Balanced Score Card Report Review of September 2017 Data Balanced - PowerPoint PPT Presentation

Balanced Score Card Report Review of September 2017 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 2016 5

6 Hour PET & 8AM TrolleyGAR per 100 ED Attends 6

PET Monthly Comparison (Non Admitted)

PET Monthly Comparison (Admitted)

Patient Experience Time >24 Hours PET >24 hours 350 300 250 320 328 316 200 264 150 100 136 98 85 50 89 68 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

>75 years >9 hour bed wait >75yrs Bed Wait >9 hrs (2017) 250 200 150 218 215 199 200 100 143 129 120 108 50 57 0

>14 Day Target Reduction

Project Flow Improving Patient’s Hospital Experience Project Flow 2017

>14 Day Review • Weekly Meetings • 193 Patients >14 Days 27 th April (9,778 BDs) • 137 Patients >14 days today (7,569 BDs) – 15 patients >100 Days (3,438 BDs) • Difficulties with Nursing Home Bed Capacity • Difficulties with Home Care Provider Capacity • Plan for increased Transition Care Beds – Clonakilty (16 beds)

Weekend Demand/Capacit y  Non Invasive Cardiology Winter Plan Submission Report average inpatient waiting time for echo / stress  Potential diagnostics as outpatient for discussion with Radiology  Communication of bi directional capacity  Bulk text message to Medical Staff  Whiteboard capture  Delegated discharge responsibility (for action)  Friday Specialty Handover (for action)

Resource Dependant Initiatives  Transitional Care (50 Beds in  Diagnostics Community) o Point of Care (H1N1, Ketones, Pregnancy testing)  Acute Beds (Ward 2A) o CT Scanning  Operational HUB o 7 Day Echocardiograph  Flow Coordinators  Bed Management & Acute Floor Information Systems  Regularisation of extra unstaffed beds  Ambulatory Care Facilities / Surgical & Cardiac Assessment  24/7 AMAU Service  Health & Social Care  ITU & HDU Capacity (Rehabilitation) 15

Patient Access - Outpatient Waiting Lists

Total Medical Patients to be seen by 15 Month Target (September) (176) (23/10/2017) 100 90 86 80 70 60 50 40 27 30 22 20 15 8 10 4 3 2 2 2 2 1 1 1 0

Total Surgical Patients to be seen by 15 Month Target (3078) (23/10/2017) 600 545 527 500 405 400 357 293 300 200 167 150 121 115 99 100 77 75 53 48 26 11 3 3 3 0

Patients Currently Waiting Longer Than 12 Months (5080) (23/10/2017) 3000 2495 2500 2000 1500 1000 838 559 500 209 194 145 123 121 109 98 51 50 36 23 9 8 6 6 0

Ophthalmology Waiting List Validation Ophthalmology Return Waiting list validation Consultant G.O.Connor E.O. Connell S.Fenton A.Cullinane Z.Idrees Total Letters sent out 737 650 444 950 468 3249 Letters left to sent out 520 486 1006 Outcomes Yes to Stay on w/l 528 230 312 678 319 2067 Request removal 25 14 12 37 11 99 RIP 4 4 8 6 22 Attended TCI 1 1 2 Query 8 2 6 7 4 27 Return Post 2 3 3 2 1 11 Diabetic Screening 16 8 14 24 17 79 No response to date 25/9/17 154 388 97 194 109 942

Patient Access - Inpatient Waiting List

Patients to be Treated by 19 th October 2017 Specialty Number of Patients Breast Surgery 0 Cardiology 0 Cardiothoracic 3 General Surgery 63 Neurology 0 Neurosurgery 0 Orthopaedics 0 Plastic Surgery 69 Respiratory Medicine 0 Urology 43 Vascular 10 Total 188

Urology Waiting List (43)

Plastic Surgery Waiting List

General Surgery Waiting List

Scope Waiting List

Quality & Safety

G ALOS All Inpatients – August 2017

A ALOS Medicine – August 2017 29

R ALOS Surgery – August 2017 30

G HIPE Coverage - Prior Month - % of cases entered into HIPE(A38)

