Trust Board Papers – 27th June 2013 - Sandwell & West ...

SWBTB (6/13) 116
AGENDA
Trust Board Public Session
Venue Boardroom, Sandwell Hospital Date 27 June 2013; 1530h
Members
In attendance
Mr R Samuda (RSM) [Chairman] Mr M Sharon (MS) [Director of Strategy & OD]
Dr S Sahota OBE (SS) [Non-Executive Director] Mr G Seager (GS) [Director of Estates & New Hosp Project]
Mrs G Hunjan (GH) [Non-Executive Director] Miss K Dhami (KD) [Director of Governance]
Prof R Lilford (RL) [Non-Executive Director] Mrs J Kinghorn (JK) [Head of Communications & Engagement]
Ms O Dutton (OD) [Non-Executive Director] Mrs C Rickards (CRI) [Trust Convener]
Ms C Robinson (CRO) [Non-Executive Director]
Mr H Kang (HK) [Non-Executive Director] Guests
Mr T Lewis (TL) [Chief Executive] Mrs L Pascall (LP) [Assistant Director of Nursing]
Mr R White (RW) [Director of Finance]
Dr R Stedman (RST) [Medical Director] Secretariat
Miss R Overfield (RO) [Chief Nurse] Mr S Grainger-Payne (SG-P) [Trust Secretary]
Miss R Barlow (RB [Chief Operating Officer]
Time Item Title Reference Number Lead
1530h 1 Apologies Verbal SG-P
2 Declaration of interests
To declare any interests members may have in connection with the agenda and
any further interests acquired since the previous meeting
3 Minutes of the previous meeting
Pg 3
To approve the minutes of the meeting held on 30 May 2013 & 6 June 2013 a
true and accurate records of discussions
Verbal
SWBTB (5/13) 115
SWBTB (6/13) 137
All
Chair
Pg 16
Pg 20
4 Update on actions arising from previous meetings SWBTB (5/13) 115 (a) SG-P
5 Chairs opening comments and Chief Executives report SWBTB (6/13) 117 Chair/
CEO
6 Questions from members of the public Verbal Public
1545h
PRESENTATION
7 Patient story Presentation LP
MATTERS FOR APPROVAL
1605h 8 Quality Account 2012/13 SWBTB (6/13) 119
SWBTB (6/13) 119 (a)
Pg 23
SWBTB (6/13) 119 (b)
1615h 9 Performance Management Regime monthly submission SWBTB (6/13) 120
Pg 28
SWBTB (6/13) 120 (a)
RST
MS
1 Version 1.0

SWBTB (5/13) 081
10 Safety, Quality and Governance
MATTERS FOR DISCUSSION
1625h
Pg 134
10.1 Update from the meeting of the Quality & Safety
Committee held on 21 June 2013, minutes from the
meeting held on 24 May 2013 and Quality & Safety
Committee Chairs annual report
SWBQS (5/13) 085
OD
1635h 10.2 Quality report SWBTB (6/13) 121
Pg 147
SWBTB (6/13) 121 (a)
RO/
KD/
RST
1650h 10.3 Update from the meeting of the Audit Committee held on 6
June 2013
Verbal
GH
1655h
Pg 157
10.4 Health Informatics Services (HIS) strategy 2013/14 SWBTB (6/13) 122
SWBTB (6/13) 122 (a)
1705h 10.5 18 weeks 2013/14 and Data Quality review SWBTB (6/13) 123
Pg 196
SWBTB (6/13) 123 (a)
1720h 10.6 Ward leadership model evaluation SWBTB (6/13) 124
Pg 202
SWBTB (6/13) 124 (a)
11 Performance Management
RST
RB
RO
1730h 11.1 Draft minutes from the meeting of the Finance &
Pg 206
Performance Management Committee held on 21 June
2013 and Chairs annual report
Hard copy
SWBFC (6/13) 059
CRO
1740h 11.2 Monthly finance report Month 2 SWBTB (6/13) 125 RW
Pg 216
SWBTB (6/13) 125 (a)
1745h 11.3 Monthly performance monitoring report SWBTB (6/13) 126 RW
Pg 219
SWBTB (6/13) 126 (a)
1750h 12 Any other business Verbal All
MATTERS FOR INFORMATION
Pg 228
13 Midland Metropolitan Hospital project: monitoring report SWBTB (6/13) 128
Pg 235
Pg 236
Pg 238
14 Foundation Trust application programme: monitoring
report
15 NHS Performance Framework & FT Compliance Framework
report
16 Minutes from the FT Programme Board held on 30 May
2013
SWBTB (6/13) 129
SWBTB (6/13) 129 (a)
SWBTB (6/13) 130
SWBTB (6/13) 130 (a)
SWBFT (5/13) 053
17 Details of next meeting
The next public Trust Board will be held on 25 July 2013 at 1230h in the Anne Gibson Boardroom, City Hospital
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f]quiring escalation or that needed to be raised for the Boards attention.
Miss Overfield advised that evaluation of the ward leadership model would be
presented at the next meeting.
4.1 Readmission rates at Sandwell Hospital Verbal
Miss Barlow reminded the Board that within the Emergency Care presentation
delivered at the last meeting, the readmission rate at Sandwell Hospital had had
been noted to be out of line with that of City Hospital. She advised that work to
understand this position was not fully complete, however the data set to inform
the investigation had now been identified. It was highlighted that readmissions
appeared to be particularly high in the respiratory speciality.
It was reported that the information would be reviewed by the Mortality &
Quality Alerts Committee, after which time the information would be presented
to the Quality & Safety Committee.
ACTION:
Miss Barlow to present the information concerning readmission
rates at Sandwell Hospital to the Quality & Safety Committee
4.2 Booking-in process in Birmingham Treatment Centre Verbal
Miss Barlow reminded the Board that the issue of the complicated booking-in
process in the Birmingham Treatment Centre (BTC) had been raised by a member
of the public at the previous meeting and had been corroborated by the
experience of a number of Board members.
The Board was advised that the matter had been discussed with the leadership
team for the area and the member of the public raising the issue had been
contacted. It was reported that additionally, a survey of over 300 patients
attending the BTC had been undertaken, which revealed that the majority had
experienced a positive visit, however the use of one check in point and the use of
check in kiosks could enhance the experience.
It was agreed that the changes to the booking system should be communicated to
the Trusts members through the membership newsletter.
5 Chairs opening comments and Chief Executives report
SWBTB (5/13) 114
The Chairman congratulated Miss Overfield on her recent appointment as Chief
Nurse at University Hospitals Leicester NHS Trust.

SWBTB (5/13) 115
Mr Lewis advised that the Leadership Conference had been well received, with a
good focus on culture and attitude. The Board was advised that the work to
support the Public Health strategy would begin to develop in July 2013.
6 Questions from members of the public Verbal
There were no members of the public present.
7 Patient story Presentation
The Board was introduced to Mrs Olwen Shaw, the daughter of a patient of the
Trust. Ms Lisa Nugent and Ms Tina Jackson were also introduced, who had taken a
significant role in the delivery of care to the patient. The story concerned poor
communication in the management of a deteriorating pressure ulcer.
Ms Dutton thanked Mrs Shaw for attending the meeting and for staff providing
the detail of the case to the Board. She asked Mrs Shaw whether, although clearly
there had been issues with the management of her mothers treatment, the end
result was satisfactory. Mrs Shaw advised that this was the case, although
underlined her frustration with being able to access appropriate expertise with
which to register her concerns.
Miss Overfield, noting the effectiveness of the new messaging system that had
been implemented to improve communication in cases such as this, asked
whether the system was being rolled out more widely within the Trust. She was
advised that this was the case and it was being audited on a quarterly basis. Mrs
Pascall advised that the ambition was to audit the process more frequently in due
course.
Dr Stedman asked Mrs Shaw in her view, what measures could be undertaken to
improve communication between the parties delivering the care. She advised that
the views of patients relatives needed to be more clearly listened to in future. Dr
Stedman asked whether it would have been useful if she could have contributed
to her mothers healthcare records. She advised that this was the case, although
in her experience, she had been advised that she was not to annotate her
mothers records.
Miss Barlow asked how patient stories were being used across Multi Disciplinary
Teams. Ms Jackson advised that lessons learned from cases such as this were
disseminated and discussed as part of clinical governance events. Mrs Pascall
added that the patient stories were being filmed and reflective practice was being
undertaken within the nursing community when they were shared.
Mr Lewis suggested that there was a need to consider whether the
communication issues extended to the range of services that provided care in the
home beyond the district nursing service.
The Chairman thanked those attending for this item and remarked that there was
a need to pick up on some of the attitudinal issues reported and the need to make
it more convenient to communicate between the various parties involved with

the care. Ms Robinson agreed and suggested the use of a hotline number if
possible. Mr Lewis advised that this was already in place in some specialities,
however he acknowledged that the use of this system on a wider scale would be
useful.
SWBTB (5/13) 115
Ms Dutton noted that the treatment delivered in this case had not been patientcentred
and highlighted the need to listen to the patient as part of the care. Miss
Dhami remarked that there was a need to empower the carer and patient and
encourage them not to tolerate poor experiences.
Dr Stedman noted that the use of IT solutions could have assisted with the
communication requirements in this case. Mr Howells suggested that the
timeliness of communications was critical, particularly in view of public
expectations in line with the use of social media for example.
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8 Changes to the Trusts Standing Orders/Standing Financial Instructions
and Scheme of Delegation
SWBTB (5/13) 083
SWBTB (5/13) 083 (a)
Mr White presented the proposed changes to the Trusts Standing
Orders/Standing Financial Instructions and Scheme of Delegation, which he
advised had been discussed in detail and endorsed by the Audit Committee. It was
highlighted that the majority of the changes were cosmetic and to bring
terminology up to date.
A substantive change was highlighted to concern the EU Procurement limit which
had changed recently. The role of the Senior Independent Director was also
highlighted to be reflected in the document. Additionally, the Board was asked to
note that, in line with a previous request from the Chairman, the changes would
also negate the need for individual invoices for a Board-approved business case to
be presented to the Board.
Mr Kang noted that the new Workforce & Organisation Development Committee
was not referenced within the Standing Orders. It was pointed out that at the
time that the changes to the document were proposed to the Audit Committee,
the Workforce and OD Committee had not been established. Mr Lewis suggested
that the further changes be reflected in a revised version to be considered in the
next financial quarter.
The Trust Board approved the proposed changes to the Trusts Standing
Orders/Standing Financial Instructions and Scheme of Delegation.
AGREEMENT: The Trust Board approved the proposed changes to the Trusts
Standing Orders/Standing Financial Instructions and Scheme of
Delegation
9 Continence product contract SWBTB (5/13) 084
Mr White asked the Board to approve expenditure to the value of £914k in
respect of an incontinence product. He advised that the products had been

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procured under a framework tender by HealthTrustEurope and that the costs
would be met from within the Sandwell Community Adults Heath division.
SWBTB (5/13) 115
The Trust Board approved the expenditure.
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Mr Seager asked the Board to approve the use of a single tender arrangement to
purchase a support contract for Olympus video and ultrasonic endoscopes to the
value of £248k (including VAT).
Mr Seager advised that he was confident that the expenditure represented good
value for money. Ms Robinson highlighted however that the absence of a
competitive tendering arrangement could mean that a non-commercial price for
the servicing contract may be offered by the supplier. It was agreed that there
was a need to ensure that the best value was obtained from arrangements such
as this in future.
Mr Lewis suggested that a standard warranty of best NHS UK price be added into
the Trusts standard contract terms.
Asking that these considerations be taken into account, the Trust Board approved
the use of a single tender arrangement.
ACTION:
Mr White to arrange for the Trusts standard contract terms to be
amended to include a warranty related to best NHS UK price
AGREEMENT: The Trust Board approved the use of a single tender arrangement
in respect of a maintenance contract for Olympus video and
ultrasonic endoscopes
11 Application of the Trust Seal to the lease for the former Cape Hill
neighbourhood office
SWBTB (5/13) 086
SWBTB (5/13) 086 (a)
The Trust Board asked to approve the application of the Trust Seal to the lease for
the former Cape Hill neighbourhood office in readiness for the establishment of
Learning Works.
Mr Seager was asked to confirm whether the term of the lease include 2014.
Subject to this clarification, the Board was approved the application of the Trust
Seal to the lease.
ACTION:
Mr Seager to confirm whether the term of the Learning Works
lease incorporated 2014
AGREEMENT: Subject to clarification of the start date, the Trust Board approved
the application of the Trust Seal to the former Cape Hill

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The Trust was asked to approve the application of the Trust Seal to the contract
between Birmingham Healthcare Services, Capitec and the Trust for monitoring
advisory services in respect of the management of the Birmingham Treatment
Centre.
The Board approved the proposal.
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SWBTB (5/13) 087 (a)
The Trust was asked to approve the use of a single tender arrangement for the
payment of the annual recharge of salaries from the University of Birmingham
medical school for clinical Academics based at the Trust.
The value of the payment was reported to be £1,605k, which was highlighted to
have been provided for in the 2013/14 budget.
The Board approved the proposal.
AGREEMENT: The Trust Board approved the use of a single tender arrangement
in respect of payment for the salary recharge from the University
of Birmingham
14 Performance Management Regime monthly submission SWBTB (5/13) 092
SWBTB (5/13) 092 (a)
Mr Sharon presented the proposed monthly Provider Management Regime (PMR)
submission. He advised that the Trust Development Authority (TDA) had
introduced an additional in-month submission, requiring declaration against an
additional set of Board statements and Monitors licencing regulations.
It was reported that non-compliance was being declared against the both the inmonth
TDA and PMR Board statements concerning compliance with registration
requirements with the Care Quality Commission (CQC), which it was highlighted
reflected the need to register Halcyon Birth Centre as an additional location from
which care was provided. Other TDA Board statements against which noncompliance
had been declared were reported to concern compliance with the
TDA Accountability Framework and assessment of risks to compliance of the
same, which was reported to reflect that an assessment of the Trusts position
against the Framework had not yet been undertaken. It was reported that an
assessment would be undertaken in July.

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SWBTB (5/13) 115
In terms of the governance risk ratings reported in the PMR, it was reported that
performance against the VTE assessment target was 90.81%.
Mr Kang asked whether there was any feedback from the regulatory bodies on
the submissions. He was advised that an escalation process was in place to
address any areas of concern and that a monthly discussion on the submission
was held with the next one being on 17 June 2013.
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Mr Grainger-Payne presented the updated register of directors interests for
approval.
Dr Sahota asked that his membership on the Smethwick Delivery Board be added.
Mrs Hunjan suggested that her involvement with some of local education
establishments be registered. It was agreed that subject to discussion as to the
appropriateness of these inclusions, the Register of Interests be approved.
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Safety, Quality & Governance
16.1 Mitigation Plan in response to IT systems failure SWBTB (5/13) 088
SWBTB (5/13) 088 (a)
Mrs Sanders presented an update on the plans to prevent a reoccurrence of the IT
systems failure that had occurred in March 2013. It was highlighted that integral
to the plans was the application of business continuity plans and disaster recovery
measures. Miss Barlow advised that an Emergency Planner was being recruited
for this purpose, with the post being advertised in June. Mr Lewis remarked that
robust local plans should be implemented prior to the commencement of the
Emergency Planner.
Ms Robinson suggested that the position should be referred to the Audit
Committee and that an independent assurance check of the mitigation should be
undertaken. Mrs Hunjan advised that the matter would be presented and be
tested as part of the consideration of the risk register at the Audit Committee. Mr
Kang suggested that the system should be stress tested to determine any areas
of weakness or improvements needed. Mrs Sanders advised that this was
planned, however the timing of this needed to be agreed with the Chief Operating
Officer given the significant planning involved.
It was agreed that the Board should receive an update of the resiliencies that had
been developed and the new back up measures that had been implemented.

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Mr Lewis asked whether the community services IT was hosted on the Trusts
general server. He was advised that this was built into the Trusts Storage Area
Network (SAN) configuration.
:6.2 Update from the meeting of the Quality & Safety Committee held on 24
May 2013 and minutes from the meeting held on 19 April 2013
SWBQS (4/13) 065
SWBQS (5/13) 077 (a)
Ms Dutton updated the Board on the key discussion points from the meeting of
the Quality & Safety Committee that had been held on 24 May 2013.
The Board was advised that the Committee endorsed the value of receiving a
patient story at the Trust Board meetings. It was reported that an update on Child
Protection matters had been requested at a future meeting and that an additional
item had been added to the agenda of all future meetings around matters of
national and topical media interest.
16.3 Quality Report SWBTB (5/13) 089
SWBTB (5/13) 089 (a)
The Board was asked to consider the Quality Report, which it was advised had
been discussed in detail at the Quality & Safety Committee on 24 May 2013.
In terms of patient safety, it was reported that pressure damage rates were
reducing, although bank and agency staffing usage had increased. Overall, it was
highlighted however that ward staffing levels had improved.
The Board was advised that a MRSA bacteraemia had been reported during the
month. The VRE infections were reported to have reduced. It was reported that a
Listening into Action event had been held on Infection Control and that a further
update would be presented to the Trust Management Board at its meeting in
June.
Regarding CQUIN targets, it was highlighted that achievement of the Friends and
Family Test requirements related to the Emergency Departments would be
challenging to achieve. Achievement of the Safety Thermometer audit
requirements was also reported to be challenging, given the potential counting
and duplication issues. The Board was informed that the revised mortality review
system was now in place and therefore there was an expectation that
performance against this target would improve. Performance to date was
highlighted to be 74%.
The Chairman asked whether there was a feeling that the Trust was performing
better now following the major operational pressures experienced in previous
months. Dr Stedman confirmed that practice in the Emergency Departments was

safe and that there had been no evidence of an increase in harm-related incidents
or mortality rates. Miss Overfield advised that improvements in Patient
Experience remained necessary.
SWBTB (5/13) 115
;6.4 Winter 2013 Must Be Better programme update Presentation
Miss Barlow delivered a presentation outlining the key elements of the Winter
2013 Must Be Better programme. She advised that the work had involved a good
level of engagement with the local Clinical Commissioning Group (CCG).
It was noted that within four weeks, good progress had been made with
delivering improvements in the delivery of Emergency Care.
Mr Kang remarked that there was considerable media attention on the delivery of
Emergency Care at present and asked who was responsible for educating the
public on the most appropriate use of Accident & Emergency Departments. Miss
Barlow advised that the current work included an educational element, however
the Urgent Care Network also had a responsibility for these communications.
Ms Robinson suggested that engagement with Social Services was a critical piece
of work and asked if more senior level interaction was needed, especially in view
of the recent budget adjustments in this sector. Mr Lewis acknowledged that
there was maybe a need to escalate Local Authority engagement in July. However
he highlighted the need to differentiate between those patients requiring Social
Services input and those requiring Community Services input and noted that the
Medically Fit for Discharge ward could assist the Trust with this.
16.5 Draft Quality Account 2012/13 SWBTB (5/13) 091
SWBTB (5/13) 091 (a)
SWBTB (5/13) 091 (b)
Dr Stedman presented the draft Quality Account for 2012/13, which he
highlighted would be presented for final approval at the Trust Board meeting
planned for 27 June 2013. It was reported that the Quality Account had been
considered by the Audit Committee and had been issued to the CCG, NHS
England, the Local Area Team and the Overview and Scrutiny Committee. Mrs
Hunjan advised that the Quality Account remained subject to review by the
Trusts external auditors.
Dr Sahota noted that the readmission rates reported were at a level below that he
expected. Dr Stedman advised that this piece of data would be revised in the final
version being presented for approval. Mr Sharon suggested that there needed to
be a degree of harmonisation with the Trusts annual plan.
17 Performance Management
17.1 Monthly performance monitoring report SWBTB (5/13) 100
SWBTB (5/13) 100 (a)
Mr White presented the latest quality and performance dashboard, which he
advised had been considered at the meeting of the Finance & Performance

Management Committee held on 24 May 2013.
SWBTB (5/13) 115
It was reported that against the NHS Performance Framework, there were a
number of underperforming areas: Emergency Department performance;
infection control; same sex accommodation breaches in Critical Care and
achievement of the 18 weeks target across all specialities. In terms of the same
sex accommodation breaches in Critical Care, the Board was informed that Level 1
patients remaining in the area for in excess of 12 hours, would be reported as a
breach in future and backdated to 1 April 2013. Mr Lewis advised that there were
clear exemptions to reporting breaches for Level 2 and 3 patients, however this
was not the case for Level 1 patients.

SWBTB (5/13) 115
>8.1 Midland Metropolitan Hospital project: monitoring report SWBTB (5/13) 110
Mr Seager presented the draft timeline for the Midland Metropolitan Hospital
project, highlighting that financial affordability and a refresh of the Long Term
financial Model remained under development. It was reported that resources to
support the project needed to be considered. Owners of land on the Grove Lane
site were reported to be being appraised of progress with the project.
It was reported that a letter had been received from the Secretary of State asking
that the project be expedited, which would assist with the extant plan to run
some aspects of the project in parallel rather than in sequence.
18.2 Foundation Trust application programme: monitoring report
SWBTB (5/13) 098
SWBTB (5/13) 098 (a)
The Trust Board received and accepted the update on progress with the Trusts
application for Foundation Trust status.
19 Update from the Committees
19.1 Update from the Audit Committee held on 9 May 2013, minutes of the
meeting held on 14 February 2013 and Committee Chairs annual report
SWBAC (2/13) 020
SWBAC (5/13) 036 (a)
Mrs Hunjan provided an update of the key points of discussion at the meeting of
the Audit Committee that had been held on 9 May 2013. She noted the assurance
now provided on harm and death not having been increased over the period
concerned. She proceeded to highlight the current state of the data quality
review. Mr Lewis drew the Boards attention to the audit of national metrics data
quality review, commissioned to report by September. Given current single sex
accommodation and 18 week referral to treatment issues, he advised that he
expected that a broader series of issues may emerge. Miss Barlow reported that
she would bring a stocktake on the 18 weeks work to the full Trust Board in June.
The Board was advised that there remained a number of outstanding internal
audit actions that were outstanding, however the matter was being progressed by
the Executive and that an update would be provided next time.
It was reported that the annual accounts for 2012/13 had been submitted on time
and that the Head of Internal Audit Opinion was likely to be significant, with the
assessment of the Board assurance Framework being categorised as A.
ACTION:
ACTION:
Mr Grainger-Payne to present an update on Internal Audit actions
still outstanding at the next Audit Committee meeting
Miss Barlow to present an update on the 18 week RTT data
quality project at the next meeting
19.2 Update from the Charitable Funds Committee held on 9 May 2013,
minutes of the meeting held on 14 February 2013 and Committee Chairs
annual report
SWBCF (2/13) 010
SWBCF (5/13) 017 (a)

SWBTB (5/13) 115
Dr Sahota provided an update of the key points of discussion at the meeting of
the Charitable Funds Committee that had been held on 9 May 2013. He advised
that a presentation had been received from the financial adviser from Barclays
Wealth, which had informed the Trustees that overall the investment markets had
improved. The Board was pleased to learn that the Lord Mayor of Sandwell had
chosen the Birmingham & Midland Eye centre as his sponsored charity.
It was highlighted that the progress with work being undertaken by the Head of
Fundraising was good and that at a forthcoming committee a review would be
held as to how the whole Board could play a role in major corporate partnerships.
?@.3
Update from the Workforce & Organisational Development Assurance
Committee held on 20 May 2013 and minutes from the meeting held on
25 March 2013
SWBWA (5/13) 012
Mr Kang reported that a structure for the operation of the Workforce &
Organisational Development Assurance Committee was being worked through,
including finalisation of the Terms of Reference for the body. It was reported that
the subcommittee structure beneath the Workforce and Organisational
Development Assurance Committee had been discussed, including the interaction
with the Trusts Joint Consultative and Negotiating Committee (JCNC).
It was reported that the Committee had considered the workforce dashboard and
had agreed the key area of focus in future.
19.4 Update and minutes from the Clinical Reconfiguration Board held on 9
May 2103
SWBTB (5/13) 097
SWBTB (5/13) 097 (a)
Mrs Hunjan in Professor Lilfords absence, advised that the Committee had
considered a number of routine updates on reconfiguration.
20 Any other business Verbal
There was none.
Matters for information
The Board received the following for information:
• Board Assurance Framework 2012/13 Quarter 4 update
• NHS Performance Framework & FT Compliance Framework report
• Minutes from the FT Programme Board held on 25 April 2013
• Minutes from the Transformation Plan Steering Group held on 12 April
2013
Details of the next meeting
Verbal
The next public session of the Trust Board meeting was noted to be scheduled to

start at 1230h on 6 June 2013 and would be held in the Anne Gibson Boardroom
at City Hospital.
SWBTB (5/13) 115
Signed:
.
Name:
.
Date:

SWBTB (6/13) 137
BCDEC FGGH IJKLMG NMOPQPMMRS TJUV WMLXJUOY Z[\C 6 June 2013
Ms Clare Robinson
Mrs Gianjeet Hunjan
Dr Sarindar Sahota OBE
Ms Olwen Dutton
Mr Toby Lewis
Mr Robert White
Miss Rachel Barlow
Miss Rachel Overfield
Dr Roger Stedman
Miss Kam Dhami
Mrs Jessamy Kinghorn
Mr Tony Wharram
dCc^C\[^e[\
Mr Simon Grainger-Payne
]^C_CD\
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feDE\C_
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j agklkmeC_ ik^ [n_CDcC BC^n[l
Apologies were received from Richard Samuda, Richard Lilford, Harjinder Kang
and Graham Seager.
ZCcl[^[\ekD ki `D\C^C_\_ BC^n[l
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There were no declarations of interest raised.
p qEC_\ekD_ i^kr rCrnC^_ ki \sC gEnlec BC^n[l
There were no members of the public present.
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SWBTB (6/13) 137
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É ÄÅÆÄÇÆÈ ·²¸»´ ¿°¿±·Â¸²¿ Ê˵§¾ Ì6/13) 039
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6 2012/13 Annual Governance Statement SWBAC (6/13) 040
|

×ØÙÚÛÙ ÛÜÝÞÖßÜ àáÛà àáß âÙÙØÛã äåÝßÕÙÛÙæß çàÛàßèßÙà éâäçê áÛÜ ëßßÙ
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ÕßÝÞßìßÜ
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åð àáß åØàæåèß åð àáß îÛÕß ôØÛãÞàí îåèèÞÖÖÞåÙõÖ ÞÙÖïßæàÞåÙÖö
ÕßÖïßæà
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SWBTB (6/13) 137
ÙØèëßÕ åð æåèèßÙàÖ ÛÙÜ ÖØññßÖàÞåÙÖ èÛÜß ÛÖ ïÛÕà åð àáßÖß ÕßÝÞßìÖò
ÛñÛÞÙÖà àáß ÷èßÕñßÙæí îÛÕß àÛÕñßàö ÜÛàÛ øØÛãÞàí ÞÙ ÕßÖïßæà àå
ïßÕðåÕèÛÙæß
ïßÕðåÕèÛÙæß ÛñÛÞÙÖà àáß ù8 week referral to treatment time target for
ÕßïåÕàÞÙñ
open pathways; and the IT failure in March 2013.
Subject to minor amendment of a date, the Trust Board was asked for and gave its
approval for the Chief Executive to sign the Annual Governance Statement.
¦¨¨¦ © ¦¦¦¨¨© ¢ú 6/13) 041
The Board reviewed the letter of representation and agreed that the Chief
Executive and the Director of Finance and Performance Management should sign
the Letter of Representation.
AGREEMENT: The Trust Board agreed that the Chief Executive and the Director
of Finance and Performance Management should sign the Letter
of Representation
8 Any other business Verbal
There was none.
9 Details of the next meeting Verbal
The next public session of the Trust Board meeting was noted to be scheduled to
start at 1530h on 27 June 2013 and would be held in the Boardroom at Sandwell
Hospital.
Signed:
.
Name:
.
Ó

SWBTB (6/13) 137
!"#$ %%%%%%%%%%%%%%%%%%%%%%%%

SWBTB (5/13) 115 (a)
Members present:
In Attendance:
Apologies:
Next Meeting: 27 June 2013, Boardroom @ Sandwell Hospital
Mr R Samuda (RSM), Ms C Robinson (CR), Dr S Sahota (SS), Mr H Kang (HK), Mrs G Hunjan (GH), Ms O Dutton (OD), Mr T Lewis (TL), Mr M Sharon (MS), Mr R White (RW), Dr R Stedman (RST), Miss R Overfield (RO), Miss
R Barlow (RB)
Mr M Sharon (MS), Miss K Dhami (KD), Mr G Seager (GS)
Prof R Lilford, Mrs J Kinghorn
Sandwell and West Birmingham Hospitals NHS Trust - Trust Board
30 May 2013, Anne Gibson Boardroom @ City Hospital
Secretariat:
Mr S Grainger-Payne (SGP)
Last Updated: 20 June 2013
Reference Item Paper Ref Date Action Assigned To
Completion
Date
Response Submitted
Status
SWBTBACT.245
T
response to the
report of the Mid
Staffordshire NHS
Foundation Trust
public inquiry
SWBTB (2/13) 032
SWBTB (2/13) 032 (a)
28-Feb-13
Present the baseline assessment against the
F
at the next meeting of the Quality & Safety
Committee and Trust Board
KD
Handling of the Francis report response discussed
at the Q & S Committee on 21/03/13. Agreed
further work was needed to fully inform the
response, particularly on those areas where a
national position needed to be agreed and
soundings from staff needed to be taken. Further
discussion about the response to the Francis
report recommendations held at the Trust Board
'Time Out' session on 26/4/13. In the meantime,
26/04/2013 however work continues in parallel to address the
30/06/2013 areas that can be progressed, particularly those
31/08/2013 specific to professional groups.
Y
SWBTBACT.249
Questions from
members of the
public Verbal 25-Apr-13
Schedule a discussion concerning EPR &
longer term HIS strategy at the July 2013
meeting of the Trust Board SG-P 25/07/13 ACTION NOT YET DUE
G
SWBTBACT.253
Improving
Emergency Care Presentation 25-Apr-13
The medicine group will focus their triumvirate
efforts on maintaining safety, improving VTE and
MRSA screening, financial balance and the actions
required to deliver WMBB13 during Q2. Work to
support the transformation of LTC will be
progressed directly with directorates by the
strategy and transformation teams. The
executive team, including in particular our COO,
will focus on national minimum standards,
financial balance, our five quality priorities,
LTFM/MMH and organisational development. If
Determine what plans or pieces of work
necessary additional project resource will be
should be paused as a consequence of the
added over the summer to operations to ensure
planned focus on improving Emergency
that the bandwidth required to deliver our
Care Executive 30/06/13 agenda before winter is in place.
G
Version 1.0
ACTIONS

SWBTB (5/13) 115 (a)
SWBTBACT.259
Mitigation Plan in
response to IT
systems failure
SWBTB (5/13) 088
SWBTB (5/13) 088 (a)
30-May-13
Provide a further update on the progress
with implementing the resiliencies that had
been developed and the new back up
measures that had been implemented to
prevent a further IT outage FS 25/07/13 ACTION NOT YET DUE
G
SWBTBACT.260
Update from the
Audit Committee
held on 9 May
2013, minutes of
the meeting held
on 14 February
2013 and
C C
annual report
SWBAC (2/13) 020
SWBAC (5/13) 036 (a)
30-May-13
Present an update on Internal Audit actions
still outstanding at the next Audit Committee
meeting SG-P 12/09/13 ACTION NOT YET DUE
G
SWBTBACT.255
SWBTBACT.256
Readmission rates
at Sandwell
Hospital
Single tender
Verbal 30-May-13
action:
maintenance
contract for
Olympus video and
ultrasonic
endoscopes SWBTB (5/13) 085 30-May-13
Update provided at Quality & Safety Committee
on 21/6/13, however further work needed to
Present the information concerning
readmission rates at Sandwell Hospital to the
Quality & Safety Committee RB
better understand the position. Further update to
be provided at the July Quality & Safety
19/07/13 Committee meeting
When single tender actions are made, the
proposer is reminded to seek an undertaking
A T
terms to be amended to include a warranty
related to best NHS UK price RW
from the company that the best price is offered.
The formal contract documentation is being
30/09/13 reviewed however.
G
G
SWBTBACT.233
Update on actions
arising from previous
meetings SWBTB (9/12) 231 (a) 25-Oct-12
Present an update on the effectiveness of the
ward leadership model at the December
2012 meeting of the Trust Board RO
20/12/2012
25/04/2013 Included as an item on the agenda of the June
30/05/2013 2013 meeting
B
SWBTBACT.250
Annual Plan
2013/14
SWBTB (4/13) 063
SWBTB (4/13) 063 (a)
25-Apr-13
Include an item on the agenda of the June
Trust Board concerning the delivery of the
HIS plans for 2013/14 SG-P
Included as an item on the agenda of the June
27/06/13 2013 meeting
B
SWBTBACT.254
Performance
against Corporate
O
Quarter 4 update
SWBTB (4/13) 067
SWBTB (4/13) 067 (a)
25-Apr-13
Determine the timescales involved with the
‘ C ‘ H MS 30/06/13 This work has been completed
B
SWBTBACT.257
Application of the
Trust Seal to the
lease for the
former Cape Hill
neighbourhood
office
SWBTB (5/13) 086
SWBTB (5/13) 086 (a)
30-May-13
Confirm whether the term of the Learning
Rent free period is 12 months from the date of
Works lease incorporated 2014 GS 27/06/13 sign off so Trust will pay rent from 1 June 2014
B
SWBTBACT.258
Register of
Interests
SWBTB (5/13) 090
SWBTB (5/13) 090 (a)
30-May-13
Updated as requested. Also now added in
U D ‘ I
with additional declarations SG-P
declaration from TL regarding directorship of UTC
27/06/13 Health Futures
B
Version 1.0
ACTIONS

SWBTB (5/13) 115 (a)
SWBTBACT.261
Update from the
Audit Committee
held on 9 May
2013, minutes of
the meeting held
on 14 February
2013 and
C C
annual report
SWBAC (2/13) 020
SWBAC (5/13) 036 (a)
30-May-13
Present an update on the 18 week RTT data
Included as an item on the agenda of the June
quality project at the next meeting FS 21/06/13 2013 meeting
B
KEY:
R
A
Y
G
B
Outstanding action due for completion more than 6 months ago. Completion has been deferred more than once or there is no firm
evidence that it is being progressed towards completion
Oustanding action due for completion more than 6 months ago. Completion has been deferred more than once but there is
substantive evidence that work is progressing towards completion
Outstanding action raised more than 3 months ago which has been deferred more than once
Action that is scheduled for completion in the future and there is evidence that work is progressing as planned towards the date set
Action that has been completed since the last meeting
Version 1.0
ACTIONS

