Balance Score Card Acute Hospitals Division

Balance Score Card Acute Hospitals Division

Balanced Score Card Review of August 2015 Data Balanced Scorecard Finance Finance Report - August 2015 Actual outturn YTD August 2015 Group budget 188.2m (2014 183.0m) Group actual expenditure 188.1m (2014 191.9m) Group actual surplus 104k ( 2014 deficit: 8.9m)

CUH Budget 176.7m (2014:170.1m) CUH /SMOH actual expenditure 177.1m (178.6m) CUH /SMOH actual deficit 421k (2014 8.5m) Mallow Budget 11.5m (2014:11.2m) Mallow actual expenditure 11.0m (2014 11.8m) Mallow actual surplus 525k ( 2014 deficit 617k) Forecast 2015 Group Budget 282.58m (2014 284.9m)

Group projected expenditure 282.2m (284.2m) Group Projected Surplus 358k ( surplus 0.7m) CUH Budget 265.3m (2014:262.8m) CUH projected actual 265.4m (265.2m) CUH projected Deficit 79k (2.4m) Mallow Budget 17.3m (2014:17.5m) Mallow Projected Actual 16.8m (16.8m) Mallow Projected Surplus 461k CUH Summary Budget v Actual Expenditure August 2015 Pay k Non-Pay k Income k Total CUH -327 -873

1,154 -46 0 1 1 -327 -873 1,115 -45 25

16 -30 11 -302 -857 1,125 -34 SMOH CUH-SMOH Mallow Total Group

CUH Budget v Actual Pay YTD - August 2015 2015 Actual Budget k k Variance k % Variance 2014 Actual k v 2014 Variance k Medical/Dental 42,820 42,975 - (155)

-0% 41,871 -(1,103) Nursing/Midwifery 58,047 58,584 - (537) -1% 58,491

- (93) Paramedical 21,428 21,324 104 0% 21,433 110 Housekeeping 7,988

8,950 - (962) -12% 8,565 -(386) Catering 2,647 2,737 - (89)

-3% 2,796 59 Portering 3,928 3,863 66 2% 4,000 137

Administration 11,898 12,014 - (116) -1% 11,847 - (167) Other Staff 2,331

2,419 - (88) -4% 2,349 - (70) - (1,778) -1% 151.351 - (1,514) Total

151,086 152,864 CUH Actual Non-pay Expenditure k YTD August 2015 v 2014 CUH Group Surplus / (Deficit) percentage % CUH Debtor days August 2015 CUH AGENCY COSTS k 2013 August 2015 CUH AGENCY WTE 2015 CUH Agency Costs August 2015 CUH Average Nursing & HCA Agency WTEs per Week 2013-15 CUH Average Specials /Other Nursing & HCA Agency WTEs per Week 2014-15

Patient Income 2013 August 2015 Mallow Budget v Actual YTD August 2015 MGH Budget Pay 10,101 Non Pay 2,885 12,987 Income -1,494 Total 11,493 Actual Variance 10,093

8 3,147 -262 13,240 -254 2,272 778 10,968 525 % Variance 0.1% -9.1% -2.0% 52.1% 4.6% Patient Access

CUH Weekly INMO Trolley Report Week ending 11th September 2015 Daily Trolley Numbers June September 2015 (18/09/2015) Ambulance Turnaround Times (August) ED 6hr & 9hr Target (9hr 77.4% - 6hr 59.6%) (14th September) R ED 6hr & 9hr Target Admitted Patients (14 th

September) ED 6hr & 9hr Target Non admitted Patients (14 th September) Delayed Discharges - 2015 January September (8th September) Inpatient Day case Waiting Lists Total Adult Waiting List Count of mrn Adaptive Wait Time Bands

Clinical Priority Wait category Routine ACTIVE 399 222 106 139

68 56 33 1 1024 PREADMIT 151 44 3 19

6 5 12 1 241 SUSPENSI ON 30 1 4

1 2 1 580 267 109 162 75 63

46 2 1304 ACTIVE 225 99 43 69 21 11

2 1 471 PREADMIT 106 27 5 2 3

5 1 149 SUSPENSI ON 8 1 1 1 12

Urgent Total 339 127 48 72 24 17 4 1

632 Grand Total 919 394 157 234 99 80 50

3 1936 Routine Total Urgent 0-3 Months 3-6 6-8 8-12 12-15 15-18 18-24 24-36 Grand Months Months Months Months Months Months Months Total 1 39

