Download CUH Balanced Scorecard August 2015

Balanced Score Card
Review of August 2015 Data
Balanced Scorecard
Finance
Quality
&
Safety
Patient
Access
Human
Resource
Management
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 WTE’s per Week 2013-15
CUH Average Specials /Other Nursing & HCA Agency WTE’s 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)
30
25
24
23
22
20
20
18
18
17
15
22
21
21
17
20
19
18
19
17
17
18
17
15
15
14
14
15
14
13
13
16
12
12
10
5
0
12
11
10
10
10
Inpatient – Day case Waiting Lists
Total Adult Waiting List
Count
of mrn
Clinical
Priority
Wait
category
Routine
ACTIVE
399
222
106
139
68
56
33
1
1024
PREADMIT
SUSPENSI
ON
151
44
3
19
6
5
12
1
241
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
SUSPENSI
ON
106
27
5
2
3
5
1
149
8
1
1
1
12
339
127
48
72
24
17
4
1
632
919
394
157
234
99
80
50
3
1936
Adaptive Wait Time
Bands
Routine
Total
Urgent
Urgent
Total
Grand
Total
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)
35
31
30
25
20
18
15
9
10
4
5
2
2
0
Gynaecology
Urology
Surgery
Cardiology
Vascular
Cario Thoracic
Waiting List – 15 month Target (269)
Count
of id
Dec 31 Status (15m)
Has Appointment before or on Dec Suspension reactivating pre Dec
No
15m Breach Month
31
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)
7
Cardio Th
9
Cardiology
10
Pl Surgery
47
G Surgery
2
Respt
15
Urology
57
Vascular
122
Gynae
0
20
40
60
80
100
120
140
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
4.16
4.09
3.79
3.86
3.75
3.68
3.74
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