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ÓæÛÕæ îÍØÖÜ ÐæÍÌÍ ÓÛÒÒ ÑÍ ÿ ¡¡ã¡¡¡ available over the next ¢ years to
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to deliver work programmesã experience frameworksã apprenticeship access to
employment programmes and assessor and supportß verifier íhe ÙØÖdwell and West
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and adapted by all of the írusts within íhe éountryß
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mentorship and support to organisationsß those isã íhis evidentlyã self central to the
public health and regeneration mission that we have established as organisationß
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SWBTB (6/13) 119
TRUST BOARD
DOCUMENT TITLE:
SPONSORING DIRECTOR:
AUTHOR:
Quality Account - Final Version
Dr Roger Stedman, Medical Director
Rosey Monaghan, Business
DATE OF MEETING: 27 June 2013
SUMMARY OF KEY POINTS:
The Quality Account is a document which describes the Trusts activities against Quality
Performance Indicators during 2012/13 and the quality indicators for 2013/14. It is a public
facing document and every attempt has been made to write it in plain English.
It is written in a format prescribed by the Department of Health & Monitor and complies with
their guidance.
The draft version of this document was presented to the Audit Committee in April 2013 & the
Trust Board in May 2013 and was amended following comment.
This document was sent to the External Auditor and a Limited Assurance Report will be issued
which will be appended to the Quality Account. This will be circulated as soon as it becomes
available.
Section 1- Chief Executives Statement
Section 2- Priorities for Improvement 2013/14
Section 3- Review of Quality Performance 2012/13
This Quality Account is required to be published on the NHS Choices website and
submitted to the Secretary of State by 30 th June 2013.
PURPOSE OF THE REPORT (Indicate with x the purpose that applies):
Approval Receipt and Noting Discussion
X
ACTIONS REQUIRED, INCLUDING RECOMMENDATION:
The Trust Board is asked to approve and sign off this Quality Account
Page 1

SWBTB (6/13) 119
ALIGNMENT TO OBJECTIVES AND INSPECTION CRITERIA:
Safe High Quality Care, Accessible & Responsive Care
Strategic objectives
Annual priorities
NHS LA standards
CQC Essential Standards
of Quality and Safety
Various
Auditors Local Evaluation
IMPACT ASSESSMENT (Indicate with x all those that apply in the second column):
Financial
Business and market share
Clinical
Workforce
Environmental
Y
Y
Y
Legal & Policy
Equality and Diversity
Patient Experience
Communications & Media
Y
Y
Y
Risks
PREVIOUS CONSIDERATION:
Initial Draft to Execs & reviewed by Audit Committee in April 2013. Draft to the Trust
Board in May 2013.
Page 2

SWBTB (6/13) 119 (a)
Quality
Account
2012-2013

2
Part 1 Chief Executives Statement 5
Part 2
Priorities for improvement and statements of assurance from the
Board
2.1 Priorities for Quality Improvement in 2013/14 7
2.11 How we decided on the priorities for our Quality Account for
2013/14
2.12 The Priorities for improvement in 2013/14 8
2.13 Focus area 1 - Continuing to improve the patient experience and
safety in Emergency Departments (ED)
2.14 Focus area 2 - Reducing preventable deaths (Mortality) 10
2.15 Focus area 3 - Being a Health Promoting Hospital 11
2.16 Focus area 4 - Reducing Emergency Readmissions 12
2.17 Focus area 5 - Patient Experience 13
2.2 Statements of Assurance from the Board 16
2.21 Statements of directors’ responsibilities in respect of the Quality
Account
2.22 Annual Governance Statement 17
2.23 Review of Services 17
2.24 Participation in Clinical Audits 17
2.25 Participation in Clinical Research 18
2.26 Goals agreed with Commissioners for 2013/14 18
2.27 What others say about us - Care Quality Commission
- West Midlands Quality Review Service
2.28 Limited Assurance Report 22
2.29 Data Quality & Information Governance 23
Part 3 Review of Quality Performance 2012/13 25
3.1 Report on Quality Priorities for 2012/13 25
3.12 Continuing to deliver service improvement and outcomes in
Stroke and Transient Ischaemic Attacks (TIA) Services(Patient
Safety)
3.13 Essential Standards of Nursing Care 31
3.14 Mortality Reporting and Analysis 40
3.15 Improving Emergency Department Performance 44
3.16 Strengthening Governance Arrangements at SWBH 46
3.17 Patient Safety & Incident Reporting 47
3.18 Safeguarding Adults and Children 50
3.19 Emergency Readmissions to hospital within 28 days of discharge
from hospital
3.20 Improving Patient Experience 55
3.21 Patient Reported Outcome Measures 60
3.22 Alcohol Screening Programme 64
3.23 WHO Surgical Safety Checklist 64
7
7
9
16
21
28
53

3
3.24 CQUIN (Commissioning for Quality & Innovation) 65
3.25 Complaints 67
3.26 Staff Indicators 67
3.27 What others think about our Quality Account 70
3.28 How to provide feedback on this Quality Account 71
Table Index of tables Page
1 The 2013/14 Quality and Safety Priorities 8
2 CQUINs 2013/14 19
3 CQC findings 22
4 NHS Number 23
5 General Medical Practice Code 23
6 Summary of Key Quality Achievements 2012/13 25
7 Summary of Focus Area 1 achievements 28
8 Stroke Target Performance 30
9 Compliance of 2 hourly patient checks 31
10 Compliance of 2 hourly patient checks 32
11 C. Diff Performance 35
12 2011/12 VTE performance 38
13 2012/13 VTE performance 38
14 Summary of Focus Topic 3 achievements 40
15 Mortality Performance Statistics 2012/13 42
16 SHMI performance 43
17 Palliative Care Coding 43
18 Summary of Focus Topic 4 achievements 44
19 Number of serious incidents during 2012/13 49
20 Incident rate 50
21 Incidents - Degree of Harm 50
22 Compliance with safeguarding training at the end of March 2013 52
23 Emergency Readmissions 0-15 years within 28 days of discharge 54
24 Emergency Readmissions 16+ years within 28 days of discharge 54
25 Emergency Readmissions 0-14 years within 28 days of discharge 55
26 Emergency Readmissions 15+ years within 28 days of discharge 55
27 Friends and family test scores 57
28 Results for each responsiveness to personal need questions 59
29 Patient Experience Performance 59
30 Summary of PROMs 61
31
Percentage of patients reporting an improvement 2011/12
(provisional data)
62

4
Table Index of tables Page
32 Average adjusted health gain 2011/12 (provisional data) 62
33 Think Alcohol Audit 64
34 WHO checklist compliance 65
35 CQUIN performance 2012/13 66
36 Complaints by category 67
37 Staff indicators 68
Figure
number
Index of Figures
1 Nutrition Audit 33
2 Reportable C.Diff Infections 34
3 Harm free care trend 36
4 Number of hospital acquired pressure damage 37
5 Preferred place of death/death of patients on SCP 40
6 Year-on-year increase in incident reporting 48
7 Type of Incidents 48
8 Friends & Family response rate 57
9 Local inpatient survey 58
10 Net Promoter performance 60
Page
Appendix
number
Index of Appendices- Separate Document
1 Annual Governance Statement 2
2
Participation in national clinical audits & national confidential
enquiries
3 National clinical audits- summary of learning & actions 14
4 Local clinical audits- summary of learning & actions 21
Page
5 Auditor’s limited assurance report 29
12

5
Part 1: Chief Executive’s Statement
The fourth quality account issued by the Trust reflects performance last financial year. I joined
the organization in April 2013 and have had the opportunity to reflect with the Trust Board in
delivery in the year to which this report relates.
A great deal was achieved by clinical and managerial teams during 2012-13, in partnerships with
patients, visitors, and other partners. We are especially proud of our improved performance in:
•
•
•
•
•
Transforming stroke care for patients; by creating a single acute unit and a specialised
rehabilitation facility. Both are located on our Sandwell site. Whilst ambulance travel times
for some patients are therefore increased, time to treatment times are not because we
can concentrate diagnostic and other specialist resources into one place. A pathway exists
to rapidly assess patients with suspected strokes and get them into our facility rapidly. We
expect to see the time taken to do that to reduce further in the year ahead.
Continuing to reduce pressure damage and to tackle avoidable infection; though this winter
saw considerable bed closure through managing noro virus in our predominantly open plan
older wards, other forms of infection continued to reduce. In parallel our nursing teams
succeeded in reducing pressure damage and many higher risk wards saw many months
without a pressure sore in their beds. We have work to do to extend these successes into
how we maintain patients in home in our community services.
We successfully focused on improvement in health visiting and midwifery services; the report
relates awards, and gains in performance, through these teams. Each work increasingly
closely with general practice, as well as integrating care into hospital services. There is more
to do, and we have agreed with our CCG a programme to focus attention on community
district nursing services in 2013-14.
We delivered the majority of our CQUIN goals; two of which in particular stand out in that
they reflect substantial improvement from prior years. Our mortality review programme
is now well embedded in the Trust and allows us space to learn from error and to reflect
on excellence. And our focus on every contact counts, particularly in respect of alcohol,
will provide a good basis for the health promoting hospital work set out in our 2013-14
priorities.
We sustained our successful trial recruitment programme for research; we know that
organisations that undertake substantial research programmes not only provide benefit to
future science, but also typically deliver better care to their patients. Our research profile
remains strong and trial recruitment has grown over recent years. We are exploring what
steps are necessary to substantially increase recruitment over the next five years in order to
provide outstanding access to research medicine for local residents.
Whilst noting these successes, I trust that you find this quality account candid about where we
did not succeed or where we have quality indicators that give our Board and leaders cause for
concern. The third section of this report details where delivery is been slower than intended or
has not yet achieved the goals that we set. In our organization that is particularly true of our
emergency care pathways.
1

6
Whilst improvements in stroke, changes in gynaecology and other developments, provide an
indication of some success, the largest number of patients still attend our two A&E departments.
In particular over the winter too many patients waited longer than the national minimum
standard of four hours. Whilst we have worked to ensure the safety of those departments, the
experience of care in a long-wait environment is poorer and the pressure it places on our staff
is significant. We intend to make changes to our system this summer to address this as we move
towards next winter. Funding has been made available to make this happen, and we need to
succeed in recruiting key clinicians to help us to succeed. We work collaboratively with local
GPs, mental health service colleagues, the ambulance service, and social service departments
to provide high quality emergency care. All of those services, like us, are reflecting on how
we change models of care to provide timely help to patients all seven days of the week. You
will see that both initial attendance at A&E and the possibility of re-admission after discharge
feature among our five top quality priorities for 2013-14.
Results matter. But culture is crucial to the safety of patients and staff. A culture of openness
and learning is important if we are to understand what we do when services succeed and what
happened when things go wrong. This report outlines the initial steps that we have taken to
begin to build that culture. Transparency about data, and clarity about scrutiny and assurance
are important and the Board has taken determined steps to alter those arrangements here.
During 2013-14 we will work with patient representatives, through our patient surveys, and
with our staff, to make sure that the knowledge given to us through best practice evidence,
incident reporting, complaints and compliments, and through professional expertise, are all
brought to bear to set priorities for further improvement. When we report next year, I will
assess how I believe that culture change programme has progressed. As a Board we remain
focused on the three goals that have underpinned our approach to quality over recent years:
1. To reduce adverse events that result in avoidable harm
2. To reduce avoidable mortality and morbidity
3. To increase the percentage of patients who would recommend us to their friends and family
That consistency of purpose will be important in ensuring that over coming years we improve
care in our Trust, both in our community teams and in our hospital based services.
Toby Lewis
Chief Executive

7
Part 2: Priorities for improvement in
2013/14 and statements of assurance
from the Board
In section 2 you will find a description of how we decided on our priorities for the
coming year and who we have involved in making these decisions.
Section 2.1 sets out the priorities for 2013/14 and explains the reasons for selecting
those priorities. This section also identifies how progress in each of the areas will be
monitored, measured and reported.
Section 2.2 contains the statements of assurance from the Board. The purpose of these
is to provide assurance to the public that SWBH is performing to essential standards,
that we have appropriate systems in place to measure our clinical processes and
performance, and that we are committed to implementing projects and initiatives
aimed at improving quality. These statements are set out in a standard format to allow
comparison with other similar providers.
Section 3 contains a review of Quality Performance in the Trust. It is in this section that
you will find how we met the plans that we had from 2012/13. In addition, we describe
our performance against other measures of quality.
Where you see a red asterisk * this is an indication that the text and data is as specified
by the Department of Health using the mandated wording and format.
2.1 Priorities for Quality Improvement in 2013/14
2.11 How we decided on the priorities for our Quality Account for 2013/14
Sandwell and West Birmingham Hospitals NHS Trust is always passionate about engaging
with the people it serves.
During September 2012, staff were asked for their views to help influence the
development of the Trust’s priorities for 2013/14. In particular, they were asked to
consider what had improved and got worse over the last 12 months, including where
the Trust was and was not performing well, as part of the monthly hot topics discussion.
Feedback from the priorities event and hot topics, together with feedback from people
attending the Trust’s Annual General Meeting, was reviewed by the Trust Board in
November, along with information from patient surveys and other patient and staff
engagement.
At a Clinical Directors Away Day in December 2012, which was attended by most of
the medical leaders in the Trust, we asked what they thought were the most pressing

8
quality priorities. All the responses were collated and brought together to feed into
the development of this year’s plan.
Birmingham and Sandwell LINks organisations carried out a joint ‘enter and view’ review
into Dignity and Nutrition at our hospitals in 2012, making three recommendations.
They also looked at maternity and A&E services and have recommended Sandwell
Healthwatch pick up the following subjects in 2013/14:
• Review of discharge procedures (follows a Sandwell LINk enter and view report in
2011);
• Review of complaints procedures;
• On-going review of stroke / TIA services;
• Review of hospital meals;
• Review hospital appointment administration.
Before handing over to Healthwatch, Sandwell LINk also expressed a strong interest
in understanding more about the supportive care pathway, particularly in the light of
adverse media coverage, via an information request and through setting out potential
priorities in their legacy document (published 27th March 2013). This information has
been considered in putting together the Trust’s quality priorities for 2013/14.
The Trust has continued to work on the development and implementation of its Quality
and Safety Strategy. Our performance will continue to be reported in the Quality Report
and to the Trust Board every month.
2.12 The Priorities for improvement in 2013/14
Our Quality& Safety Priorities sit within three domains described in our Quality and
Safety Strategy, as our number 1 strategic objective and in our NHS Trust Development
Authority (NTDA) Annual Plan. Our aim is firmly to deliver safe, high quality care and
the 3 domains are:
Patient Safety
Effectiveness of
care
To reduce adverse events which
result in avoidable harm
To reduce avoidable mortality
and morbidity
= We do no harm to patients
= Fewer patients dying
and fewer having
complications
Patient Experience To increase the percentage of
patients who would recommend
the Trust to family and friends
= Improved patient
satisfaction
Table 1. The 2013/14 Quality and Safety Priorities.

9
Although all the areas in Table 1 are key priorities, in this Quality Account we have
selected four focus areas for particular attention and more detailed description.
These focus areas are:
1. Continuing to improve the patient experience and safety in Emergency Departments
(ED);
2. Reducing preventable deaths (mortality);
3. Being a Health Promoting Hospital;
4. Reducing emergency readmissions;
5. Patient Experience.
2.13 Focus Area 1- Continuing to improve the patient experience and
safety in Emergency Departments (ED)
This is a theme which we have chosen to continue to work on as we still have much
to be done to improve the service and experience we offer to our service users. Many
patients first contact with our trust is when they attend ED so it is important for us to
improve.
We plan to ensure that at least 95% of people who attend ED are seen and either
treated and discharged or admitted within 4 hours of arrival. Our performance last
year was 92.34%.
The quality of the experience in ED is not only determined by the service provided
within the EDs themselves, but also on the bed flow and availability across a day for
those requiring in-patient care. Our plans to improve our patient experience and
the quality of our service for emergency care therefore include development in the
Emergency Departments and across emergency care as a whole.
Key areas of work to improve include:
• Delivery of investment plans and recruitment in ED;
• Implementation of a new informatics system in ED;
• Development of our acute assessment and elderly care models in both hospitals;
altering our surgical flow; changing our elderly care ward model, and introducing
more step down capability for those patients requiring help to get home;
• Establishment of joint health and social care team to include both Birmingham and
Sandwell Social Services;
• Improving the profile of discharges to precede admissions, building on the
developments of the Transformation Plan with daily early senior ward reviews,
transport and pharmacy projects to expedite early discharge;

10
• Establishment of a 7 day capacity team with an Operational Centre to determine a
better predictive emergency care flow and planning.
How we plan to measure and monitor our progress:
The improvement programme will be chaired by the Chief Executive. These meetings
will be held fortnightly and report to the Trust Board on a monthly basis. An integrated
emergency flow score card will report progress and exceptions against planned
improvement trajectories for key measures.
2.14 Focus Area 2 - Reducing preventable deaths (Mortality)
This was an area we worked on last year and, in the light of the Francis Report, feel we
must continue to give it a very high profile in our priorities.
We aim to improve our death rate from lower half of the 2nd centile to upper half of
2nd centile. This means becoming a trust where death rates are lower (better) than
half, if not more, hospital trusts in England.
We also aim to reduce the variation in the mortality between our 2 main hospital sites.
Death rates are higher at Sandwell Hospital than City Hospital. It is important to us to
understand why this is and to take action to improve the death rate at Sandwell.
How we plan to measure and monitor our progress
• In 2012/13 we have increased the percentage of deaths that have been reviewed by
senior doctors. However, we are committed to reviewing at least 80% of all deaths
within 42 days of death;
• We will feedback to consultants regularly on deaths which have been identified as
preventable so that lessons can be learnt by the organisation about how we can do
things better;
• Ensure that 95% of admitted patients have a VTE risk assessment carried out;
• We will carry out root-cause analysis of confirmed cases of hospital associated
thrombosis;
• We will set up a small, clinically-led group by the end of June 2013 who will be
looking into deaths at Sandwell hospital and will identify themes which may need
addressing to improve outcomes for patients;
• We will improve our mortality performance to be better than the England average
by March 2014.
Reporting of progress against these goals will be reported to the Mortality, Quality
Alerts Committee (MQuAC) which is chaired by the Medical Director. In addition, the
Quality Report will be submitted to Quality & Safety Committee and will be reviewed
by the Clinical Commissioning Group (CCG) at the Clinical Quality Review Meeting.

11
2.15 Focus Area 3 - Being a Health Promoting Hospital
A Health Promoting Hospital is one which recognises its duty to engage with patients,
relatives, staff, the membership group and wider local population to encourage health
improvement. It demonstrates this by explicitly stating that Health Improvement is part
of its mission, and by taking practical steps to make it happen.
In December 2012 SWBH joined the World Health Organisation (WHO) Health Promoting
Hospital (HPH) network to build on the Health Improvement activities already taking
place in the Trust.
What are the benefits of the WHO HPH network?
• Using the WHO and HPH logos on internal and external documents to act as reminders
of the international importance of prevention, and to help raising awareness about
these goals.
• Membership gives an opportunity to discuss and compare different health
improvement projects from hospitals and health systems worldwide, in order to see
what works elsewhere and might be tried locally.
• In addition, the HPN publishes a list of 40 standards for a member organisation. We
can use them to assess how well we compare in health promotion activities.
In the first place, the WHO HPH requires a mission statement, strategy and coordinating
group to deliver a programme of awareness amongst all staff.
They also are explicit around routine assessment of patients’ need for health promotion,
how information is given to patients and to staff to help them improve their health, and
that health promotion is written into job plans, patient pathways and departmental
policies.
Finally the standards encourage the hospital as an organisation to work to engage in
health promotion throughout the local community.
What we plan to do & how we will measure and monitor our progress
We have already appointed a Clinical Champion for Prevention at SWBH and a
Prevention Steering Group has been established with wide representation from across
the health community. Links have been established with the Public Health Teams and
Health and Wellbeing Boards in our locality, and with the SWB Clinical Commissioning
Group. Work has begun with our partners on a Health Improvement Strategy for SWBH.

12
We will:
• Submit a Health Improvement Strategy using the WHO HPH standards and local
priorities from our partners by July 2013;
• Develop an action plan from the Strategy and implement new health improvement
activities in SWBH using specialist staff by September 2013;
• Reinvigorate Health Improvement Training in the Trust including the Making Every
Contact Count (MECC) programme, for all staff, focusing on stopping smoking,
reducing alcohol consumption and making lifestyle preventive interventions for
patients and employees by November 2013;
• Formally adopt the principles of the Health Promotion Hospital network into our
mission statement, policies and procedures by December 2013.
Reporting of progress will be via the Prevention Steering Group, which reports to the
Clinical Effectiveness Committee, and Trust Management Board. Progress will also be
reported in the Quality Report, which is shared with the CCG.
2.16 Focus Area 4 - Reducing Emergency Readmissions
Readmission to the hospital once their treatment has been completed is not good for
the patient, their families or the Trust. We want to improve our care, and support
arrangements on discharge to keep patients at home so that we are at least as good as
the top 50% of hospital trusts in England.
Over recent months The Trust Transformation Programme has completed a project that
compares emergency readmission rates from the last three years by ward, by speciality,
by diagnosis and by procedure. From this work, things have been identified which will
help up to monitor performance on a month by month basis.
What we plan to do & how we will measure and monitor our progress
We will:
• Put in place action plans to ensure that emergency readmission will be avoided;
• By March 2014 we will aim to meet the national mean for 30 day non-elective & 28
day non-elective readmissions in 2013;
• By the end of June 2013, The Mortality & Quality Alerts Committee will develop and
oversee an action plan to improve emergency readmission rates;
• The Trust is also planning to review readmission rates of babies within 30 days, and will
review current maternity bed capacity in line with Birthrate plus recommendations.
This will be completed by March 2014, but is subject to business case approval in
Spring 2013.

13
How we plan to measure and monitor our progress
Reporting of progress against these goals will be reported to the Mortality & Quality
Alerts Committee (MQuAC) which is chaired by the Medical Director. In addition, the
Quality Report will be submitted to Quality & Safety Committee and will be reviewed
by the Clinical Commissioning Group (CCG) at the Clinical Quality Review Meeting.
2.17 Focus Area 5 - Patient Experience
Safe, high quality care remains the first priority of the Trust with a focus on improving
the experience of patients being one element. We will listen and learn from patients,
carers, staff and relatives as we develop and deliver leading hospital services to the
people of Sandwell and West Birmingham.
We want our patients to be confident in us and recognise us as a listening and caring
organisation.
We want our patients to experience:
• Excellent communication;
• Staff that listen to and act on feedback;
• That their care is planned (whatever their route of admission);
• That they feel safe in our care;
• That they are receiving the right information;
• No, or the minimum of delays;
• Always being treated with dignity and respect;
• That our staff work as a confident team;
• That we care about their environment;
• That they receive the food they have chosen and they get help if they need it;
• That they are cared for with kindness, respect and compassion.
We are particularly focusing on people’s experiences in outpatients as this is where
most people have contact with the Trust. We have developed 8 ‘outpatient standards’
which are all about ensuring that patients find attending an outpatient appointment
is a positive experience. These standards are what we aspire to and have set up a
programme of work to drive them forward. The 8 outpatient standards are:
1. All patients will be seen within 6 weeks of the hospital receiving their referral. All
referral letters will be scanned into CDA within 24hrs of receipt;
2. The patient’s first visit will always be to the correct clinic;
3. No patient will wait more than 20 minutes later than their appointment time to be
seen;

14
4. By March 2014, no patient will have their clinic appointment cancelled by the
hospital;
5. All patients will have their first appointment for diagnostics within locally agreed
targets;
6. All patients will be investigated and treated according to the Directorate’s agreed
clinical pathways;
7. A documented outcome of an outpatient visit will be available to the GP electronically
within 2 working days. All communications will be easily accessible within the
Electronic Patient Record. All patients will receive a copy letter within 5 working
days;
8. All patients will be given an opportunity to comment on the outpatient service that
they have received.
The Trust has identified equality, diversity and inclusiveness, in accordance with the
Equality Act 2010, as core to its values and is committed to developing opportunities
that are inclusive, appropriate and positive.
What we plan to do and how we will measure and monitor our progress
Patient Experience Strategy
A Trust Patient Experience Strategy has been written and formally accepted by the
Trust Quality and Safety Committee during April 2013, with an implementation plan in
place to be rolled out during 2013.
Friends and Family Test
The national ‘Friends and Family Test’ was introduced on 1 April 2013 for inpatients who
have spent at least one night in hospital and have attended an emergency department.
The Trust will ensure that all patients falling into this group are offered the opportunity
to complete a survey within 48 hours of discharge and that at least 15% respond. The
Net Promoter Score is calculated using responses to the question “How likely are you
to recommend our ward/A&E department to friends and family if they needed similar
care or treatment?” Responses range from ‘extremely likely’ to ‘extremely unlikely’
and ‘don’t know’.
Women using maternity services will be included in national reporting from October
2013. At present, this information is collected locally.
Patients under 16 years of age, outpatients and Community Services are not included in
the national programme, but information is collected locally from participating services
and reported to the Patient Experience Professional Advisory Group (PEPAG) and the
Patient Experience Committee every month.
National reporting systems are in place and reported on a monthly basis.

15
Key milestones are:
• Increasing the response rate in the acute inpatients and A&E areas. Achieving a
response rate within the top 50% of Trusts nationally, showing an improvement on
our Quarter 1 response rate;
• Phased expansion of the FFT to Maternity by end of Oct 2013 and additional services
(yet to be defined nationally) by end of March 2014;
• Increase the FFT score within the 2013/14 staff survey compared to 2012/13.
National & Local Patient Surveys
The Trust is participating in the following national patient surveys during 2013 such as
the Inpatient Survey, A&E Survey, Maternity Survey, Outpatient Survey, Cancer Patient
Experience Survey, and Chemotherapy Patient Experience Survey. We also carry out
local inpatient surveys every quarter.
Reports are received and we shape our services to improve based on the findings.
Patient Engagement Programme
The Trust has staged a number of interactive patient engagement/entertainment
activities during January – April 2013 in a variety of ward environments to include
paediatrics, elderly care, rehabilitation and surgery. This has been done by engaging
with local entertainment providers, to include the charities ‘Kissing it Better’ and
‘Music in Hospitals’. Activities include music, dance and drama events. An on-going
programme of events is also being built to expand and increase the opportunities
available for regular patient engagement.
Patient Stories
A programme of patient stories, which commenced in March 2013, has been devised
to take to the Trust Board every month. These are supplied by each division, supported
by the Patient Experience team. Plans are also being made to use these stories for staff
training and awareness raising events. We want to provide an opportunity for divisions
to share their care experiences with Board members on a ‘ward-to-board’ basis.
Volunteers
The Patient Experience team have been working closely with the WRVS to build up a
team of reliable hospital volunteers to help and assist with various patient experience
activities such as completion of patient surveys, directing people through the hospitals,
ward-based volunteers and dementia buddies. The aim is to increase the overall number
of volunteers and recruit from different age groups and ethnicities.

16
2.2 Statements of Assurance from the Board
2.21 Statement of Directors responsibilities in respect of the Quality Account
The directors are required under the Health Act 2009 to prepare a Quality Account for
each financial year. The Department of Health has issued guidance on the form and
content of annual Quality Accounts (which incorporates the legal requirements in the
Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2012 (as
amended by the National Health Service (Quality Accounts) Amendment Regulations
2011).
In preparing the Quality Account, directors are required to take steps to satisfy
themselves that:
• The quality Account presents a balanced picture of the trust’s performance over the
period covered;
• The performance information reported in the Quality Account is reliable and
accurate;
• There are proper internal controls over the collection and reporting of the measures
of performance included in the Quality Account, and these controls are subject to
review to confirm that they are working effectively in practice;
• The data underpinning the measures of performance reported in the Quality
Account is robust and reliable and conforms to specified data quality standards and
prescribed definitions, and is subject to scrutiny and review; and
• The Quality Account has been prepared in accordance with Department of Health
guidance.
The directors confirm to the best of their knowledge and belief that the have
complied with the above requirements in preparing the Quality Account
By order of the Board
27/06/13
………………………….. Date ………………………………….. Richard Samuda - Chair
27/06/13
………………………….. Date ……………………………….… Toby Lewis - Chief Executive

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2.22 Annual Governance Statement
This Statement sets out for our staff and stakeholders of Sandwell & West Birmingham
NHS Hospitals Trust the way in which it is governed and managed; and how it is
accountable for what it does. The Governance Statement is Appendix 1, which can be
found at the end of this Quality Account.
2.23 Review of Services
During the period 2012/13 the Sandwell and West Birmingham Hospitals NHS Trust
provided and/or subcontracted 46 NHS services.
The Sandwell and West Birmingham Hospitals NHS Trust has reviewed all the data
available to it on the quality of the care in 46 of these services. Where the trust has
subcontracted any activity, it would only be to a provider which was registered with
the CQC. Agreements between the Trust and the subcontracted providers require that
the same high standards of care given by SWBH are maintained when giving care on
our behalf. The health benefit and activity data undergo the same level of scrutiny as
that delivered in the Trust.
The Income Generated by the NHS services reviewed in 2012/ 13 represents 100% per
cent of the total income generated from the provision of NHS services by the Sandwell
and West Birmingham Hospitals NHS Trust for 2012/13.
2.24 Participation in Clinical Audits
During 2012/ 13, Sandwell & West Birmingham NHS Hospitals Trust has participated in
31 national clinical audits and 2 national confidential enquiries covering NHS services
which the Trust provides. The SWBH has reviewed all the data available to them on the
quality of care in all of these services.
During that period Sandwell and West Birmingham NHS Trust participated in 97% of
national clinical audits and 100% national confidential enquiries of the national clinical
audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Sandwell and West
Birmingham NHS Trust participated in and for which data collection was completed
during 2012/ 13, are listed in the Appendix 2 alongside the number of cases submitted
to each audit or enquiry as a percentage of the number of registered cases required by
the terms of that audit or enquiry.
The reports of 14 national clinical audits were reviewed by the provider in 2012/13 and
Sandwell and West Birmingham NHS Trust intends to take the following actions, of
which a brief summary can be found in Appendix 3.

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The reports of 17 local clinical audits were reviewed by the provider in 2012/ 13 and
Sandwell and West Birmingham NHS Trust intends to take the following actions, of
which a brief summary can be found in Appendix 4.
2.25 Participation in Clinical Research
The number of patients receiving NHS services provided or subcontracted by Sandwell
and West Birmingham NHS Trust in 2012/ 13 that were recruited during that period to
participate in research approved by a research ethics committee was in excess of 1700
for National Institute for Health Research (NIHR) Portfolio studies and approximately
600 for non-NIHR Portfolio studies.
Participation in clinical research is really important for understanding and adding to
treatments for health problems and demonstrates the Trust’s commitment to improving
the quality of care offered and to making a contribution to wider health improvement.
Engagement with clinical research also demonstrates the Trust’s commitment to testing
and offering the latest treatments and techniques. If further ensures that clinical staff
stay abreast of the latest possible treatment possibilities and active participation in
research leads to successful patient outcomes.
Sandwell & West Birmingham Hospitals NHS Trust was involved in conducting over
250 clinical research studies during 2012/ 13, of which around 200 were UK Clinical
Research Network (UKCRN) portfolio studies. Research is undertaken across a wide
range of disciplines including Cancer (breast, lung, colorectal, haematology, gynaeoncology,
urology), Rheumatology, Ophthalmology, Stroke, Neurology, Cardiovascular,
Diabetes, Gastroenterology, Surgery, Dermatology and Women and Children’s Health.
Sandwell & West Birmingham Hospitals NHS Trust uses national systems to manage
the studies in proportion to risk and implements the NIHR Research Support Service
standard operating procedures.
2.26 Goals agreed with Commissioners for 2013/14
Use of the CQUIN payment Framework
The Trust has been working closely with the commissioners to develop a whole raft of
quality schemes which are summarised in the table below. They are a combination of
national and local priorities and some of them are highest priorities and have been
described in more detail at the beginning of our Quality Account.
The process of developing the schemes for inclusion in this year’s CQUINs has been
through discussion with the newly established Clinical Commissioning Group (CCG). As
we indicated earlier in the report, we are continuing with some of the CQUINs from last
year as our highest priorities. We are doing this with the approval of our commissioners

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and we believe that patients will really benefit from this added attention and focus.
A proportion of SWBH’s income is conditional on achieving quality improvement and
innovation goals agreed between the Commissioning Clusters and any person or body
they entered into a contract, agreement or arrangement with for the provision of
NHS services, through the Commissioning for Quality Framework. In 2013/14 it will
be 2.5% of our total income. These schemes are known as CQUINs (Commissioning for
Quality & Innovation).
You will note in the table below that many of last year’s indicators are no longer there.
This is because there has been a change to how the trust has contracts with the CCG.
The ‘old’ CQUINs have now become part of the baseline contract and will continue
to be performance managed as part of usual contract management discussions. The
focus on quality remains and has been heightened.
Table 2. CQUINs 2013/14
Goal
CQUIN
Pre Qualifiers
1 Intra-operative fluid
management (IOFM)
Criteria for providers
Providers will need to:
• establish 2012/13 baseline use
• put in place trajectories for
2013/14.
2 Digital First Establish a 2012/13 baseline and a
trajectory for improvement to reduce
inappropriate face-to-face contact.
3 Carers for people with
dementia
Demonstrate that plans have been
put in place to ensure that for
every person who is admitted to
hospital where there is a diagnosis of
dementia, their carer is sign-posted
to relevant advice and receives
relevant information to help and
support them.
Quality
Domain
Innovation
Innovation
Innovation
Goal
CQUIN
Goal Name
1 Friends and Family
Test
Description of Goal
To improve the experience of
patients in line with Domain 4 of
the NHS Outcomes Framework. The
Friends and Family Test will provide
timely, granular feedback from
patients about their experience. The
2011/12 national inpatient survey
showed that only 13 per cent of
patients in acute hospital inpatient
wards and A&E departments were
asked for feedback.
Quality
Domain
Patient
Experience

20
2 NHS Safety
Thermometer
To reduce harm. The power of the
NHS Safety Thermometer lies in
allowing frontline teams to measure
how safe their services are and to
deliver improvement locally.
3 Dementia To incentivise the identification of
patients with dementia and other
causes of cognitive impairment
alongside their other medical
conditions, to prompt appropriate
referral and follow up after they
leave hospital and to ensure that
hospitals deliver high quality care to
people with dementia and support
their carers.
4 VTE To reduce avoidable death, disability
and chronic ill health from venous
thromboembolism (VTE).
Patient Safety
Clinical
Effectiveness
Patient Safety
5 Safe Storage of
Medicines
To improve compliance and safety
of storage of all medicines and
controlled drugs at ward level.
Patient Safety
6 Dementia patient
stimulation
Dementia – programme of
stimulating activities for patients
whilst an inpatient.
Patient
Experience
7 Use of pain care
bundles
Use standard procedures to assess
and manage a patient’s pain
throughout the course of care.
Clinical
Effectiveness
8 Use of sepsis care
bundles
(Sepsis six)
Reducing mortality due to severe
sepsis.
Patient Safety
9 Community Risk
assessment and advice
offered. (Falls and
Pressure Ulcers)
10 (Recording DNAR
Decisions)
Do Not Attempt CPR
- Improved patient
communications and
documented decisions
Risk assessment at each patient
review for falls and pressure ulcer
– documented to care plan with
additional documentation of advice
provided to the patient/carer (System
1).
Improvement of communications
about resuscitation with patients
and clear recording of discussion
and clear recording of any DNAR
decision.
Patient Safety
Patient
Experience

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Specialised Services CQUINs
Service
1 Specialised cancer Access to and impact of clinical nurse specialist
support on patient experience.
2 HIV Registration and communication with GPs about the
care of HIV patients.
3 Neonatal Intensive
care
Improved access to breast milk in preterm infants.
Timely administration of total parenteral nutrition
(TPN) in preterm infants.
Timely simple discharge.
Retinopathy of Prematurity (ROP) screening.
2.27 What others say about us
Statement from The Care Quality Commission -Registration and Compliance
SWBH is required to register with the Care Quality Commission (CQC)
• Sandwell and West Birmingham Hospitals NHS Trust is registered without conditions
with the CQC, the independent regulator of health and social care in England.
• The CQC has not taken enforcement action against the Trust during the period 1
April 2012 to 31 March 2013.
• The Trust has participated in the following reviews by the CQC:
Sandwell Hospital was inspected by the CQC in July 2012. The CQC carried out this
review because concerns were identified in relation to:
Outcome 01 - Respecting and involving people who use services;
Outcome 04 - Care and welfare of people who use services;
Outcome 14 - Supporting staff.
The CQC team made the overall judgement that ‘Sandwell General Hospital was
meeting all the essential standards of quality and safety inspected’.
The CQC carried out unannounced inspections at City & Sandwell Hospitals on 27th,
28th September & 1st October 2012.

