Balanced Score Card Review of July 2015 Data

Balanced Scorecard Finance Patient Access Quality & Safety Human Resource Management

Finance

Finance Report - July 2015 Actual outturn YTD July 2015 Group budget €164.2m (2014 €159.9m) Group actual expenditure €164.1m (2014 €167.7m) Group actual surplus €138k ( 2014 deficit: €7.8m) CUH Budget €154.2m (2014:€148.6m) CUH /SMOH actual expenditure €154.6m (€156.0m) CUH /SMOH actual deficit €375k (2014 €7.4m) Mallow Budget €10.0m (2014:€9.7m) Mallow actual expenditure €9.5m (2014 €10.3m) Mallow actual surplus €514k ( 2014 deficit €560k)

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 June 2015 Pay €kNon-Pay €kIncome €kTotal CUH SMOH CUH-SMOH Mallow Total

CUH Budget v Actual Pay YTD - June 2015 Budget €k 2015 Actual €kVariance €k% Variance2014 Actual €k v 2014 Variance €k Medical/Dental31,81832, %31, Nursing/Midwifery43,22743, %44, Paramedical15,96915,925440%15,96843 Housekeeping5,9846, %6-240 Catering1,9721,97020%2,06596 Portering32,878652%3, Administration8,8378, %8, Other Staff1, %1, Total112,486114, %113,

CUH Actual Non-pay Expenditure €k YTD July 2015 v 2014

CUH Group –Surplus / (Deficit) percentage %

CUH Debtor days – July 2015

CUH AGENCY COSTS €k 2013 – July 2015

CUH Agency Costs – June 2015

CUH Average Nursing & HCA Agency WTE’s per Week CUH Average Specials /Other Nursing & HCA Agency WTE’s per Week

Cost Containment Plan

Patient Income 2013 – July 2015

Mallow Budget v Actual YTD June 2015

Patient Access

CUH Weekly INMO Trolley Report Week ending 14 th August 2015

Daily Trolley Numbers – June – August 2015 (23/8/2015)

Ambulance Turnaround Times (June)

ED – 6hr & 9hr Target (17 th August) (9hr – 77.4% - 6hr – 59.6%) R

Delayed Discharges January – August (18 th August)

Inpatient – Day case Waiting Lists

Total Waiting List – 14/08/2015 Wait category 0-3 Months 3-6 Months 6-8 Months 8-12 Months12-15 Months15-18 Months18-24 Months24-36 MonthsGrand Total ACTIVE PREADMIT SUSPENSION ACTIVE PREADMIT SUSPENSION

18 Month Breaches (54)

18 Month Breaches by Speciality

15 Month Breaches - December 2015 (313)

15 Month Breaches by Specialty

Outpatient Waiting Lists

Patients in breach of the 18m deadline- 30 th June

Patients Currently in Breach 0f 12mth Target

Medical Patients to be seen by the 31/12/2015 (1,382)

Surgical Patients to be seen by the 31/12/2015 (5,244)

Women and Children Patients to be seen by the 31/12/2015 (2,329)

Scope Waiting List

Scopes Routine – June 2015 R

Medical ALOS (June Dashboard) G

New Patients Treated with Radiation Oncology - July 2015

Reason for Treatment Delay - July 2015

Quality & Safety

Time to Surgery (June Dashboard) G

ALOS – Excluding LOS over 30 days (June Dashboard) G

Cancer KPI – Breast-Lung-Prostate -Jan – July

Serious Reportable Events (SRE’s) 11 SREs communicated in communicated in July & August 3 environmental events serious disability for patient associated with a fall whist in hospital 3 care management events Maternal death, serious disability associated with a diagnostic error & stage 3 pressure ulcer after admission 1 surgical event Unintended retention of a foreign object post surgical procedure

Reportable Events

Re Reportable Events portable Events

Patient Experience - Complaints Complaints received - July % of complaints investigated within 30 working days 9 Safe and Effective Care 6 Access 2 Dignity and Respect 2 Communication and Information 1 Accountability

5 Treatment and Care 2 Medication 3 Appointment 1 Human Resources 1 Hygiene 1 Parking 1 Accessibility / Resources 1 Admission 1 Delivery of Care 1 Alleged inappropriate behaviour 1 Communicatio n Skills Patient Experience - Complaints

Risk Register Risk Register update in June Open Risk Assessments on register Update & amendments made to 11 risk assessments Closed 6 previously identified risks - CUH 16, CUH 31, CUH 44, CUH 45, CUH 46, CUH 49 Reopened 1, CUH 39 - Theatre Staffing Four new risks identified CUH 52, CUH 53, CUH 54, CUH 55 6 risk assessment escalated to CEO South / South West Hospital Group for consideration of additional controls CUH 17, CUH 39, CUH 52, CUH 53, CUH 54, CUH 55

Reducing Healthcare Acquired Infection (MRSA) (June Dashboard) G

Reducing Healthcare Acquired Infection- C diff (June Dashboard) G

Reducing Healthcare Acquired Infection (June Dashboard) G

National Early Warning Score National Early Warning Score programme extending to include sepsis recognition and treatment National sepsis screening tool and pathway Implementation on implementation Audit results indicate a decrease in compliance - a number of measures identified for improvements Mandatory online education nurses, NCHDs and consultants- you must do it to work here Commitment that NEWS score will be used in all patient handover e.g. ward, virtual hospital, bed management Commitment to ISBAR Support for an electronic tool Irish Maternity Early Warning Score - New Modified IMEWS Chart rolled out in CUMH, ISBAR sticker for IMEWS developed and in use

NEWS Implementation (June Dashboard) G

IMEWS Implementation (June 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 – July 2015

Staffing & Costs

EWTD Compliance

Capital Projects ProjectStatus MRI UnitCompleted and operational Paediatric Unit Phase 1 - build programme commenced in July Phase 2 – submitted for capital funding Mental Health UnitCompleted and operational Acute Medical Assessment Unit – Phase 3 & Endoscopy Unit Completed and operational Radiation Oncology Unit  Planning permission granted  Enabling works to commence in November 2015 Cystic Fibrosis/ Respiratory WardWard refurbishment completed – operational from October Blood Sciences ProjectDesign Team appointed – request for managed service approved Oncology Service  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 2Project group in place HelipadInterim helipad in place - final solution being assessed by CAA. Step Down UnitDiscussion has commenced on Procurement Process

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