Balanced Score Card Review of October 2015 Data

Balanced Scorecard Finance Patient Access Quality & Safety Human Resource Management

Finance

Finance Report – October 2015 Actual outturn YTD - October 2015 Group budget €235.2m (2014 €228.3m) Group actual expenditure €236.5m (2014 €235.8m) Group actual deficit €1.3m ( 2014 : €7.5m) Less: Additional bad debts provision re MOU €1.1m Loss of earnings –Radiation therapists €150k Waiting list penalties €170K Adjusted group surplus –YTD Oct €0m CUH Budget €220.8m (2014:€212.5m) CUH /SMOH actual expenditure €222.6m (2014 €219.6m) CUH /SMOH actual deficit €1.8m (2014 €7.1m) Adjusted deficit (excl bad debt/LOE)–ytd Oct €0.4m Mallow Budget €14.4m (2014:€13.9m) Mallow actual expenditure €13.9m (2014 €14.3m) Mallow actual surplus €460k ( 2014 deficit €372k)

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

CUH Group Summary – Budget v Actual Expenditure YTD - October 2015 Pay €kNon-Pay €kIncome €kTotal CUH-2,816-7,6158,579-1,852 SMOH CUH-SMOH-2,816-7,6398,652-1,805 Mallow Total-2,820-8,1439,620-1,343

CUH Budget v Actual Pay YTD – October Budget €k 2015 Actual €k Variance €k % Variance 2014 Actual €k v 2014 Variance €k Medical/Dental53,44754,344-(897)-1.7%52,797-(1,547) Nursing/Midwif ery72,38673,002-(616)-.9%72,862-(140) Paramedical26,73927,016-(277)1%26,918-(98) Housekeeping5,4795,652-(173)-3%5,324-(327) Care Assistants5,0535,567-(514)-10%5,324-(243) Catering3,3033, %3, Portering4,8144, %4, Administration14,86515, %14, Other Staff2,9082, %2,97833 Total188,994191,810-2, %189,424-2,386

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 October 2015

Forecast Group Budget €283.0m (2014 €284.9m) Group projected expenditure €286.4m (€284.2m) Collection of EU Charges €0.7m Group Projected Deficit €2.6m ( surplus 0.7m) Less: Additional bad debts provision re MOU €2.2m Loss of earnings –Radiation therapists €0.4m Waiting list penalties €170k Add National service contracts €210k Adjusted group projected surplus €0.4m CUH Budget €265.8m (2014:€265.1m) CUH projected actual €268.7m (€265.3m) CUH projected Deficit €2.9m (€0.2m) Mallow Budget €17.2m (2014:€17.5m) Mallow Projected Actual €16.9m (€16.8m) Mallow Projected Surplus €0.3m (€0.7m)

Patient Access

CUH Weekly INMO Trolley Report Week ending 13 th November 2015

Ambulance Turnaround Times - October

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

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

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

Delayed Discharges January - October (10 th November)

Inpatient – Day case Waiting Lists

Inpatient & Daycase Breaches – 31 st December 2015

Outpatient Waiting Lists

OPD Potential Breaches – 21 st December 2105

Scope Waiting List

Scopes Urgent – September G

Scopes Routine - September R

Medical ALOS (September Dashboard) A

New Patients Treated with Radiation Oncology in Target - October

Reasons for Treatment Delay - October

New Patients Treated within Target 2014 Vs 2015

Brachytherapy Activity January 2015 – October 2015

Quality & Safety

Day Surgery Admission Rate (September Dashboard) G

Surgery – Length of Stay (September Dashboard) A

ALOS – Excluding LOS over 30 days (September Dashboard) A

Cancer KPI – Breast-Lung-Prostate –January – October

OPAT Outpatient Parenteral Antimicrobial Therapy – IV antibiotics/antifungals/antivirals given at home Reduces patients length of stay in hospital Avoids Admission for long period Reduces healthcare associated infection risk Patients can return to work

Bed Days Saved

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

Patient Experience Report Jan – June 2015

Complaints by Directorate

Compliance with Timeframes

Compliments

Complaint Management Review Group Lean mapping project June 2015 Pilot project November 2015 on improvements in the  Triage  administration support  pooling of investigative resources  data capture on process  recommendations for improvements  monitoring of recommendations

Risk Register Risk Register update submitted 22 nd October 11 on-going investigations Three new risks escalated to Group CEO in November  Risk Assessment –Grade 3 Pressure Ulcer  Risk Assessment –Grade 4 Pressure Ulcer  Risk Assessment – Sexual Assault

HIQA Announced Visit Antimicrobial Stewardship Programme Site visit on Tuesday 20 th October 2015 Acknowledged good progress with Antimicrobial Stewardship Programme that ties in with the National Stewardship programme Challenges  Medication Safety officer  Infection Control Nurse staffing levels  Clinical Pharmacist resources  Lack of surgical site surveillance  Laboratory surveillance of multi-drug resistant organisms not performed

Reducing Healthcare Acquired Infection (MRSA) (September Dashboard) R

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

Antibiotic Consumption Rate (September Dashboard) G

Human Resource Management

Sick Leave – October 2015

Staffing & Costs October 2015

EWTD Compliance (Jan – October)

Nursing - 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 WardCompleted Education and Training CentreStatement of Need being developed 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. Transitional Care UnitCompleted

Key Issues Reopening of 31 inpatient beds 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