22
The CQC inspected the following standards as part of a routine inspection. This is
what was found:
Consent to care and treatment
Care and welfare of people who use services
Cooperating with other providers
Safeguarding people who use services from abuse
Supporting workers
Assessing and monitoring the quality of service Provision
Complaints
Table 3. CQC findings
Action needed
Met this standard
Met this standard
Met this standard
Met this standard
Action needed
Met this standard
The CQC did comment that both the areas for action to be taken would have minor impact
on people who use the service. The CQC view was that the impact was not significant and the
matter could be managed or resolved quickly. A summary of the actions the Trust has taken
resolve these issues include:
Consent to Care and Treatment
•
•
•
•
•
•
•
Improving staff awareness of consent and mental capacity issues through a range of media
and training interventions;
Developing a staff information leaflet regarding Mental Capacity, IMCA and advance
directives;
Carrying out a survey of staff regarding knowledge of Mental Capacity Act (including
application to Consent) and Deprivation of liberty safeguards to identify future training
needs;
Reviewing the MCA policy to ensure that it is up to date;
Raising staff awareness of applying MCA to practice;
Carrying out a review and update the Trust’s Consent Policy;
Undertaking monthly consent audits.
Assessing and monitoring the quality of service provision
• Providing timely feedback to staff about the outcomes of incidents reported;
• Monthly review of corporate wide action plans to monitor corporate trends;

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• Maintaining safe staffing levels by developing the Trust’s monitoring of staffing
ratios across the wards and assessment units to identify issues at an early stage;
• Review the data inclusion and improvement of complaints / incident information
within the Trust Quality Report;
• Develop an organisation-wide ‘Lessons Learned’ policy;
• Improve complaints handling ensuing timely and proportionate responses.
West Midlands Quality Review Service (WMQRS) Inspection
The WMQRS carried out a review of the care of adults with long term conditions and
the care of children and young people with diabetes between 5-8 February 2013. The
aim of the standards and the review programme is to help providers and commissioners
of services to improve clinical outcomes and service users’ and carers’ experiences by
improving the quality of services.
Many areas of good practice were identified, and recommendations for improvement
were also made.
The final report has not yet been issued.
2.28 Limited Assurance Report
The External Auditors have provided the Trust’s management with a signed limited
assurance report. This report is attached as Appendix 5.
2.29 Data Quality & Information Governance
Statement on relevance of Data Quality and our actions to improve our Data Quality
We need to know that we are counting, recording and storing information about
people’s care very carefully. We do not have concerns about inappropriate disclosure
of data. We are however not yet assured about data quality in every domain of key
quality performance. Given this concern, which arises principally from the discovery in
2012-13 of a potential backlog of patients needing expedited elective care, we have
commissioned an external review of all our data reporting for key national indicators
to take place in July-September 2013.
NHS Number and General Medical Practice Code Validity
Below is the National, SHA and Trust performance on validity of these data items as
published through the Health & Social Care Information Centre (IC) through Secondary
User Service Data Quality Dashboard – Provider Based using 2012/13 financial month 12
data, which is the latest we have.
It shows we remain above the national benchmarks for all but 1 indicators in A&E (the
conclusion time). We remain above all indicators for Outpatients except Patient Pathway

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Identifier (which is optional). We remain above all indicators for inpatients except for
ethnic origin 96.3%, compared to the national average performance of 98.2%, patient
pathway identifier (optional) and we are slightly below NHS number coverage at 98.9%
which which compared to a national average performance of 99.1%. However we will
be resubmitting our data with another NHS Number trace before year end.
National SHA SWBH
Inpatients 99.1% 99.4% 98.9%
Outpatients 99.3% 99.6% 99.6%
A&E 94.9% 96.9% 96.8%
Table 4. NHS Number
National SHA SWBH
Inpatients 99.9% 99.4% 100%
Outpatients 99.9% 99.6% 100%
A&E 99.7% 100% 100%
Table 5. General Medical Practice Code
Clinical Coding Error Rate
The latest final Payment by Results external clinical coding audit shows the trust has a
2.0% Finished Consultant Episode HRG error rate against national error rate of 7.5%.
The overall error rate was 3.5% for clinical diagnosis coding, and 9.1% for clinical
treatment coding.
Information Governance Toolkit (IGT) attainment levels
Last year we reported that we had work to carry out to achieve compliance with the
Information Governance Toolkit.
The standards which we failed to meet were:
• 110 - Formal contractual arrangements that include compliance with information
governance requirements are in place with all contractors and support organisations;
• 112 - Information Governance awareness and mandatory training procedures are in
place and all staff are appropriately trained;
• 324 - This requirement will be achieved by default on attainment of level 2 for
requirements 110 and 112.
• Such progress has been made that Sandwell and West Birmingham Hospitals NHS
Trust Information Governance (IG) Assessment Report overall score for 2012/13 is
now graded Satisfactory (GREEN) according to the IGT Grading Scheme.

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Part 3: Review of Quality Performance
2012/13
3.1 Report on Quality Priorities for 2012/13
In last year’s Quality Account, we identified four focus areas for prioritization. They sat
within the 3 domains, patient safety, clinical effectiveness & positive patient experience
which are identified in our Quality & Safety Strategy.
The focus areas were:
1. Continuing to Improve the Stroke & TIA Services (Patient Safety);
2. Essential Standards of Nursing Care (encompassing Patient Safety, Effectiveness of
Care, and Patient Experience);
3. Mortality reporting and analysis (Clinical Effectiveness);
4. Improving Emergency Department Safety and Performance (Patient Safety).
For each of the focus areas, our achievements are summarised in the Table 6 below.
For more detail, there is a section describing our activities later in this Quality Account.
Table 6. Summary of Key Quality Achievements 2012/13
Aims
Actions
We did what we
said we’d do
Focus Area 1 : Continuing to Improve the Stroke & TIA Services (Patient Safety)
Continuously deliver safe,
timely care for stroke and TIA
& value for money
Consultation and open
reconfigured stroke & TIA
services
We completed the consultation
Opened 55 bedded stroke &
neurology unit at Sandwell
Hospital.
Monitoring of our performance
against agreed targets
We set targets for stroke
performance achieving 4 out
of the 5 main targets, and
only slightly underperforming
against the target we failed
(CT scan within 24 hours arrival
in hospital).

26
Focus Area 2: Essential standards of Nursing Care
To reduce avoidable hospitalacquired
weight loss in elderly
patients and vulnerable adults
To meet agreed Control of
Infection Standards
To increase Harm Free Care
To increase dementia
awareness and assessment
• Introduced ‘care rounds’.
• Improved meal time
experience.
• Ensured patient hydration
requirements are met.
• Protected patients dignity
at all times.
• Met targets set for C.
Difficile (C. Diff), Methicillinresistant
Staphylococcus
aureus (MRSA) bacteraemia
methicillin-sensitive
Staphylococcus aureus
(MSSA) and Escherichia
Coli (E. coli) cases 30 day
mortality for C. Diff.
• Reduced the use of
antibiotics.
• Achieved hand hygiene
standards, CQC standards &
Patient Environment Action
Team (PEAT) scores at
excellent.
We did not achieve the
MRSA screening targets for
emergency patients by 8%
below target.
Introduced the ‘Safety
Thermometer’, reduced
falls, assess 90% of admitted
patients for VTE risk, reduce
serious pressure sores,
avoidable weight loss, and
increasing the number of
people on supported care
pathways at the end of their
lives.
We carried out a trust wide
campaign, increased the
number over the age of
75yrs assessed, and improved
referrals to support services.

27
Focus Area 3: Mortality Reporting & Analysis
Analyse and understand the
causes of death in the Trust
better and reduce mortality
Carried out reviews by
consultants of more than 60%
of deaths.
Used HSMR and SHMI to ensure
that we are achieving less than
average mortality rate.
Carried out in depth
investigations into any alerts
raised though mortality alerts
systems.
Focus area 4: Improving Emergency Department Performance
To increase the senior medical
team
To improve clinical systems and
IT
Meet to national 4 hour wait
performance target
Work more closely with our
primary Care and Social Care
partners
The trust has not been
successful in increasing the
senior medical team
Although an ED clinical
director has been appointed.
Whilst work is well underway
with the ED dashboard the
installation of a new ED system
is scheduled go live in May
2013.
The achievement of national
4 hour waiting time was
narrowly missed.
A rapid response team has
provided additional social work
support.
GPs are providing services in
the ED at City
Work is in progress around
transforming urgent care
both in the trust and in the
community.

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3.12 Focus Topic 1 - Continuing to deliver service improvement and
outcomes in Stroke and Transient Ischaemic Attacks (TIA) Services (Patient
Safety)
Focus Area 1 : Continuing to Improve the Stroke & TIA Services (Patient Safety)
Continuously deliver safe,
timely care for stroke and
TIA & value for money
Consultation and open
reconfigured stroke & TIA
services
Monitoring of our
performance against
agreed targets
Table 7. Summary of Focus Topic 1 achievements
We completed the consultation
Opened 55 bedded stroke & neurology unit at
Sandwell Hospital
We set targets for stroke performance achieving
4 out of the 5 main targets, and only slightly
underperforming against the target we failed (CT
scan within 24 hours arrival in hospital).
Last year we said we were going to continue with improvements to Stroke & TIA
services. We said we would:
• Continuously deliver safe, timely care for stroke and TIA resulting in a reduction in
long term complications including death;
• Agree a preferred option for a reconfigured Stroke & TIA Service;
• Continue to develop and implement our Stroke Strategy;
• Improve the discharge arrangements for patients admitted with a stroke;
• Achieve a target of early supported discharge for 40% of patients with Stroke by
the end of March 2013;
• Develop systems to monitor and respond to the experience of patients receiving
treatment in our care;
• Develop a monitoring system for stroke nursing competency training by the end of
March 2013;
• Carry out daily assessment of patients by specialist consultant clinicians for stroke;
• Deliver Value for Money by ensuring delivery of stroke care that consistently achieves
the expected quality indicators required to attract the Best Practice Tariff for Stroke.
This means that the better care we give, the better the reimbursement from our
commissioners, as set out in the Best Practice Stroke Tariff.
We said we would do this by:
• Participating in national and local audits of our Stroke services;
• Focusing and developing the Stroke and TIA pathways;

29
29
• Completion of the public consultation and confirming the preferred option for the
future;
• We will meet all the main targets, some of which are new and are higher than
last year, on the stroke dashboard and continue to improve the stroke discharge
pathway which we achieved in 2010/11, outlined.
Over the past year significant progress has been made with Stroke and TIA services.
The public consultation was completed. After the public consultation, the first part of
a new 55-bed acute Stroke and Neurology Unit was opened at Sandwell Hospital on
Monday, March 11th 2013. The new acute Stroke and Neurology Unit is part of the
Trust’s plans to concentrate all its services for Stroke patients and Neurology inpatients
at one hospital. All rehabilitation and outpatient services for Stroke patients have also
moved to Sandwell Hospital. This saw the opening of the hyper-acute and acute Stroke
and Neurology ward where patients will spend the initial part of their hospital stay.
The ward has been designed to meet the specific needs of Stroke and Neurology
patients including beds with additional monitoring facilities and a gym for therapy
staff to work with patients from an early stage. There are also enhanced levels of
nursing and therapy staff in line with nationally recommended standards.
By concentrating all stroke services at Sandwell Hospital, the Trust can provide a
better service for Stroke patients and offer greater training and career development
opportunities for staff.
The move saw doctors and nurses from City Hospital transferring to Sandwell Hospital
to create a large, specialist Stroke Unit providing high quality care for patients suffering
Strokes in Sandwell and West Birmingham. There is a hyper-acute stroke unit with
supporting acute beds on one ward and rehabilitation beds on an adjacent ward.
In addition, the hospital team is working closely with community nursing and therapy
teams, including specialist stroke community staff and early supported discharge teams,
to ensure patients can be discharged home safely as soon as possible with the support
they need. The Unit also provides acute and rehabilitation Neurology beds.
There is evidence that specialist hyper-acute stroke units with a larger number of
skilled doctors, nurses and therapy staff give patients a better chance of making a full
recovery after a stroke. Additional staff supporting the new unit includes specialist
therapists, nurses and ward clerks. The new unit is expected to treat about 600 stroke
patients every year.
The Ambulance Service now takes anyone suspected of having had a stroke directly to
Sandwell Hospital. There are robust and safe procedures in place to care for anyone
who self-presents at City Hospital with a suspected stroke.

30
The benefits of the new hyper-acute Stroke Unit include:
• Patients will continue to receive safe, timely care for stroke and Transient Ischaemic
Attacks (TIAs) resulting in a reduction in long-term complications including death;
• All stroke patients will be admitted directly to a stroke bed, with imaging en-route
to the ward, within four hours of arriving in hospital;
• All stroke patients will be assessed daily by a specialist consultant clinician for stroke;
• At least 50% of stroke patients will have a CT scan within an hour of arrival and
100% will have a CT scan within 24 hours;
• Early supportive discharge teams will be in place for all patients living in Sandwell
and there are plans to extend the service to Birmingham residents;
• All patients suspected of having a serious TIA will be seen on the unit within 24
hours.
As part of the plans for the new Stroke Unit a new £680,000 64-slice CT scanner has
been installed at Sandwell Hospital. This scanner replaces the oldest 4-slice scanner
currently at City Hospital. The second more modern CT scanner at City Hospital will
remain on the City site for both in-patients and out-patients.
The new scanner will improve the service available for stroke. Outpatient services for
Neurology patients will continue to be provided at City Hospital.
The Stroke Dashboard has been developed which gives clinicians access to performance
information at their fingertips.
The table below summarises our performance against our main targets.
Main Stroke Targets
Target
Achievement
YTD Feb 2013
Patients spending >90% stay on Acute Stroke Unit 80% 87.6%
Patients receiving CT Scan within 24 hrs of arrival 100% 92.1%
Patients receiving CT Scan within 1 hr of arrival 50% 52.2%
TIA (High Risk) Treatment

31
bringing together nursing and medical stroke expertise into one place, we will be able
to offer better care and achieve our objectives. Stroke & TIA services continue to be in
our priorities for 2013/14.
3.13 Focus Topic 2-Essential Standards of Nursing Care (Patient Safety,
Effectiveness of Care & Patient Experience)
To reduce avoidable
hospital-acquired weight
loss in elderly patients
and vulnerable adults
To meet agreed Control
of Infection Standards
To increase Harm Free
Care
To increase dementia
awareness and assessment
• Introduced ‘care rounds’
• Improved meal time experience
• Ensured patient hydration requirements are
met
• Protected patients dignity at all times
Met targets set for C. Difficile (C. Diff), Methicillinresistant
Staphylococcus aureus (MRSA)
bacteraemia methicillin-sensitive Staphylococcus
aureus (MSSA) and Escherichia Coli (E. coli) cases
30 day mortality for C. Diff
• Reduced the use of antibiotics
• Achieved hand hygiene standards, CQC
standards & Patient Environment Action Team
(PEAT) scores at excellent
We did not achieve the MRSA screening targets
for emergency patients by 8% below target.
Introduced the ‘Safety Thermometer’, reduced
falls, assess 90% of admitted patients for VTE risk,
reduce serious pressure sores, avoidable weight
loss, and increasing the number of people on
supported care pathways at the end of their lives.
We carried out a trust wide campaign, increased
the number over the age of 75yrs assessed, and
improved referrals to support services.
Table 9. Summary of Focus Topic 2 achievements
We said we would continue to improve the safety and experience of our in patients
through specific attention to the reduction of events which harm our patients and
through efforts to greatly improve the care we deliver.
We gave this priority the name of ‘Essential Standards of Nursing Care’ because it
covered several of the quality priorities; reducing avoidable weight loss in elderly &
vulnerable patients; health care associated infections (HCAIs) to below national and
local standards; increasing harm-free care, including reducing pressure damage, falls
with harm, venous thromboembolism (VTE), catheter associated infection, dementia
awareness and assessment.

32
1 - Reduction of avoidable hospital-acquired weight loss in elderly patients and
vulnerable adults
Specifically we said we would:
• Introduce ‘intentional rounding’ (senior nurse ward rounds every 1-2 hours where
a checklist of questions are asked, answered and documented) to ensure patients
essential care requirements are not missed;
• Improve meal time experience;
• Ensure patient hydration requirements are met;
• Protect patients dignity at all times.
What we have achieved:
1 ‘Intentional Rounding’ (Care Rounds)
‘Care Rounds’ were implemented in adult inpatient areas in 2012 for patients who
do not require high levels of intervention, whereby a nurse visits the patient every
two hours to attend to comfort needs (pain relief, positioning, toileting, food/ fluids)
and follows prescribed standards of care. For those patients whose clinical condition
dictates a higher level of intervention, the care standards are replaced with detailed
care plans.
The results of this are shown in Table 10. The different factors which are included in
this check are also included, and some of the interventions are described in more detail
later on in this section.
Compliance with the 2 hourly patient checks %
1 Allocated nurse 75
2 Active daily care standard/ Goal list 91
3 Mobility 87
4 Hygiene 87
5 Elimination 87
6 Eating and drinking 87
7 Cups target/ Dietary intake 58
8 Personal safety 69
9 Frequency of care 78
10 Events log 40
11 Carer involvement 24
Table 10. Compliance of 2 hourly patient checks (March 2013)

33
Nutritional Audits
Nutritional audits are carried out every month to check our performance. By paying
a high level of attention to patients’ food and fluid intake we can be confident that
patients will not become malnourished during their stay with us, especially those who
are identified as particularly vulnerable and at risk. We set a met or exceeded our
target of 90% of patients being MUST (malnutrition universal screening tool) assessed
within 12 hours admission in 9 months of the past 12 months. Nutrition continues to
be high priority with the nursing staff.
Figure 1. Nutrition Audit
Protected mealtimes are in place which means that staff and visitors are discouraged
from entering the wards so that patients can have peaceful, undisrupted time to eat
and rest. It also means that the nursing staff can give those needing help with food
and drink, their full attention and preserving privacy and dignity as much as possible.
Findings from the care round audits are reviewed at the Patient Experience Professional
Advisory Group, which meets monthly. This is where ward managers are held to account
for the findings and actions are agreed to improve patient experience and quality
standards.
Standards and targets for infection control.
These standards included:
• Meeting targets set for C. Difficile (C. Diff);
• Meeting targets for Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia;
• Monitoring and recording methicillin-sensitive Staphylococcus aureus (MSSA) and
Escherichia Coli (E. coli) cases;

34
• Monitoring 30 day mortality for C. Diff;
• Reducing the use of antibiotic associated with C. Diff;
• Maintaining Patient Environment Action Team (PEAT) scores at good or excellent;
• Achieving hand hygiene standards;
• Achieving MRSA screening targets;
• Complying with CQC standards.
What we have achieved:
C. Difficile (C. Diff) Incidences.
In 2012/13 we have been very successful in keeping well below the number of occurrences
agreed by the department of health, with only 37 occurrences of C. Diff. against a
trajectory of 57 during the past year.
Actions to achieve this good performance included hand hygiene audits, a reduction in
the use of antibiotics and maintaining a high level of environmental cleanliness.
Figure 2. Reportable C.Diff Infections
*SWBH NHS Hospital Trust considers that this data is as described for the following
reasons:
During the reporting periods in the table below, the Trust was getting to grips with
the C. Diff issue. We have implemented stringent infection control measures and have
continued to maintain a high level of vigilance and activity of infection control, as
described in this section of the Quality Account.

35
It can be observed in the table below that the rate of infection per 100,000 bed days
has decreased from 87.5 in 2007/08 to 31.8 in 2011/12. Our performance has improved
thru 2012/13 as described on the previous page.
Year
Trust
Apportionment
Total
occurrences
Trust Rate
National
Average
Lowest
rate
Highest
rate
2007/8 281 423 87.5 93.3 0 205
2008/9 158 237 49.5 54.9 0 133
2009/10 148 306 48.2 36.7 0 85.2
2010/11 116 240 39.7 29.6 0 71.8
2011/12 93 202 31.8 21.8 0 51.6
Table 11. C. Diff Performance
C.Diff performance is described in terms of rate per 100,000 bed days for specimens
taken from patients aged 2 years and over, using the IC data.
MRSA Screening & Bacteraemia
The aim for us was to screen 85% of eligible patients for MRSA by March 2013. The
target was exceeded for elective patients but we achieved 76.8% for non-elective
(emergency) admissions which did not meet the required standard. We are not satisfied
that we have not achieved this standard.
We are working with teams to improve their focus on carrying out screening on all
patients, and we are striving to ensure that we capture the data in the most timely and
complete way possible.
Across the whole of 2012/13 the total number of MRSA bacteraemias attributed to the
Trust target to date was 1, which is below the set tolerance of 2.
PEAT Score
The PEAT score for national standards of cleanliness was an average of 96%.
Reduction of Antibiotic usage
The Trust met the Medicines Stewardship antibiotic related reduction target scoring 83
against a target of 70, which is better than the required standard.
Increase Harm-free care
We said we would increase harm-free care across Inpatient areas and District Nurse
caseloads in 4 key areas.
We said we intended to continue to improve the safety and enhance patient experience

38
every Trust had to achieve VTE assessment rates of 90% in admitted patients. The Trust
met the 90% VTE target in 10 out of the 12 months. However, the 90% of admitted
patients did receive a VTE risk assessment across the year.
2011/12 Quarter1 Quarter2 Quarter3 Quarter4
SWBH 92.1% 89.6% 91.2% 89.58
England Highest 100 100 100 Not Available
England Lowest 80.8 80.9 84.6 Not Available
Average 93.7 93.8 94.3 Not Available
Table 12. 2011/12 VTE performance
Data source- Health & Social Care Information Centre (IC) (Q1, 2 & 3). Local data Q4
The 2012/13 performance against the 90% VTE assessment target is displayed below in
table 11. Comparative data cannot be displayed as this is local data.
2012/13 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
% VTE Assessed 92.44 92.87 90.95 91.28 87.41 90.97 91.8 91.96 90.66 91.83 91.14 87.44
Table 13. 2012/13 VTE performance
*The SWBH NHS Hospital Trust considers that this data is as described for the following
reasons:
During March 2013 there was a major technical problem which meant that we could
not guarantee that the data was complete for VTE risk assessments.
The SWBH NHS Hospital trust intends to take the following actions to improve this
number by taking the steps described in Focus Area 2 in Part 2 of this Quality Account,
as it acknowledges that it is a high priority for improving patients’ safety.
A new electronic tool is being designed to make it easier for clinicians to record their
VTE assessments. An indicator has been added to the electronic bed boards in every
ward which show when VTE assessments are required.
In addition, the clinically led Thrombosis Group meet bi-monthly to address issues
relating to VTE risk assessment management, amongst other clinical issues, and is
reviewing hospital associated incidences of embolus. This group reports to the MQuAC.
Dementia awareness and assessment
We said we would raise dementia awareness and assessment by:
• Delivering a trust-wide awareness-raising campaign;
• Carrying out assessments of all people over the age of 75 who are admitted as
emergencies who are staying in more than 72 hours;

39
39
• As part of the 2 levels of the assessment, a referral may result to a consultant or GP
ensuring better care if dementia is suspected.
It is estimated that 25% of general hospital beds are occupied by people with dementia,
rising to 40% or higher in certain groups such as elderly care wards. The presence of
dementia is associated with longer lengths of stay, delayed discharges, readmissions
and inter-ward transfers. This can result in patients not feeling as well cared for as they
would have liked and distress for the carer.
By introducing the Dementia CQUIN, awareness has been raised across the trust. This
has helped us identify patients with dementia and other causes of impaired cognition
alongside their other medical conditions. Also, this meant that patients were much more
likely to get a prompt referral to appropriate services and follow up in the community
after leaving hospital.
Of the 40% of people over 75years of age with dementia admitted to general hospitals,
it is estimated that only half have been diagnosed before admission. The better we are
at picking up dementia, the better care patients will get.
The target was met and it is we are confident that this will have improved how patients
and carers are offered care and supported.
End of Life Care
We said we would increase, by 10%, the number of patients achieving death in their
preferred place and who were on a supportive care pathway (SCP) in both the acute
hospitals and in the community. This means that patients have services set up to have a
dignified death in the place of their choice. This standard is very important in making
sure that patients can have every dignity afforded to them at a time when they can be
very vulnerable.
The 53% target has been exceeded every month since July 2012 and 60% has been
achieved or exceeded for 3 out of the last 4 months of the year.

40
Figure 5. Preferred place of death/death of patients on SCP
3.14 Focus Topic 3 – Mortality Reporting & Analysis (Clinical Effectiveness)
Analyse and understand
the causes of death in the
Trust better and reduce
mortality
• Carried out reviews by consultants of more
than 60% of deaths.
• Used HSMR and SHMI to ensure that we are
achieving less than average mortality rate.
• Carried out in depth investigations into any
alerts raised though mortality alerts systems.
Table 14. Summary of Focus Topic 2 achievements
We said we would continue to develop a system wide improvement in our knowledge
and understanding of the Trust’s mortality performance and the factors that influence
deaths in our hospitals. We said we would use the Hospital Standardised Mortality Rates
(HSMR) and Summary Hospital Mortality Index (SHMI), to monitor and improve the
Trust’s performance. These measures allowed us to measure our performance against
other trusts’ performance across the country. By adopting these systems, processes and
practices at every level we said we would aim to reduce avoidable harm and death.
The improvements we said we would make were:
1. Reducing mortality in the Trust;
2. Understanding the causes of deaths in our hospitals better, including in Emergency
Departments;
3. Continue to review the agreed % of deaths in each month for all directorates using
our Mortality Review System and learn from our findings;

41
4. Develop an internal trigger system to alert specialties to trends or concerns in
mortality;
5. Broaden the tools we use to analyse the mortality data.
What we have achieved:
Over the past year, we have continued to monitor the mortality rates in the Trust.
Consultants have continued to review deaths of patients and have exceeded 60%.
There have been a lot of very ill, often frail and elderly patients, admitted to our
hospitals over the winter which has meant that there has been a high level of activity.
Our staff have been spending time with patients rather than carrying out reviews.
This has meant that we have not been able to carry out quite as many reviews as we
intended.
Where reviews have been carried out, and a death has been identified by the reviewer
as preventable, a deeper review is carried out to explore what can be learned from this
and what we can do better in future. However, this is an area we want to improve on
and have included it in something we want to do this year.
Use of Hospital Standardised Mortality Ratio (HSMR) & Summary Hospital – Level
Mortality Indicator (SHMI)
We said we would use a range of tools to analyse mortality. We use HSMR and SHMI. It
is reported every month to the Quality & Safety Committee, the Commissioners, and is
discussed in detail at the MQuAC. We also carry out in-depth reviews of any diagnostic
code that has shown that our incidence of disease seems to higher than expected.
HSMR is a standardised measure of hospital mortality and is an expression of the
relative risk of mortality. It is the observed number of in- hospital spells resulting in
death divided by an expected figure.
The Trusts 12-month cumulative HSMR (87.8) at the Trust remains below 100, and is less
than the lower statistical confidence limit and continues to remain lower than that of
the SHA Peer (96.7). The in-month (January 13) HSMR for the Trust has decreased to
81.4
The 12 month cumulative site specific HSMRs are 76.2 and 99.7 for City and Sandwell
respectively, neither of which are currently in excess of upper statistical confidence
limits. We are looking at the differences between the 2 sites to identify if there are any
significant reasons for this.

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Summary Hospital – Level Mortality Indicator (SHMI)
The SHMI is a national mortality indicator launched at the end of October 2011. The
intention is that it will complement the HSMR in the monitoring and assessment of
Hospital Mortality. One SHMI value is calculated for each trust. The baseline value is 1.
A trust would only get a SHMI value of 1 if the number of patients who die following
treatment was exactly the same as the number expected using the SHMI methodology.
SHMI values have also been categorised into the following bandings.
1 where the Trust’s mortality rate is ‘higher than expected’
2 where the trust’s mortality rate is ‘as expected’
3 where the trust’s mortality rate is ‘lower than expected’
The last SHMI data was published on 24/01/13 for the period July 11 – June 12. For this
period the Trust has a SHMI value of 0.97 and was categorised in band 2.
• 11 trusts had a SHMI value categorised as ‘higher than expected’
• 16 trusts had a SHMI value categorised as ‘lower than expected’
• 115 trusts had a SHMI value categorised as ‘as expected’
Further SHMI data for the period October 2011 – September 2012 is due to be published
this month. In addition, the UHB Healthcare Evaluation Data (HED) tool provides data
in month based on the SHMI criteria. The SHMI includes all deaths up to 30 days after
hospital discharge. The Trust SHMI for the most recent period for which data is available
is 94.4.
Internal Data: Apr May Jun Jul Aug Sep Oct Nov Dec Jan
Hospital Deaths 133 146 126 121 132 121 139 106 140 157
Dr Foster 56 HSMR Groups:
Deaths 110 129 111 100 113 101 124 89 126 132
HSMR (Month) 84.6 89.2 89.7 85.5 83.9 84.8 91.1 64.2 83.3 81.4
HSMR (12 month cumulative) 89.7 88.3 96.4 95.5 94.2 93.1 92.5 90.4 89.1 87.8
HSMR (Peer SHA 12 month
cumulative)
Healthcare Evaluation Data (HED)
SHMI (12 month cumulative)
94.9 93.3 101.3 100.2 98.7 97.8 96.7 96.4 96.8 96.7
96.2 96.0 96.3 96.3 94.2 95.6 94.9 94.4 . .
Table 15. Mortality Performance Statistics 2012/13

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SWBH
April 11 -
March 12
July 11 - June
12
Observed
deaths
Expected
deaths
Rate
Band
2171 2243 0.96 2
2196 2256 0.97 2
Table 16. SHMI performance - Data source –IC, 8/4/13*mandatory entry
Palliative care
Over the past couple of years the palliative care service has been developing. This
service focuses on ensuring that people end their lives with a dignified death in the
place of their choice and without pain.
SWBH Denominator Numerator
Rate of
palliative care
coding
National
average
National
Lowest
National
Highest
April 11 - March 12 2171 440 20.3 18 0 44.2
July 11 - June 12 2196 494 22.5 18.6 0.3 46.3
Table 17. Palliative Care Coding
* The SWBH NHS Trust considers that this data is as described for the following reasons:
Actions have been in place over the past few years which is to do with the scrutiny of
the HSMR, SHMI and reviews by the senior medical staff. SWBH remains in Band 2 and
the HSMR and SHMI is below 100 using both indicators.
That the focus on developing the palliative care service has increased which has led to
more patients being coded as on a palliative care pathway.
The SWBH NHS Trust has taken the following actions to improve this percentage and
so the quality of its services by employing palliative care medical consultants and
strengthen work across the acute and community services to develop better end of life
care for patients.
Palliative care consultants and nurses are actively involved in the MQuAC which reviews
a broad range of aspects of mortality including HSMR, SHMI, CQC alerts, incidents and
internally identified concerns.
The Trust intends to take the actions described in Part 2, Section 2.14- Focus Area 2.

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3.15 Focus Topic 4 - Improving Emergency Department (ED) Performance
(Patient Safety & Patient Experience)
To increase the senior
medical team
To improve clinical
systems and IT
Meet to national 4 hour
wait performance target
Work more closely with
our primary Care and
Social Care partners
Recruitment continues but a key risk to us
remains senior medical presence. Recruitment in
other professional groups in ED is substantially
improved.
Whilst work is well underway with the ED
dashboard the installation of a new ED system
went live in May 2013.
The achievement of national 4 hour waiting time
was narrowly missed.
A rapid response team has provided additional
social work support.
GPs are providing services in the ED at City
Work is in progress around transforming urgent
care both in the trust and in the community.
Table 18. Summary of Focus Topic 4 achievements
The ED is the place many local people, many of them very unwell, frail and elderly,
first come into contact with our hospitals. It is an area which has been under a lot of
pressure during the past year. We have not succeeded to achieve all that we wanted to
in the EDs.
Last year we said we would:
• Continue to recruit more middle and consultant grade doctors to the EDs;
• Continue to develop and monitor systems to ensure that clinical care is of a
consistently high standard;
• Continue to closely analyse incidents and take action to eliminate identified root
causes;
• Ensure that there is a process in place for any deaths in ED to be reviewed by senior
doctors;
• Support the delivery of the Integrated Development Plan for our Emergency
Departments, working in partnership with the commissioners;
• Improve the Information Technology systems to support the development of
automated clinical dashboards;
• Continue work with our partners in Primary Care to ensure patients who do not
need to be treated in the Emergency Department are appropriately redirected;
• Continue to meet national standards in respect of 4 hour waits, and perform better
against the other national standards for Emergency Departments;
• Ensure protocols/guidelines are being followed to provide a consistent level of high
quality care.

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ED Performance against the national 4 hour wait standard
Performance in the ED has not achieved the standards which we wanted. This is due,
particularly to there being high levels of winter illnesses which have had a knock
on effect of beds being unavailable when patients require admission. The Trust has
experienced a significant and prolonged norovirus outbreak over the winter months.
Several wards were closed due to infection control precautions, further impacting on
capacity.
The performance across the year was that 92.34% of patients were waiting in ED for
less than 4 hours, which does not meet the 95% standard.
The reasons behind this were to do with patients not being seen and treated within 4
hours in the ED or because when it was decided to admit them to hospital, a bed was
not available immediately.
Our aim remains for patients to get the appropriate care within as short a time as
possible and that no one should wait more than 4 hours to get the care they need. We
know we need to work more effectively on achieving this and that is why we are taking
this forward into 2013/14 as a top priority.
ED Staff Recruitment
We have tried to recruit more senior doctors for the EDs. This has not been as successful
as we would have hoped.
The Trust Board approved a workforce investment business case in November 2012 to
increase medical and nursing establishment for ED. The £2.186 million investment case
was based on a workforce model to strengthen clinical leadership providing an increase
in 7 day consultant coverage of the department and expansion of nursing staff.
We are continuing to work on our staff plans and developing training opportunities
for leadership team.
High Standard of Care
Much of what leads to a high standard of care and a positive experience for patients is
by having a well trained workforce. We have begun work on a raft of training to help
raise standards.
We are adopting the West Mercia Guidelines for Emergency Care which is a collection
of pathways which offer the proven best ways of caring for people in our emergency
medicine areas. This will also mean that there will be standardised care across our
hospitals.
We are pleased to report that we have seen a reduction in the number of serious
incidents reported in the EDs, which is very positive for service users.

