Balanced Score Card Review of December 2015 Data

Balanced Scorecard Finance Patient Access Quality & Safety Human Resource Management Patient and Service User

Finance

Finance Report – December 2015 Provisional outturn Group budget €286.1m (2014 €284.9m) Group actual expenditure (net) €285.9m (2014 €284.1m) Group actual surplus €0.3m ( 2014 surplus: €0.7m) CUH Budget €268.8m (2014:€265.1m) CUH /SMOH actual expenditure €269.2m (2014 €265.3m) CUH /SMOH actual deficit (€0.3m) (2014 €0.2m) Mallow Budget €17.3m (2014:€17.5m) Mallow actual expenditure €16.7m (2014 €16.8m) Mallow actual surplus €0.6m (2014 surplus: €0.8m )

CUH Group –Surplus / (Deficit) percentage % (December)

CUH Group Summary – Budget v Actual Expenditure YTD 2015 Pay €kNon-Pay €kIncome €kTotal CUH-3,983-7,07110, SMOH CUH-SMOH-3,983-7,13910, Mallow-6851, Total-3,984-7,82412,071263

CUH Budget v Actual Pay YTD Budget €k 2015 Actual €k Variance €k % Variance 2014 Actual €k v 2014 Variance €k Medical/Dental ,975-1,540-2%63,6372,338 Nursing/Midwif ery87,13987, ,-1%87, Paramedical32,08832, %32, Housekeeping6,5676, %6, Care Assistants5,9676, %6, Catering3,9764, %4,13353 Portering5,8005,785160%5, Administration17,87518, %17, Other Staff3,5013,504-30%3,52420 Total227,34923,133-3,983-2%227,4673,864

CUH Actual Non-pay Expenditure €k YTD 2015

CUH AGENCY COSTS €k 2013 – YTD 2015

CUH AGENCY WTE – YTD 2015

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

Patient Income 2013 – YTD 2015

CUH Debtor Days –YTD 2015

Mallow Budget v Actual YTD 2015 Budget €kActual €kVariance €k%Variance Pay15,16115, % Non - Pay4,3735, % 19,53420, % Income-2,244-3,5221, % Total17,29016, %

Patient Access

INMO Trolley Report Annual data for 2015 and comparative data for 2014

CUH Weekly INMO Trolley Report Week ending 15 th January 2015

ED – 6hr & 9hr Target – All Patients (January – December) R

ED – 6hr & 9hr Target – Admitted Patients (January – December)

ED – 6hr & 9hr Target – Non Admitted Patients

Times of Ambulance Presentations Week Ending 10 th January 2016

Ambulance Distribution Monthly

Improvement Initiatives More options for Ambulance Crews Decision making on destination hospital ED visibility of incoming ambulances NAS visibility of ED Status Ambulance Management assistance with clinical handover when required Separate Ambulance Triage Nurse

Delayed Discharges YTD 2015

Outpatient Waiting Lists

Patients to be seen by 31 st January to meet maximum 15 - Month Wait Timeline

Patients with no Appointment before End of January 2016 and Patients with an Appointment post January 2016 by Specialty

Medical Patients to be seen by 31 st January, 2016 to meet maximum 15-Month Wait Timeline

Surgical patients to be seen by 31 st January, 2016 to meet maximum 15 - Month Wait Timeline

Women and Children Patients to be seen by 31 st January, 2016 to meet maximum 15 - Month Wait Timeline

Current Waiting List 13/01/2016

Scope Waiting List

Scopes Urgent – November G

Scopes Routine - November R

Medical ALOS - November G

Quality & Safety

Day Surgery Admission Rate - November G

Surgery – Length of Stay - November G

ALOS – Excluding LOS over 30 days - November G

ALOS for all inpatients- November G

Emergency Re admission – Medicine - November

Emergency Re admission – Surgery - November G

Day Case Rate – Elective Cholecystectomy - November G

ALOS for all inpatients- November G

Emergency Hip Fracture Rate – November G

ALOS for all inpatients- November G

NEWS Full Implementation G

IMEWS Implementation for pregnant patients G

Reducing Healthcare Acquired Infection (MRSA) November R

Reducing Healthcare Acquired Infection- C diff (October Dashboard) R

Antibiotic Consumption Rate (October Dashboard) G

Cancer KPI – Breast-Lung-Prostate January – December

CUH OPAT Referrals 2015

CUH - OPAT Bed Days Saved 2015

CIT Referrals – January 2016 (01/01/2016 – 12/01/2016)

CIT Referral Source - January 2016 (01/01/2016 – 12/01/2016)

Quality and Safety  Appointment of Clinical Director for Women and Children Directorate  Appointment of Lead for Clinical Audit  External Expert for Radiology Review identified  Improvement Programme on Complaints Management  Housekeeping Services Project Group – Principals agreed  Pilot project on risk assessment, risk escalation and risk register using module on Q Pulse (medium term plan is an electronic system)  Quality Improvement Programme for Outpatient services  Interviews for post of Risk Manager, Quality Assurance Manager and Quality Improvement Manager completed – In place 1 st Quarter 2016

Risk Management December KPI data Serious Reportable Events (x2) -Fractures (incidents happened in November but not reported until December) Reportable events (Safety Incident Reporting) – 67 (*timelag in reporting due to manual system, electronic reporting 2016 at ward level) Medication Safety Incidents reported - 0 (*) Complaints – 24 complaints raised in December on average 41% closed within 30 day timeframe Claims - 3 new claims notified to hospital (one claim previously reported as incident) 1 risk escalated in November

Human Resource Management

Sick Leave – November 2015

Staffing & Costs November YTD 2015

EWTD Compliance 2015

Capital Projects Project Status MRI Unit Completed and operational Paediatric Unit Phase 1 - build programme commenced in July Phase 2 – submitted for capital funding Mental Health Unit Completed and operational Acute Medical Assessment Unit – Phase 3 & Endoscopy Unit Completed and operational Radiation Oncology Unit  Planning permission granted  Enabling works to commence in January 2016 Cystic Fibrosis/ Respiratory Ward Completed and operational Education and Training Centre Statement of Need being developed Blood Sciences Project Design 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 2 Project group in place Helipad Interim helipad in place - final solution being assessed by CAA. Interim Transitional Care Unit Completed

Key Issues Reopening of 30 inpatient beds (Transitional Care Unit) Recognition of Budgetary performance Dependency on patient income 2016 Budget / Estimates Undergraduate Training costs - €6.5m per annum Management of Unscheduled Care Implementation of Change Programme Initiatives