Balanced Score Card Review of August 2015 Data

Balanced Scorecard Finance Patient Access Quality & Safety 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 €kNon-Pay €kIncome €kTotal CUH , SMOH 011 CUH-SMOH , Mallow Total Group ,125-34

CUH Budget v Actual Pay YTD - August 2015 Budget €k 2015 Actual €kVariance €k% Variance2014 Actual €k v 2014 Variance €k Medical/Dental42,82042,975- (155)-0%41,871-(1,103) Nursing/Midwifery58,04758,584- (537)-1%58,491- (93) Paramedical21,42821, %21, Housekeeping7,9888,950- (962)-12%8,565-(386) Catering2,6472,737- (89)-3%2,79659 Portering3,9283,863662%4, Administration11,89812,014- (116)-1%11,847- (167) Other Staff2,3312,419- (88)-4%2,349- (70) Total151,086152,864- (1,778)-1% (1,514)

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

Patient Income 2013 – August 2015

Mallow Budget v Actual YTD August 2015

Patient Access

CUH Weekly INMO Trolley Report Week ending 11 th September 2015

Daily Trolley Numbers – June – September 2015 (18/09/2015)

Ambulance Turnaround Times (August)

ED – 6hr & 9hr Target (14 th September) (9hr – 77.4% - 6hr – 59.6%) R

ED – 6hr & 9hr Target – Admitted Patients (14 th September)

ED – 6hr & 9hr Target – Non admitted Patients (14 th September)

Delayed Discharges January – September (8 th September)

Inpatient – Day case Waiting Lists

Total Adult Waiting List Count of mrn Adaptive Wait Time Bands Clinical Priority Wait category 0-3 Months 3-6 Months 6-8 Months 8-12 Months Months Months Months Months Grand Total RoutineACTIVE PREADMIT SUSPENSI ON Routine Total UrgentACTIVE PREADMIT SUSPENSI ON Urgent Total Grand Total

Waiting List – 18 month Target (66) Count of id Wait category EoM Status (18m)ACTIVEPREADMITGrand Total Appointment before or at EoM99 Appointment Post EoM77 No Appointment50 Grand Total501666

Waiting List - 18 month Target (66)

Waiting List – 15 month Target (269) Count of idDec 31 Status (15m) 15m Breach Month Has Appointment before or on Dec 31 Suspension reactivating pre Dec 31 No Appointment Grand Total 2014/ / / / / / / / / / / / / / / Grand Total

15 month target by Speciality (269)

Inpatient Breach Plan – December 2015

Outpatient Waiting Lists

Patients in breach of the 18m deadline

Status of patients in breach of the 18m deadline (9 th September 2015)

Patients to be seen by the 31 st of December 2015

Medical Patients to be seen by the 31 st December ( as of 9 th September)

Surgical Patients to be seen by the 31 st December ( as of 9 th September)

Women and Children Patients to be seen by the 31 st December ( as of 9 th September)

New and Return DNA Rate

New to Return Ratio

OPD Breach Plan – December 2015

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 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

Staffing & Costs

EWTD Compliance

CUH Staff Nurse Starters/Leavers 2015

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 2015 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 UnitProcurement 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