46
Improvements of the ED Information Technology systems
The ED has worked closely to develop electronic tools to help managers and clinicians
understand the patients’ progress in the ED.
Work is in progress on installing a new ED electronic system. It is planned to go live in
May 2013. This will help doctors and nurses look after patients better by freeing up
time and keeping the information they need in one place.
Working with our Commissioners, Primary Care and Social Care
We have been working closely with our commissioners, primary care and social care
services. The Trust continues to work with external partners to reduce delayed transfers
of care and appropriate admission avoidance schemes.
Additional social work capacity has been provided Monday to Friday by Birmingham
Social Services to work with the Rapid Response Team based in ED and the assessment
units.
A recent improvement is that GP services are being provided in the City ED, as they are
at Sandwell where appropriately identified patients are seen. This is helping reduce
waits for patients and also means that patients are seen by the right health professional.
Work has commenced between the CCG, Social Services and the Trust to develop a joint
social and health care team and determine a priority plan to reduce delays in the acute
sector. The initial scoping phase of urgent care transformation has been completed with
a multi-agency team presenting an outline conceptual model for urgent care provision
across the system. This will now be formally commissioned as a project hosted by the
CCG to be progressed over the first half of 2013/14.
3.16 Strengthening Governance Arrangements at SWBH
The decision was taken to review and strengthen Clinical Quality Governance
arrangements in the Trust. The move to divide the Governance Committee into 4 areas
of scrutiny was taken replacing it with 4 committees:
1. Patient Safety Committee;
2. Clinical Effectiveness Committee;
3. Compliance & Assurance Committee;
4. Patient Experience Committee.
The purpose is to be able to focus and attention to really making sure we are giving
patients the best experience and safest care possible. These 4 committees report into
the Quality & Safety Committee which is a sub-committee of the Board.

47
The Committees’ key agenda items focus on all aspects of quality and making sure that
a good level of assurance is provided to the Board that clinical services are appropriately
delivered in terms of patient experience, quality, effectiveness and safety. They also
aim to ensure that the Trust has effective and efficient arrangements in place for
quality assessment, quality improvement and quality assurance. Where quality and
performance falls below acceptable standards, they ensure that action is taken to
bring it back in line with expectations, and to promote improvement and excellence. In
addition, the committees ensure that service user and carer perspectives on quality are
at the heart of the Trust’s quality assurance framework.
Led by Clinical Directorates, teams are held accountable for the services they deliver.
Clinical directorate teams are responsible to the Divisional Management Teams (Division
Director (senior doctor), Senior Nurse & Senior Manager). In turn, they are responsible
to the Board.
3.17 Patient Safety & Incident Reporting
An effective safety culture is often evidenced by high levels of incident reporting. The
Trust submits patient safety incidents to the National Reporting & Learning System
(NRLS) which provides comparative data with like sized Trusts. The next comparative
report was due in March 2013 although this was not available at the time of writing
this Quality Account.
The Trust has a system for investigating incidents of all grades and learning from our
mistakes. Staff are actively encouraged to report incidents and near misses, whether
the incident directly affects patient safety or they relate to the health and safety of
staff and members of the public.
Electronic incident reporting has improved reporting rates across clinical staff, however,
at a Listening into Action (LiA) event (staff engagement) in April 2012, staff identified
that feedback was often not provided following submission of an incident being
reported. Following the LiA, feedback to staff was made compulsory on the electronic
system. Quality of data and information has become more robust since moving to an
electronic system.
We see the increase in reporting of incidents as a positive step as it means that our staff
are better at identifying risks and then, as an organisation we are able to learn from
them and take action to prevent these incidents happening again in the future.

49
Serious incidents are reported to the CCG and investigated corporately. The Trust also
assigns the designation “corporate amber” to some incidents either because they require
reporting to other external stakeholders or to raise awareness. Examples are: pressure
sores, selected sharps injuries, selected violent incidents and selected medication errors.
During 2012/13 the total number of patient safety incidents of all grades from reported
to the National Reporting & Learning Service was 9846. The number of serious incidents
reported, classified as severe (resulting in permanent or long term harm), was 14, and
the number reported classified as resulting in death (death caused by the incident) was
12: a total of 26. The percentage of patient safety incidents resulting in severe harm or
death during 2012/13 was 0.26%. This was local data and was extracted from the Trust’s
reporting system. The numbers may be changed following investigation and change to
the grading of the incident. The national reporting period of October 2012-March 2013
and the final position will not be released until September 2013. For this reason, there
is no comparative information about performance against other trusts and the rate has
not been calculated.
The number of serious incidents (not exclusively patient safety incidents) reported
internally was 66 in 2011/12 and reduced to 42 in 2012/13, excluding pressure sores,
fractures resulting from falls, ward closures, some infection control issues or health and
safety incidents.
Month
2012/13
No. Serious
Incidents
reported
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
7 7 8 2 3 6 2 1 2 0 3 1
Table 19. Number of Serious Incidents reported during 2012/13*
*The serious incidents reported in the table above do not include pressure sores, fractures resulting from
falls, ward closures, some infection control issues or health and safety incidents.
The SWBH NHS Hospital Trust considers that this data (below) is as described for the
following reasons:
The Trust has improved its reporting culture which has led to more incidents being
reported. From the first period reported above to the second period we have moved
from being in the middle 50% of reports to the highest 25% of reporters, which is very
positive.
Rate of incidents per
100 admissions
October 2011 - March 2012 April 2012 - September 2012
SWBH 6.7 9.4
England Median 5.9 (of 41 large acute trusts) 6.2 (of 39 large acute trusts)
Table 20. Incident rate

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Degree of Harm
Number
Oct - March12
Number
April - Sept 12
None 2207 3138
low 1159 1668
Moderate 471 347
Severe 40 30
Death 6 12
Tables 21. Incidents-Degree of Harm Source: (IC)
The percent of severe incidents between October and March 12 was 1.0% at SWBH,
compared to 0.6% in all large acute organisations. The percent of severe incidents
between April and September 12 was 0.6% at SWBH, compared to 0.6% in all large
acute organisations which is an improvement.
The percent of incidents resulting in death between October and March 12 was 0.2%
at SWBH, compared to 0.1% in all large acute organisations. The percent of incidents
resulting in death between April and September 12 was 0.2% at SWBH, compared to
0.1% in all large acute organisations.
As described in our Quality & Safety Strategy, SWBH Hospitals Trust intends to continue
the actions to improve safety by taking the steps described in Section 2 of this Quality
Account, as it acknowledges that it is a high priority for improving patients’ safety &
experience. Crucial to this success is complying with governance arrangements which
are conducive to openness and honesty. Learning from incidents also ranks highly at
the top of our agenda and sharing lessons learnt.
‘Never Events’
‘Never events’ are serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented. However, we
have reported 2 never events since 1 April 2012. One related to the retention of a guide
wire following the insertion of a central venous line and the second was the removal
of the wrong tooth, which is classed as wrong site surgery. Both were fully investigated
and actions taken to avoid these incidents occurring again.
The use of the WHO Surgical Safety Checklist at all our hospital sites for all surgical
procedures and many interventional procedures has significantly improved patient
safety over the past two years and work continues to ensure that this safety mechanism
is embedded.
NHS Litigation Authority Risk Management Standards
The NHS Litigation Authority (NHSLA) through their claims data, develop risk
management standards which Trusts are assessed against. There are three levels, 1, 2
and 3 (1 being the lowest). The Acute Trust attained Level 2 compliance in February 2011

51
and with the transfer of Sandwell Community services were required to be reassessed
in February 2013. Due to changes within the NHSLA, we requested a postponement of
this assessment, which was granted until 2014/15.
Maternity services undertook a separate assessment called CNST (Clinical Negligence
Scheme for Trusts), as well as being part of the Acute assessment. Maternity undertook
a Level 2 assessment in February 2013 and were deemed compliant with a compliance
of 44/50. This is an extremely good achievement as many maternity services struggle to
achieve this level of attainment. However, the maternity services wish to progress to an
even higher level and a Level 3 assessment is provisionally booked for February 2014.
What this means is that the risk of harm to patients has been assessed as lower because
the Trust has systems and processes in place, which are being followed, to protect
patients, or in the case of maternity, to protect women and their babies.
3.18 Safeguarding Adults and Children
The safeguarding of children, young people and vulnerable adults is a key responsibility
of the Trust. Safeguarding level 1, 2 and 3 training is delivered across in accordance with
the intercollegiate document (2010). Training is delivered across the Trust, covering
Community, Acute, Adult and Children’s Services staff together.
Safeguarding Adults Training continued as planned throughout 2012/13. Increasing
awareness across the trust was targeted by attaching updated Safeguarding information
leaflets to all wage slips in June 2012. We also have scheduled Mental Capacity and
Deprivation of Liberty Safeguard leaflets to be attached to all wage slips in May 2013.
The Learning Disability Liaison Nurse continues to work across the Trust with patients
from Sandwell, and with the Birmingham Community Services Health Facilitation
Service assisting patients living in Birmingham. The ‘Good Healthcare for All’ group
continues to meet supported by the ‘Changing our Lives’ group from Sandwell.
The Trust has a comprehensive plan to improve the care of patients with dementia,
as referred to earlier in section 3.13. This work is very important and the Chief Nurse
personally oversees these activities.
Safeguarding Children
We have embraced a new commitment to developing a safeguarding children’s service
that is focused around the journey of the child. This pathway may consist of a child
visiting the Emergency Department, being admitted to a children’s ward and then
being discharged back home and to the community services. By training and working
together across acute and community boundaries, we feel this approach strengthens
our approach to safeguarding our most vulnerable children.

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In addition to training, staff need to know where to go for support to be able to
safeguard the vulnerable. We have a key contacts identified named safeguarding
professionals for advice and support. We focus closely on the child travelling through
our services and providing early support and interventions where possible. We offer
support to staff through supervision, increasing staff knowledge, skills and experience
and moving away from criticism and fear of getting it wrong.
Safeguarding Children is everyone’s responsibility and all children have a right to be
safe and protected from harm.
Compliance with Safeguarding training at the end of March 2013 is illustrated in the
table below.
Training
% staff compliant
Safeguarding Adults Level 1 99.36
Safeguarding Adults Level 2 80.11
Safeguarding Children Level 1 99.37
Safeguarding Children Level 2 63.07
Safeguarding Children Level 3 79.97
Table 22. Compliance with safeguarding training at the end of March 2013.
Health Visiting
We have developed a Directorate Integrated Development Plan that brings together
the activities required to deliver The Health Visiting National Strategy 2011 - 2015,
‘A Call to Action’.
We are on track to meet the workforce plan of recruiting 41 additional health visitors
(HVs) for Sandwell by 2015. Seventeen student HVs are in training and will qualify in
September 2013, who add to the previous eight we supported through training last
year. We are continuing to offer good opportunities to attract qualified health visitors
to work in the Sandwell area.
We are working on reducing the caseload of our HVs down to between 250-350: some
had between 700-900 on their books. We are making good progress with the average
case load of 540.
To our credit, we were identified by the Strategic Health Authority (SHA now dissolved)
and the Department of Health (DH) as an early adopter site for the ‘A Call to Action’
Health Visiting Strategy. This was in recognition of our current journey in developing,
delivering and transforming our HV service. By working with the DH we were able
to share our leadership, commitment and resilience in taking forward this challenge
in number of key areas. We presented a joint project between HV and midwifery on

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domestic abuse in pregnancy at the National Leadership Event for the DH. We had the
opportunity to meet the Minister for Children and showcase our work.
We were also nominated for best practice by the SHA for our programme that supports
our large numbers of newly qualified health visitors. This has also been recognised by
the Sandwell Safeguarding Children’s Board.
We will continue to improve the health outcomes, giving our children the best start in
life.
Midwifery Staffing
Nationally the Royal College of Midwives has stated that there is an overall deficit of up
to 5,000 midwives across the country and SWBHT mirrors the concerns that investment
is required into training and retention programmes.
The current state of play for staffing at the Trust according to the workforce planning
services for midwifery, Birthrate+, is that we are adequately staffed in each midwifery
area apart from the ward areas. Community Midwifery caseloads have been redressed
with investment from the commissioners and with the final investment equivalent to
10 whole time equivalent posts. This brings community midwifery caseloads to 1:98
which is better than the national average of 1:100. We are working on improving the
staffing levels in the postnatal ward areas.
Supervision of Midwives
The Trust currently has 16 supervisors of midwives who report to the Local Supervisory
Authority Midwifery Officer. Those supervisors oversee approximately 16-18 midwives
each which is an average number compared to other Trusts. The supervision process is
vital in maintaining robust governance.
Puerperal Sepsis
Over the last decade, there has been a rise in the number of women becoming ill
with puerperal sepsis. Puerperal sepsis is a severe infection affecting women following
childbirth and is associated with a rise in maternal morbidity and mortality. There
have been several factors linked to this such as hospital acquired infections, reduced
midwifery postnatal visiting and failure to recognise the early signs of sepsis onset.
Sepsis can overwhelm women in a relatively short period of time and due to pregnancy
immune suppression staff are expected to recognise and act with speed.
At SWBH, the population we serve is particularly at risk as many of our patients are
physically, medically or socially compromised and are more likely to be at risk of sepsis.
As a result the department has implemented a Sepsis Pathway for any woman which
helps us identify those with one or more positive symptoms. Women who present in the
postnatal period are referred back to the Midwifery Triage so they can be prioritised
and receive care without loss of time and expertise. All women who are readmitted
are treated as a priority.

54
3.19 Emergency Readmissions to hospital within 28 days of discharge from
hospital
Emergency readmissions to hospital following discharge are a useful measure about of
hospital care.
The tables below demonstrate that SWBH, based on the IC’s most up to date data for
adults of 16 years and over, had a higher than England average score for emergency
readmissions to hospital within 28 days. For children, 0-15 years of age, the SWBH
performance demonstrated a lower than England average readmission rate during the
4 year period illustrated. Over the 4 year period an increase rate of 28 day emergency
readmissions was indicated in both groups. It is the most recent data available from the
IC which gives us information about how we compare to others.
Indicator
% Emergency readmissions to hospital within
28 days of discharge from hospital
Age 0-15 10/11 09/10 08/09 07/08 06/07
England 10.08 10.18 10.09 9.14 9.61
SWBH 9.54 9.04 8.67 8.54 8.5
SHA 11.02 10.7 10.32 9.72 10
Highest* 14.34 16.5 15.85 16.03 12.97
Lowest* 6.49 6.12 5.85 6.16 5.97
Table 23. Emergency Readmissions 0-15years within 28 days of discharge from hospital
Indicator
% Emergency readmissions to hospital within
28 days of discharge from hospital
Age 16+ 10/11 09/10 08/09 07/08 06/07
England 11.42 11.16 10.9 10.57 10.43
SWBH 13.25 12.22 11.79 10.93 10.63
SHA 11.64 11.28 10.94 10.44 10.18
Highest* 14.09 13.18 13.94 12.79 12.24
Lowest* 9.18 8.92 8.64 8.71 8.61
Table 24. Emergency Readmissions 16+ years within 28 days of discharge from hospital
* Compared to other Large Acute Hospitals as defined in the IC data.
Tables 23 & 24 demonstrate the performance at SWBH, based on IC data. It is not
possible to make direct comparisons to more recent years as the ways that the results
were calculated are based on different definitions, and different age bands of people
which were required for this report. 2011/12 and 2012/13 data was not available from
the IC at the time of writing this Quality Account.
In Table 25, the data suggest that the 28 day rate of readmission of children aged 14
years and under had increased from 2011/12 compared to 2012/13. These results were

55
generated using criteria which were specified in the Quality Account guidance and we
were not able to measure the performance against other trusts as they may have been
using different definitions to produce their results.
Indicator
% Emergency readmissions to hospital within
28 days of discharge from hospital
Age 0-14 12/13 11/12
SWBH 15.65% 15.43%
England Not Available Not Available
Highest* Not Available Not Available
Lowest* Not Available Not Available
Table 25. Emergency Readmissions 0-14 years within 28 days of discharge from hospital (local data).
Indicator
% Emergency readmissions to hospital within
28 days of discharge from hospital
Age 15 years+ 12/13 11/12
SWBH 14.81% 13.79%
England Not Available Not Available
Highest* Not Available Not Available
Lowest* Not Available Not Available
Table 26. Emergency Readmissions 15+ years within 28 days of discharge from hospital (local data).
In table 26, the data suggests that the percentage of 28 day emergency readmission
in the 15 years and over increased between 2011/12 and 2012/13. These results were
generated using criteria which were specified in the Quality Account guidance and we
are not able to make comparisons against other trusts as they may have used different
definitions to produce their results.
However, we are working to reduce emergency readmissions of all patients as a priority
as described in section 2.16.
The IC’s most up to date data, which we are required to report, uses different definitions
and age groups to generate their results. It does also not relate to the required reporting
period which this Quality Account covers and has, therefore, not been included.
* The SWBH NHS Hospital Trust considers that this data is as described for the following
reasons:
The percentage of readmissions has increased, as shown in Table 25, as defined in
patients between 0 and 14 years. The percentage of readmissions has increased, as
shown in Table 26, in patients over 15 years during the defined period. We do intend
to improve the position.
The SWBH NHS Hospital Trust intends to take the following actions to improve this

56
number by taking the steps described in Section 2, 2.16 Focus Area 4- Reducing
Emergency Readmissions, of this Quality Account, as we acknowledge that it is a high
priority for improving patients’ experience and the service we provide.
3.20 Improving Patient Experience
Involving our patients, relatives, carers and community in improving patient experience
is central to our success as an organisation. It is at the heart of the NHS Constitution
(DH, 2009) and increasingly is also a key indicator of a performing NHS.
The Trust seeks patient views in a variety of ways including the national patient
inpatient and outpatient surveys, and a trust-generated internal inpatient survey. The
internal survey generates around 1000 replies every month which is in excess of 10%
of inpatient admissions. This survey is given out to patients when they are discharged
and is available in easy read format and other languages. What we find out from these
surveys really does help us to shape the services we deliver.
Everyone can contribute, everyone matters and it is everyone’s business to improve help
us care for our patients, carers and relatives better. More and more there is evidence
that a patients having a positive experience results in patient feeling better sooner
feeling like they have had a good quality service. Patients often remember the little
things – a smile, a kind tone of voice, kind words and someone there to hold a hand.
This is what matters to us all.
Patient experience will improve if Trust staff are motivated to do everything they
can to make patients feel cared for. Paying attention to equality and diversity is also
an essential requirement to be able to achieve good patient experience and good
outcomes.
The Trust is fully committed to developing and supporting patients, carers and relatives
to play an active role in all aspects of the planning, delivery and evaluation of its acute
and community health care services.
In early 2013 the Trust produced its first Patient Experience Strategy in which the key
challenge is that all staff constantly question “How does this practice, information or
change affect patients, carers and relatives? Does it improve the experience?” The
only way to know the answer is to ask and to listen.
The strategy describes the Trust’s plans and details how patients, carers, relatives and
the general public will be involved. It is hoped that all staff will welcome the strategy,
so that all patients can fully benefit from improved care and services as a result.
Friends and Family Test (FFT) Survey
The Friends and Family test asks service users, ‘How likely is it that you would recommend
this service to friends and family?’. It is based on a Department of Health Net Promoter

57
Score (NPS) methodology. It measures patients’ perceptions of the quality of the
health services they recently received. This assists the hospital in identifying both
successes and problem areas. The Trust implemented the FFT survey programme in
April 2012. There has been a steady improvement of about 2 points every month and
an average 17% response rate of inpatient admissions was achieved.
Figure 8. Friends & Family response rate.
The table below represents the IC data with regard to the percentage of staff
employed by or under contract to, the trust during the reporting period who would
recommend the trust as a provider of care to their family or friends. This is summarised
below:
SWBH England Average England lowest England Highest
2011-12 76.1 75.6 67.4 87.7
2010-11 76.1 75.7 68.2 87.3
2009-10 74.7 75.6 68.6 86
2008-09 77.3 76 68.1 87.6
Table 27. Friends and family test scores
The score allocated is based on a calculation of the aggregation of the responses to
various questions from the annual, and is scored out of 100.
* The SWBH NHS Hospital Trust considers that this data is as described for the
following reasons:
The data shows that between 2008/09 and 2011/12, compared to the England average,
patients rating of having a positive experience of care better than average.
The SWBH NHS Hospital trust intends to take the following actions to improve this
number by taking the steps described in Section 2 of this Quality Account, as it
acknowledges that it is a high priority for improving patients’ experience. As you will
note, patient experience is in Part 2, 2.17, Focus Area 5 in this year’s Quality Account
priorities.

59
Year Q32 Q34 Q36 Q56 Q62 CQUIN
2012/13 72.1 53.6 83.4 51.4 74.1 66.9
2011/12 71.4 63.7 81.4 54.4 82.9 70.8
2010/11 69.9 60 81.4 44.5 80.8 67.3
Table 28. Results for each responsiveness to personal need questions
In addition, the IC provided average score from a selection of questions from the
National Inpatient Survey measuring patient experience (Score out of 100).
* The SWBH NHS Trust considers that this data is as described for the following reasons:
1. SWBH has made progress since 07 - 08 with the experience patients have when in
our care, which is represented by the increase in the score through the years.
2. The Trust has a good history of engagement with the people we serve and plans
to continue doing so with a schedule of engagement and patient representative
involvement interventions.
The SWBH NHS Trust has identified Patient Experience as one of its top priorities as
described in Part 2, 2.17, Focus Area 5 in of this Quality Account and aims to achieve
the described metrics by March 2014.
SWBH National Average National Highest National Lowest
11-12 76.1 75.6 87.8 67.4
10-11 76.1 75.7 87.3 68.2
09-10 74.7 75.6 86.0 68.6
08-09 77.3 76.0 87.6 68.1
07-08 74.0 75.3 86.5 66.8
Table 29. Patient Experience Performance - Data Source - IC
The Trust does not just use one measure of patient experience and satisfaction, but is
using the ‘Net Promoter’. The Net Promoter Score (NPS) is a series of questions which
are prescribed. Our performance had increased to 69 at the end of February 13 which
exceeded the local SHA target of 65.

60
Figure 10. Net Promoter performance
The Trust has expanded the Patient Experience Team which means we can make a
better approach to bringing in improvements which will being benefits to patients.
3.21 Patient Reported Outcome Measures
Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to
NHS patients from the patient perspective. Currently, covering four clinical procedures,
PROMs calculate the health gains after surgical treatment using pre- and post-operative
surveys.
The four procedures are:
1. hip replacements;
2. knee replacements;
3. hernia;
4. varicose veins.
PROMs measure a patient’s health status or health-related quality of life at a single
point in time, and are collected through short, self-completed questionnaires. This
health status information is collected from patients through PROMs questionnaires
before and after a procedure and provides an indication of the outcomes or quality of
care delivered to NHS patients.

62
The data for 2009/10 and 2010/11 (above) shows that the percentage of patients
reporting improvements is below the national average percentage for most of the
measures in the two finalised data periods concerned.
Provisional data for the 2011/12 financial year published on 03/05/13 is shown below.
*The percentage of complete questionnaire pairs for the procedure and measures
where an improvement was recorded
Trust below national percentage
Trust above national percentage
Table 31. Percentage of patients reporting an improvement 2011/12 (provisional data)
An adjusted measure (adjusted health gain) takes account of the fact that organisations
deal with patients with a different case mix. The provisional adjusted health gain data
for April 2011 – March 2012 is shown in the Table 32 below.
*The Aberdeen Varicose Vein questionnaire is scored from 0 to 100, where 0 represents a patient with
no problems associated with varicose veins and 100 represents the most severe problems associated
with varicose veins. A negative adjusted health gain and a lower average post-operative score than preoperative
score suggests an improved performance.
Trust below national percentage
Trust above national percentage
Table 32. Average adjusted health gain 2011/12 (provisional data)

63
* The SWBH NHS Hospitals Trust considers that this data is as described for the following
reasons in that since it was published that progress has been made.
In response the Trust has taken action taken to improve the percentage of patients
reporting improvements and so the quality of its services which included the following:
Hip & Knee
• It has been made a requirement that all patients undergoing hip and knee surgery
attend pre-operatively the Hip & Knee Club, where full information on the care and
recovery pathway can be explained.
• Patient information booklets have been reviewed to include raising the awareness
of PROMs.
• A poster campaign has been run to improve referral information.
Varicose veins
The focus has been on increasing the participation rate in the PROMs for this condition.
Provisional data for 2012/13 shows that the Trust is now demonstrating above the
national average percentage improvements for the health status questionnaire (EQ-5D
Index) and for the procedure specific instrument (Aberdeen Score).
The Trust intends to take the following action to improve the scores in relation to
hernia repairs:
• To take measures to increase the percentage of patients participating in the PROMs
programme .This to include informing patients that PROMs is a way of monitoring
the effectiveness of services and that their feedback is important to this process.
• To consider establishing a single source dedicated hernia clinic, where full information
on the care and recovery pathway can be explained.

64
3.22 Alcohol Screening Programme
We agreed with the commissioners to carry out screening of patients to check if they
are at risk of harm from alcohol. It is very important to assess alcohol risk to ensure that
patients are treated appropriately and also to be able to advise them on health issues
if appropriate.
We have carried out audits every 3 months to test if we meet this standard of 80%: we
have been successful in exceeding it.
We have spread this intervention to include more services, so we can screen even more
patients. These services include inpatients in the medical assessment units, and to new
patients attending Gastroenterology, Cardiology, and Endocrinology outpatient clinics.
Our findings are summarised in Table 33.
Attendance Type
Number of
Attendances
Number of
Think Alcohol
Assessments
Target
% Compliance
Inpatient - MAU / EAU 411 356 80% 86.62
New Gastroenterology
Appointment
New Cardiology
Appointment
New Endocrinology
Appointment
102 96 80% 94.12
61 55 80% 90.16
9 9 80% 100
Total 583 516 80% 88.51
Table 33. Think Alcohol Audit (March 2013)
3.23 WHO Surgical Safety Checklist
Last year we identified that we needed to improve our use of the WHO Surgical Safety
Checklist. We wanted to go even further than just using the Checklist and ensure that
the NPSA “Five Steps to Safer Surgery” were adopted across the trust and recorded
for every patient undergoing a surgical intervention or operation. Patients are very
vulnerable during operations and safety is very important.
The work was led by a project team and the contribution of the theatre and ward staff
was vital. Whilst we have been able to collect how many checklists were completed and
how many pre-operating list briefings and debriefings were done, we also started doing
reviews to focus on how well the checklists were being used to test that communication
was working well.

65
The Trust has agreed checklists and a ‘Safer Surgery’ Policy in place, so staff are clear
about what is expected of them.
The reported compliance with the 3 sections in the checklist over the past year is shown
in Table 34.
Table 34. WHO checklist compliance (data source CDA SHA submission and CQUIN Compliance Report
9/4/13)
3.24 CQUIN (Commissioning for Quality and Innovation)
This part of the 2012/13 Quality Account is intended to provide additional evidence of
our performance in respect of the quality of our services and the care delivered to our
patients during the last 12 months. Most of the data presented here is available in other
reports and documents, particularly in the Quality report presented to our Quality &
Safety Committee and at our Trust Board throughout the year. The detail behind many
of the figures has been reviewed by our commissioners and other stakeholders and the
most critical indicators are discussed with our commissioners during monthly Quality
Review Meetings, which also explore specific issues or concerns arising throughout the
year.
Last year the Trust agreed CQUIN goals with our commissioners. We successfully met
or exceeded all but a few of our targets. These are targets are specifically to do with
quality of care as we know that they make a real difference to patient safety, patient
experience, and clinical effectiveness (how well a treatment works). The 2012/13 goals
are shown in table 35, below, and shows our performance against each CQUIN target.
Some of the CQUINs are included in the key priorities such as stroke, end of life care
and basic nursing where a broader explanation of achievement can be found.

66
CQUIN SCHEMES 12/13
Actual
12/13
Data
Period
12/13
Target
Acute VTE Risk Assessment (Adult IP) % 90.7 M1 - 12 90
Pt. Experience (Acute) - Personal
Needs
Score 66.9 M1 - 12 71.6
Appropriate Use of Warfarin Comply M1 - 11 Comply with
audit
Safety Thermometer Submit M1 - 12 Submit data
Antibiotic Use Score 83 M1 - 12 70
Reducing avoidable Pressure Ulcers Comply M1 - 12 Comply with
audit
Nutrition and weight Management Comply M1 - 12 Comply with
audit
Safe Surgery Operating Theatres % 100 M12 100
Safe Surgery Other Areas % 99.7 M12 98
Stroke Care Comply M1 - 9 Comply with
requirements
Dementia % M1 - 12 Comply with
requirements
Mortality Review % 63.0 Ytd M10 Year end 80%
Net promoter No. 69.0 M1 - 11 65
End Of Life care % 62.0 M1 - 11 53
Every Contact Counts - Alcohol % 89.0 M1 - 12 80
Every Contact Counts - Smoking % M1 - 11
Community Safety Thermometer Submit M1 - 11 Submit Data
Specialised
Commissioners
Reducing avoidable Pressure Ulcers Comply M1 - 11 Comply with
audit
Nutrition and weight Management Comply M1 - 11 Comply with
audit
Dementia % M1 - 11 Comply with
requirements
Pt. Experience (Community) -
Personal Needs
Score 92.0 M1 - 11 90
Net promoter Number 50.0 M11 75
Every Contact Counts Meet M1 - 11 Comply with
requirements
Smoking Cessation Meet M1 - 11 Comply with
requirements
Clinical Quality Dashboards M1 - 12 Comply with
requirements
Neonatal - Hypothermia Treatment % M1 - 12 Comply with
requirements
Neonatal - Discharge Planning
/ family Experience
% M1 - 12 Comply with
requirements
HIV Optimum Therapy % M1 - 12 Comply with
requirements
Table 35. CQUIN performance 2012/13

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3.25 Complaints
The Trust remains committed to providing timely and fair responses to formal complaints
which it receives about its services. Complaints provide us with vital information about
how patients and their families have felt about their experience whilst using our services
and we can use this information to improve.
The table below shows the top themes of complaints received over the last 3 years,
which we use with other patient experience sources to set our priorities.
Category Type 2010/11 2011/12 2012/13
All Aspects Of Clinical Treatment 553 573 578
Attitude Of Staff 161 127 142
Appointment Delay/cancellation
outpatient appointment
Appointments Delay/cancelled
inpatient
Communication/Information To
Patient
126 84 94
26 28 33
92 55 66
Admissions/discharges, Transfers 44 42 59
Transport Services 12 17 7
Totals 1014 926 979
Table 36. Complaints by category
3.26 Staff Indicators
As we mentioned earlier in the report, we regard staff training and as key to delivering
good, compassionate patient care. Our workforce ambition is to become the ‘employer
of choice’ and for our staff to consistently highly recommend our Trust as a place to
work or receive treatment.
Workforce Development
Our new appraisal policy strengthens the Trust’s approach to succession planning and
career development by ensuring that future leaders are identified and developed
and staff are supported to reach their full potential. A variety of staff education and
training programmes have been introduced and run throughout the year including
‘Action-Centred Leadership’ programmes and leadership development training for
clinical teams.
Widening Participation
We are a major employer in the area. We are well aware of the long-term economic
wellbeing of our local population. We are dedicated to helping tackle unemployment
and social deprivation in the area by employing people from the local community, with

68
the right attitudes and behaviours. We also aim to support them through learning to
reach their full potential.
At the end of March our ‘Learning Works’ opened in conjunction with our high profile
partners including Sandwell Council, Birmingham City Council, Job Centre Plus, other
major employers and charities. Together we are providing:
• Work experience schemes through schools for 15 to 16 year olds;
• Work placement schemes for the long-term unemployed;
• Apprenticeships for young people aged 16-21;
• Staff support for developing the Trust’s own staff.
Staff Experience
We value insight and ideas from our staff about their experience of working at the
Trust and view this as a good barometer of the quality of leadership and management
of the Trust, our approach to risk management and the standards of care we provide:
NHS Staff Survey
Following significant year on year improvement across the whole range of key
findings since 2008, our results in 2012 include a mixture of some positive shifts and
some worsening trends. The overall position is one of no significant changes overall,
indicating that there is still much more to achieve to move towards the top quartile.
Our key achievements and areas for improvement are set out below:
Key achievements
5% more staff than last year said they were
appraised in the last 12 months (better than
England average)
6% more staff than last year said that their
appraisal was well-structured (best 20% of Trusts
nationally)
12% more staff than last year said that they are
informed about errors, near misses and incidents
that happen in the organisation (around the
national average)
10% more staff than last year said that their
immediate manager takes a positive interest in
their health and well- being (around the national
average)
5% more staff than last year said that they are
satisfied with the recognition they get for good
work (better than the national average)
Areas for improvement
Staff agreeing that their role makes
a difference to patients (worse than
England average)
Staff feeling pressure in last 3 months
to attend work when feeling unwell
(worse than England average)
Staff satisfaction at work (worse than
England average)
Staff motivation at work (average)
Staff believing that the trust provides
equal opportunities for career
progression or promotion (worse
than average)
Table 37. Staff indicators

69
Staff Engagement
We are very proud that our last five years of success in this area is recognised nationally
and that this is further endorsed by our most recent success as the winner of the 2012
prestigious Health Service Journal Award in Staff Engagement. Our pioneering approach
to staff engagement, called ‘Listening into Action’, continues to be instrumental in
engaging staff at all levels from across the Trust to drive improvements to deliver better
outcomes for patients and making our Trust a good place to work. This way of working
has been used to drive our service transformation plan, enhance our patient safety
culture and redesign and reconfigure how care is delivered, such as stroke services.
We recognise that there is still more to do to ensure that engaging and involving
staff in driving improvements becomes well embedded and sustainable. Our overall
score for staff engagement, as determined by the NHS staff survey in 2012, has not
significantly changed since the previous year and is average when compared to acute
Trust’s nationally.
Key Staff Performance Indicators
A range of workforce KPIs are included in the Trust’s Performance Management
Framework and we are in the process of implementing the NHS Workforce Assurance
Tool to further enhance the management of workforce risks. An overview of our
performance against the key indicators is set out below.
Staff Turnover
Staff turnover (excluding junior medical staff) has fallen steadily year on year since
2008/09 when it was 11% and is currently running at around 10%. This represents
a reasonably healthy level of staff leavers, notwithstanding that this will have been
influenced, to some degree, by our workforce reduction programme.
Mandatory Training
Our compliance in this area shows a continuing improving trend across a comprehensive
range of training topics. The trust compliance at the end of March 2013 was 87.74%.
There is more work to do to consistently achieve the higher standards and we continue
to look at this at directorate and divisional level. A radical review of access to training
and methods of delivery has resulted in the introduction of more e-learning modules
and a new ‘mandatory training day’, both of which aim to deliver high quality training
whilst minimising, as far as possible, time spent away from the work place.
Appraisal
87% of staff participating in the 2012 NHS staff survey said that they had received an
appraisal in the last 12 months (5% higher than in 2011), ranking the Trust as better
than the national average for acute trusts. 42% of staff reported that their appraisal
had been well-structured (6% higher than the previous year), placing the Trust in the
best 20% of all acute trusts for this finding.

