by the Chief Finance Officer.

- It was highlighted that the Pennine Improvement plan is ongoing with actions being undertaken in relation to controlled medicines and patient case notes. A position statement was requested by EARC.

- It was highlighted that staffing at Oldham MAU was a concern, adjustments have been made to resources for stabilisation.

- A number of IM&T, Radiology and HR risks which were presented to the committee with scores of 12 and above. The Director of Corporate Services and Assurance Framework Manager have been asked by the committee to review the risks proposed to verify the accuracy of the scoring.

- An issue was raised at the committee regarding the process of locum appointment; the committee requested a report into the management of medical locums which will be reported back to EARC in August.

- Emergent risks were highlighted to EARC as follows 1) the risk posed to Oldham CO by the expected retirement of a vascular consultant, 2) Hosted services in relation to an agreement of business rules, 3) A risk in relation to the LCO at North Manchester

- It was highlighted that the EARC considered the approach that should be taken regarding 217 historic incidents of harm at Pennine where the duty of candour requirement has yet to be enacted. The committee requested the Director of Patient safety return a proposal documenting the different approaches that could be adopted to the next meeting of the Committee.

3. Key matters from Group Information and Performance CommitteeThe key matters from the Group Information and Performance Committee were conveyed to the committee by the Chief Executive Officer.

- The Information and Performance Committee received presentations from “Lightfoot” detailing an offering in providing greater analytical support with a focus on presentation through SPC charting. The Group Information and Performance Committee has agreed to progress this as required.

- The Committee reviewed the Draper and Dash scorecard. Some changes to the scorecard were noted and further changes requested.

- The committee reviewed the Group Scorecard.

4. Key matters from the Hosted Services BoardThe key matters from the Hosted Services Board were conveyed to the committee by the Chief Finance Officer.

- It was highlighted to the committee that there are two hosted services which are planning to vacate the Salford site subject to the negotiation of leases. It was highlighted that this will impact on the hosted services income.

2/4 156/158

- It was highlighted that for the AHSM, there is a programme of work in place with Health Innovation Manchester. The process will be overseen by Hosted Services Board with reports into Group CIC in line with the agreed process.

5. Care Organisation Board Assurance Frameworks/Risk RegistersThe Assurance Framework Manager presented the covering report and risk matrix which was designed to support GRAC with the read across of the risk profile of each Care Organisation.GRAC discussed the risk matrix and endorsed its usefulness. The GRAC members queried the differing interpretations of risk scores across the Care Organisations and concluded that differing levels of risk maturity and appetite were reflective of the current position. The Chief Executive Officer requested that a focus be placed on the mechanics of risk scoring across the Care Organisations and Group, along with a determination of risk appetite at the upcoming Group away day.Further refinements to the risk matrix were requested to reflect the position of Group following the completion of risk assessments against Group objectives which will be presented in a short paper to Group CIC in July.

The key areas of risk noted across all Care Organisations were noted to be: The achievement of Mandatory Access Standards – A&E and RTT Recruiting to establishment and a high volume of agency usage. The delivery of Financial Plans Delivering against Quality Improvement initiatives (mortality, recognising the deteriorating patient,

care for patients with sepsis, Infection control standards, learning and embedding improvement)

6. Chief Officers Statements of Assurance

SalfordThe Salford Care Organisation Medical Director presented the statement of assurance and highlighted to the GRAC:

Significant work has been undertaken to address the key performance issues in relation to the A&E 4hr standard. The work has 4 key work-streams within it which are being overseen by the Care Organisation Improvement Board.

Additional beds have been identified to support in times of pressure. Physical capacity has been created but will not be utilised until required, the beds will be held in reserve to cope with areas of risk.

Conversations are currently ongoing with Salford Council regarding the approval of planning permission to open a 30 bedded modular building on the Stott Lane car park to provide additional intermediate care beds. It was noted that NHSI expect a statement of intent to be made by end of the calendar month stating the intention to build capacity on the Salford site. The Director of Capital, Estates and Facilities was asked to support Salford Care Organisation in the development of plans.

North ManchesterThe North Manchester Care Organisation Chief Officer presented the statement of assurance and highlighted to the GRAC:

The Care Organisation has achieved A&E performance for the first quarter of 2017/18. Achievement of the 62 day cancer target is presenting a significant challenge to the Care

Organisation.

OldhamThe Oldham Care Organisation Chief Officer presented the Statement of Assurance to GRAC:

It was highlighted that there are a number of critical areas within the Care Organisation that are causing concern these are in relation to the nursing and surgical workforce, the low number of middle grade doctors in A&E, achieving the Urgent Care targets, General Surgery in its totality and the lack of clarity regarding business rules for hosted services.

3/4 157/158

It was highlighted that a piece of work is being undertaken within the Care Organisation to analyse the problems in General Surgery holistically and a request was made that Group support a resolution to the problems once they are understood. The committee requested that the Chief Delivery Officer provide advice on the hierarchy of the holistic plan.

The business rules for Hosted Services were discussed. It was agreed that a resolution would be reached at the next meeting of the Transition Board Meeting.

Bury and RochdaleThe Bury and Rochdale Care Organisation Chief Officer presented the statement of assurance to GRAC.

It was highlighted that there are currently issues in relation to RTT targets, that there some operational issues in relation to the chronic pain service, a deterioration in compliance with the WHO surgical checklist has been noted.

Plans are being developed to retrieve the WHO checklist compliance with an expectation that these will be completed by mid-August.

7. Delivery of Financial PlansThe Chief Executive Officer requested that the rest of the meeting be dedicated to discussion about delivery of financial plans and the impact that high agency usage and premium rates.The Chief Finance Officer provided an overview of the current financial position advising that STF funding has been achieved in Quarter 1 but it is expected that pressure will be faced in Quarter 3. A lack of delivery against BCLC was noted to be driving the issue along with the current high volumes of bank and agency usage. GRAC agreed that plans to retrieve the position would be developed with Executive Leadership provided by Chief Strategy Officer and the Chief Medical Officer for clinical workforce and by the Chief Nursing Officer for nursing workforce. It was agreed that plans would be developed and submitted for review within two weeks.

8. Any other businessThe Chief Finance Officer alerted GRAC to a heightened level of risk caused by the Salford finance purchase to pay system. This risk will be articulated and included on the risk register in July.

4/4 158/158