1. An Associated University Hospital of Brighton and Sussex Medical School 1 Integrated Performance Report M11 – February 2016 Presented by: Angela Stevenson (Chief Operating Officer) Des Holden (Medical Director) Fiona Allsop (Chief Nurse) Paul Simpson (Chief Financial Officer) An Associated University Hospital of Brighton and Sussex Medical School

2. An Associated University Hospital of Brighton and Sussex Medical School 22 Patient Safety There were six SIs declared in February 2016 and no Never Events. Patient safety indicators continue to show expected levels of performance. The Trust had no MRSA bloodstream infections and one Trust acquired C-Diff cases in February 2016. Clinical Effectiveness Mortality is lower than expected for our patient group when benchmarked against national comparators. Maternity indicators continue to show expected performance. Access and Responsiveness The 4hr ED standard was not achieved with performance of 91.4% in February 2016 All Cancer Access Standards except the TWR Breast Symptomatic were achieved in February 2016 18 Weeks RTT - The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month. Patient Experience In February 2016 the Inpatient FFT decreased slightly to 95.0%. The ED FFT increased from 95.8% to 96.3%. Workforce The Trust is actively reviewing initiatives to improve recruitment and retention, such as reducing time to recruit and ongoing local and overseas recruitment. The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. Agency usage increased in February and the Trust is adverse to its agency trajectory. Performance – February 2016

3. An Associated University Hospital of Brighton and Sussex Medical School 33 Action: The Board are asked to note and accept this report Legal: All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance on safe high quality care (Including mortality). Regulation: The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license care services under the Health and Social Care Act 2009 and associated regulations. Patient experience/ engagement: This paper includes significant detail on both patient experience and access to services. Risk & performance management This is the main Board assurance report for performance against quality and financial measures and is linked to risk management through the SRR. NHS constitution; equality & diversity; communication. This report covers performance against access standards with the NHS Constitution. Finance The Trust forecast for the year is a £(6.6)m deficit (after donated asset technical adjustments), due to further industrial action by the Junior Doctors and variance to forecast at M11. This position also includes £3.0m non-recurrent income from the TDA (capital to revenue transfer). Risk to this position is now estimated at £1.0m in respect of final contract settlement with CCG’s. Key Risks The Significant Risk Register for the Trust includes five quality risks in relation to “Right bed first time”, ED Access standards, Outbreak of viral gastroenteritis, Increasing sickness absence levels and RTT Access Standards. Performance – February 2016

4. An Associated University Hospital of Brighton and Sussex Medical School 4 Patient Safety There were no Never Events reported in February 2016. VTE risk assessment performance for February 2016 is undergoing validation - performance of 95% is expected. Safety Thermometer – performance decreased to 89.1% for the “All Harm” indicator and 93.8% for the “New Harm” indicator. This was driven by an increase in patients who had had a fall with harm (3.65% of patients compared to 1.80% in January 2016) and New VTEs (1.16% of patients compared to 0.16% in January 2016). Patient Safety

5. An Associated University Hospital of Brighton and Sussex Medical School 5 Six SIs were declared in February 2016 (in all cases full investigations have been started): 2016/2935 A visco-elastic gel containing preservative was used in error during two cataract procedures to maintain volume and pressure within the eyeball during surgery. The preservative is toxic to the endothelium of the cornea. Both patients are experiencing blurred vision and will be monitored. It is not known at this stage whether the effects will be permanent. 2016/2938 Patient assessed to have fractured neck of femur of unknown origin on day 6 of admission (date of admission 12/01/16). Patient's consultant reports that hip pain was present on admission. 2016/3554 An EWS score of 7 was recorded for this patient, the score was not escalated according to Trust policy. Shortly after he sustained a cardiac arrest, was transferred to ITU where he subsequently died. 2016/4063 Patient prescribed 4 litres of fluid for 24 hours, but only received approximately 1.5 litres within that period. The patient already had previous problems with renal function having only one kidney, but had largely recovered. Failure to deliver fluids has led to worsened acute renal failure. 2016/4494 26/11/15 patient attended ED as a surgical referral, assessed by surgical team and sent home with ultrasound appointment for following day. His family postponed the appointment until 21/12/2015. The ultrasound was completed and found to be abnormal but there was a delay in the result being reviewed by a clinician. The patient's symptoms did not resolve so he returned to GP who identified the abnormality on the image and referred the patient back to the surgical team. 2016/5396 The patient was an 85 year old male under the care of the palliative care team. He was displaying signs of agitation and was confused due to possible urine infection and hypoxia. He was repositioned by the nursing staff at 05:00. When the nurse went to check the patient again at 06:00, he was found dead, on the floor, at his bedside. He had sustained a head trauma. Patient Safety

6. An Associated University Hospital of Brighton and Sussex Medical School 6 Infection Control There were no cases of MRSA in February 2016 and 1 case of Trust acquired C.diff. In light of the on-going risk of outbreaks of viral gastroenteritis, the following risk is on the Trust's significant risk register: Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3). Patient Safety

7. An Associated University Hospital of Brighton and Sussex Medical School 7 Mortality and Readmissions Latest HSMR data for the Trust shows mortality remains lower than expected for our patient group when benchmarked against national comparators. Maternity Maternity indicators continue to show expected performance. Clinical Effectiveness