70
Sickness Absence
Our sickness rate demonstrated a steady improvement from April to June 2012.
Since that time this has gradually worsened, with only February 2013 showing an
improvement. The sickness absence rate for 2012/13 was 4.5%, compared to 4.04% in
2011/12 and 4.11% in 2010/11 (Source-CDA Workforce local information). This is above
the target of 3.5%.
We have an ambitious improvement plan in place to address this.
Our plan includes the following key actions:
• Improving levels of staff engagement;
• Effective management of change;
• Regular sickness absence case management review;
• Development of focused action plans in response to ‘hot spot’ areas.
We continue to deliver a wide range of staff initiatives, including physical exercise,
weight management classes, and a programme of healthy lifestyle topics that link
to the national health promotion programme and are aligned to our internal work
about the key reasons for absence from work due to sickness. The Trust also has an
occupational health and well-being service, an on–site gymnasium and a dedicated
counselling service for staff.
3.27 What others think about our Quality Account
We invited our Commissioners, the Overview and Scrutiny Committees (OSC) in both
Sandwell and Birmingham and both Healthwatch groups in Sandwell and Birmingham
what they thought about our Quality Account.
Our Commissioners, made the following statement:
On behalf of the Cross City CCG, the Black Country CCG commented:
• Good explanation of priorities and intention to achieve these;
• Great Patient Experience section overall;
• All relevant elements are included and discussed clearly for easy reading for the
public;
• The document is open and honest in content and reflects accurate data;
• The only omission noticed is there is nothing on Safeguarding - amended by the
Trust following feedback;
• Overall a good QA.

71
The Birmingham Overview and Scrutiny Committee issued the following statement:
‘Thank you for providing the Birmingham Health & Overview Scrutiny Committee with
a copy of your Quality accounts. The committee appreciated the opportunity to read
the accounts and the information contained therein.
At a recent meeting the members decided not to provide statements to any of the
Quality Account providers and requested that a letter be drafted to the Secretary
of State about the Quality Account process and the issue this gives rise to for the
Birmingham Scrutiny Committee on an annual basis.’
3.28 How to provide feedback on this Quality Account
As an organisation, we would like to know what you thought of our Quality Account.
After all, this document is for the public and we would like to know what you think.
As a result of reading this document, do you think you have a better understanding of
how committed we are to providing high quality care.
You can e-mail the Trust Board Secretary on simon.graingerpayne@nhs.net
Or send us a letter to:
Mr Toby Lewis,
Chief Executive,
D29 Corporate Management Suite,
Sandwell & West Birmingham NHS Hospitals Trust,
City Hospital,
Dudley Road,
Birmingham,
B18 7QH
We will value your feedback.

SWBTB (6/13) 119 (b)

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Mímírship ç
14 & 28
/2/13
6/12/12
13/9/12
#"6/12
Atínänîíç
Gianjeet Hunjan (Ch)
Roger Trotman A A
Sarindar Sahota
Derek Alderson A A
Olwen Dutton A A A
Phil Gayle
Clare Robinson
Harjinder Kang A
&'()
A
Attended
Apologies tendered
Not in post or not required to attend
3

& 1A23/0 C4MM.//33
*+,-./0
7on 389:utiv9 ;9rship Five Non-Executive Directors and six of the Executive Directors with specialist advisers
in attendance when required
21/3/13
21/2/13
25/1/13
14/12/12
22/11/12
19/10/12
20/9/12
19/7/12
24/5/12
Derek Alderson (Ch) A A
Olwen Dutton (Ch) #1 A
Sarindar Sahota
Richard Samuda A A A A A
Gianjeet Hunjan #2 A A
Richard Lilford #3 A A A A
John Adler #4 A
Mike Sharon #5
Robert White A A A A A
Rachel Overfield A
Rachel Barlow A A A A
Deva Situnayake #6
Roger Stedman #7 A
Kam Dhami
?@ABC
#1 Assumed chair of Committee from July 2013
#2 Member of Committee from July 2013
#3 Commenced in post as a Non Executive Director from September 2012
#4 Departed the Trust from January 2013
#5 Acting CEO from January 2013
#6 Acting Medical Director until August 2012
#7 Commenced in post as Medical Director from August 2012
DEFG
A
Attended
Apologies tendered
Not in post or not required to attend
2.7A7C3 A7; H3I24IMA7C3 MA7AJ3M37/ C4MM.//33
4

KLMNOP QRS TUVWXYZN[W \NOWXZRO
• Considers regular financial reports and forecasts, including prime statement of accounts and
supporting analyses and forecasts
• Reviews the performance of the Trusts major clinical and corporate divisions and considers
remedial action plans in the case of significant variances/deviations
• Reviews the annual financial plan and budget, prior to submission to the Trust Board for approval
• Monitors performance against external targets set by the Department of Health, Trust
Development Authority, Commissioners and Monitor
• Monitors performance against a range of internally developed clinical, financial and operational
indicators
• Considers plans and business cases in support of significant investment, prior to presentation to
the Trust Board for approval
WnXyP ]OWqu
MWm^Wrship P
Monthly
Three Non-Executive directors, CEO, Director of Finance and Chief Operating Officer
19/4/12
24/5/12
21/6/12
20/7/12
24/8/12
20/9/12
fghi
19/10/12
23/11/12
20/12/12
25/1/13
22/2/13
22/3/13
Roger Trotman (Ch)
_`abcdea
NO MEETING
Clare Robinson (Ch)
Richard Samuda A
Gianjeet Hunjan
Phil Gayle A A A
Harjinder Kang
John Adler A
Robert White A
Mike Sharon
Rachel Barlow A A
jklmn
# NED attendance rationalised from July 2012 to restrict membership to three NEDs;
# Chair ship changed from Mr Trotman to Ms Robinson from November 2012
# Following his departure in December 2012, Mr Adlers seat on the Committee was given to Mr Sharon in his capacity as acting Chief Executive
opqr
A
Attended
Apologies tendered
Not in post or not required to attend
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5

• Sets the pay and conditions of senior managers
• Recommends the remuneration and terms and conditions of employment for any employees who
are not subject to national terms and conditions of service
• Scrutinises and agree any termination payments made to the Chief Executive and Executive
Directors
• Ensures the consistent application of the Trust policy on remuneration and terms and conditions of
employment for the Chief Executive and the Executive Directors
|n}y~ z{|qu
The committee meets as required
~ M|m|rship All Non-Executive Directors.
2/12/12
31/5/12
At|n€ n}|~
Richard Samuda
Roger Trotman
Sarindar Sahota
Gianjeet Hunjan
Derek Alderson
A
Richard Lilford
Olwen Dutton
Phil Gayle
A
Clare Robinson
Harjinder Kang
‚ƒ„…
A
Attended
Apologies tendered
Not in post or not required to attend
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‘‹’|}utiv| Ž“r|}tor
• Monitors the safeguarding of those assets donated or bequeathed in cash or other forms to the
Trusts charitable funds
• Ensures as far as is practical that the expressed wishes of donors or benefactors are met in the
deployment of funds.
• Monitors and reviews banking and audit arrangements
• Monitors the performance of the Trusts Charitable Funds portfolio
• Advises on the appointment of investment brokers
|n}y~ z{|qu
Four times per year
6

”•–—•˜š›œ
All voting Directors are Trustees, however they are represented by six voting Board
members. The HoCE and Head of Fundraising also attend
14 /2/13
6/12/12
13/9/12
17/5/12
Sarindar Sahota (Ch)
Richard Samuda A A
Roger Trotman A
Gianjeet Hunjan
Olwen Dutton A A
Derek Alderson
A
Clare Robinson
Phil Gayle A
John Adler
Mike Sharon
Robert White A
Rachel Overfield A A
Rachel Barlow A A
Roger Stedman
¡ žŸ
A
Attended
Apologies tendered
Not in post or not required to attend
2.2 The Trust Board and its committees are administered by a Trust Secretary who maintains the
Directors Register of Interests and a register of attendance at meetings.
2.3 On an annual basis, the Trust Board is asked to consider and approve a proposed cycle of
business for the forthcoming year, which is largely based on the best practice guidelines
suggested in the Dr Foster publication, The Intelligent Board and the National Leadership
Councils report, The Healthy Board. The reporting cycle is customised with items of local
interest and significance to the Board, with matters being categorised into Quality, Safety and
Governance; Strategy & Development; Performance Management; and Operational
Management sections.
2.4 Integral to the preparation for the Trusts application for Foundation Trust status, is a number
of Board assessments, development activities and opportunities. Much of this work has been
facilitated by independent sources, most notably being the in-year assessments against the
Board Governance Assurance Framework and Monitors Quality Governance Framework. The
assessments although largely focussed on the degree to which governance arrangements and
quality is embedded into the organisation, also focus on the operation of the Board, including a
comprehensive assessment of the skills and capabilities of Board members. The actions to
address the recommendations arising from the assessments have been incorporated into an
Integrated Development Plan. Given the thoroughness of the external scrutiny and the Boards
7

close engagement with the work, a formal internal self-assessment has not been necessary this
year. The FT readiness assessment work also included observations and feedback sessions on a
series of Board and Committee meetings, a review of the Trusts Integrated Business Plan and a
preparatory mock Board to Board meeting in advance of formal assessments. The outcome
from these processes has been carefully considered by the Board and included within the
Integrated Development Plan, including action as required. Finally, the Development Plan is
monitored by the Board on a routine basis through the FT Programme Board.
2.5 In addition to the Integrated Development Plan, a plan specifically including matters pertaining
to Board Development has been prepared. This incorporates both short term needs to focus on
creating a cohesive team following the change in membership over recent months and longer
term development requirements to develop the Board into a more effective and highly
performing unit.
2.6 Within the last year there has been a refresh of the terms of reference of the Board
Committees to bring them in line with best practice examples and to strengthen the role in
providing the Board with the assurance it needs to satisfy itself that the organisation is
operating legally, effectively and safely. The remit of the Quality & Safety Committee has been
broadened to include a wider range of assurance matters, including the consideration of a
comprehensive monthly report, which provides an update on the key activities and
performance across the various dimensions of quality & safety. In addition to the minutes of
the Committee meetings being presented to the Trust Board as a matter of course, a
comprehensive verbal update is provided by the relevant sub-committee Chair following the
most recent Committee meeting. Annual reports on the work of each of the Committees are
also presented as part of the annual reporting cycle of the Trust Board.
2.7 A key area of interest for the Audit Committee during the year has been the process to assess
the quality of data in respect of the Trusts performance against the national 18 week referral
to treatment target. During the year the Committee has also considered the selection process
and a revised specification for the provision of Internal Audit services to the Trust. The
Committee took the opportunity to receive an update on the Trusts position in relation to the
reference cost index (RCI) data and an analysis for the 2011-2012 financial year, where it was
highlighted that the Trust RCI remained unchanged at 102 between 2010-2011 and 2011-2012,
a period which included the incorporation of Sandwells community services into the index.
2.8 The Board considers that the Trust has, throughout the 2012/13 reporting year, applied the
principles and met the requirements of the Code of Governance. In summary, the Trust has
an effective board of directors, which has taken collective responsibility for leading the
organisation, exercising its statutory powers and setting the strategic direction of the Trust.
2.9 The Boards routine reporting includes a review of performance against the priorities of the
Operating Framework, principally by measuring compliance against the NHS Performance
Framework. The assessment reported the Trust to be classified as a Performing organisation
throughout the year.
8

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3.1 The publicly held Trust Board meetings cover the full gamut of clinical, corporate and business
risk and discuss and monitor the delivery of corporate objectives and the detail of the
Assurance Framework.
3.2 The risk management process is an integral part of the Trusts business planning process and
budget setting and performance review frameworks.
3.3 At a strategic level, risks are identified by the nominated directors against the Trusts strategic
objectives and Annual Priorities. These identified risks provide information to support the
Board Assurance Framework and where risks are identified as being serious, these are
escalated to the Corporate Risk Register and monitored by the Trust Board and its delegated
committees.
3.4 At an operational level, risks are maintained in appropriate local risk registers. Where a risk
cannot be managed locally (requiring a supporting business case), has a major impact on
service capability or Trust reputation or may result in major litigation, this will be presented for
inclusion on the Corporate Risk Register.
3.5 Actions identified from risk assessments are mitigated at the appropriate level, and where
actions require escalation, the risk will be escalated to the next tier of risk management.
3.6 Those risks that are presented for addition to the corporate risk register are presented
monthly to the Trust Board. The Trust Board is asked to approve a proposal for the risk to be
tolerated or treated.
3.7 The decision to treat a risk will be based on the actions required to mitigate that risk, its
resource implications balanced against the possible financial penalty if the risk is realised.
Every risk identified is backed up by a full risk assessment which covers the points above and
an action plan to enable risk reduction, avoidance, transfer or elimination. The action plan
defines the time for completion and who is responsible for carrying out the action. The status
of the action plan will be monitored at intervals determined by the risk rating. Any difficulties
in meeting the deadlines of the actions or in securing resources to enable mitigation are
reported on the monthly risk register update that the Board receives.
3.8 New risks identified during the year have largely centred on the impact of the pause in the
delivery of the Trusts bed configuration plan; the impact of the higher than planned
operational pressures on the Trusts achievement of national performance targets; and the
potential historic inaccuracy with reporting of the Trusts performance against the 18 week
referral to treatment time target. All risks, together with their respective mitigation are
included on the Trusts Corporate Risk Register, the summary of which is reported to the Trust
Board on a monthly basis.
3.9 The Board, as part of the monthly Quality Report, receives a summary of the Care Quality
Commissions Quality & Risk Profile (QRP). Overall the QRP shows the Trust as being at a low
risk of non-compliance with the CQCs 16 essential standards of quality and safety, with the
exception of Outcome 4 which relates to the care and welfare of people who use services.
9

The indicators forming this judgement and assessing the Trusts position as worse than the
expected position or moving in that direction were reviewed and details were presented to the
Quality & Safety Committee. The data sources include the Stroke Improvement National Audit
Programme, PROMs (groin hernia surgery and knee replacement), the CQC A&E Survey and Dr
Foster Intelligence.
3.10 Overall, the Trust remains fully compliant with the CQC essential standards of quality and
safety. However within the year, the Sandwell Hospital was subjected to a responsive review of
compliance by the CQC in connection with Outcomes 1, 4 and 14. The CQC assessed the Trust
as meeting the standards at this site. Additionally, within the year, the Trusts position was
assessed for compliance against a further set of outcomes including consent to care &
treatment, assessing & monitoring the quality of service provision and complaints. The Trust
was assessed as having shortfalls against a number of the standards and therefore an action
plan was developed to address these matters. Good progress is being made with the
delivery of the action plan, which is monitored on a monthly basis by the Quality & Safety
Committee.
3.11 There have been no data security lapses that have warranted reporting to the Strategic Health
Authority or the Information Commissioners Office during the period.
3.12 Within the year, the Trust experienced a catastrophic hardware (disk) failure which
resulted in a number of core systems including ICM and the Clinical Data Archive being
unavailable to users between the 6th March 2013 and the 10th March 2013. None of the
Trusts financial systems were affected. To prevent a reoccurrence of the situation, a threefold
approach was undertaken to include: independent solution assurance; implementation of
more robust operational monitoring of infrastructure and strengthened business
continuity arrangements. The Trust Board was appraised of the situation and consequences
of the IT failure at its Board meeting in March 2013, with a request for further detail and
assurance on the measures being implemented to safeguard against a further incident.
ª« ¬­® ¯°±² & C³´¬¯³L µ¯AM®³¯²
4.1 Sandwell and West Birmingham Hospitals NHS Trust has a comprehensive, trustwide system
for managing risk, based on approved policies and strategies available on the Trust intranet.
4.2 The Trust has a Board approved Risk Management Strategy which identifies that the Chief
Executive has overall responsibility for risk management within the Trust. The Chief Executive
is supported with his responsibilities by the Director of Governance. All managers and clinicians
accept the management of risks as one of their fundamental duties. Additionally the Strategy
recognises that every member of staff must be committed to identifying and reducing risks. In
order to achieve this the Trust promotes an environment of accountability to encourage staff
at all levels to report when things go wrong, allowing open discussion to prevent their reoccurrence.
4.3 In Clinical Directorates, Clinical Directors, supported by Divisional Directors, General Managers
and Heads of Nursing are responsible for managing risk. In all non-clinical directorates and
departments, the appropriate Executive Director is responsible for managing risk through the
chain of reporting.
10

4.4 The Trust has a designated Head of Risk Management within the Governance Directorate.
Board Assurance Framework
4.5 The Trust has a Board Assurance Framework which includes all key components required,
including objectives, risks, controls, positive assurance, gaps in control and/or assurance and
remedial action. In a recent review by Internal Audit, it was determined ·¸¹º¸»¸¼½º¾
that
was provided by the Board Assurance Framework, with further areas for
¿ÀÀÁ½º¼Ã
development identified to assist the Trust with continued improvement to the effectiveness of
the processes in 2013/14.
4.6 The Board Assurance Framework is considered on a quarterly basis by the Trust Board and
twice yearly by the Audit Committee.
4.7 The Board Assurance Framework informs the declarations made in this Governance Statement.
4.8 Gaps in controls and assurance of the management of the risks associated with the delivery of
a number of the Trusts objectives were identified, however the Trust has taken remedial
action to address them which is reported in the quarterly update of the Board Assurance
Framework.
Quality Account
4.9 The Trust has in place robust processes to develop its annual Quality Account. The process and
progress with developing the Quality Account is monitored by the Audit Committee.
Transformation Plan Quality Impact Assessment
4.10 A major piece of work within 2012/13 continued to be the development of the
Transformation Plan, a five year view of how the Trust means to achieve the required cost
savings within the period 2012/13 2016/17 in line with national efficiency requirements and
local strategy. Quality Impact Assessment of schemes put forward as part of the 2013/14
element of the Transformation Plan was undertaken by the Chief Nurse and Medical Director.
The assessments highlighted that there were some schemes where quality of care might be
impacted and in these cases mitigation plans were produced, to minimise the effects of any
risk realised. Those which remained a concern following the proposed mitigation were not
approved as viable schemes. Responsibility for monitoring the actions has been devolved to
divisions and where a risk is no longer controlled by those mitigating actions, the matter will be
escalated.
NHSLA accreditation
4.11 Building on the successful accreditation against the NHSLA Risk Management general standards
at Level 2 in February 2011, work continues to prepare for the reassessment against general
standards in 2014/15. In February 2013, the Trust gained accreditation against CNST maternity
standards at Level 2, with the Level 3 assessment planned for 2014.
Information security
3.17 Senior responsibility for information security, risks and incidents rests with the Chief Executive,
as supported by the Interim Chief Information Officer. The Information Security Senior
Responsible Owner (SRO) is supported by the Information Governance Manager and Head of
11

Risk Management. The Information Governance Manager manages information security risk
and incidents on a day to day basis and seeks support from the Head of Risk Management and
SRO.
Regular reports are produced to identify information security incidents and the appropriate
action planned to reduce the risk impact or likelihood of reoccurrence. These incidents are
reviewed by the Information Governance Steering Committee to ensure appropriate action is
taken.
Counterfraud and Whistleblowing
3.19 The Trust is supported through its Internal Audit function by a Counter Fraud service that
reports routinely to the Audit Committee. The service, whose annual workplan is approved by
the Audit Committee, is proactive in its role countering fraudulent activity within the Trust. A
whistleblowing policy also exists and may be accessed by staff via the Trusts intranet, which
provides the basis by which legitimate concerns can be fairly, effectively and speedily aired and
responded to by the use of internal mechanisms. Work has been undertaken during the year to
revise the policy and strengthen the processes for raising, logging and processing
concerns. The policy advises that concerns should initially be raised at a local level with the
facility for employees to register concerns directly with a designated Non Executive Director if
necessary.
Alignment with the local context
3.20 The Trust is working closely with emerging Clinical Commissioning Groups to ensure alignment
with their strategies and objectives these bodies have for improving the health, intervention,
experience and outcomes for their patients within the overall context of the Right Care,
Right Here programme.
Internal Audit opinion
3.21 ÄÅÆÇÈÅÉÊ ËÌÍÎÆÏÈÐÑ ÒÇÉrÓnÍ The ÔÇport and opinion on the effectiveness of the system of
internal control is commented on below. The internal auditors overall opinion is that
can be given that there is a generally sound system of internal control,
ÕiÖni×iØÉntAsurÉnØÇ
designed to meet the organisations objectives, and that controls are generally being applied
consistently. As part of the auditors opinion, concerns were highlighted with regard to the
effectiveness of controls over data quality in relation to A&E indicators and 18 week referral to
treatment reporting that led to the provision of only moderate assurance in both instances.
Weaknesses with regard to theatre utilisation were also highlighted, which resulted in the
provision of moderate assurance. The auditor did however advise that action plans had been
agreed with management in relation to these moderate assurance areas and the
implementation of those plans will be monitored.
The weighted opinion considers specific audit reviews and the level of assurance assigned to
each. In addition to this, the overall arrangements put in place by the Board for conducting its
own assessment of the system of internal control is reviewed. The principal tool for such an
assessment is the Board Assurance Framework (BAF) and the internal auditor concluded that
the BAF has been designed and is operating to meet the requirements of the 2012/13
Governance Statement and provides reasonable assurance that there is an effective system of
internal control to manage the principal risks to the organisation.
12

The internal auditor concluded that in his view, taking account of the respective levels of
assurance provided for each audit review, an assessment of the relevant weighting of each
individual assignment and the extent to which agreed actions have been implemented, that
the Trust has a generally sound system of internal control.
5.1 As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of
internal control. My review is informed in a number of ways. The Head of Internal Audit
provides me with an opinion on the overall arrangements for gaining assurance through the
Board Assurance Framework and on the controls reviewed as part of the internal audit work.
The overall level of assurance provided by the Head of Internal Audit Opinion for 2012/13 is
äiåniæiçènt . Executive managers within the organisation who have responsibility for the
development and maintenance of the system of internal control provide me with assurance.
The Board Assurance Framework itself provides me with evidence that the effectiveness of
controls that manage the risks to the organisation achieving its principal objectives have been
reviewed. My review is also informed by reports and comments made by the external auditor,
the Care Quality Commission and the NHS Litigation Authority, clinical auditors, accreditation
bodies and peer reviews.
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ÛÜÝÞÜß àá ÜááÜCâÞÝÜãÜää
5.2 During the year, I have been advised on the implications of the result of my review of the
effectiveness of the system of internal control by the Trust Board, Audit Committee, Finance &
Performance Management Committee, Quality & Safety Committee, Clinical Quality Review
Group, Quality Committees, Governance Board, Health & Safety Committee and the Adverse
Events CommitteeÚ
5.3 The Trust Board is responsible for reviewing the effectiveness of internal control and the Board
is supported in this by its corporate committees.
5.4 The Trust Board has receives a monthly update within the Quality Report from the Director of
Infection Prevention and Control (a role currently within the remit of the Chief Nurse) on
performance against national infection rate targets, together with effectiveness of structures in
place to support infection control and measures to ensure continuous improvement in this
area
5.5 Individual Executive Directors and managers are responsible for ensuring the adequacy and
effectiveness of internal control within their sphere of responsibility.
5.6 Internal Audit carries out a continuous review of the internal control system and report the
result of their reviews and recommendations for improvements in control to management and
the Trusts Audit Committee.
5.7 Specific reviews have been undertaken by Internal Audit, External Audit, NHS Litigation
Authority as well as various external bodies.
6 Significant control issues
13

6.1 Within the year, there were no data security breaches reported which warranted reporting to
the Information Commissioners Office and Strategic Health Authority.
6.2 Two inspections by the Care Quality Commission which occurred within the year, one of which
identified that there were concerns over compliance with a number of outcomes across City
and Sandwell Hospitals, prompting the development of robust action plans to address the
issues raised, progress with the delivery of which was given close oversight by the Quality &
Safety Committee.
6.3 The Trust failed to meet the required performance against the Emergency Care 4-hour
maximum wait target, being 92.55% for the year against a target of 95%. A robust winter plan
for 2013 is in preparation intended to provide better resilience against increases in demand or
reductions in supply. This is overseen by the Chief Executive, the Chief Nurse and Medical
Director, alongside the Chief Operating Officer who is responsible for its execution.
6.4 During the year, a data quality issue related to potential under reporting of 18 weeks referral
to treatment pathways was identified. The Trust established a recovery and improvement
programme to rectify the issues identified, the first stage of which validated the extent of the
reporting problem. The second stage of the programme established an improvement
programme to resolve the issues identified, progress with which was reported routinely to the
Trust Board and Audit Committee. The issue remains open and considerable work is needed in
2013/14 to establish stable systems. In light of these difficulties, the Trust has commissioned
external advice on our data quality across all national performance indicators.
6.5 The Trust experienced a catastrophic hardware (disk) failure. To prevent a reoccurrence of the
situation, a robust, multiple workstream approach was undertaken to include: independent
solution assurance; implementation of more robust operational monitoring of infrastructure
and strengthened business continuity arrangements. The Trust Board was appraised of the
situation and consequences of the IT failure and continues to receive information to assure
itself that safeguards are in place to prevent a reoccurrence.
7.1 With the exception of the internal control issues that I have outlined in this statement, my
review confirms that Sandwell & West Birmingham Hospitals NHS Trust has a generally sound
system of internal controls that supports the achievement of its policies, aims and objectives
and that those control issues have been or are being addressed.
é
êëìíîïðñìò óôõöó÷ø
Signed . Chief Executive (On behalf of the Board)
Date
.
14

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National Audits in which SWBH participated 2012/13
National Audits
Womens & Child Health
Participated
Yes /No
Percentage of
eligible cases
submitted
Neonatal intensive and special care (NNAP) Yes 100%
Paediatric pneumonia (British Thoracic Society) Yes 92%
Paediatric asthma (British Thoracic Society) Yes 100%
Childhood epilepsy (RCPH National Childhood EpilepsyYes 100%
Audit)
Diabetes (RCPH National Paediatric Diabetes Audit) Yes 100%
Fever in Children (College of Emergency Medicine) Yes 95%
Acute care
Emergency use of oxygen (British Thoracic Society) Yes 100%
Hip, knee and ankle replacements (National JointYes 93%
Registry)
Renal Colic (College of Emergency Medicine) Yes 100%
Severe trauma (Trauma Audit & Research Network) Yes 46%
Long term conditions
Diabetes (National Diabetes Audit) Adult Yes 100%
Parkinsons disease (National Parkinsons Audit) Yes 50%
Adult asthma (British Thoracic Society) Yes 90%
Bronchiectasis (British Thoracic Society) Yes 100%
Heart
Acute Myocardial Infarction & other ACS (MINAP) Yes 100%
Heart Failure (Heart Failure Audit) Yes 100%
Cardiac Rhythm Management Audit Yes 100%
Acute stroke (SINAP /SSNAP) Yes TBD
15

Cardiac arrest (National Cardiac Arrest Audit) Yes 100%
Peripheral vascular surgery (VSGBI Vascular SurgeryYes 77%
Database)
Coronary angioplasty (NICOR Adult CardiacYes 100%
interventions audit)
Cancer
Lung cancer (National Lung Cancer Audit) Yes 100%
Bowel Cancer (National Bowel Cancer AuditYes 100%
Programme)
Head & neck cancer (DAHNO) Yes 100%
Oesophago- gastric cancer (National O-G Cancer Audit) Yes 100%
Blood and Transplant
National Comparative Audit of Blood Transfusion No N/A
Potential donor audit (NHS Blood & Transplant) Yes 100%
Older people
Carotid interventions (Carotid Intervention Audit) Yes 100%
Hip fracture (National Hip Fracture Database) Yes 99%
National audit of dementia (NAD) Yes 100%
Other
Elective Surgery (National PROMs Programme) Yes 76%
National Confidential Enquiries (Clinical Outcome
Review Programmes)
National Review of Asthma Deaths Yes 67%
Medical & surgical programme - National Confidential
Enquiry into Patient Outcome & Death (NCEPOD)
The Trust participated in the following studies in
2011/12
- Subarachnoid Haemorrhage
- Alcohol Related Liver Disease
- Bariatric Surgery
- Cardiac arrest procedures
Yes
87.5%
100%
100%
100%
16

©
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Actions taken in response to national clinical audits 2012/13
Report
Findings, Our Learning, & Our Actions
Provisional Patient Reported
Outcome Measures (PROMs) in
England
Audit description
An audit of outcomes reported by
patients undergoing hip
replacement, knee replacement,
varicose vein surgery and surgery
for inguinal hernia repair
Key findings/learning
The provisional data for April 2010 March
2011 shows little change in the Trusts average
adjusted heath gain for all the four index
procedures in comparison with the national
average. In particular, it highlighted that
improvements were required in relation to
procedure specific scores for patients
undergoing knee replacement.
Action
A number of steps have been taken to ensure
that patients undergoing knee replacement
receive appropriate information and support.
The actions include incorporating information
on PROMs into an existing information leaflet
and to require all patients to attend the preoperative
Hip & Knee Club where information
can be exchanged.
In addition, posters have been distributed to
local GP surgeries to support a campaign to
improve referral information and information
provided to patients.
National Adult Cardiac Surgery
Audit
Annual Report 2010-2011.
Audit description
The main objective of this audit is
to collect information on activity,
trends and outcomes in adult
cardiac surgery in GB and Ireland.
In the report data is presented for
surgery performed in England and
Wales
National Confidential Enquiry into
Post-operative Outcomes and
Death (NCEPOD) Report- A time
to intervene?
Audit description
This was an audit conducted by
Key findings/learning
The audit found that despite the increasing
patient risk profiles, mortality for all cardiac
surgery continues to fall.
The report did not contain specific
recommendations. It has been considered that
no specific action is required as cardiac surgery
is not performed in the Trust.
Key findings/learning
The report indicated that for many acutely ill
people better assessment and action early in
their hospital admission may have led to
interventions that may have prevented
progression to cardio respiratory arrest or
recognition that the person was dying and that
17

Report
the National Confidential Enquiry
into Post-operative Outcomes
and Death (NCEPOD) . It reviewed
the care of patients who
underwent cardiopulmonary
resuscitation as the result of an in
hospital cardio respiratory arrest
National Neonatal Audit
Programme Annual Report 2011
Audit description
The key aims of the audit are:
• To assess whether babies
requiring neonatal care
received consistent care
across England in relation
to the audit questions;
• To identify areas for
improvement in neonatal
units in relation to delivery
and outcomes of care;
• To provide a mechanism
for ensuring consistent
high quality care in
neonatal services
Findings, Our Learning, & Our Actions
attempted resuscitation would be
inappropriate.
Action
The recommendations contained in the report
were reviewed and the following initial actions
were identified.
• The Resuscitation Team to consider
ways of utilising the data collection
tool used by NCEPOD for ongoing data
capture
• To review local Trust policies on
resuscitation to incorporate the key
recommendations
• To ensure that all CPR attempts are
reported through the Trusts incident
reporting system and to ensure that
there is a detailed review of the period
prior to cardiac arrest to examine
whether any antecedent factors were
present.
.
Key findings/learning
The audit showed that compliance was below
the national average for antenatal steroid
rates and for the proportion of babies
discharged from the neonatal unit receiving
their mothers milk. The recorded antenatal
steroid rate has improved compared to the
previous year but was lower than the national
average. It was considered that this was due in
part to inadequate recording on the BADGER
database system. Data from BADGER feeds
into the national report.
Action
To improve the compliance, the neonatal
admission summary document is now entered
directly onto BADGER which will improve the
recording of steroid use, and it is planned to
increase the number of staff trained to
counsel mothers with regard to breast
feeding.
National Diabetes Inpatient Audit-
2011 Report
Key findings/learning
Overall the audit found that
18
despite the

Report
Audit description
The National Diabetes Inpatient
Audit (NaDIA) is commissioned by
the Healthcare Quality
Improvement Partnership (HQIP)
It is a snapshot audit of diabetes
inpatient care in England and
Wales. The aims of the audit
include finding the answers to the
following questions:-
• Did diabetes management
minimise the risk of
avoidable complications?
• Did harm result from the
inpatient stay?
• Was patient experience of
the inpatient stay
favourable?
Findings, Our Learning, & Our Actions
commitment of diabetes teams there had
been little change in diabetes staffing with
inadequate provision of inpatient specialist
diabetes care at many sites and especially in
the provision of multidisciplinary foot care
teams. As a result, support and investment will
be required for under resourced teams if they
are to improve care. Locally, a review of the
report highlighted the need to enhance
primary prevention strategies across the
health economy and for all stakeholders to
continue to work to develop services.
In addition, local audit findings highlighted
some areas where improvements in
performance against several quality markers
were required, particularly at Sandwell
Hospital. In particular improvements in
aspects of medicines management and in the
education and training of staff in diabetes
were required.
Action
The actions identified to improve education
and training included considering making the
NHS Diabetes e-learning module on the safe
administration of insulin required training for
relevant staff. To enhance medicines
management a series rolling audits of insulin
prescribing, storage and administration of
insulin and other diabetes medications were
commenced.
The National Bowel Cancer Audit
2012 Report
Audit description
The audit is run in conjunction
with the Association of
Coloproctology of Great Britain
and Ireland and is designed to
assess whether patients with
colorectal cancer receive the
appropriate treatment for their
cancer when it is first discovered.
Key findings/learning
Data for the Trust indicated a higher than
expected rate for 30 day and 90 day postoperative
mortality. An investigation has
indicated that in many cases the risk profiling
could have been influenced by the poor
recording of patients pre-operative health
status. In particular, the ASA status (grading of
co-morbidity) for the patients was understated
in many cases.
Action
To ensure that data to be submitted to the
audit is reviewed and discussed prior to
19

Report
Epilepsy 12 National Report
2012
Audit description
Epilepsy12 is a UK-wide
multicentre collaborative audit
which measured systematically
the quality of health care for
childhood epilepsies. The 12
refers to the 12 measures of
quality applied to the first 12
months of care after the initial
paediatric assessment. Care was
compared to National Institute of
Clinical Excellence (NICE) and
Scottish Intercollegiate Guidelines
Network (SIGN) Epilepsies
guideline recommendations.1,2
National Audit of Percutaneous
Coronary Interventional
Procedures Report 2011
Audit description
The National audit of PCI is
managed by the National Institute
for Cardiovascular Outcomes
Research (NICOR). The audit is
one of six national cardiac clinical
audits managed by NICOR, part of
the National Centre for
Cardiovascular Prevention and
Outcomes at University College
London. The purpose of NICOR is
to provide information on quality
Findings, Our Learning, & Our Actions
submission to ensure that it is as accurate and
complete as possible.
Key findings/learning
Nationally, the results showed that
improvements are needed for many aspects of
service delivery and professional input,
including diagnosis, investigation, treatment
and communication. In particular, there had
been a considerable lack of progress in the
availability of childrens epilepsy specialist
nurses to provide support and advice to
children and their families.
In addition, it was recommended that where
there was evidence of a diagnoses of epilepsy
being made and then subsequently
withdrawn, this should be investigated to
understand the reasons behind this.
Action
Although the Trust was not an outlier in the
audit, it was identified that increased
paediatric epilepsy specialist nurse input was
needed particularly for West Birmingham
patients and therefore a business case for
increased resources was needed be made to
commissioners.
.In order to help to ensure a correct diagnosis
of epilepsy, the training provided for junior
doctors has been adapted to include epileptic
and non epileptic scenario based teaching.
Key findings/learning
Nationally, there is evidence that suggests
improved outcomes for patients being treated
in higher volume PCI centres, particularly
those that perform at least 400 procedures
per
annum (pa). The overall rate of death before
discharge from hospital following PCI
has gradually risen over the past few
years. This is due to a change in case
mix.
The report did not contain specific
recommendations and it has been determined
that no specific actions are required.
20