Cancer KPI – Breast-Lung-Prostate January – September 2017

Chemotherapy Patients In/Out of Target - September Outside Target, 6, 14% In Target, 36, 86% 33

Reason for Treatment Delay - September 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Personal Medical Capacity Data Other Choice Reasons Missing Total 0 1 5 0 0 34

Radiotherapy Patients In/Out of Target - September OUT OF TARGET, 36, IN TARGET, 39, IN TARGET 48% 52% OUT OF TARGET 35

Consultants Reasons for Out of Target - September 3 2 3 Dr. Paul Kelly (RO) 3 Dr. Frederik Vernimmen (RO) Personal choice 2 1 1 Dr. Carol McGibney (RO) Medical Capacity Data Missing 3 5 Dr. Bolanle Ofi (Locum RO) Other 1 2 6 Dr. Aileen Flavin (RO) 1 3 Dr Faisal Jamaluddin (Locum RO) 0 1 2 3 4 5 6 7 8 9 36

Risk Management – September KPI data  Serious Reportable Events reported CUH -1  Medication Safety Incidents reported - 24  Complaints – 7 complaints raised in July with 42% closed within 30 day timeframe  New claims notified to hospital – 75 Risk Register  Risk Register updated in June – one new risk added

Quality and Safety Pressure Ulcer To Zero  Continue to roll out PUTZ initiative – ward 3B and ICU SWARTZ Round  2 nd round scheduled for 31 st October National Patient Satisfaction Survey  CUH – 55% response rate  Emerging theme is the Discharge Process  Workshop at Group level to review results of the survey Staff Quality Survey Completed  Vision  Mission Statement

National Patient Survey Key areas for Improvement & Nationally  Discharge Planning – Need for information on discharge – Danger signs, what to look out for – Written information, medication information  Care on the Ward ‾ Nutrition ‾ Worries and Fears  Examinations/diagnosis/Treatment  Need for information  Improved communication

Quality and Safety Vision Delivering Safe, Effective, Person- Centred care, Every time Mission Statement All CUH staff are committed to delivering the highest level of Quality Care achievable. We will work with you, our service users in enhancing services that are safe, clinically effective and 5 top priorities delivered in a clean environment. 20 additional priorities 40

Human Resource Management

CUH Sick Leave 2016 v 2017- CHANGE CUH – Total % Sick Leave 2016 v 2017 6 4.77 3.77 4.53 3.65 4.22 3.98 3.94 4.17 4.08 4.98 3.92 3.9 3.84 3.78 4 4.65 4.59 % 4.27 4.04 3.91 3.39 2 0 Jan Feb Mar April May June July August Sept Oct Nov Dec 2016% 2017% % Target CUH Long Term Sick Leave – WTE’s 50 41.8 40.05 38.81 40 35.76 43.96 44.55 34.55 28.89 44.15 40.76 37.35 WTE’s 30 31.14 32.49 20 10 0 May-17 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Jun-17 Jul-17 Aug-17

EWTD Compliance – January - August 2017

Capital Projects Project Status Paediatric Unit Phase 1 - build programme completed Phase 2 – funding received – proceed to Design Stage  Builder commenced on site on Monday 20 th February Radiation Oncology Unit Education and Training Centre Draft Statement of Need completed and discussion ongoing with UCC Meeting held with UCC Blood Sciences Project Design Team appointed Infrastructural works are near completion  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  Application for planning permission submitted  Tender Pack being prepared Helipad Meeting held with the IAA Ground Level Helipad the agreed option

Finance

Finance Report – August 2017 CUH Actual outturn YTD 2017 PAY & NONPAY  Gross pay & non pay budget € 268.2m (2016 : € 256.4m)  Actual pay & non pay € 277.8m (2016: € 263.9m)  Actual Deficit € 9.6m (-3.6%) (2016 : € 7.5m/-2.9%) Less Adjustments € 5.4m Increase in Bad debts provision € 2.7m PCRS Drugs € 0.7m LRA Restoration unfunded € 1.7m Living out allowance € 334k Adjusted Deficit € 4.2m(-1.55%) (2016 : € 3.5m/-1.4%)

CUH – Pay & Non pay Budget Surplus/(Deficit) %

CUH – Patient Income Budget Surplus/Deficit %