8. An Associated University Hospital of Brighton and Sussex Medical School 8 Emergency Department The ED 4hr standard was not achieved in February 2016 with performance of 91.4%. Volumes /Acuity of emergency attendances / admissions continue to be an issue, with overnight non-elective admissions up 7% (3% for East Surrey CCG and 16% for Crawley CCG) compared to last year. Discharge delays are also a significant driver of performance with an average of 104 beds occupied by patients who are medically ready for discharge Ambulance turnaround performance has deteriorated alongside the 4hr Standard with an increase in handover delays over 30 and 60 minutes. In light of the on-going operational pressures in the Trust, the following risks are on the significant risk register: ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system – Risk score 16 (Likelihood of 4 and consequence of 4) Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3) Access and Responsiveness

9. An Associated University Hospital of Brighton and Sussex Medical School 9 Cancer In February 2016, all Cancer Access Standard except the TWR Breast Symptomatic were achieved. On the Breast Symptomatic pathway, 20 patients breached the standard. This was primarily driven by patient deferrals / cancellations. Access and Responsiveness

10. An Associated University Hospital of Brighton and Sussex Medical School 10 Referral to Treatment (RTT) and Diagnostics At aggregate level, the trust continues to deliver against the incomplete pathways standard which measures % of patients waiting less than 18 weeks at the end of each month. Challenges remain in General Surgery, Trauma and Orthopaedics, Ophthalmology and Cardiology. A number of newly recruited consultants will increase capacity and support reduction in patients over 18 weeks with performance expected to improve over the coming months. The diagnostic standard continues to be achieved. 133 patients were cancelled at the “last minute” for non clinical reasons. A significant factor is the bed pressures that result from the high volumes of Emergency admissions. This has also meant that the Trust has not been able to offer patients their treatment within 28 days following a last minute cancellation with 7 breaches of the 28 day standard in January and 4 breaches in February. The following risk is on the significant risk register: RTT Access Standards - Due to on-going operational pressures and increasing demand for elective services, the Trust cannot offer all services within the 18 weeks standards set out in the NHS Constitution. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints. (effectiveness, experience and safety) – Risk score 15 (Likelihood of 5 and consequence of 3) Access and Responsiveness

11. An Associated University Hospital of Brighton and Sussex Medical School 11 Patient Voice Inpatients – The February Friends and Family Test (FFT) score for inpatient wards has decreased slightly to 95.0%. Emergency Department – The February FFT score has increased from 95.8% to 96.3%. ED staff have had a renewed push on promoting the FFT, particularly within Minors. The response rate for February is the highest it has ever been (28%). Maternity - Both FFT scores and response rates have improved for the delivery and postnatal ward touchpoints. The antenatal FFT score has increased but is based on a lower response rate this month (17% compared to 23%). A number of measures to support patient experience are being put in place including: New “Standards of behaviour” are being implemented across volunteers, agency and bank staff. A trial to extend visiting hours to 9.30-20.00 will start on three wards and one consultant is trialling Skype for a relative to be present remotely. National comparisons for December Nationally, the combined score for inpatients and daycases for January 2016 was 96.0%. The combined SASH score for January was 96.9%, just above average. Nationally the ED was ranked 11 th in January 2016. Patient Experience

12. An Associated University Hospital of Brighton and Sussex Medical School 12 Workforce The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. Agency usage increased in February and the Trust remains adverse to its agency trajectory. Sickness absence increased to 4.3% in February 2016 The increasing trend on sickness absence levels which impacts on day to day management and expenditure remains on the Trust’s significant risk register – Risk score 15 (Likelihood of 5 and consequence of 3) The Trust continues to make good progress in maintaining its vacancy rate below 10%. Although on a downward trend, Turnover remains high at 13.8% with vacancy levels being kept low low by committing significant resources into recruiting to vacancies. Workforce

13. An Associated University Hospital of Brighton and Sussex Medical School 13 Finance The Trust is reporting against the revised plan submitted to the TDA in September 2015. The Trust forecast for the year is a £(6.6)m deficit (after donated asset technical adjustments), due to further industrial action by the Junior Doctors and variance to forecast at M11. This position also includes £3.0m non-recurrent income from the TDA (capital to revenue transfer). Risk to this position is now estimated at £1.0m in respect of final contract settlement with CCG’s. At the end of month 11 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(4.8)m which is £(4.8)m adverse to the revised TDA plan. The underlying position at the end of February is a £(5.6)m deficit and the year end underlying position is now a £(7.2)m deficit, reflecting the movement in the forecast. The Trust has achieved £4.1m of savings to date (a £3.1m shortfall measured against the TDA plan). The forecast CIP position is £3.5m adverse to the full year plan and this has been factored into the overall Trust forecast.

14. An Associated University Hospital of Brighton and Sussex Medical School 14 Finance The Trust’s cash balance at the end of February was £6.8m, with a forecast year end cash balance of £2.5m. Backlog creditors remained at over £11m. The Trust has secured an increase to its revolving working capital facility from £6.2m to £12.5m and the balance of the facility £6.3m will be drawn in March 2016 (£12.5m facility is based on 20 days operating expenses). This covers immediate cash needs. The capital spend forecast this year has reduced by £3.0m, from £17.1m to £14.1m following the approval by the TDA of a Capital to Revenue transfer.