Report
and outcome of care provided to
people with heart disease and to
provide technical infrastructure,
project management and
statistical support for the national
cardiac audits and clinical
registries
Myocardial Ischaemia National
Audit Project Eleventh National
Public Report
Audit description
It presents analyses from all
hospitals and ambulance services,
in England, Wales and Belfast,
that provided care for patients
with suspected heart attack
between April 2011 and March
2012 (2011/12).
Findings, Our Learning, & Our Actions
Key findings/learning
The purpose of the report is to inform the
public about the quality of local care for heart
attack patients. For the first time data was
presented on primary PCI within 120 minutes
of calling for help.
Action
It has been determined that action is required
to further improve the door to balloon times
for patients. As a result, the possibility of
implementing a system of direct access to the
catheter lab is now being explored.
National Heavy Menstrual
Bleeding Audit Second Annual
Report 2012
Audit description
Eligible women who had
consented to participate in the
audit were asked to complete a
questionnaire at their first
gynaecology outpatient visit (the
baseline questionnaire).
Questions included were on the
severity of the condition, the
impact its symptoms had on
quality of life and the treatments
they had received in primary care.
In this report the patientreported
outcomes from the
baseline questionnaire are
described.
Key findings/learning
The report was considered by the audit lead
and it was determined that no specific action
was required. The report did not contain any
recommendations and therefore there were
no specific implications for the service.
National Confidential Enquiry into
Suicide and Homicide for people
with Mental illness - Annual
Key findings/learning
The report has been considered and although
there are no specific recommendations
21

Report
Report 2012
Audit description
The enquiry examines all
incidences of suicide and
homicide by people in contact
with mental health services in the
UK. They also examine all cases of
sudden death in the psychiatric
in- patent population.
British Isles Network of
Congenital Anomaly Registers -
Congenital Anomaly Statistics
2010.
Audit description
The report which was published
on 02/08/12, collates data from
six regional congenital anomaly
registers, which together cover
35% of the births in England and
Wales, to provide an estimate of
the prevalence of congenital
anomalies nationally.
Findings, Our Learning, & Our Actions
requiring action, the Trust continues to ensure
that its systems are robust in order to assess
the level of suicide risk and to take
appropriate action. For example, a
Therapeutic Observation Policy which
indicates the level of staff supervision
dependent on the level of risk, and a tool for
reviewing environmental risk to patients who
are at risk of suicide, are in place.
Key findings/learning
The report has been considered by the
relevant Directorate and discussed with
neonatal colleagues. The report does not
contain any specific recommendations. As a
result, it has been indicated that no changes
are required to be made to local practice in
light of the report.
National Joint Registry (NJR) 9th
Annual Report 2012
Audit description
The NJR aims to improve patient
safety and clinical outcomes by
providing information to all those
involved in the management and
delivery of joint replacement
surgery, and to patients. This is
achieved by collecting data in
order to monitor the
effectiveness of hip, knee and
ankle replacement surgery and
prosthetic implants.
National Confidential Enquiry in
Patient Outcome and Death
(NCEPOD) Report Too Leaner a
Service?
Key findings/learning
The report has been considered by the service
lead clinician and no specific action was
determined. The recommendations in the
report concerned ensuring that there are local
systems in place for the monitoring of
performance. These monitoring arrangements
are already in place and demonstrate good
compliance with the requirements.
Key findings/learning
The report was considered not to be directly
relevant to the Trust as bariatric surgery is not
performed within in the organisation.
22

Report
Audit description
The report was published on
18/12/12 and contained the
findings arising from a review of
the care of patients who
underwent bariatric surgery.
Findings, Our Learning, & Our Actions
23

.
Actions taken in response to local clinical audits
The actions are a brief summary, and not intended to give the full details.
Audit topic
Actions identified
WHO Checklist Compliance Audit
Audit description
To assess the compliance with
the Five Steps to Safer Surgery
in the Trust. This includes use of
the Surgical Safety Checklist.
Key findings/learning
Results have shown that there is good
compliance with the completion of the three
sections on the Surgical Safety Checklist.
Action
Further work is required to ensure that a
debrief session is recorded at the end of
theatre lists. To address this, a series of
observational audits have been conducted in
theatres to provide feedback to staff and with
the aim of improving compliance with all five
steps, including debriefing at the end of a list.
An audit of pre-operative
investigations of patients
undergoing surgery for breast
cancer.
Audit description
A retrospective audit all pre
operative investigations for
patients undergoing breast
surgery for cancer in a 12 month
period to determine the cost
effectiveness and relevance of
routinely performed pre
operative tests.
An audit of the use of the
Paediatric Early Warning Scoring
System (PEWS)
Audit description
An audit to evaluate the use of
the PEWS system on the
paediatric wards.
Key findings/learning
The audit found that the majority of tests that
were performed were normal and so changes
required to investigations arising from as a
result of abnormal pre-op tests were not
identified.
Action
Based on the findings it was recommended to
stop all pre-op tests for patients with breast
cancer who were under the age of 50 who
were without significant co-morbidity, and to
create a local guideline/algorithm for the pre
assessment of patients undergoing breast
surgery.
Key findings/learning
The audit found that in the sample examined,
the vast majority of cases (85%) the PEWS
scores were added appropriately and that the
action taken in response was appropriate in
93% of cases. Despite this, the recoding of
specific physiological parameters could be
improved e.g. respiratory distress.
Action
To take steps to further improve the recording
of physiological parameters on the PEWS chart
and to undertake a further audit with an
increased focus on HDU cases to confirm
whether the escalation tool functions
24

Audit topic
Re-audit of complications
following TRUS prostatic biopsy
Audit description
An audit of infection rates
following TRUS-guided prostatic
biopsy with particular emphasis
on admission rate due to sepsis
Actions identified
effectively.
Key findings/learning
The audit found that the incidence of urosepsis
was low with only 1 patient requiring
admission into hospital for intravenous
antibiotics in the 12 month audit period. A
further 3 pateint presented to the hospital
with urinary tract infections which were
treated on an outpatient basis. As a result, it
was concluded that the current antibiotic
protocol should be continued.
Action
It was agreed to continue to the audit to
ensure that the urosepsis rate remains low and
to confirm the optimal antibiotic protocol.
Nasogastric tube audit
Audit description
An audit to assess compliance
with the NPSA Patient Safety
Alert (PSA002) Reducing the
harm caused by misplaced
nasogastric feeding tubes.
Key findings/learning
The audit found that only a small number of
junior doctors at the time of the audit had
accessed the elearning module for safe NGT
insertion and therefore this need to be
improved. In addition, the audit found that a
number of NG tubes were being placed after
2100hrs and that clearer documentation of the
reasoning behind insertions was required.
Action
Action to improve compliance have included
making the completion of elearning module
for junior doctors mandatory, and also
implementing a programme of quarterly audits
to monitor compliance with the requirements
going forward.
.
Emergency Department Audits
Audit description
A series of specific audits
covering the use of proformas to
be used with patients presenting
with a head Injury, alcohol
intoxication or a headache.
An audit to assess Directorate
Key findings/learning
The spot check audits continue to show good
compliance at greater than 90%.
Action
Instances of non compliance are addressed.
Reminders are issued and training is provided
if required.
Key findings/learning
25

Audit topic
compliance with the Trust policy
on the management of clinical
diagnostic tests.
Audit description
An audit to assess the compliance
with the NPSA Safer Practice
Notice 16 Early identification of
failure to act on radiological
imaging reports. It included
assessing compliance with local
Directorate protocols setting out
how clinical diagnostic tests are
to be managed in their
Directorate.
Actions identified
The audit also found that many Directorate
protocols required to be revisited in order to
meet all of the required standards and that
these were not embedded in practice.
Electronic Results Acknowledgement (eRA)
was developed and implemented to provide
real time access and acknowledgement
functionality. The audit found that 50% of
radiology reports were acknowledged
electronically, with the remainder following a
paper based system.
Action
The actions determined to improve compliance
included:-
• Requiring Directorates to revisit their
local policies for the management of
clinical diagnostic tests;
• To develop a communication plan to
re-communicate the key messages
around the safe management of the
results of radiological imaging;
• To take steps to improve the usage of
eRA in the Emergency Departments.
:
Healthcare Records Audit
Audit description
An annual audit of healthcare
records to measure compliance
with local policy and to address
risk management standards as
set out by the NHS Litigation
Authority.
Key findings/learning
The results highlighted that there were aspects
of record keeping that required to be
improved. These included improving the
physical quality of the healthcare record.
Overall, the compliance with the basics of
record keeping standards had shown some
improvement when compared to the previous
year.
Action
Specific actions that were identified included:-
• Introducing monthly monitoring audits
to assess compliance with standards
and to ensure timely feedback to
Directorates;
• To raise the awareness of the essential
quality standards by recirculating the
leaflet previously sent out with
26

Audit topic
Audits of basic care
Audit description
A composite of audits conducted
biannually that includes assessing
compliance with the Essences of
care contained in the Essence of
Care getting the basics right,
(NHS Plan 2000).
The audit assessed the quality of
record keeping and whether the
following assessments had been
conducted.
•Communication needs
•Pain
•Bladder and bowel care
•Personal hygiene needs
•Mental health needs
•Hydration and nutrition
•Tissue viability
•Falls risk
•Moving and handling needs
•Oral hygiene needs
•Infection prevention and control
Actions identified
payslips.
Key findings/learning
The findings highlighted that there had been
improvements in the assessment of personal
hygiene/ self- care and oral hygiene. This was
considered to be as a direct consequence of
the implementation of care rounds and new
clinical documentation. In addition, compliance
with mental health assessments had also
improved in comparison with the previous
audit and also in the completion of pressure
ulcer and falls risk assessments remained high
with 97% completion rates for both.
Action
All wards and Divisions are presented with
performance reports and action plans are
required to be developed to address specific
areas of unsatisfactory performance.
It was identified that further work is required
to ensure that improvements are also made in
record keeping. In addition, a review of the
audit tools was identified and this would be
conducted through a series of workshops. This
would then be informed by the feedback from
staff on their experience of using the tools.
Audit of Antenatal Steroid
Compliance
Audit description
The National Neonatal
Programme Audit Report 2010
(published July 11) had indicated
that, according to data extracted
from the Badger database, the
percentage of eligible mothers
receiving any dose of steroids
was below the national average.
It was considered that this in part
was due to poor recording of this
data onto the Badger System. To
confirm this , an audit of
casenotes was conducted to
establish the level of compliance.
Key findings/learning
The audit confirmed that the inputs into the
BADGER system needed to be improved. The
compliance with antenatal steroid
administration in the sample audited was
81.8% across the Trust. This was better than
that recorded on the Badger system for same
period.
Action
The audit recommended a number of actions
to improve the accuracy of the data submitted
. These included inputting the neonatal
admission summary directly onto the BADGER
database and to ensure that this aspect is
covered in the Neonatal Induction programme.
In addition, to review local guidelines to
ensure that they are clear about the
27

Audit topic
The audit examined antenatal
steroid use for babies less than
34 weeks gestation.
Actions identified
administration of steroids.
Management of urodynamic
stress incontinence in City and
Sandwell hospitals.
Audit description
The aim of the audit was to
assess whether the management
of urodynamic stress
incontinence in City and Sandwell
Hospitals conforms to local Trust
guidance.
A retrospective audit of the
quality ratings for intra-oral
radiographs taken within the Oral
Surgery Department.
Audit description
The main objective of the audit
was to examine the effectiveness
of the current radiograph quality
assurance system used in oral
surgery to assesses compliance
with National Radiological
Protection Board (NRPB)
Guidelines for the rating of film
quality i.e. that these are taken
well and are of diagnostic value.
Radiographs were independently
reviewed and rated for image
quality.
Key findings/learning
The audit found that although the
documentation of the clinical assessment was
good, there was poor documentaion of
whether:-
• general lifestyle advice had been
supplied;
• a bladder diary had been assessed;
• pelvic floor physiotherapy had occured.
(A trial of supervised pelvic floor muscle
training of at least 3 months' duration
should be offered to all women with
stress incontinence as first-line
treatment)
Action
To introduce a standardised Urogynaecology
proforma to be used during clinical assessment
(History, Examination, Investigations and
Management Plan) in all patients with
urogynaecological symtoms.
To conduct a reaudit in January 2014
Key findings/learning
Incomplete documentation was found to be
present in a third of cases. A third of
radiographs were re-rated on the second
independent review.
Actions
To provide educational sessions for clinicians
and radiography trained nurses on the NRPB
rating system. This will inciude development
of a handbook with an explanation of
subjective QA ratings and pictorial examples
of common errors.
In addition, to develop a clearer radiology
reporting form to support the ongoing quality
assurance process and for reassessment of the
system in August 2013.
28

Audit topic
Mortality audits
Audit description
Audits of specific diagnostic
groups to determine whether any
quality of care issues are present
Actions identified
Key findings/learning
The audits have identified areas where care
processes and the recording of care can be
enhanced. In particular, greater accuracy in
death certification and clinical coding have
been identified as key work streams. In
addition, further work is required to ensure
compliance with best practice in the
management of sepsis.
Action
To help to improve the accuracy of death
certification, a draft educational package has
been developed. This will be utilised in the
training provided for Junior Doctors that will
commence from March 13.
To enhance the management of sepsis, the
Sepsis Committee is spearheading the
continued implementation and audit of the
Sepsis Six Care Bundle, and aspects of sepsis
management are to be included as a
Commissioning for Quality and Innovation
(CQUIN) target for 2013/14.
An audit of ultrasound accuracy
in predicting axillary lymph node
positive disease in breast cancer
Audit description
The purpose of the audit was to
determine a baseline predictive
value for preoperative axillary
ultrasound in the detection of
positive lymph nodes in breast
cancer and to compare this with
published data.
Re-audit of the diagnosis and
management of gastroenteritis in
children under 5.
Audit description
The main purpose of the audit
was to review practice against
NICE Clinical Guideline 84
(Diarrhoea ans vomiting in
children). Children at risk of
Key findings/learning
The audit found that the sensitivity and
specificity of pre-operative axillary utrasound
was in line with publshed data. In addition,
that in some cases it was not documented in
the records as to whether the patient had
received an axillary ultrasound scan.
Action
To use the findings as a baseline for further
audit and to take steps to ensure that the
occurrence of an axillary ultrasound scan is
documented in all cases.
Key findings/learning
All patients identified with red flags indicating
that IV fluids should be given, received an
infusion, however, not all patients who were at
risk of dehydration were offered ORS.
Action
• To develop and implement a checklist
for the management and discharge of
patients presenting with diarrhoea and
vomiting.
29

Audit topic
dehydration should be offered
oral replacement supplements
(ORS)
Actions identified
• To raise the profile of current
guidelines further through publishing
information on the assessment of
dehydration in ward areas.
• To reaudit in 2013
An audit of adherence to the
Trusts antibiotic guidelines on the
Medical Assessment Unit.
Audit description
The aim of the audit was to
establish whether antibiotic
prescribing practice on the MAU
was appropriate and in
accordance with Trust guidelines.
An audit to measure compliance
with NICE Clinical Guideline 101
(Chronic Obstructive Pulmonary
Disease) Pulmonary
rehabilitation component
Audit description
An audit to assess compliance
with the requirement that
pulmonary rehabilitation should
be made available to all
appropriate people with COPD,
including those who have had a
recent hospitalisation for an
acute exacerbation. Pulmonary
rehabilitation should be offered
to all patients who consider
Key findings/learning
Overall, the audit findings indicated that
adherence to the Trusts antimicrobial
guidelines on the unit at this time was below
the expected level. There were examples
where the indications for the antibiotic use
were not clearly documented, and also that
the duration for antibiotic treatment was not
recorded.
Action
Specific actions identified have included:-
• Increasing the frequency of training in
antimicrobial stewardship for medical
staff at all levels;
• Considering adding an antibiotics
section to the admission clerking
proforma to enhance compliance with
the key requirements;
• To reaudit 6 months after the
implementation of changes to improve
practice.
Key findings/learning
The audit found that only 40% of patients
referred to the Community Respiratory Service
during the audit period were offered
rehabilitation, but that it was not possible to
determine clearly what percentage of these
patients had a MRC scale of 3 or above. In
addition the findings indiacted that 51% of
patients who were offered rehabilitation
actually partcipated in it, and that 71% of
those who partcipated in the programme
actually completed it.
Action
The actions identified included:-
• To take steps to improve how staff
members communicate about the
rehabilitation programme to patients
e.g. about the benefits of the
30

Audit topic
themselves functionally disabled
by COPD (usually MRC grade 3
and above).
Actions identified
programme.
• Community Respiratory Team to
provide the British Lung Foundation
leaflet to patients in addition to a DVD
already in use.
• To discuss the findings with the whole
respiratory team to ensure appropriate
referrals for rehabiliation are made
including from an acute hospital
admission.
31

Auitor
sttmnto Limit Liility
32

JK;45

SELF-CERTIFICATION RETURNS
Organisation Name:
Sandwell & West Birmingham Hospitals NHS Trust
Monitoring Period:
May 2013
NHS Trust Over-sight self certification template
Returns to XXX by the last working day of each

NHS Trust Governance Declarations :
2013/14 In-Year Reporting
Sandwell & West Birmingham Hospitals NHS
Name of Organisation: Period: May 2013
Trust
Organisational risk rating
Each organisation is required to calculate their risk score and RAG rate their current performance, in addition to providing comment with regard to any
contractual issues and compliance with CQC essential standards:
Governance Risk Rating (RAG as per SOM guidance)
Key Area for rating / comment by Provider
Score / RAG rating*
AG
Normalised YTD Financial Risk Rating (Assign number as per SOM guidance) 3
* Please type in R, AR, AG or G and assign a number for the FRR
Governance Declarations
Declaration 1 or declaration 2 reflects whether the Board believes the Trust is currently performing at a level compatible with FT authorisation.
Supporting detail is required where compliance cannot be confirmed.
Please complete sign one of the two declarations below. If you sign declaration 2, provide supporting detail using the form below. Signature may be either hand
written or electronic, you are required to print your name.
Governance declaration 1
The Board is sufficiently assured in its ability to declare conformity with all of the Clinical Quality, Finance and Governance elements of the Board Statements.
Signed by:
Print Name:
on behalf of the Trust Board
Acting in capacity as:
Signed by:
Print Name:
on behalf of the Trust Board
Acting in capacity as:
Governance declaration 2
At the current time, the board is yet to gain sufficient assurance to declare conformity with all of the Clinical Quality, Finance and Governance elements of the
Board Statements.
Signed by : Print Name :
Richard Samuda
on behalf of the Trust Board
Acting in capacity as:
Chairman
Signed by : Print Name :
Toby Lewis
on behalf of the Trust Board
Acting in capacity as:
Chief Executive
If Declaration 2 has been signed:
For each target/standard, where the board is declaring insufficient assurance please state the reason for being unable to sign the declaration, and explain
briefly what steps are being taken to resolve the issue. Please provide an appropriate level of detail.
Target/Standard:
The Issue :
Action :
11. Plans in place to ensure ongoing compliance with all existing targets.
The Trust year to date is underperforming against Emergency Care target
An agreed trajectory to achieve compliance with this target by the end of Q2 is in place
Target/Standard:
The Issue :
Action :
Target/Standard:
The Issue :
Action :
Target/Standard:
The Issue :
Action :
Target/Standard:
The Issue :
Action :

Board Statements
Sandwell & West Birmingham Hospitals NHS Tru
May 2013
For each statement, the Board is asked to confirm the following:
For CLINICAL QUALITY, that:
Response
The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the SOM's
1
Oversight Regime (supported by Care Quality Commission information, its own information on serious incidents, patterns
of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place, effective
Yes
arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s
2 Yes
registration requirements.
The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on
3 Yes
behalf of the trust have met the relevant registration and revalidation requirements.
For FINANCE, that:
Response
4 The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months.
Yes
5
The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accounting standards
in force from time to time.
Yes
For GOVERNANCE, that:
Response
6 The board will ensure that the trust at all times has regard to the NHS Constitution.
Yes
All current key risks have been identified (raised either internally or by external audit and assessment bodies) and
7 Yes
addressed – or there are appropriate action plans in place to address the issues – in a timely manner
The board has considered all likely future risks and has reviewed appropriate evidence regarding the level of severity,
8 Yes
likelihood of occurrence and the plans for mitigation of these risks.
The necessary planning, performance management and corporate and clinical risk management processes and
9 mitigation plans are in place to deliver the annual plan, including that all audit committee recommendations accepted by Yes
the board are implemented satisfactorily.
An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance
10 framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury
Yes
(www.hm-treasury.gov.uk).
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the
11 application of thresholds) as set out in the Governance Risk Rating; and a commitment to comply with all commissioned No
targets going forward.
The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance
12 Yes
Toolkit.
The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests,
13
ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or
plans are in place to fill any vacancies, and that any elections to the shadow board of governors are held in accordance
Yes
with the election rules.
The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and
14 skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, Yes
and ensuring management capacity and capability.
The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the
15 Yes
annual plan; and the management structure in place is adequate to deliver the annual plan.
Signed on behalf of the Trust: Print name Date
CEO Richard Samuda 27/06/2013
Chair Toby Lewis 27/06/2013

QUALITY
Information to inform the discussion meeting
Sandwell & West Birmingham Hospitals NHS Trust
Insert Performance in Month
Refresh Data for new Month
Criteria
Unit Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Jan-13 Mar-13 Apr-13 May-13 Board Action
1 SHMI - latest data Score 97.5 96.8 96.2 96.0 96.3 95.3 94.2 95.6 94.9 94.4 94.2 94.3
2
Venous Thromboembolism (VTE)
Screening
% 91.0 91.4 87.5 91.0 91.5 91.7 90.2 91.5 91.0 86.1 90.8 92.5
3a Elective MRSA Screening % 40.7 42.0 39.5 38.7 104.6 96.2 112.0 130.9 193.6 138.9 196.6 173.2
SHMI data relates to period February 2012 - January 2013
which is the most recent period for which data is available
(source HED).
Data reported is screens not matched with patients. Screens
matched to patients for the month is 59.9%.
3b Non Elective MRSA Screening % 66.3 68.0 69.1 66.1 66.0 78.6 78.4 80.7 82.3 76.8 79.2 82.2
Data reported is screens not matched with patients. Screens
matched to patients for the month is 72.6%.
4
Single Sex Accommodation
Breaches
Number 0 0 0 0 0 0 0 0 0 0 >0 >0
Breaches relate to Critical Care, where Level 1 patients,
medically fit for transfer to an acute ward, have remained
on the unit(s).
5
Open Serious Incidents Requiring
Investigation (SIRI)
Number 9 10 4 2 3 1 2 0 4 2 5 3
6 "Never Events" occurring in month Number 0 1 0 1 0 0 0 0 0 0 0 0
No incidents are overdue for completion
7 CQC Conditions or Warning Notices Number 0 0 0 0 0 0 0 0 0 0 0 0
8
Open Central Alert System (CAS)
Alerts
Number 17 14 9 10 8 5 4 3 10 10 5 5
3 open alerts. Spinal / Epidural needles remain a
manufacturing problem. 1 alert deadline of 24/05 is waiting
for confirmation of items.
9
RED rated areas on your maternity
dashboard?
Number 2 4 3 3 2 4 4 2 2 3 2 3
April - Midwifery Staff Sickness Absence (7.0%), Admissions
to Level 2 unit from Delivery Suite >37 weeks (11.0%) and
Adjusted Perinatal Mortality Rate (11.7 / 1000 babies).
10
Falls resulting in severe injury or
death
Number 1 1 2 6 0 2 2 1 2 2 3 2
11 Grade 3 or 4 pressure ulcers Number 2 2 3 3 1 1 6 1 2 2 2 1
There was 1 avoidable grade 3 pressure ulcer reported for
the month of May. A further 1 unavoidable pressures ulcer
was reported.
12
100% compliance with WHO surgical
checklist
Y/N No No No No No No No No No No No No
Compliance was 99.9% in Mayl (3056 records compliant of
3058 total). All list and individual checklists are checked for
completeness by staff at the end of the session and then
entered onto a database.
13 Formal complaints received Number 61 62 79 56 62 68 38 60 70 57 63 59
14
Agency as a % of Employee Benefit
Expenditure
% 1.9 1.9 2.2 1.8 2.3 2.45 2.91 2.62 4.57 6.41 4.29 4.28
15 Sickness absence rate % 4.23 4.16 4.10 4.18 4.51 4.47 4.58 4.86 4.42 4.55 4.36 4.01
16
Consultants which, at their last
appraisal, had fully completed their
previous years PDP
% 69 71 79 84 83 87 86 88 81 77 77 78
These figures indicate the percentage of Consultant
Appraisals that were completed at that time without
reference to completed PDPs which are seen as a more
dynamic document.

FINANCIAL RISK RATING
Sandwell & West Birmingham Hospitals NHS
Trust
Risk Ratings
Insert the Score (1-5) Achieved for each
Criteria Per Month
Reported
Position
Normalised
Position*
Criteria Indicator Weight 5 4 3 2 1
Year to
Date
Forecast
Outturn
Year to
Date
Forecast
Outturn
Board Action
Underlying
performance
Achievement
of plan
Financial
efficiency
EBITDA margin % 25% 11 9 5 1

FINANCIAL RISK TRIGGERS
Sandwell & West Birmingham Hospitals
NHS Trust
Insert "Yes" / "No" Assessment for the Month
Refresh Triggers for New Quarter
Historic Data
Current Data
Criteria
Qtr to
Sep-12
Qtr to
Dec-12
Qtr to
Mar-13
Apr-13 May-13 Jun-13
Qtr to
Jun-13
Board Action
1
Unplanned decrease in EBITDA margin in two
consecutive quarters
No No No No No
2
Quarterly self-certification by trust that the normalised
financial risk rating (FRR) may be less than 3 in the next
12 months
No No No No No
3
Working capital facility (WCF) agreement includes default
clause
N/a N/a N/a N/a N/a N/a N/a
4
Debtors > 90 days past due account for more than 5% of
total debtor balances
Yes Yes Yes Yes Yes
Escalation processes in place and reported to Finance
Committee which is monitoring progress.
5
Creditors > 90 days past due account for more than 5% of
total creditor balances
No No No No No
6
Two or more changes in Finance Director in a twelve
month period
No No No No No
7
Interim Finance Director in place over more than one
quarter end
No No No No No
8
Quarter end cash balance

GOVERNANCE RISK RATINGS
Sandwell & West Birmingham Hospitals NHS Trust
See 'Notes' for further detail of each of the below indicators
Effectiveness
Patient Experience
Quality
1b
Area Ref Indicator Sub Sections
Threshold
Referral to treatment information 50%
1a
Data completeness: Community services
Referral information 50%
comprising:
Treatment activity information 50%
Weighting
Qtr to
Sep-12
Historic Data
Qtr to
Dec-12
Qtr to
Mar-13
Apr-13 May-13 Jun-13
Patient identifier information 50% No Yes Yes Yes Yes
Patients dying at home / care home 50% Yes Yes Yes Yes Yes
1c Data completeness: identifiers MHMDS 97% 0.5 N/a N/a N/a N/a N/a
1c
2a
2b
2c
2d
3a
3c
3e
3g
3h
Data completeness: outcomes for patients
on CPA
From point of referral to treatment in
aggregate (RTT) – admitted
From point of referral to treatment in
aggregate (RTT) – non-admitted
From point of referral to treatment in
aggregate (RTT) – patients on an
incomplete pathway
Certification against compliance with
requirements regarding access to
healthcare for people with a learning
disability
3b All cancers: 62-day wait for first treatment:
3f
Data completeness, community services:
(may be introduced later)
All cancers: 31-day wait for second or
subsequent treatment, comprising:
All Cancers: 31-day wait from diagnosis to
first treatment
Cancer: 2 week wait from referral to date
3d
first seen, comprising:
A&E: From arrival to
admission/transfer/discharge
Care Programme Approach (CPA) patients,
comprising:
Minimising mental health delayed transfers
of care
Admissions to inpatients services had
access to Crisis Resolution/Home
Treatment teams
50% 0.5 N/a N/a N/a N/a N/a
Maximum time of 18 weeks 90% 1.0 Yes Yes Yes Yes Yes
Maximum time of 18 weeks 95% 1.0 Yes Yes Yes Yes Yes
Maximum time of 18 weeks 92% 1.0 Yes Yes Yes Yes Yes
Surgery 94%
Anti cancer drug treatments 98%
Radiotherapy 94%
From urgent GP referral for
suspected cancer
From NHS Cancer Screening
Service referral
N/A 0.5 Yes Yes Yes Yes Yes
85%
90%
all urgent referrals 93%
for symptomatic breast patients
(cancer not initially suspected)
96% 0.5 Yes Yes Yes Yes Yes
93%
Maximum waiting time of four hours 95% 1.0 No No No No No
Receiving follow-up contact within 7
days of discharge
Having formal review
within 12 months
95%
95%
1.0
1.0
1.0
0.5
1.0
No
Yes
Yes
Yes
N/a
Yes
Insert YES, NO or N/A (as appropriate)
Yes
Yes Yes Yes Yes
Yes
Yes
N/a
Yes
Yes
≤7.5% 1.0 N/a N/a N/a N/a N/a
95% 1.0 N/a N/a N/a N/a N/a
N/a
Yes
Yes
Yes
N/a
Current Data
Yes
Yes
Yes
N/a
Qtr to
Jun-13
Refresh GRR for New Quarter
Board Action
April 2013 performance confirmed from
National Cancer Waiting Times system
report. May performance projected.
April 2013 performance confirmed from
National Cancer Waiting Times system
report. May performance projected.
April 2013 performance confirmed from
National Cancer Waiting Times system
report. May performance projected.
April 2013 performance confirmed from
National Cancer Waiting Times system
report. May performance projected.
Performance in May was 94.4%.
3i
3j
3k
Meeting commitment to serve new
psychosis cases by early intervention teams
Category A call –emergency response
within 8 minutes
Category A call – ambulance vehicle arrives
within 19 minutes
95% 0.5 N/a N/a N/a N/a N/a
Red 1 80% 0.5 N/a N/a N/a N/a N/a
Red 2 75% 0.5 N/a N/a N/a N/a N/a
95% 1.0 N/a N/a N/a N/a N/a
Is the Trust below the de minimus 12
4a
Clostridium Difficile
Enter
Is the Trust below the YTD ceiling contractual
ceiling
1.0
Yes Yes Yes Yes Yes
Safety
4b
MRSA
CQC Registration
Non-Compliance with CQC Essential
A Standards resulting in a Major Impact on
Patients
Is the Trust below the de minimus 6 Yes Yes Yes Yes Yes
Enter 1.0
Is the Trust below the YTD ceiling contractual
ceiling
Yes Yes Yes No No
0 2.0 No No No No No
There was 1 case of post 48 hour MRSA
Bacteraemia (contaminant) reported during
April.
B
Non-Compliance with CQC Essential
Standards resulting in Enforcement Action
0 4.0 No No No No No
C
NHS Litigation Authority – Failure to
maintain, or certify a minimum published
CNST level of 1.0 or have in place
appropriate alternative arrangements
0 2.0 No No No No No
TOTAL 2.0 1.0 1.0 1.0 1.0 0.0 0.0
RAG RATING : AR AG AG AG AG G G
GREEN = Score less than 1
AMBER/GREEN = Score greater than or equal to 1, but less than 2
AMBER / RED = Score greater than or equal to 2, but less than 4
RED = Score greater than or equal to 4

GOVERNANCE RISK RATINGS
Sandwell & West Birmingham Hospitals NHS Trust
Insert YES, NO or N/A (as appropriate)
Refresh GRR for New Quarter
See 'Notes' for further detail of each of the below indicators Historic Data Current Data
Overriding Rules - Nature and Duration of Override at SHA's Discretion
i) Meeting the MRSA Objective
Greater than six cases in the year to date, and breaches the
cumulative year-to-date trajectory for three successive quarters
ii)
iii)
Meeting the C-Diff Objective
RTT Waiting Times
Greater than 12 cases in the year to date, and either:
Breaches the cumulative year-to-date trajectory for three
successive quarters
Reports important or signficant outbreaks of C.difficile, as
defined by the Health Protection Agency.
Breaches:
The admitted patients 18 weeks waiting time measure for a
third successive quarter
The non-admitted patients 18 weeks waiting time measure for a
third successive quarter
The incomplete pathway 18 weeks waiting time measure for a
third successive quarter
iv)
v)
vi)
A&E Clinical Quality Indicator
Cancer Wait Times
Ambulance Response Times
Fails to meet the A&E target twice in any two quarters over a 12-
month period and fails the indicator in a quarter during the
subsequent nine-month period or the full year.
Breaches either:
the 31-day cancer waiting time target for a third successive
quarter
the 62-day cancer waiting time target for a third successive
quarter
Breaches either:
the category A 8-minute response time target for a third
successive quarter
the category A 19-minute response time target for a third
successive quarter
either Red 1 or Red 2 targets for a third successive quarter
vii)
Community Services data completeness
Fails to maintain the threshold for data completeness for:
referral to treatment information for a third successive quarter;
service referral information for a third successive quarter, or;
treatment activity information for a third successive quarter
viii) Any other Indicator weighted 1.0
Breaches the indicator for three successive quarters.
Adjusted Governance Risk Rating 2.0 1.0 1.0 1.0 1.0 0.0 0.0
AR AG AG AG AG G G

CONTRACTUAL DATA
Information to inform the discussion meeting
Sandwell & West Birmingham
Hospitals NHS Trust
Insert "Yes" / "No" Assessment for the Month
Refresh Data for new Quarter
Historic Data
Current Data
Criteria
Qtr to
Sep-12
Qtr to
Dec-12
Qtr to
Mar-13
Apr-13 May-13 Jun-13
Qtr to
Jun-13
Board Action
1 Are the prior year contracts* closed? Yes Yes Yes Yes Yes
2
3
Are all current year contracts* agreed and
signed?
Has the Trust received income support outside of
the NHS standard contract e.g. transformational
support?
Yes Yes Yes Yes Yes
No No No No No
As part of QIPP initiatives there is a small
element of TFF (transitional financial
framework) funding of approximately 1/3rd
of one percent of turnover associated with
the RCRH programme. The Trust does not
regard this as support as it is linked to a
jointly agreed reduction in secondary care
activity.
4
5
6
Are both the NHS Trust and commissioner
fulfilling the terms of the contract?
Are there any disputes over the terms of the
contract?
Might the dispute require third party intervention
or arbitration?
Yes Yes Yes Yes Yes
No No No No No
No No No N/a N/a
7 Are the parties already in arbitration? No No No N/a N/a
8 Have any performance notices been issued? Yes Yes Yes No No
9 Have any penalties been applied? Yes Yes Yes No No
*All contracts which represent more than 25% of the Trust's operating revenue.

