Trust Board papers November 2012 - Barking Havering and ...

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ACTION LOG – PART I 104/2012 MATTERS ARISING 45/2012 - Joint review of potential for a positive journal article on the Trust’s experience of meeting NHSL performance indicators for emergency LSCS. Responsibility IS / DO 70/2012 – NICE compliance updates from CDs to be agenda item in October. CDs 74/2012 – Mortality update to the next meeting PS 81/2012 – Continuing risks to patient care from high levels of cancelled outpatient appointments and delays with rebooking patients to be escalated to the Directorate General Manager for Outpatients for early resolution and feedback. 104/2012 – Schedule of Directorate presentations on progress with embedding clinical governance to be developed, circulated and included in Rolling Programme. 107/2012 DEANERY / GMC VISIT REPORT AND ACTION PLAN Clarification to be sought concerning repatriation of junior doctors from KGH to Queen’s within 72 hours of MLU opening. It was agreed that JA would write to the Clinical Directors requesting that each area should have a written policy that clearly states the level of clinical supervision expected 111/2012 SURGICAL SITE INFECTION SURVEILLANCE Fractured neck of femur infections to be reviewed. 112/2012 IMPLEMENTING PATIENT STORIES This item to be included in the October meeting agenda. 114/2012 COMPLAINTS POLICY Any comments on the policy to be submitted to Gary Etheridge within 1 week 115/2012 ANY OTHER BUSINESS Any comments on the Complaints Annual Report to be submitted to Gary Etheridge within 2 weeks. 116/2012 ISSUES FOR ESCALATION TO TRUST BOARD The continuing risks to patient care from high levels of cancelled outpatient appointments and delays with rebooking patients to be escalated. 117/2012 DATE OF NEXT MEETING Dates for 2013 to be circulated to members AK MG / SB / PS MG JA GS / MS GE All All CR CR 7
EXECUTIVE SUMMARY TITLE: Finance Report – Month Six (September) 2012/13 BOARD/GROUP/COMMITTEE: Trust Board 1. KEY ISSUES: REVIEWED BY (BOARD/COMMITTEE) and DATE: • In the six month period to the end of September the trust recorded a year to date deficit of £26.0m (adjusted for impairments & IFRS reversals), which is £2.0m worse than plan for the period. This adverse variance is primarily explained by a £2.2m shortfall against the CIP target to date. • The in-month deficit of (£3.5m) was in line with plan. This represents an improvement on the average monthly run rate deficit to Month 5 of £4.5m and the deficit in Month 5 of £5.5m. • The income position to date is £2.1m ahead of plan. Some payment for over-performance with ONEL has now been agreed and £2.7m of this additional income is reflected in the year to date income position. Underperformance on non-ONEL SLAs (primarily Essex) has reduced income during the period by £0.4m. • The projected income position at the year-end is for an over-performance of £19.6m on the ONEL contract, less £0.9m under-performance for non-ONEL. This represents a significant risk as the commissioners have not yet agreed to fund £5.0m of these treatments. • Aside from the CIP shortfall, the expenditure position shows a £1.7m overspending year to date. This overspending is largely associated with the activity overperformance. An appropriate proportion of the income over-performance is being devolved to business units, to mitigate the marginal cost of over-performance. • The CIP position shows year to date delivery of £4.3m against a target for the period of £6.5m, a shortfall of £2.2m. The forecast delivery is £17.7m of which £4.8m is considered to be at high risk, which is an improvement on the £6.2m of high risk schemes reported last month. The Trust aims to have plans in place by the end of the month to deliver all of the £17.7m forecast. • This compares to a CIP target of £23.1m for the year. The PMO/E&Y are leading further work to mitigate the risks, maximise the savings opportunities and is aiming to deliver at least £20m CIPs. □ S&SIB ………………□ EPB…...………….. □ FINANCE ……………□ AUDIT ….……..…. □ CLINICAL GOVERNANCE …………..…...... □ CHARITABLE FUNDS ………………………. TRUST BOARD ……………………………… □ REMUNERATION …………………………… □ OTHER ………………………(please specify) CATEGORY: □ NATIONAL TARGET □ CNST □ STANDARDS FOR BETTER HEALTH □ ASSURANCE FRAMEWORK □ TARGET FROM COMMISSIONERS CORPORATE OBJECTIVE To achieve financial security for the Trust, with reduced costs, improved productivity and collecting income due □ OTHER …………………….. (please specify) AUTHOR/PRESENTER: Alan Davies, Deputy Director of Finance / David Gilburt, Director of Finance DATE: • The Trust has significant risks to both income and CIP delivery. With this level of risk our ability to deliver the £39.7m year-end control total must be in doubt. • We need Commissioners to fund the projected activity and the Trust has to deliver the CIP savings. • Discussions continue with the commissions and a detailed review of the forecast outturn will be completed and reported to the November Finance Committee 2. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST: Set out under key issues 3. ALTERNATIVES CONSIDERED/REASONS FOR REJECTION: 1
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TRUST BOARD MEETING Wednesday, 7 No
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2 Following Mr White’s concerns r
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4 forecast in terms of community be
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6 The Trust Board noted the Plan fo
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8 The Co-Chair of the Improving Pat
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TRUST BOARD MEETING Actions from Mi
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Agenda Item Action Deadline Date Da
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Question: Mr Skillman was pleased t
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CQC Trust-wide Action Plan Review a
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1.0 PURPOSE 1.1 Background This rep
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• Review the Senior Responsible O
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APPENDIX 1 ‐ CQC ACTION PLAN - EX
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RECORDS records management to ensur
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CQC Update Report 2012 Theme CQC Re
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CQC Update Report 2012 ASSESSING &
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CQC Update Report 2012 ASSESSING &
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CQC Update Report 2012 pathways thr
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CQC Update Report 2012 identified i
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CQC Update Report 2012 outlining th
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CQC Update Report 2012 improvements
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CQC Update Report 2012 aware of the
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CQC Update Report 2012 are now supe
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CQC Update Report 2012 autumn. RECO