Waiting List 18 month Target (66) Count of id EoM Status (18m) Wait category ACTIVE PREADMIT Grand Total Appointment before or at EoM 9 9 Appointment Post EoM

7 7 No Appointment 50 Grand Total 50 50 16 66 Waiting List - 18 month Target (66)

Waiting List 15 month Target (269) Count of id Dec 31 Status (15m) 15m Breach Month Has Appointment before or on Dec 31 Suspension reactivating pre Dec No 31 Appointment 2014/08 2014/09

1 1 Grand Total 1 1 2014/10 1 1 2015/01 2 2

2015/02 1 1 2015/03 1 2015/04 4 2015/05 6

2015/06 1 17 21 13 20 5 13 18 2015/07

3 25 28 2015/08 4 26 30 2015/09 2 1

23 26 2015/10 2 1 38 41 2015/11 1

24 25 2015/12 6 1 46 53 Grand Total 34 5

230 269 1 15 month target by Speciality (269) Inpatient Breach Plan December 2015 Specialty Cardiology Cardio-Thoracic Surgery General Surgery Gynaecology Plastic Surgery Respiratory Medicine Urology

Vascular Surgery Breaches Breaches Breaches Breaches Total End Sept End Oct End Nov End Dec 2015 2015 2015 2015 3 5 1 1 4 1 1 1 31 5 6 10 77 19

15 28 3 3 4 2 1 6 1 8 49 11 2 3 Sep-15 Oct-15 Nov-15 Dec-15 Excess /Gap 10 7

52 139 10 3 15 65 4 20 16 24 12 1 9 18 4 25 20

22 15 1 11 20 4 25 20 22 15 1 11 20 4 20 15 16

16 0 10 19 6 83 19 -55 48 0 26 12 Outpatient Waiting Lists Patients in breach of the 18m deadline Status of patients in breach of the 18m deadline

(9th September 2015) Patients to be seen by the 31st of December 2015 Medical Patients to be seen by the 31st December (1386 - as of 9th September) Surgical Patients to be seen by the 31st December (3321 - as of 9th September) Women and Children Patients to be seen by the 31st December (1425 - as of 9th September) New and Return DNA Rate New to Return Ratio OPD Breach Plan December 2015 Specialty

Breast Surgery Cardiology Diabetes Mellitus Endocrinology Gastro-Enterology General Medicine General Surgery Gynaecology Infectious Diseases Neurosurgery Ophthalmology Paed Endocrinology Paediatric Neurology Paediatrics Plastic Surgery Respiratory Medicine Rheumatology Urology

Vascular Surgery End Sept End Oct 2015 2015 End Nov End Dec Total 2015 2015 64 252 138 76 4 149 825 41

20 6 63 5 38 159 25 14 2 51 2 56 131 238 1152 114

254 56 118 246 38 104 145 68 3673 8 24 50 13 32 41 20 888

80 226 1 3 20 51 12 27 42 16 759 2 50 7 7 72 3

64 165 2 104 239 1 6 34 57 15 46 61 31 966 2 180 293 153

262 14 307 1280 2 536 1871 2 73 196 404 78 209 289 135 6286 Sep-15

Oct-15 Nov-15 Dec-15 Excess /Gap -2 -180 -293 -153 -262 -14 -307 -1280 -2 -536 -1871 -2

-73 -196 -404 -78 -209 -289 -135 -6286 Outsource Qty Max 20% Scope Waiting List Scopes Urgent August G Scopes Routine - August

R Medical ALOS (July Dashboard) A New Patients Treated with Radiation Oncology - August Reason for Treatment Delay - August 2015 Quality & Safety Day Surgery Admission Rate (July Dashboard) G