TFA Progress
Jun-13
Sandwell & West Birmingham Hospitals NHS Trust
Select the Performance from the drop-down list
TFA Milestone (All including those delivered)
Milestone
Date
Due or Delivered
Milestones
Future Milestones
Board Action
1 Draft IBP and LTFM submitted Aug-11 Fully achieved in time
2 Assess and challenge IBP/LTFM Sep-11 Fully achieved in time
3 HDD stage 1 Dec-11 Fully achieved in time
4 8 week public engagement completed Mar-12 Fully achieved in time
5 First cut Quality Governance self-assessment May-12 Fully achieved in time
6 BGAF process Sep-12 Fully achieved in time
7 Submit IBP/LTFM to SHA for review Sep-12 Fully achieved in time
8 Final cut Quality Governance self-assessment Sep-12 Fully achieved in time
9 Submission of key FT application documentation for review Sep-12 Fully achieved in time
10 External validation of final Quality Governance sef-assessment Oct-12 Fully achieved in time
11 FT readiness review with SHA Oct-12 Fully achieved in time
12 Final IBP/LTFM - SHA submission Nov-12 Fully achieved but late
Agreed with SHA not to submit at this stage pending further discussion on
TFA milestones.
13 BGAF validation Nov-12 Fully achieved in time
14 Board able to certify compliance with IG toolkit Dec-12 Fully achieved but late
15 SHA approval review Dec-12 Fully achieved but late Agreed with SHA pending further discussion on TFA milestones
16 HDD Stage 2 Dec-12 Fully achieved in time
17 SHA FT quality assessment Jan-13 Not fully achieved
18 Final submission of all key outstanding documentation to SHA Jan-13 Not fully achieved
19 Final SHA Board to Board Feb-13 Not fully achieved
20 Submission of FT application to DH Mar-13 Not fully achieved
Agreed with SHA to delay at this stage pending further discussion on TFA
milestones
Agreed with SHA to delay at this stage pending further discussion on TFA
milestones
Agreed with SHA to delay at this stage pending further discussion on TFA
milestones
Agreed with SHA to delay at this stage pending further discussion on TFA
milestones
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

Notes
Ref Indicator Details
Thresholds
1a
1b
1c
The SHA will not utilise a general rounding principle when considering compliance with these targets and standards, e.g. a performance of 94.5% will be considered as failing to
achieve a 95% target. However, exceptional cases may be considered on an individual basis, taking into account issues such as low activity or thresholds that have little or no tolerance
against the target, e.g. those set between 99-100%.
Data
Completeness:
Community
Services
Data
Completeness
Community
Services (further
data):
Mental Health
MDS
Data completeness levels for trusts commissioned to provide community services, using Community Information Data Set (CIDS) definitions, to
consist of:
- Referral to treatment times – consultant-led treatment in hospitals and Allied Healthcare Professional-led treatments in the community;
- Community treatment activity – referrals; and
- Community treatment activity – care contact activity.
While failure against any threshold will score 1.0, the overall impact will be capped at 1.0. Failure of the same measure for three quarters will
result in a red-rating.
Numerator:
all data in the denominator actually captured by the trust electronically (not solely CIDS-specified systems).
Denominator:
all activity data required by CIDS.
The inclusion of this data collection in addition to Monitor's indicators (until the Compliance Framework is changed) is in order for the SHA to track
the Trust's action plan to produce such data.
This data excludes a weighting, and therefore does not currently impact on the Trust's governance risk rating.
Patient identity data completeness metrics (from MHMDS) to consist of:
- NHS number;
- Date of birth;
- Postcode (normal residence);
- Current gender;
- Registered General Medical Practice organisation code; and
- Commissioner organisation code.
1d
Mental Health:
CPA
Numerator:
count of valid entries for each data item above.
(For details of how data items are classified as VALID please refer to the data quality constructions available on the Information Centre’s website:
www.ic.nhs.uk/services/mhmds/dq)
Denominator:
total number of entries.
Outcomes for patients on Care Programme Approach:
• Employment status:
Numerator:
the number of adults in the denominator whose employment status is known at the time of their most recent assessment, formal review or other
multi-disciplinary care planning meeting, in a financial year. Include only those whose assessments or reviews were carried out during the
reference period. The reference period is the last 12 months working back from the end of the reported month.
Denominator:
the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during the
reported month.
• Accommodation status:
Numerator:
the number of adults in the denominator whose accommodation status (i.e. settled or non-settled accommodation) is known at the time of their
most recent assessment, formal review or other multi-disciplinary care planning meeting. Include only those whose assessments or reviews were
carried out during the reference period. The reference period is the last 12 months working back from the end of the reported month.
Denominator:
the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during the
reported month.
• Having a Health of the Nation Outcome Scales (HoNOS) assessment in the past 12 months:
Numerator:
The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months.
Denominator:
The total number of adults who have received secondary mental health services and who were on the CPA during the reference period.
2a-c
2d
3a
3b
RTT
Learning
Disabilities:
Access to
healthcare
Cancer:
31 day wait
Cancer:
62 day wait
Performance is measured on an aggregate (rather than specialty) basis and trusts are required to meet the threshold on a monthly basis.
Consequently, any failure in one month is considered to be a quarterly failure. Failure in any month of a quarter following two quarters’ failure of
the same measure represents a third successive quarter failure and should be reported via the exception reporting process.
Will apply to consultant-led admitted, non-admitted and incomplete pathways provided. While failure against any threshold will score 1.0, the
overall impact will be capped at 2.0. The measures apply to acute patients whether in an acute or community setting. Where a trust with existing
acute facilities acquires a community hospital, performance will be assessed on a combined basis.
The SHA will take account of breaches of the referral to treatment target in 2011/12 when considering consecutive failures of the referral to
treatment target in 2012/13. For example, if a trust fails the 2011/12 admitted patients target at quarter 4 and the 2012/13 admitted patients target
in quarters 1 and 2, it will be considered to have breached for three quarters in a row.
Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH,
2008):
a) Does the trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways of care
are reasonably adjusted to meet the health needs of these patients?
b) Does the trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria:
- treatment options;
- complaints procedures; and
- appointments?
c) Does the trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities?
d) Does the trust have protocols in place to routinely include training on providing healthcare to patients with learning disabilities for all staff?
e) Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers?
f) Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings in
routine public reports?
Note: trust boards are required to certify that their trusts meet requirements a) to f) above at the annual plan stage and in each month. Failure to
do so will result in the application of the service performance score for this indicator.
31-day wait: measured from cancer treatment period start date to treatment start date. Failure against any threshold represents a failure against
the overall target. The target will not apply to trusts having five cases or less in a quarter. The SHA will not score trusts failing individual cancer
thresholds but only reporting a single patient breach over the quarter.. Will apply to any community providers providing the specific cancer
treatment pathways
62-day wait: measured from day of receipt of referral to treatment start date. This includes referrals from screening service and other consultants.
Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases or less in a
quarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply to
any community providers providing the specific cancer treatment pathways.
National guidance states that for patients referred from one provider to another, breaches of this target are automatically shared and treated on a
50:50 basis. These breaches may be reallocated in full back to the referring organisation(s) provided the SHA receive evidence of written
agreement to do so between the relevant providers (signed by both Chief Executives) in place at the time the trust makes its monthly declaration
to the SHA.
In the absence of any locally-agreed contractual arrangements, the SHA encourages trusts to work with other providers to reach a local systemwide
agreement on the allocation of cancer target breaches to ensure that patients are treated in a timely manner. Once an agreement of this
nature has been reached, the SHA will consider applying the terms of the agreement to trusts party to the arrangement.
3c
Cancer
Measured from decision to treat to first definitive treatment. The target will not apply to trusts having five cases or fewer in a quarter. The SHA will
not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply to any community
providers providing the specific cancer treatment pathways.

Notes
Ref Indicator Details
3d Cancer
Measured from day of receipt of referral – existing standard (includes referrals from general dental practitioners and any primary care
professional).Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases or
fewer in a quarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will
apply to any community providers providing the specific cancer treatment pathways.
Specific guidance and documentation concerning cancer waiting targets can be found at:
http://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/documentation
3e
A&E
Waiting time is assessed on a site basis: no activity from off-site partner organisations should be included. The 4-hour waiting time indicator will
apply to minor injury units/walk in centres.
3f Mental 7-day follow up:
Numerator:
the number of people under adult mental illness specialties on CPA who were followed up (either by face-to-face contact or by phone discussion)
within seven days of discharge from psychiatric inpatient care.
Denominator:
the total number of people under adult mental illness specialties on CPA who were discharged from psychiatric inpatient care.
All patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed up within
seven days of discharge. Where a patient has been transferred to prison, contact should be made via the prison in-reach team.
Exemptions from both the numerator and the denominator of the indicator include:
- patients who die within seven days of discharge;
- where legal precedence has forced the removal of a patient from the country; or
- patients discharged to another NHS psychiatric inpatient ward.
For 12 month review (from Mental Health Minimum Data Set):
Numerator:
the number of adults in the denominator who have had at least one formal review in the last 12 months.
Denominator:
the total number of adults who have received secondary mental health services during the reporting period (month) who had spent at least 12
months on CPA (by the end of the reporting period OR when their time on CPA ended).
For full details of the changes to the CPA process, please see the implementation guidance Refocusing the Care Programme Approach on the
Department of Health’s website.
3g
Mental Health:
DTOC
Numerator:
the number of non-acute patients (aged 18 and over on admission) per day under consultant and non-consultant-led care whose transfer of care
was delayed during the month. For example, one patient delayed for five days counts as five.
Denominator:
the total number of occupied bed days (consultant-led and non-consultant-led) during the month.
Delayed transfers of care attributable to social care services are included.
3h
Mental Health: I/P
and CRHT
This indicator applies only to admissions to the foundation trust’s mental health psychiatric inpatient care. The following cases can be excluded:
- planned admissions for psychiatric care from specialist units;
- internal transfers of service users between wards in a trust and transfers from other trusts;
- patients recalled on Community Treatment Orders; or
- patients on leave under Section 17 of the Mental Health Act 1983.
The indicator applies to users of working age (16-65) only, unless otherwise contracted. An admission has been gate-kept by a crisis resolution
team if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted in
admission.
For full details of the features of gate-keeping, please see Guidance Statement on Fidelity and Best Practice for Crisis Services on the
Department of Health’s website. As set out in this guidance, the crisis resolution home treatment team should:
a) provide a mobile 24 hour, seven days a week response to requests for assessments;
b) be actively involved in all requests for admission: for the avoidance of doubt, ‘actively involved’ requires face-to-face contact unless it can be
demonstrated that face-to-face contact was not appropriate or possible. For each case where face-to-face contact is deemed inappropriate, a
declaration that the face-to-face contact was not the most appropriate action from a clinical perspective will be required;
c) be notified of all pending Mental Health Act assessments;
d) be assessing all these cases before admission happens; and
e) be central to the decision making process in conjunction with the rest of the multidisciplinary team.
3i
Mental Health
Ambulance
Cat A
Monthly performance against commissioner contract. Threshold represents a minimum level of performance against contract performance,
rounded down.
For patients with immediately life-threatening conditions.
3j-k
The Operating Framework for 2012-13 requires all Ambulance Trusts to reach 75 per cent of urgent cases, Category A patients, within 8 minutes.
From 1 June 2012, Category A cases will be split into Red 1 and Red 2 calls:
• Red 1 calls are patients who are suffering cardiac arrest, are unconscious or who have stopped breathing.
• Red 2 calls are serious cases, but are not ones where up to 60 additional seconds will affect a patient’s outcome, for example diabetic
episodes and fits.
Ambulance Trusts will be required to improve their performance to show they can reach 80 per cent of Red 1 calls within 8 minutes by April 2013.
Will apply to any inpatient facility with a centrally set C. difficile objective. Where a trust with existing acute facilities acquires a community
hospital, the combined objective will be an aggregate of the two organisations’ separate objectives. Both avoidable and unavoidable cases of C.
difficile will be taken into account for regulatory purposes.
Where there is no objective (i.e. if a mental health trust without a C. difficile objective acquires a community provider without an allocated C.
difficile objective) we will not apply a C. difficile score to the trust’s governance risk rating.
4a
C.Diff
Monitor’s annual de minimis limit for cases of C. difficile is set at 12. However, Monitor may consider scoring cases of

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SWBQS (5/13) 085
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8 Tissue ViabiÈity uÉdate
SWBQS (5/13) 068
SWBQS (5/13) 068 (a)
ÄÇÇÅ
Mrs Talbot ÄsÄntÄd anupdat Ä pr Ä ontissu Æ viability which Ä sh thÄ rÄmindÄd
ÄÄ Committ had bÄÄninstigat Äd by a Äqu Äst r from Ässor Prof Lilford a
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Äd port at
SandwÄll Hospital Är was thanat high ÇÅ City Mrs Hospita Talbot Äd advisÄ
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rÄasons for Ä wÄrÄ this varianc not c
Dr Sahota highlight Äd that Ä th Trust had
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& ÄÄ Quality Ärts Å Al Committ routin Äly
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advis
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ÇÄvÄl of 80% of all ÄÅ deaths was
being targeted and that learning needed to be distilled from cases where possible.
P½¾¿ ÀÁ Âà ÀÀ

11 Patieæt stçry fçr the Trust Bçard Verbaè
SWBQS (5/13) 085
Ms Dutton commented that the delivery of the patient story at the last Trust Board
meeting had been well received. Mr Samuda suggested that a story from a
complainant should be presented at a future meeting.
12 Cçéêèaiæts deveèçêéeæt êèaæ: uêdate
SWBQS (5/13) 072
SWBQS (5/13) 072 (a)
SWBQS (5/13) 072 (b)
Ms Binns advised that progress with the majority of actions within the complaints
development plan were on track to be delivered as planned.
It was reported that the information currently available on the Trusts internet site
was to be amended and a leaflet was being developed providing guidance on how
concerns might be managed. It was reported that the leaflet would be issued in the
top five most common languages.
Ms Dutton asked whether the necessary co-operation was being gained from the
organisation to deliver the plan effectively. Ms Binns confirmed that this was the
case.
Miss Dhami advised that the Trust currently had 49 overdue complaints, which
were being monitored on a weekly basis.
It was reported that the Key Performance Indicators (KPIs), both core and
developmental, that would be used to monitor the effectiveness of complaints
handling were being developed. Ms Binns suggested that these might include the
number of days to receive the information from clinicians to inform the responses
to be issued and the number of days to acknowledge a complaint received. In
terms of developmental KPIs, it was suggested that these might include the
number of complaints handled locally and the number of complainants satisfied
with their responses. Dr Sahota suggested that the number of compliments
received should also be recorded if possible.
13 Seriçus Iæcideæt reêçrt
SWBQS (5/13) 073
SWBQS (5/13) 073 (a)
SWBQS (5/13) 073 (b)
The latest Serious Incident report was presented for receiving and acceptance. Ms
Binns advised that it was proposed to amend the report in future to allow the most
up to date information to be incorporated. It was proposed that the key themes
and trends should be included within future reports and that matters would be
reported to the Trust Board by exception.
Ms Dutton suggested that there remained a need to see the data, however there
was a reliance on the Executive to manage the process and act on the data.
Dr Sahota suggested that incidents 1, 2, 3 and 4 presented a particular concern
from an infection control perspective.
Pßàá âã äå ââ

17 Fòuödatiòö Trust Quaõity Gòveröaöce Verbaõ
REPORT BACø ùúûü ýþÿ ûüü¡ýýÿÿ¢
SWBQS (5/13) 085
Mrs Hunjan asked whether the new approach to reporting would impact on the
Trusts assessment against the Board Governance Assurance Framework (BGAF) or
Quality Governance Assurance Framework (QGAF). She was advised that this was
not the case.
The Committee agreed that the revised approach to reporting serious incident
information was acceptable.
14 Seriòus graded còóôõaiöts reôòrt
SWBQS (5/13) 074
SWBQS (5/13) 074 (a)
It was reported that during the month, one red graded and six amber graded
complaints had been received.
It was highlighted that some incidents were associated with these complaints.
15 Cõiöicaõ Audit fòrward ôõaö: òutturö reôòrt
SWBQS (5/13) 075
SWBQS (5/13) 075 (a)
The Committee was presented with an assessment of the delivery of the Clinical
Audit forward plan for 2012/13. It was highlighted that there had been good
participation in national audits.
Ms Dutton encouraged learning from the audits to be disseminated.
MATTERS FOR RECEIPT AND ACCEPTANCE
16 CQC actiòö ôõaö uôdate
SWBQS (5/13) 076
SWBQS (5/13) 076 (a) ÷
SWBQS (5/13) 076 (c)
The Committee received the updated action plans to achieve compliance with
Outcomes 2 and 16.
Miss Dhami advised that from October/November 2013, a self-assessment against
the Quality Governance Assurance Framework would need to be undertaken, with
a view to submitting a final version by December 2013.
18 Quaõity & Safety Còóóittee chairs aööuaõ reôòrt
SWBQS (5/13) 077
SWBQS (5/13) 077 (a)
The Committee received and accepted the Quality & Safety Committee chairs
annual report.
£¤ ¥¦tient¢¦fety òmite ¢W§¨¢ ©£ 4
Dr Stedman reported that the Committee had discussed the launch of the
Surviving Sepsis campaign. Ms Dutton suggested that the Committee should
receive an update on the Trusts compliance with Child Protection requirements at
Pëìí îï ðñ îî

a future meeting.
SWBQS (5/13) 085
The Committee was also reported to have considered mental capacity issues and
the elderly & frailty agenda.
It was highlighted that the position concerning the number of unmanaged
incidents had improved.
ACTION:
Miss t Overfied a rvide udate the Trusts ciace
with Prtecti Chid t requirements futuremeting
tient !e"omite xperien
The Committee was advised that the Patient Experience Committee had not met
during the month.
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The Committee received and accepted the update from the Clinical Effectiveness
Committee.
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Miss Dhami advised that the divisions would be asked to self-assess themselves
against a set of indicators, which would evaluate the robustness of the governance
arrangements which were in place.
In terms of action plans, it was highlighted that a central repository of corporate
action plans would be created.
# 234 031/05
./0U1
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The Quality and Safety Committee received and noted the minutes from the
Clinical Quality Review Group meeting held on 8 April 2013.
4
-nyother 9usines
Ver9l
Ms Dutton noted that recent media coverage had suggested that the NHS was poor
at managing the administration of intravenous (IV) fluids and asked whether one of
the quality committees was focussed on this. Mrs Talbot advised that a training
and assessment programme was in place, however the prescription element of IV
medicines needed better consideration.
It was agreed to prompt discussion of matter such as this, a standard item needed
to be added to the agenda of future meetings, National and Topical Issues.
Dr Sahota reported that Birmingham City Council was establishing Social Care
P

25 DetaiAs Bf the Cext DeetiCg VerbaA
Boards, which may influence the handling of delayed transfers of care.
SWBQS (5/13) 085
The date of the next meeting of the Quality and Safety Committee was reported to
be 21 June 2013 at 0930h in the D29 (Corporate Suite) Meeting Room, City
Hospital.
SigCed
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3.9% ÀǪ) ¦° ª³«¹¨ª (66 ¯°Æ¦±¯¨°±ª ¦° 49 ¯° ÀÇ)
• À° «Å ׯŨ Ȧ¹¨ á ±­¨ ¹¦±¨ «Å ±­¨ °´º¬¨¹ «Å Ʀ±¯¨°±ª ¦³­¯¨Â¯°§ ƹ¨Å¨¹¹¨ Æ©¦³¨ «Å
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85%).
87.56% (

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• üñìç õóçêòöòêåîîï
• ÿ÷çéç òõ ìñí÷òìæ õóçêòöòê íñ ìñíç ñ çé åìð å¡ñ ç í÷ç ñí÷çé ¢åííçéõ ÷òæ÷îòæ÷íçð å¡ñ çþ
SWBTB (3/13) 051 (a)
• ÿ÷ç ÿéëõí òõ êëééçìíîï ¢ççíòìæ òíõ ñ çéåîî ¢åìðåíñéyíéåòìòìæ íåéæçí åí 88.13% (íåéæçí 85%).
• 䣤 éåíçõ åéç îñúçé í÷åì ñëé íåéæçí éåíç åí 70.34% (íåéæçí 85%).
• ¥òêûìçõõ å¡õçìêç úåõ 4.54% òì ¦óéòî§ ú÷òê÷ éç¢åòìõ å¡ñ ç í÷ç íåéæçí (3.5%) ¡ëí òõ å õò¢òîåé
öòæëéç íñ í÷ç õå¢ç íò¢ç îåõí ïçåé.
3 TARGETED AREAS OF SUPPORT
úç åéç åîõñ îññûòìæ êîñõçîï åí üýþ
4 EMERGING TRENDS/NOTICEABLE PATTERNS
5 OF SPECIFIC NOTE
6 KEY CLINICAL RISKS
ã | ä å æ ç

6 | ¨ ©
SWBTB (3/13) 051 (a)
7 CARE QUALITY COMMISSIONS QUALITY AND RISK PROFILE
y ! " # $

SWBTB (6/13) 121 (a)
8 PATIENT SAFETY
8.1 Safety Thermometer
Apr-12
May-
12
Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12
Dec-
12
Jan-13 Feb-13 Mar-13
91.12
%↑
94.75
%↑
93.74%
↓
93.55%
↓
93.79%
↑
93.43%
↓
91.52%
↓
93.78%
↑
92.47
%↓
94%
↑
96%
↑
95%
↓
Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sept-13
Oct-13
Nov-13
Dec-13
Jan-
14
Feb-
14
Mar
-14
95%↓ 93.5%↓ 94.83%↑
Figure 1: %armfrecaretrend
7 | P a g e

8 | & ' ( )
SWBTB (3/13) 051 (a)
Figure 2: Number of patients by type
./0/1/231 6 4'-/)3-1 )54)6/)3+)7 1 new harm8 No 4'-/)3-1 )54)6/)3+)7 2, 3 or 4 harms
*+,-)
6 4'-/)3-1 )54)6/)3+)7 1 new harm8 1 4'-/)3- )54)6/)3+)7 2 harms. No 4'-/)3-1
92::,3/-y./0/1/23
3 or 4 harms.
)54)6/)3+)7
a) Falls
'6) 32 =26:'> -'6()-1 1)- =26 ='>>1 =26 ?@A?BAC 2->1 '+6211 -

SWBTB (3/13) 051 (a)
Figure 3: Trend of falls
Figure 4: Incidence of falls per 1000 bed days across Acute Inpatient Divisions
OPQRS TU V OWXSN
MONTH Ward/Area Grade of Fall Injury TTR outcome
RED Preventable
RED Preventable
RED Awaiting TTR
Figure 5: Falls resulting in serious injury from April 2013- March 2014 (City and Sandwell Hospital)
J | K L M N

) Pressure Damage
SWBTB (3/13) 051 (a)
75
50
25
0
Apr M ay Jun Jul Aug Sep Oct Nov Dec Jan Feb M ar
2009-2010 2010-2011 2011-2012 2012-2013
Figure 6: Number of hospital acquired pressure damage Grade 2, 3 & 4, April 2009 - July 2012
Grade of Sore 2012-2013
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
12/13 Total
Grade 2 21 16 17 21 11 14 11 11 11 7 9 9 158
Grade 3 2 2 2 2 3 3 1 0 3 3 0 3 24
klmnop
Grade 4 0 0 0 0 0 0 0 0 0 0 0 0 0
Trust Total 23 18 19 23 14 17 12 11 14 10 9 12 182
7: Table of avoidable hospital acquired pressure ulcers by grade
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c) VTE Risk Assessment
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8.2 Nutrition/Fluids
SWBTB (3/13) 051 (a)
Figure 8: Nutrition Audit Results
8.3 Infection Control
MRSA
¤¥¦§¦ ¨¦§¦ ©ª «ª¬­®¯8 ¥ª°§ ±²³´ µ·­¦§¦¸¹ ºª§ ´«§¹». ¤¥¦ ­ª­» ©°¸µ¦§ ªº ±²³´ µ·­¦§¦¸¹ ­ª ¼­¦ ¹¬ 1.
MRSA Screening
MRSA Screening
- Elective
MRSA Screening
- Non
Elective
Patient Not Matched
Figure 9: MRSA screening eligibility
To Date (*=most
recent month)
TARGET
YTD 13/14
% 173.2* 86 90
Best Practice - Patient Matched % 59.9* 71 80
Patient Not Matched
% 82.2* 86 90
Best Practice - Patient Matched % 72.6* 71 80
ŸŸ | ¡ ¢ £

SWBTB (3/13) 051 (a)
Clostridium difficile
ÈÃ
ÇÃ
ÆÃ
ÅÃ
ÄÃ
Ã
ÉÊËÌÄÆ ÍÎyÌÄÆ ÏÐÑÌÄÆ ÏÐÒÌÄÆ ÉÐÓÌÄÆ ÔÕÊÌÄÆ Ö×ØÌÄÆ ÙÚÛÌÄÆ ÜÕ×ÌÄÆ ÏÎÑÌÄÇ ÝÕÞÌÄÇ ÍÎËÌÄÇ
æçèy éêëäìêíåâ îïðñðåàèçòäó éëðìè éíèàå îïðñðåàèçòäó
ßàáâãäåå
2013-2014
Sandwell ô õ
ö ô
÷ ô õ õ õ õ õ õ õ õ õ õ
Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Total
1
City 3
Trust 4
DoH Trajectory 46
Trust Total (cumulative) -
Threshold (cumulative) 8 12 16 20 24 28 32 36 40 43 46 -
Figure 10: SHA Reportable CDI
6
5
4
3
2
1
0
ùúû-13 üýþ-13 ÿ ¡-13 ÿ ¢-13 ù £-13 ¤¥ú-13 ¦§¨-13 ©-13 ¥§-13 ÿý¡-14 ¥-14 üýû-14
Figure 11: Trust Best Practice Data
2013-2014
Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Total
Sandwell 5 3 8
City 2 3 5
Trust 7 6 0 0 0 0 0 0 0 0 0 0 13
Intermediate Care 0 0 0 0 0 0 0 0 0 0 0 0 0
Trust Total (cumulative) 7 13 13 13 13 13 13 13 13 13 13 13 -
½¾ | ¿ À Á Â

Blood Contaminants
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
Percentage Possibly Contaminated
Consultant Data City
Consultant Data Sand
SWBTB (3/13) 051 (a)
0.0%
05/2012 06/2012 07/2012 08/2012 09/2012 10/2012 11/2012 12/2012 01/2013 02/2013 03/2013 04/2103 05/2013
Figure 12: Blood Contaminants
E Coli Bacteraemia
%
$
#
"
!
&'()!# *+y)!# ,-.)!# ,-/)!# &-0)!# 12')!# 345)!# 678)!# 924)!# ,+.)!$ :2;)!$ *+()!$
Figure 13: E Coli Bacteraemia
MSSA
?@ABB CDEy FGHIE FJE=B KLHMHB=EDNAO
"
&'()!# *+y)!# ,-.)!# ,-/)!# &-0)!# 12')!# 345)!# 678)!# 924)!# ,+.)!$ :2;)!$ *+()!$
Figure 14: MSSA
?@ABB CDEy FPGAIPJB? KLHMHB=EDNAO FGHIE FJE=B KLHMHB=EDNAO
|

Post-Partum Haemorrhage (PPH)(>2000ml): tXV]V kV]V l cT\^Ve\[ ]V_a]bVb \a XTmV XTb T SSn ai
Adjusted Perinatal Mortality Rate (per 1000 babies): \XV Tbsd[\Vb cV]^eT\Tg fa]\Tg^\y]T\V ia]
thl kX^_X kT[ ZVgak \XV \]TsV_\a]yu 8) Teb kT[ gakV] \XTe \XV c]Vm^ad[ fae\X (13.2). SV]^eT\Tg
kT[
]T\V[ fd[\ ZV _ae[^bV]Vb T[ T 3 vVT] ]agg^eU TmV]TUV bdV \a \XV [fTgg edfZV][ ^emagmVb Teb
fa]\Tg^\v
SWBTB (3/13) 051 (a)
8.4 Maternity
WXV YZ[\V\]^_ `T[XZaT]b ^[ c]abd_Vb ae T fae\XgyZT[^[h Yi ea\Vj
opqqqfg ^e rT]_X
rT]_X
\XV [^Ue^i^_Te\ mT]^Te_V[ i]af fae\X \a fae\X.
Caesarean Section \XV edfZV] ai _TV[T]VTe [V_\^ae[ _T]]^Vb ad\ ^e rT]_X kT[ Rate: kX^_X ^[
25.4%,
\XV \]TsV_\a]v ai 25% amV] \XV vVT] Teb X^UXV] \XTe \XV c]Vm^ad[ fae\X.
TZamV
Delivery Decision Interval (Grade I, CS) >30 mins: \XV bVg^mV]v bV_^[^ae ^e\V]mTg ]T\V ia] rT]_X kT[ 9%
kX^_X ^[ ZVgak \XV \]TsV_\a]v (15).
Community Midwife Caseload (bi-monthly): WXV _affde^\v f^bk^iV _T[VgaTb ^e rT]_X kT[ 127, kX^_X
^[ ZVgak \XV \]TsV_\a]v ai 140.
8.5 Medicine Management
Antibiotic Stewardship CQUIN
ca^e\ c]VmTgVe_V Tdb^\[ ai Te\^Z^a\^_ c]V[_]^Z^eU T_]a[[ Tgg ^ecT\^Ve\ T]VT[ T]V _T]]^Vb ad\; \XV
rae\Xgv
ia] wVZ]dT]v Teb rT]_X T]V [dffT]^[Vb ZVgak:
]V[dg\[
2013
Indicator SWBH City Sandwell Baseline
624 314 310 -
% 97.9% 97.1% 98.7% 91.7%
% 34.6% 30.3% 39.0% 30.8%
% 17.5% 17.2% 17.7% 14.6%
% 48 63.3% 66.7% 60.0% 61.4%
% {{h{% {{h{% {{hq% |h}%
% withstop ~review Ttedocumentedon d
Trt drugch 84.7% 81.1% 87.6% 77.1%
% 73.1% 69.5% 76.0% 8.8%
% 95.8% 97.9% 94.2% 87.5%
QR | S T U V

“¤•‚–‡„ £•”ˆ ”ˆ„ ”†Ž—” ƒŽ•¡„¤•–„— ’„¤¤ ”‘ 92.9% ‡‘ “‚†„¡ ”‘ 95.8% •– ¨„ †Ž‚†§, Ž” †„ ‚•–— ‚ ‘¦„
¥‘
”‚†ƒ„” ( ›Š%ªœ
”ˆ„
SWBTB (3/13) 051 (a)
‰Š‹Œ
…‚†‡ˆ
Indicator SWBH City Sandwell Baseline
„† “‚”•„–”— Ž š
6‹˜ ‘’ Œ‰
‘– ž ‚–”• •‘”•‡—
‘– ‚–”• ž •‘”•‡— ’‘† ”ˆ‚– ‘†„ ˆ‘Ž†—
‘– •‘”•‡— ‚–”• Ÿ ’‘† ¡‚y—
£•”ˆ ¡†Žƒ •–¡•‡‚”•‘– ‡ˆ‚†” ¡‘‡Ž „–”„¡ ‘–
‚–”• £•”ˆ •‘”•‡— •– ¤•–„ £•”ˆ ƒŽ•¡„¤•–„—
% with ‚llergy ‚tus documented st
97.2% ›˜œ‹% ›˜œ% 91.7%
‰˜5
% on ‚ntiotics Œœ‰% Œ6œ% Œ‰œ5% ŒŠœ8%
% 14.7% 14.2% 15.2% 14.6%
% 48 58.2% 56.4% 59.6% 61.4%
% ‹Šœ›% ‹Œœ‹% ›œ‹% ›œ˜%
% withstop ¢review ‚tedocumentedondrugch ‚rt d
83.4% 81.0% 85.6% 77.1%
% 70.1% 68.0% 72.1% 8.8%
% 92.9% 95% 91% 87.5%
“¤•‚–‡„ £•”ˆ †„‡‘†¡•–ƒ ‘’ —”‘“ ‘† †„¦•„£ ¡‚”„— ¡„‡¤•–„¡ —¤•ƒˆ”¤§ •– …‚†‡ˆ (83.4%) ‡‘ “‚†„¡ ”‘
¥‘
†Ž‚†§ (84.7%) Ž” †„ ‚•–„¡ ‚ ‘¦„ ”ˆ„ ‚—„¤•–„ ‚——„—— „–” (77.1%).
¨„
‘’ ”ˆ„ •–¡•‡‚”•‘– ’‘† ‚–”• •‘”•‡— ‘– ”ˆ„ ¡†Žƒ ‡ˆ‚†” ’„¤¤ —¤•ƒˆ”¤§ ”‘ 70.1% ‡‘
©„‡‘†¡•–ƒ
†Ž‚†§ ’•ƒŽ†„ ‘’ 73.1%, Ž” †„ ‚•–— £„¤¤ ‚ ‘¦„ ”ˆ„ ‚—„¤•–„ ‘’ 8.8%.
¨„
“‚†„¡ ”‘ ”ˆ„
Warfarin CQUIN
«hequ ‚rterly ‚udit ‚tients ofp ‚dmittedt ‚kingw ‚nN© ‚ ‚rf ‚rinwith ove5 —‚geh‚d whosedo en
‚djustedor reviewedprior to ¬ w‚s ‚rriedout c over ‚ ‹ wek …‚rch periodin œ thenext dose
¥omp ¤•‚nceof ‹ŠŠ% œ w‚s ‚chieved
Drug Storage Audits
­‚rddru
‚rised summ elow
‚ge‚udits gstor ‚rec ® ‚rriedout theresults ¯‚nu‚ry ¬ monthly ¨eru ‚ry for ‚nd…‚rch ‚re
°
±„ner‚l ²rugs
¥omp ¤•‚nce ¯‚nu‚ry ¨eru ‚ry
…‚rch
›Šš‹ŠŠ% ›Œ% 80% 75%
70-89% 100% 100% 100%
¥‘–”†‘¤¤„¡ ²†Žƒ—
“¤•‚–‡„ ¯‚–Ž‚†§ ¨„ †Ž‚†§ …‚†‡ˆ
¥‘
90-100% 80% 80% 80%
70-89% 90% 85% 90%
50-69% 100% 100% 100%
€ | ‚ ƒ „

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SWBTB (3/13) 051 (a)
8.6 Incidents
Incidents
1800
1600
1400
Number
1200
1000
800
600
2011/12
2012/13
2013/14
400
200
0
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Month
Incidents in May 2013
Total Number of Incidents reported 1631
Of the total: (* incidents still under investigation)
Near miss 220
No Harm 840
Low (minimal harm) 447
Moderate 113
Severe (permanent or long term harm) 7
*Death (related to the patient safety incident) 4
"Top 5" Reporters (Acute)
1 Emergency Departments (both) 275
2 Labour Ward 58
3 Emergency Assessment Unit 48
4 Priory 5 42
5 D41 35
"Top 3" Reporters (Community)
1 Community Nurses Mesty 34
2 Community Nurses Mace 28

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åÓæÞåÝÙßÒ
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3 Community Nurses Cross 21
"Top 5" Type**
1 Verbal abuse (patient on staff) 117
2 Communication failure - with patient/team 54
3 Pressure sores – community acquired 45
4 Clinical Assessment - other 32
5 Organisational issues - other 29
** 317 incidents are not yet assigned to a causative group
ÔÕÕÖÓ×ØÙÕÚ ÛÜÝÙÞß ÝÞ ÝÑÚÓ×ÝÑÚÓß àáÞ ây àáÓß ây
SWBTB (3/13) 051 (a)
óÜÝÞâÓå ôõö÷
ßÑÝÙÞßÑê ÓÑåêñ çÑåßÙßÒ ÕÜÞåÓ ÜáÑåÝë
8.7 Serious Incidents (SIs)
Ôß May 2013 ÝáÓåÓ çÓåÓ ô ßÓç ðÔ åÓæÞåÝÓè ÝÞ ììø
1 2013/14566 Acute Medicine
ùÑÙêÖåÓ ÝÞ éÑßÑÒÓ ðÓæÕÙÕ Ñßè ÕÖâÞæÝÙéÑê ÜÑåÓ Þä Ñ èÓÝÓåÙÞåÑÝÙßÒ æÑÝÙÓßÝ
2 2013/15156 Maternity
úßÓûæÓÜÝÓè èÓÑÝá Þä Ñ ßÓÞßÑÝÓ
ÎÏ | Ð Ñ Ò Ó

£ ¤¥¦§£ ¥¨©¥ ¨£ ¤ ¦¤ ¥¨ ¢ ÿ¤þ¢ þ¦ ¦ ¨¦ ¥¨©§ ¤ ££§¤ £¦¤ £ ¤þ©§¤ £ ¤ £§¥¨ÿ
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SWBTB (3/13) 051 (a)
SI's reported
Number
14
12
10
8
6
4
2
2011/12
2012/13
2013/14
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Month
¥£ ©¥¦¨ ¦ þ þ ¨ ¢¦ y ¢ ¨
££§
y
ý
¤ ¦¤ þ£ £ ¤¥¦§£
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8.8 Patient Safety Walkabouts
¦¨ ¤¦ ¢ ¥¦ ýþ¥ ¨ $þ yþþ¦§£ þ¨¦¢ ¤ ¦ ¢þ þ ¨ þ© %¨ 7 þy !"
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þ ¥y&¦£¥þ þ£ ¥£¥ þ¨ ¦¨ ' (§¨ !" )*¨¦¨ +¤¦§¨)*¨¦¨ ! þ $þ¨ þ£ ¥£¥
7
8.9 Inquests
§¤¥¨ÿ þy !"

