Balanced Score Card Report Review of May 2018 Data Balanced - PowerPoint PPT Presentation

Balanced Score Card Report Review of May 2018 Data

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

Patient Access – Emergency Department

CUH 30 Day Moving Average 2017 v 2018 4

6 Hour PET & 8AM TrolleyGAR per 100 ED Attends

PET Greater than 24 Hours

Non Admit PET Year to date Comparison Annual Non Admit PET 2014 - 2017 80% 70% 60% 50% 79% 75% 40% 71% 70% 67% 30% 20% 10% 0% 2014 2015 2016 2017 2018

>75yrs Bed Wait >9hrs >75yrs Bed Wait >9 hrs (2018) 250 200 150 248 249 232 203 190 100 50 0 Jan-18 Feb-18 Mar-18 Apr-18 May-18

Targeted >14 Day Occupancy >14 Day Patients and >14 Day Occupancy 10000 220 9000 200 8000 180 7000 160 6000 140 5000 120 4000 100 01/09/2017 01/10/2017 01/11/2017 01/12/2017 01/01/2018 01/02/2018 01/03/2018 01/04/2018 01/05/2018 01/06/2018 Bed Days Patients >14 Days

>100 Day Occupancy >100 Days Patients & Bed Days 4000 20 18 3500 16 3000 14 2500 12 2000 10 8 1500 6 1000 4 500 2 0 0 01/09/2017 01/10/2017 01/11/2017 01/12/2017 01/01/2018 01/02/2018 01/03/2018 01/04/2018 01/05/2018 01/06/2018 Bed Days Patients

AMAU Activity May2018 171 180 154 160 140 114 120 100 87 80 60 40 13 20 4 0 ED Surge ED GP Planned Repeat OPD Other Referrals

AMAU Boarders at 8:00am - May 2018 14 12 12 12 12 12 12 12 12 12 12 11 10 10 10 10 10 10 10 9 8 8 8 8 8 8 7 6 4 2 0 0 0 0 0 0 0 0 0

Project Flow Improving Patient’s Hospital Experience Project Flow 2018

Project Flow Objectives  Bed Capacity Review  Implement the SAFER Patient Flow Bundle in 2018 on all inpatient wards.  90% of patient notes should have a Planned Date of Discharge (PDD).  Achieve a 25% increase in weekend discharges by September 2018.  Achieve monthly 80% either green or amber (40% green) at 8am on TrolleyGAR  Achieve a 10% reduction in bed days used by patients >14 days.  No patient should spend >24 hours in any area of the Acute Floor  95% of non-admitted patients should achieve a patient experience time (PET) <6 hrs on the Acute Floor  75% of all patients should achieve a PET <6 hours  100% of patients needing medical (excluding patients requiring care in the Resuscitation Room) will be reviewed in the Acute Medical Assessment Unit (AMAU)

Project Flow Initiatives Initiative Nominated Lead  SAFER Implementation  Ms. Olivia Wall  Weekend Discharges  Ms. Deirdre Feehely  >75 Year Old Patient Flow Improvement  Dr. Mike O’Connor  >14 Day Process Improvement  Ms. Noreen Galvin  Patient Experience Time Improvement  To be Confirmed  Acute Ambulatory Care / Discharge to  To be Confirmed Assess Pathways  Acute Floor Implementation  To be Confirmed  Communication & Education  To be Confirmed  Diagnostic Flow needs to be reviewed  To be Confirmed  Bi-Directional Flow Improvement  Ms. Lorraine Kearney

Patient Access - Outpatient Waiting Lists

Total Medical Patients to be seen by 15 Month Target (241) (June)

Total Surgical Patients to be seen by 15 Month Target (5062) (June)

Patients Currently Waiting Longer Than 12 Months (5062) (May)

Patients to be seen by 15 Month Target June 2018 3739 Urgent and Routine Patients who need to be seen in relation to the 15 month deadline by month end June 2018 Count of Patients % No of Patients with an Appointment before or on End of Month 122 3.26% Number of Patients with an Appointment Post End of Month 155 4.15% Number of Patients with No Appointment 3462 92.59%

Patient Access - Inpatient Waiting List

Total Inpatient & Day case Waiting List (12/06/2018) Grand wl type ACTIVE PREADMIT SUSPENSION Total Adult 1190 304 40 1,534 Child 85 32 5 122 GI Scope 136 211 8 355 Grand Total 1411 547 53 2,011

Perspective Adult Pivot - to be Treated by October 2018 (433)

General Surgery Waiting List (141)

Plastic Surgery Waiting List ( 90 )

Urology Waiting List (76)

Quality & Safety

Scope Breaches (June 2018)

Cancer KPI – Breast-Lung-Prostate October 2017 – May 2018

Radiotherapy Patients In/Out of Target - May 2018 OUT OF TARGET, 46, 49% IN TARGET, 48, 51% 94 Patients

Consultants In/Out of Target May 2018 25 20 15 10 5 0 Dr Faisal Dr. Aileen Dr. Bolanle Ofi Dr. Carol Dr. Kathy Rock Dr. Frederik Dr. Paul Kelly Jamaluddin Flavin (RO) (Locum RO) McGibney (RO) (RO) Vernimmen (RO) (Locum RO) (RO) Total 16 16 16 17 3 4 22 In Target 9 10 6 5 2 2 14 Out of Target 7 6 10 12 1 2 8