ALOS Excluding LOS over 30 days (July Dashboard) G Cancer KPI Breast-Lung-Prostate -Jan August Note: Breast data is estimated as data not fully inputted on system Quality Programme Board On Board Quality Improvement Project Develop a comprehensive picture of quality of clinical care Have an understanding of same Act to hold the hospital accountable on the quality of care delivered Improvement Actions Selecting Quality Indicators (ten in total selected) Develop a Quality Dashboard Targeted reading for Board members to increase knowledge

Shared learning with Sir Stephen Moss ISBAR (Identify, Situation, Background, Assessment & Recommendation) Communication tool for discussion Quality Programme Clinical Care Indicators 1)Medical Readmission rates 2)Surgical readmission rates 3)Patient experience of nursing care 4)Staph Aureus rates 5)C. Difficile Rates 6)Training in hand hygiene (online or in person) 7)End of life care in a single room 8)Presence of family room on ward (and further standard or room) 9)Falls 10)Smoking cessation Learning Hold to Account

Restructuring of Board Agenda Spend time at board meeting on discussing quality (and measure) Act - Restructuring of Board minutes to reflect recommendations Non executive quality walk rounds to meet clinical team on wards providing the care Results Dedicated time for the discussion of quality of clinical care at board meetings Quality of Clinical Care Indicators are analysed monthly by the Board 150% increase in the time spent discussing quality of clinical care at board

meetings Improvement in quality of discussion & number of recommendations by the Board in relation to quality of clinical care Risk Register Risk Register update in September 2015 49 Open Risk Assessments on Risk Register Two new risks escalated to Group CEO: Risk Assessment 56 Keogh Billing system Risk Assessment 57 - Delayed intervention for patients requiring Implantable Cardio Defibrillator (ICD) procedures. Reducing Healthcare Acquired Infection (MRSA) (July Dashboard)

G Reducing Healthcare Acquired Infection- C diff (July Dashboard) G Reducing Healthcare Acquired Infection (July Dashboard) G NEWS Implementation (July Dashboard) G IMEWS Implementation (July Dashboard)

G HIQA Reports - Portlaoise Presentation at EMB and Executive Quality & Safety Committee Self assessment report submitted against S/SWH Group template Filling of permanent Director of Midwifery post, Clinical Director post and experience Risk Manager post Critical Care Capacity Human Resource Management Sick Leave August 2015 % CUH - Total % Sick Leave 2014 v 2015 4.44

3.79 4.16 3.74 4.09 3.86 3.75 3.68 3.16 3.07 3.7

3.37 3.91 3.74 3.89 % Target Dec % 2014 Sick Leave Nov Oct Month

% 2015 Sick Leave 4.22 3.8 3.86 Sept Aug July June May April

Feb Jan Mar 5 4.58 4.5 4.01 4 3.5 3 2.5 2 1.5 1 0.5 0 Staffing & Costs

EWTD Compliance CUH Staff Nurse Starters/Leavers 2015 Capital Projects Project Status MRI Unit Paediatric Unit Completed and operational Phase 1 - build programme commenced in July Phase 2 submitted for capital funding Mental Health Unit Acute Medical Assessment Unit Phase 3

& Endoscopy Unit Completed and operational Completed and operational Radiation Oncology Unit Cystic Fibrosis/ Respiratory Ward Ward refurbishment completed operational from October 2015 Blood Sciences Project Design Team appointed request for managed service approved

Oncology Service Planning permission granted Enabling works to commence in November 2015 Expansion of Day Unit plan signed off submitted for Philanthropic funding (ACT) Refurbishment of Ward 2D capital funding in place Medical Oncology Centre developing Statement of Need Ophthalmology Transfer phase 2 Project group in place Helipad

Interim helipad in place - final solution being assessed by CAA. Step Down Unit Procurement Process for staffing being progressed Key Issues Recruitment of Nursing staff 31 beds closed Recognition of Budgetary performance Dependency on patient income 2016 Estimates Undergraduate Training costs - 6.5m per annum Management of Unscheduled Care Implementation of Change Programme Initiatives Scheduled Care Implementation of plan to meet waiting list targets Hospital Group approach to maximise capacity

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