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CQC Update Report 2012 of the pilot
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EXECUTIVE SUMMARY TITLE: Informatio
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INFORMATION GOVERNANCE STRATEGY 201
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Information is a vital asset in ter
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starters as well as being mandatory
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The standards are split into the ar
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10a Reapproval of IG training progr
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343 Directorate Anaesthetic: Risk:
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Table of Contents TRUST PRINCIPAL O
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BHRUT STRATEGIC OBJECTIVES WITH EAC
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DIRECTORATES RISKS REVIEW 12 10 8 6
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RISKS DETAILS PRINCIPAL RISK What c
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PRINCIPAL RISK What could prevent t
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RISK DESCRIPTORS OBJECTIVE SAFE, HI
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BOARD ASSURANCE FRAMEWORK ELEMENTS
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EXECUTIVE SUMMARY TITLE: Risk Manag
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Contents Section Page 1 Introductio
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incorporate mitigation controls wit
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“Risk Register” “Risk Registe
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potential risks they may face in ac
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4.1.1 Quality and Safety Committee
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• Financial risks: risks associat
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Proactive risk assessment enables t
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Trust’s risk matrix and will popu
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Risk Grading Staff Group Evidence R
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4.8 RISK REGISTER The Risk Register
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5.1 Consultation and Communication
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The Trust recognises the importance
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timescale with supporting evidence
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Checklist for the Review and Approv
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Equality Impact Assessment Tool To
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Plan for Dissemination of Procedura
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Consequence score (severity levels)
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Frequency How often might it/does i
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Appendix 3 Framework for Risk Manag
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Risk Register inventory they are ex
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2. DECISION REQUIRED: CATEGORY: The
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• A review of data capture to ens
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Pilot Wards Division Discharges Per
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Workforce Appraisals - the actions
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Delayed transfers of care (DTOC) -
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EXECUTIVE SUMMARY TITLE: Emergency
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• Training competencies are being
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Appendix A: Trajectory for all type
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would welcome feedback from the Tru
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Maternity Services Monthly Performa
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4. Capping The maternity service is
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7. Obstetric Assessment Unit (OAU)
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10. Serious Incidents Reported Inci
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12. Maternity Dashboard The dashboa
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It should also be noted that the ta
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Priority Action Lead Monitoring Too
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Priority Action Lead Monitoring Too
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Contents Section No: Description Pa
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3. Complaints Activity 3.1 Total Co
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3.5 Themes General care issues and
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Corporate Non Clinical Category Num
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order to resolve concerns. Particul
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The findings of the review were tha
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SELF-CERTIFICATION RETURNS Organisa
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12 AA - Quality Improvement Strateg
Page 173 and 174: TFA Progress BHR University Hospita
Page 175 and 176: 25 TFA - Final IBP /; LTFM Dec-12 H
Page 177 and 178: Effectiveness GOVERNANCE RISK RATIN
Page 179 and 180: Safety 4b MRSA Enter Are you below
Page 181 and 182: FINANCIAL RISK RATING BHR Universit
Page 183 and 184: CONTRACTUAL DATA BHR University Hos
Page 185 and 186: 4 Single Sex Accommodation Breaches
Page 187 and 188: TITLE: EXECUTIVE SUMMARY BOARD/GROU
Page 189 and 190: causes/ Not specified' will be remo
Page 191 and 192: Staff In Post Starters & Leavers FT
Page 193 and 194: TURNOVER Actual Versus Target Annua
Page 195 and 196: FTE Lost due to Sickness Absence by
Page 197 and 198: The data on the previous page has b
Page 199 and 200: Indicator Target Apr-12 May-12 Jun-
Page 201 and 202: Starters *¹ 7.00 3.60 5.00 7.43 6.
Page 203 and 204: EXECUTIVE SUMMARY TITLE: COST IMPRO
Page 205 and 206: Month 6 CIP Performance Workstream
Page 207 and 208: Governance The Cost Improvement Pro
Page 209 and 210: 1 REPORT TO: REPORT FROM: Trust Boa
Page 211 and 212: 3 Preparations for winter planning
Page 213 and 214: 5 Preparing the Payment by Results
Page 215 and 216: 7 People with dementia to receive m
Page 217 and 218: 9 Clinical Patient Management and H
Page 219 and 220: 102/2012 Apologies Apologies were r
Page 221 and 222: Action Members were advised that ac
Page 223: Action 115/2012 Any Other Business
Page 227 and 228: 1. EXECUTIVE SUMMARY Monthly I&E Ru
Page 229 and 230: Trust I&E summary by Division/Direc
Page 231 and 232: Income by POD In Month Year to date
Page 233 and 234: Devolved income Annual Budget Forec
Page 237 and 238: 4. BALANCE SHEET Balance Sheet Curr
Page 239: 6. Business Unit Summaries Attached
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