Reasons for Out of Target – May 2018 45 40 35 30 25 20 15 10 5 0 Personal Medical Capacity Data Other choice Missing Total 2 1 42 0 1

Chemotherapy Patients In/Out of Target – May 2018 Outside Target, 8, 17% In Target, 39, 83%

Consultants In/Out of Target May 2018 16 14 12 10 8 6 4 2 0 Dr Deirdre Dr Derek Dr Dr Derville Prof Mary Dr Richard Dr Vitaliy Prof O'Mahony Power Dearbhaile O'Shea Cahill Bambury Mykytiv Seamus Collins O'Reilly Total 10 4 4 3 2 16 1 7 In Target 8 3 4 3 1 14 1 5 Out of Target 2 1 0 0 1 2 0 2

Reasons for Out of Target – May 2018 6 5 4 3 2 1 0 Personal Medicinal Capacity Total 1 1 6

Risk Management – April KPI data DRAFT  Serious Reportable Events reported CUH - 3 communicated in April  Medication Safety Incidents reported - 36  Complaints – 4 with 0% closed within the 30 day timeframe.  New claims notified to hospital - 3 Risk Register CUH3, CUH4, CUH49, CUH64 updated Updated Risk Register submitted to the SSWHG

Human Resource Management

Total Sick Leave CUH – Total % Sick Leave 2017 v 2018 6 3.98 4.01 4.35 4.42 3.89 4.15 3.92 3.8 3.65 4 4.77 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 3.5 4.22 4.17 % 3.5 3.84 3.84 3.9 2 0 Jan Feb Mar April May June July August Sept Oct Nov Dec 2017% 2018% % Target CUH Long Term Sick Leave – WTE’s 50 37.35 40 34.88 44.15 34.55 44.55 40.05 31.32 31 28.89 WTE’s 30 24 29.2 26.8 31.14 26.11 20 10 0 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

EWTD Compliance - October 2017 – May 2018

Finance

Finance Report – May 2018 Actual outturn ytd 2018 CUH -PAY & NONPAY  Gross pay & non pay budget € 137.85m  Actual pay & non pay € 143.49m  Actual Deficit € 5.63m (-3.6%) Less adjustments € 3.22m - Bad debts provision € 1.5m - PCRS € 665k - Surge/Storm Emma/CPE € 723k -Outsourced Mater € 248k -GDP Adj -12 th ICU bed € 93k Adjusted Deficit € 2.41m (-1.75%) CUMH DIRECT PAY & NONPAY  Gross Direct pay & non pay budget € 17.1m  Actual direct pay & non pay € 18.17m  Actual Deficit € 1.06m (-6%) CUH/CUM PAY & NONPAY  Gross pay & non pay budget € 154.95m (2017 : € 147m)  Actual pay & non pay € 161.67m (2017: € 151.2m)  Actual Deficit € 6.72m (-4.3%) (2017 : € 4.2m/-3%) Less adjustments € 3.22m (2017 : € 3.2m) Adjusted Deficit € 3.5m(-2.26%) (2017 : € 1.06m/-0.7%)

CUH /CUMH SUMMARY FINANCIAL POSITION AS AT MAY 2018 May € k % Apr € % YTD Gross Expenditure 161,654 128,163 YTD Gross MEL 158,264 125,772 YTD April Deficit 3,390 2.1% 2,391 1.9% Less Bad Debt Increase 1,496 974 YTD Deficit after Bad Debt 1,894 1.2% 1,416 1.1% Storm Emma Costs 82 82 CPE Costs 34 34 12th ICU Bed not included in GDP Allocation (opened April) 93 49 YTD Deficit after Bad Debt, Storm Emma, CPE & 12TH ICU Bed 1,685 1.1% 1,251 1.0% PCRS Increase YTD April 665 458 YTD Deficit after Bad Debt, Storm Emma, CPE, 12TH ICU Bed & PCRS 1,020 0.6% 793 0.6% Surge Costs CUH additional beds 606 573 Outsourced Patients to Mater Private re Surge 248 154 YTD Deficit after Bad Debt, Storm Emma, CPE, 12th ICU Bed ,PCRS & Surge 166 0.1% 66 0.1%

Finance Report – May 2018 CUH/CUMH Other Income outturn  Income budget € 7.17m (2017 : € 6.82m)  Actual Income € 8.58m (2016 : € 8.34m)  Actual Surplus € 1.41m (20%) (2016 : € 1.51m/22%) CUH Other Income  Other Income budget € 6.84m  Actual Income € 8.31m  Actual Surplus € 1.47m (21%) CUMH Other Income  Other Income budget € 332k  Actual Income € 268k  Actual Deficit € 64k (-19%)

Finance Report – May 2018 CUH Actual Non-pay Expenditure € k YTD 2018 v 2017 CUH/CUMH Income outturn  Income budget € 33.39m (2017 : € 33.0m)  Actual Income € 32.07m (2016 : € 32.3m)  Actual Deficit € 1.3m (-4%) (2016 :- € 0.7/-2%) CUH  Income budget € 28.28m  Actual Income € 27.77m  Actual Deficit € 513k (-1.8%) CUMH  Income budget € 5.11m  Actual Income € 4.3m  Actual Deficit € 813k (-16%)