SWBTB (3/13) 051 (a)
New Inquests
14
12
Number
10
8
6
4
2011/12
2012/13
2013/14
2
0
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Month
91y :;8?53@A B1@3@ C363 BDE@3FG
456782
H D1623 85IJ36 EK 78?53@A@ C363 BDE@3F KEDDEC782 1 63L73C EK E56 B1@3@G MN7@ 63L73C 7@ E82E782
18F AN3 85IJ36 EK BDE@3F K7D3@ 7@ 1D@E D7O3DP AE J3 N72N 78 Q583G
Inquests Closed
80
70
60
Number
50
40
30
20
10
2011/12
2012/13
2013/14
0
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Month
./ | 0 1 2 3

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XYUZVW
cybYW X^]^ZW]
a[]W_bWa
qUy rstik
SWBTB (3/13) 051 (a)
Issue / Risk Action to take / taken Who by When by
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Medicine
SWBTB (6/13) 121 (a)
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SWBTB (3/13) 051 (a)
Community
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24 | P a g e

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HSMR (Source: Dr Foster)
SWBTB (3/13) 051 (a)
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Summary Hospital Level Mortality Indicator (SHMI)
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Š‹ƒ Š . „…ƒ †‘œ ŠŽŸŒ– ƒˆ ŒŒ ƒ ‹…ˆ –‰ ‹‡ 30 ¥ˆ —‹ƒ …‡ˆ‰Š‹ Œ ŠˆŸ… ‚ƒ. „…ƒ „ –ˆ‹ †‘œ —‡ ‹…ƒ
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SWBTB (3/13) 051 (a)
Mortality table 2012/13
Apr May June July Aug Sept Oct Nov Dec Jan Feb
Internal Data:
µ·¸¹º»¼ ½¾»º¿· ÀÁ ÀÃ6 ÀÂ5 ÀÀ8 130 124 144 106 140 157 148
Dr Foster 56 HSMR Groups:
½¾»º¿· 110 129 111 100 113 101 126 90 126 132 140
µÄÅÆ (ÅǺ¿) ÈÉÊ·º 84.6 89.2 89.7 85.5 83.9 84.8 92.6 65.0 83.2 81.4 102.5
µÄÅÆ (ÅǺ¿) ˹ºÌ 84.5 74.7 82.0 75.2 80.5 85.5 71.8 66.1 62.9 73.9 89.1
µÄÅÆ (ÅǺ¿) Ä»ÇÍξ¼¼ 101.9 117.1 100.5 95.3 87.5 84.2 112.6 63.6 103.8 88.3 121.4
µÄÅÆ (12 ÏǺ¿ ÐÊÏʼ»º¹Ñ¾) ÈÉÊ·º 89.7 88.3 96.4 95.5 94.2 93.1 92.7 90.5 89.1 87.8 88.1
µÄÅÆ (12 ÏǺ¿ ÐÊÏʼ»º¹Ñ¾) ˹ºÌ 87.6 84.3 84.8 83.6 83.1 83.3 81.7 79.7 76.6 78.2 77.2
µÄÅÆ (12 ÏǺ¿ ÐÊÏʼ»º¹Ñ¾) Ä»ÇÍξ¼¼ 109.1 109.0 108.8 107.9 105.9 103.5 104.1 101.7 101.9 99.7 99.3
ÔÑ»¼Ê»º¹Ç ½»º» (µÔ½) ĵÅÕ
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16:
96.2 96.0 96.3 95.3 94.2 95.6 94.9 94.4 94.2 94.3
µÄÅÆ (Ò¾¾É ÄµÓ 12 ÏǺ¿ ÐÊÏʼ»º¹Ñ¾) 94.9 93.3 101.3 100.2 98.7 97.0 96.7 96.4 97.0 96.7 97
Figure 17: HSMR/Readmission rate data April 05 - February 13
¯° | ± ² ³ ´

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CQC Mortality Alerts received in 2012/13
SWBTB (3/13) 051 (a)
åæ çäè éæêëâìíëyæîëìíäê âìäêëï ðâñä òääç êäóäíñäôõ
Dr Foster generated alerts (Quality Investigator Tool)
öç ëðä ôâëâ ÷äêíæô ø÷êíì ùúûù
National Clinical Audit Supplier Potential Outlier Alerts
åæ çäè ÷æëäçëíâì æîëìíäê âìäêëï ðâñä òääç çæëíþíäôõ
9.2 Clinical Audit
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SWBTB (3/13) 051 (a)

o.8 Ward Clinical Dashboard
31 | P a g e
MRSA bacteraemias (post
48 hours) - No
MRSA Screening - Elective -
%
MRSA Screening - Non
Elective - %
Hand Hygiene - %
Red Incidents - No
Amber Incidents - No
Falls - Total (Acute) hosp
acquired avoidable - No
VIP monitoring - %
Safety Thermometer -
Harm Free - %
Safety Thermometer -
Catheters & UTIs - %
Safety Thermometer - No
New Harms - %
Complaints - No
SWBTB (6/13) 121 (a)
BTC - Adult Surgical Unit 0■ 0■ 96▲ ■ 0■ 1▼ 4▼ 0■ ■ ■ 0■ ■ ■ ■ ■ ■ 0▼ 75■ 86▼ 5▲ 57▼ 72■
CCS - Critical Care Services -
City
0▼ 0■ 0▼ 88▼ 0▼ 0■ 4▼ 0■ 1■ 0■ 84■ 100■ 0■ 100■ 0▼ 85■ 91▼ 7▼ 80▼
Coronary Care Unit - City 0■ 0■ 83▼ 0■ 0■ 0■ 0■ 0■ 0■ 100■ 0■ 74■ 91▼ 3▼ 65▼ 92■
Coronary Care Unit - Sandw ell 0■ 0■ 66▲ 91▼ 0■ 0■ 1▼ 0■ ■ ■ 0■ 0■ 86■ 100▲ 0■ 100■ 0■ 90■ 88▲ 2▼ 81■ 85■
Critical Care - Sandw ell 0■ 0■ ■ 100■ 97▲ 0■ 18▼ 0■ ■ ■ 4■ 0■ 66■ 90▲ 10▼ 90▲ 0■ 96■ 93▼ 10▼ 75▼ ■
D12 - Isolation 0■ 0■ 0▼ 80▲ 98▼ 0■ 0■ 0■ 100▲ 1▼ 0■ 0■ 79■ 100■ 0■ 100■ 4▼ 0■ 88▼ 7▼ 26▲ 64■
D15 - Medical 0■ 0■ 50▼ 25▼ 91▼ 0■ 0■ 0■ 77▼ 3▲ 0■ 7■ 46■ 100▲ 0■ 100■ 8▼ 71■ 74▼ 0▲ 45▼ 58■
D16 - Medical 0■ 0■ ■ ■ 86▼ 0■ 0■ 4■ 91▼ 2▼ 0■ 16■ 47■ 100▲ 0■ 100■ 2▲ 45■ 72▼ 8▼ 76▲ 44■
D17 - Medical 0■ 0■ ■ 50▲ 100■ 0■ 2▼ 1■ 76▼ 0▲ 1■ 0■ 47■ 88▼ 0■ 100■ 0▼ -2■ 84▼ 5▲ 86▼ 65■
D18 - Medical 0■ 0■ ■ 100▲ 97▼ 0■ 2▼ 4■ 100■ 3▲ 3■ 0■ 94■ 87▲ 0■ 100■ 0▼ 90■ 82▼ 7▲ 76▲ 45■
D19 - Paediatric Medicine 0■ 0■ 0■ 0■ 96▼ 0■ 0■ 0■ ■ ■ 0■ 0■ 100■ 100■ 0■ 100■ 0■ 0■ 94▼ 12▼ 70▼ ■
D21 - Male Surgery ENT/Urology 0■ 0■ 100■ 77■ 0▼ 1▼ 1▼ 2■ 100▲ 3▲ 0■ 0■ 91■ 95▲ 4▲ 100■ 0■ 74■ 92▼ 9▲ 75▼ 56■
D25 - Surgical (Female) 0■ 0■ 100■ 33▼ 0■ 0■ 0■ 0■ 100▲ 1■ 0■ 0■ 100■ 100▲ 0■ 100■ 0▼ 63■ 89▼ 8▲ 53▼ 60■
D27 - Oncology 0■ 0■ 100▼ 0▼ 95▼ 0■ 0■ 0■ 100■ 2▼ 0■ 7■ 71■ 100■ 0■ 100■ 0■ 40■ 82▼ 5▼ 62▼ 66■
D30 - Winter pressures 0■ 0■ ■ 0▼ 98▼ 0■ 0■ 4■ 94▲ 1▲ 1■ 25■ 66■ 100▲ 0■ 100▲ 0■ 0■ 0■ 0■ 0■ ■
D41 - Medical Short Stay Unit 0■ 1▼ 0▼ 25▼ 96▼ 0■ 3▼ 2■ 100■ ■ 0■ 0■ 100■ 93▼ 0▲ 93▼ 0■ 32■ 94▼ 0▲ 71▼ 75■
D7 - Medical 0■ 0■ ■ 0▼ 100▼ 0■ 1▼ 0■ 90▼ 5▲ 0■ 0■ 88■ 87▼ 0■ 95▼ 0■ 0■ 73▼ 7▼ 34▼ 47■
Day Treatment Unit - Sandw ell 0■ 0■ 74▼ 50▼ 0■ 0■ 0■ 0■ ■ ■ 0■ ■ ■ ■ ■ ■ 0▼ 0■ 81▼ 12▲ 50▼ ■
EAU - Sandw ell 0■ 0■ 100▼ 74▲ 0■ 0■ 4▼ 0■ 100■ ■ 0■ 0■ 45■ 42▼ 0■ 100▲ 3▼ 61■ 77▲ 4▲ 51▼ 50■
Lyndon 1 0■ 0■ 0■ 0■ 100▲ 0■ 0■ 0■ ■ ■ 0■ 0■ 58■ 100■ 0■ 100■ 0■ 0■ 89▲ 4▼ 85▲ 73■
Lyndon 2 0■ 0▼ ■ 80▲ 100▲ 0■ 7▼ 0■ 100▲ 0■ 0■ 9■ 62■ 70▼ 5▼ 94▼ 0▼ 31■ 79▼ 21▼ 62▼ 56■
Lyndon 3 0■ 0■ 95▼ ■ 99▲ 0■ 1▼ 1■ 78▼ 0▲ 1■ 0■ 84■ 100■ 0■ 100■ 0▼ 60■ 84▼ 5▼ 51■ 58■
Lyndon 4 0■ 0■ ■ ■ 0▼ 0■ 5▼ 0■ 81▼ 4▼ 1■ 0■ 66■ 90▲ 0▲ 100▲ 0▼ 0■ 82▼ 2▲ 67▼ 56■
Lyndon 5 0■ 0■ ■ 50▲ 97▼ 0■ 2▼ 0■ 94▼ 7▼ 1■ 0■ 61■ 78▼ 6▼ 100■ 0■ 33■ 83▼ 4▼ 64▼ ■
Lyndon Ground 0■ 0■ 0■ 0■ 92▼ 0■ 0■ 0■ ■ ■ 0■ 0■ 100■ 100■ 0■ 100■ 0▼ 0■ 95▲ 3▼ 91▲ 77■
MAU - Mau Transfer - City 1▼ 0■ ■ 63▲ 0■ 0■ 1▼ 0■ 80▼ ■ 0■ 0■ 39■ 100■ 0■ 100■ 2▲ 57■ 86▼ 2▲ 76▲ 64■
Neonatal Unit - City 0■ 0■ ■ ■ 0■ 0■ 0■ 0■ ■ ■ 0■ 0■ 83■ 100■ 0■ 100■ 0■ 0■ 90▲ 4▼ 84▲ ■
New ton 1 Short stay unit 0■ 0■ 0■ 75▲ 0■ 0■ 0■ 2■ ■ ■ 0■ 0■ 78■ 0▼ 0▼ 0▼ 0■ 100■ 54■ 0▲ 100■ 83■
New ton 2 0■ 0■ 95▼ 51▼ 79▼ 0■ 3▼ 2■ 93■ 0■ 0■ 0■ 55■ 93▼ 0■ 100■ 0■ 0■ 88▲ 4▲ 59■ 62■
New ton 3 0■ 0■ 100■ 90▲ 100■ 0■ 2▼ 2■ 100■ 0▲ 0■ 0■ 66■ 100▲ 0■ 100▲ 6▼ 100■ 83▼ 4▼ 29▼ 57■
New ton 4 - Stroke rehab 0■ 0■ ■ 100▲ 100▼ 0■ 2▼ 2■ 100■ 10▼ 0■ 0■ 33■ 100■ 0■ 100■ 4▼ 77■ 82▲ 2▲ 79▲ 48■
New ton 5 0■ 0■ ■ 100■ 96▼ 0■ 1▼ 1■ 100■ 2▼ 0■ 0■ 100■ 91▼ 0■ 100■ 0■ 0■ 94▼ 2▲ 78■ 69■
Ophthalmology Main Ward - City 0■ 0■ 43▼ 71▼ 0■ 0■ 0■ 0■ 100■ 0■ 0■ 0■ 100■ 100■ 0■ 100■ 0■ 76■ 82▼ 5▼ 26▼ 82■
Planned Admissions Unit (D6) 0■ 0■ 97▲ ■ 0■ 0■ 0■ 0■ 100■ ■ 0■ ■ ■ ■ ■ ■ 0▼ 0■ 95▼ 0▲ 100■ 75■
Post Coronary Care - City 0■ 1▼ ■ ■ 0■ 0■ 0■ 0■ 88▲ 0■ 0■ ■ ■ 100■ 0■ 100■ 0■ 0■ 0■ 0■ 0■ ■
Priory 2 0■ 0■ 100■ 50▼ 86▼ 0■ 1▼ 0■ 68▼ 8▼ 1■ 0■ 53■ 78▼ 5▼ 94▼ 0■ 50■ 82▼ 9▼ 93■ 61■
Priory 3 0■ 0■ ■ ■ 98▼ 0■ 1▼ 3■ 96▼ 6▼ 0■ 0■ 100■ 96▲ 0■ 96▲ 0■ 100■ 76▼ 15▼ 33▼ 50■
Priory 4 - acute stroke unit 0■ 1▼ 0▼ 74▼ 97▼ 0■ 5▼ 0■ 95▼ 0▼ 0■ ■ ■ 96▼ 0▼ 100▼ 0▼ 100■ 82▲ 8▼ 79▼ 58■
Priory 5 0■ 0■ 36▲ 25▼ 88▼ 1▼ 7▼ 3■ 92▼ 4▲ 0■ 0■ 69■ 85▼ 0■ 100■ 1▼ 66■ 80▼ 3▲ 90▼ 50■
Priory Ground 0■ 0■ 0■ 0▼ 0■ 0■ 0■ 0■ ■ ■ 0■ 0■ 0■ ■ ■ ■ 0■ 0■ 93▲ 4▲ 62▼ 82■
Surgical Assesment Unit (D42) -
City
C.Difficile Cases (post 48
hours) - No
MUST - within 12 hours of
admission - %
& 4 - No
MUST - Avoidable Weight
Loss - No
Pressure Ulcers - hosp
acquired avoidable grade 3
0■ 0■ 100▼ 93▲ 0■ 0■ 1▼ 2■ 100■ ■ 0■ 0■ 100■ 0▼ 0▼ 0▼ 0▼ 56■ 94■ 1▲ 78▼ 73■
Phlebitis rate - %
Pt Exp - Friends and family
recommendation - %
Mandatory Training Rate -
%
Sickness Absence - %
PDR Completion Rate - %
Trained Nursing Staff - %

SWBTB (6/13) 121 (a)
pq.1 10 Patient PATIENT Survey EXPERIENCE
Results
10.1 Net Promoter
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32 | P a g e

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SWBTB (3/13) 051 (a)
10.2 Complaints
Formal Complaints received
Number
120
100
80
60
40
20
2011/12
2012/13
2013/14
0
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Month
Link Complaints received
Number
18
16
14
12
10
8
6
4
2
0
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Month
2011/12
2012/13
2013/14
š›œ ž–—Ÿ: the complainant has received the substantive response to their complaint but has returned as they remain dissatisfied
•–—˜
and/or require additional clarification.
Complaints comparative data
Context
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Cases referred to the Ombudsman
Number
7
6
5
4
3
2
1
0
2
0
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Month
2011/12
2012/13
2013/14
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10.4 PALS
SWBTB (3/13) 051 (a)
PALS enquiries
250
Number
200
150
100
50
2011/2012
2012/2013
2013/2014
0
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
Month
PALS comparative data
Context
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SWBTB (3/13) 051 (a)
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End of Life Report
referred l eof e h of ients on oint N
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SWBTB (3/13) 051 (a)
11 WORKFORCE QUALITY
ij\^c
% Trust % Target
Mandatory Training 88.13% (85%)
PDR 70.34% (85%)
Turnover (leavers) 11.03% -
Sickness absence - 4.54% (3.5%)
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SWBTB (6/13) 122 (a)
Organisation
HISLead
Date of Report
Sandwell & West Birmingham Hospitals NHS Trust
Fiona Sanders, Interim CIO
June2013
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Management Summary - Progress
Project Current Status RAG
Status
Health Informatics Programme
1314 Priorities
The Trust Board approved informatics strategy in September 2012. 2013/14
identifies 1314as an “enabling year” which prepares the Trust for replacement of
core systems and preparing the foundations for the delivery of the overall
informaticsstrategy. There are five work streams, which are detailed below.
Where relevant additional updates are provided for consideration by the board.
Health Systems
• Delivery of the replacement Radiology Information System by Q1/1314
• Delivery of the replacement maternity system by Q3/1314
• Delivery of aTrust wide A&E solution by Q1/1314
• Delivery of the procurement and delivery of the chemotherapy system;
• by Q4/1314
• Evaluationand procurement of PACSand Vendor Neutral Archive
replacement by Q4/1314
• Completion of the options appraisal for the replacement of the EPR
solution by Q2/1314
• Continued development of eBMS on-going development cycle
Infrastructure
• Trust-wide infrastructure stabilization:
o upgrade to the network including transfer to the core
network by Q2/1314
o Upgrade to cabinets, wireless access points (WAP) and
Power over Ethernet by Q4/1314
• Upgrade to the data centre at City Hospital
• Pilot of speech recognition/digital dictation;
• Refresh of PC estate, including revised image for windows 7
deployment by Q2/1314
Customer Services
• Transformation of the Customer Services function, relocation to a new
location by Q2/1314
• Replacement of call logging and incident tracking system by Q2/1314
Telecommunications
• Rollout of Voice over Internet protocol (VoIP) by Q2/1314and wireless
VoIP by Q4/1314
• Rollout of unified comms by Q2/1314
• Rollout of video conferencing by Q2/1314
Information
• Development of the business intelligence/service line management
functionby Q3/1314
• Development of 18WW RTT audit solution and reportingby Q2/1314
Work stream: Health Systems The new Radiology systemwas successfully commissionedon the 1 st June 2013
without any major issues. This was a transfer of the system from the CSC hosted
1

SWBTB (6/13) 122 (a)
Management Summary - Progress
Project Current Status RAG
Status
System Replacement: Radiology
Information System
solutionto a locally delivered HSC supported system.
The Trust will have a shared instance andwill host the Royal Orthopaedic
Hospital
Work stream: Health Systems
System Replacement:
Maternity
CRIS go live completed successfully including the business continuity solution.
The maternity replacement system has been kicked off. The Trust has elected to
implement community midwifery first. This application will be deployed using
mobile technology based on the use of iPADS. The version of BadgerNet which
supports iOS technology will not be available until the end of July.
Work stream: Health Systems
Accident and Emergency System
consolidation/ replacement
Work stream: Health Systems
System Replacement:
Chemotherapy
Work stream: Health Systems
System Replacement:
PACSand Vendor Neutral
Archive (VNA)
The new ED IT system Patient First was commissioned on the 8 th May at City
and the 14 th May at Sandwell. This provides a unified informatics platform across
the City and Sandwell sites.
The project is now in a post implementation phase and the focus at this time is
data quality and ensuring that the data entered by staff in the EDs is accurate
and that the new reporting from the system is reviewed and used as an
opportunity for improvement. Once this phase has concluded, the project will
proceed to implement other outstanding functionality such as the prescribing of
TTOs.
This project was initiated on the 31 st May for the first phase of the project, which
is the procurement phase. There are two contenders for procurement which are
the market leaders Varian and Chemocare. An OBS is being prepared to
benchmark the systems with an option appraisal scoring.
An investment proposal has been presented to IAP for consideration. It is
proposed that the procurement is split between 1314 and 1415.
The Trust PACS solution was procured outside of the national programme and
comes to the contract end in September 2013. The supplier MERGE Healthcare
will continue to support the product. It is proposed that theTrust replaces the
PACSviewer (this functionality is currently supplied by eFILM) andPACS
application. It is proposed that this will be deliveredby Q413/14.
The second component of the solution is the provision of a vendor neutral
archive which will provide a Trust wide storage solution to support dicom images
(both current and historic) within the Trust. This is not confined to Imaging alone
and would be extended to cardiology, ophthalmology and histopathology. This
capability canalsobe provisioned by our storage area network (SAN) and the
Trust is exploring the options. It should be noted that the PACS replacement
can be delivered without the need for VNA
Work stream: Health Systems
EPR
Work stream: Health Systems
eBMS
Funding for the replacement of PACS has been identified in line with the Health
Informatics Strategy, however as the procurement is subject to IAP approval the
project has an amber RAG status
Work continues on the strategic outline case for the replacement of EPR. A
number of supplier education visits are scheduled for July. In parallel planning
and resourcing for the procurement is underway. This includes a review of the
LTFM and resourcing for the procurement phase.
eBMS development continues with the primary focus beingthe development of
functionality to enable the data captured from the newly deployed ED systems
and to be available in eBMS. This includes functionality for the development of
the Assessment Units, ED & CDU views, as well as completion of the Capacity
Management reporting to bring the new Operations Centre live with complete
real-time management of beds and capacity.
Other areas of high priority under development are the redesign of the VTE
functionality to enable more accurate recording by junior medical staff and
2

SWBTB (6/13) 122 (a)
Management Summary - Progress
Project Current Status RAG
Status
completion of the Nursing Handover and Shift Coordinator to complement the
Additional deliverables
Work stream: Health Systems
Clinical Letters System Rollout
and EDT
Safety Briefing for the nursing division.
The Clinical Letters System is nowfully deployed within the Trust and provides
the Trust with the ability to send clinical letters directly to GPs.
The increase in letters sent electronically is restricted due to the availability of
the EDT functionality within the practices. Afurther 13 practices are now live
bringing the total in May to 55. This results in a further 3,663 letters being sent
via EDT.
The Trust is now working with CMCSU(Central Midlands Commissioning
Support Unit) to review options for expediting this rollout.
National area
Practices live
at end May 13
Letters Sent at
end April 13
Letters Sent at
end May 13
South Birmingham
PCT Area
36 5883 7621
HOB PCT Area 11 254 1859
Sandwell PCT
Area
3 594 878
BEN PCT Area 5 8 44
Total Number of
Practices
Live/Letters sent
55 6739 10402
Work stream: Infrastructure
Network Stabilisation and
network upgrade:
Anumber of work streams have been established to upgrade the Trust’s Core
network in order to meet the infrastructure demands of the Informatics Strategy
Transfer to core network
The Trust has established a core network and devices that are currently on the
old Sandwell and City Network will be transferred to the core, this will be
concluded by the 26 th June.
Network cabinet upgrades
As part of the transfer all network cabinets will be reviewed and upgraded to
provide standardisation and additional Power of Ethernet (PoE) This allows a
single cable to provide both data connection and electrical power to devices
such as network hubs. PoE also allows long cable lengths to be used and this
will improve both the wired and wireless capability within the Trust. The cabinet
and PoE upgrades is foundation work for the deployment of wireless telephony
VoIP. Additional wireless access points are already being deployed across the
estate.
Work stream: Infrastructure
Agile Working
Work stream: Infrastructure
Data Centre Upgrade: City
eBMS Wiring
A number of problems have been reported with the eBMS screens with the
wireless connectors being removed. eBMS is now being hardwired into the
network and a remote checking system is under pilot to pole the eBMS screens.
As this work is within clinical and ward areas it is being undertake in partnership
with the Ward Managers. This will conclude by the 27 th June.
Plan to have Coffee Pot re-engineered as Exec working space at Sandwell
before end of May. (Temporary rooms already provisioned for Exec use in old
Nurses home at Sandwell.) PCs being installed in Coffee Pot week commencing
3 rd June 2013.
Remedial work is being undertaken at the City Computer Room: New secondary
air conditioningandserver racks are beingreconfigured to allow better air flow
and more efficient cooling.
The City Computer Room and Telecoms exchange will need to be moved to a
site on the retained estate, and options are currently being explored with Estates
and third party suppliers.
3

SWBTB (6/13) 122 (a)
Management Summary - Progress
Project Current Status RAG
Status
Updates
Work stream: Infrastructure
Updates
PC refresh
Additional deliverables
Work stream: Infrastructure
A business case is being developed to deliver a Trust wide digital dictation
platform. The core requirement is the integration of the solution with core
components of the EPR and UK English medical lexicon.
Subject to business case approval procurement will commence.
The Trust has provideda significant revenue investment to support the refresh of
the PC estate. This will result in the replacement of priority PCs. To improve the
process the Trust has engaged Ricoh to develop an imaging and deployment
process. Once proved this approach will be used for the deployment of all PC
refreshes.
The first 50 PCS will be deployed via this mechanism in July 2013. The priority
for rollout is clinical areas and functions.
Patient Transport System
A replacement patient transport scheme, Cleric Systems has been implemented
and staff to commence in later June
Mailsafe email archive.
Mailsafe is a solution procured to allow staff to archive emails for later retrieval in
place of PST files. Access will be possible from iPad and web browsers once
work onconfiguration completed. This will support the move to agile working
Patient information kiosks
The use of patient information kiosks is being piloted. In the first instance these
will be used for access to Centro travel information have been installed in 4
locations at City and Sandwell. This capability can also be used for patient selfchecking.
Agile Working
Plan to have Coffee Pot re-engineered as Exec working space at Sandwell
before end of May. (Temporary rooms already provisioned for Exec use in old
Nurses home at Sandwell.) PCs being installed in Coffee Pot week commencing
3 rd June 2013.
Updates
Work stream: Infrastructure
Network Outage: 13 th June 2013
Updates
Work stream: Infrastructure
System Failure: 6 th March to 11 th
March 2013
Work stream: Customer Services
Relocationof customer services
function
Work stream: Customer Services
Replacement ServiceDesk
logging system
Work stream: Telecoms
Wireless telephony and VoIP
Asa result of work to configure and migrate further network cabinets onto the
new core network at Sandwell an error was introduced into the routing
configuration on the new core network which affected network routing within the
Sandwell site. Configurationwas removed from the core switches and manually
re-entered. This corrected the fault and restored network operations at Sandwell.
HP have reviewed the Storage Area Network (SAN) and confirmed that it has
been deployed as per the specification. HPhas confirmed that the initial problem
was the result of disk and controller failures that were not picked up by the
firmware. The firmware has now been upgraded.
The Trust will be implementing the HP Proactive Care which will provide an
engineering view of the system. This will provide an increased monitoring of the
SAN solution
Planning is underway to physically relocate the Customer Service Desk to City.
Development of requirements for a replacement service desk is underway. To
maximise options for the Trust this is likely to be a managed service.
In addition to transferring devices to the core network, planning is underway to
provide an upgrade path; this will develop the existing core network for the
sustainable roll out of wireless telephony and VoIP issues.
4

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SWBTB (6/13) 122 (a)
Management Summary - Progress
Project Current Status RAG
Status
The server configuration for VoIP telephony and wireless VoIP is underway.
VoIPServers are installed at City and Sandwell. The Rowley Regis Server will
be installed week commencing the 17 th June 2013
Wireless VoIPservers will be configured week commencing the 17th June.
Additional wireless access points are being deployed. Handsets will commence
rollout from the 1st July 2013.
Work stream: Telecoms
Unified Communications
Work stream: Telecoms
Video Conferencing Facilities
Work stream: Information
18 WW RTT
SLM
The unified comms server install is planned in parallel with the VoIP deployment.
This is planned for week commencing 17 th June2013
Deployment of unified comms software to PC’s is plannedfor week commencing
1st July 2013. Training of Unified Communications is planned for week
commencing the 1 st July 13
Video conferencing for 10 locations has been completed and training
commenced on the 1 st June. A further 10 locations have been identified and
these are to be scheduled.
The key areas for project delivery are service line management (SLM) and
18WW RTT. With regard to SLM there is now an agreed way forward for
handling Acute Medicine and the removal of general medicine from reporting. 18
WWRTT continues and agreement is being sort from the executive for the
treatment of open and incomplete pathways.
5

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REPORT TO TRUbT cOARD 27 JUNE 2013
1.0 cAdKGROUND
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Treatment (RTT) patient pathways for non-urgent, elective referrals. Some pathways appear
to be incomplete on the PAS and had not been updated to reflect treatment that has been
given; mostly on an outpatient basis.
1.2 The legacy of open pathways (patients on the system whose treatment has not been
recorded as closed) goes back to the merger of IT systems in 2007 ; when the trust IT
systems were merged additional referrals were erroneously created during the take-on
process. A data extract was written at the time the PAS systems were merged to address
legacy data. This extract was written and revised and continued to be used. It has
subsequently been found to have been incorrectly applied over some years. This has
resulted in some patients being excluded from 18 week formal reporting, although their
treatment and care continued to be planned and delivered.
1.3 A review of over 30,000 of these records has shown that most patients had indeed been
treated but their pathways had not been formally updated and closed on the computer
system. The review of these patients has not revealed any evidence that actual patient
treatment has been affected by these administrative issues, other than potentially in terms
of timeliness due to a failure to manage the administration to complete the 18 week
pathway. Where patients were identified as having an active open pathway the operational
team have ensured this is progressed where possible within 18 weeks.
1.4 There is a small number, less than 0.5%, who have waited over 52 weeks for treatment. Each
of these cases has been risk assessed by a senior clinician and no adverse outcome has been
identified. Although statistically small, this is not an acceptable wait for patients experience
and the intention is to eradicate such waits this year.
1.5 The backlog of open pathways has been reported to the NTDA, CCG and former SHA.
cUbINEbb PROdEbb
2.0 NEW
2.1 New operational processes have been designed to ensure accurate recording of the 18 week
treatment outcomes and discharge process. These processes are supported by a new
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quality assurance reporting to the audit committee.
2.3 A new post of 18 week Access Manager is being recruited, to provide expert leadership to
the on-going 18 week management of patient pathways. A dedicated validation team is
supporting the validation of patient records and is now focussed on prospective validation to
ensure good data quality.
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3.1 There are 129,834 open pathways across the whole patient record system (PAS). This
includes all patients who have been referred since the problem occurred until now and
whose treatment has not been recorded as complete. It is proposed that the next phase of
this work is focussed on three areas:
1. Referrals from 1.1.2013: Full reporting of open patient pathways for referrals since 1.1.2013,
within new processes supported by prospective data validation.
Of the patients referred for planned treatment since 1 st January 2013, there are 28,139
patients with open pathways. 94% of them are currently within 18 weeks against an
expectation of 92% minimum target.
2. Referrals from 1.4.2012 31.12.2012: There are 9045 open pathways in this group.
Manual validation of these open pathways will be completed by the end September.
If there are any patients identified who are still to receive treatment, they will be contacted
and their case reviewed by a senior clinician. Patients who require treatment will be
scheduled quickly.
Noting the previous long waits, there may be some patients who have waited over 52 weeks
for treatment. Each patient will be risk assessed for impact of delay and treated quickly. It
should be noted to date there has been no adverse impact identified from long waits for
treatment on the affected 18 week pathways.
3. Referrals predating 1.4.2012: there are 92,650 open pathways on the system dating back to
2007. It is likely the majority of these will have received treatment but their record has not
been closed.
3.2 The intention is to close off these open pathways. To make sure every patient who should
have been treated has in fact been treated, we will advise patients and their GPs of the
administration error and invite any patients who are concerned their treatment may not be
complete to contact us.
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referral to treatment.
3.6 Communication of this plan has been made with the CCG, LAT and NTDA.
4.1 The Trust Board is asked to note this approach to validating and closing the historic backlog
of open patient records.
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The Trust Board approved the business case for investment into a new model of ward
leadership in May 2012. The model proposed a merging of the Ward Manager and Matron
roles and the subsequent creation of Ward Matron and Ward Senior Sisters/Charge Nurses.
Investment ensured that there were sufficient leadership resources across the new roles to
have around 1.4 1.8 WTE supervisory ward leadership for every crica 30-40 beds
(excepting EDs, Critical Care and other specialist units).
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The expectation was that there would be much closer and more consistent leadership at
ward level and a resultant improvement in clinical and professional standards, patient
experience, relative/carer support and patient flow.
The main arguments for the investment centred around:
• Matrons were essentially corridor based and responsible for 70 80 beds and then
spent a considerable amount of time in meetings and away from their clinical areas,
often several of them in the same meeting. The wards did not therefore benefit
from their experience and expertise.
• The Ward Managers were responsible for 20 35 WTE, clinical and professional
standards and operational management of their ward but only had 7 hours
management time to undertake this role.
• Nursing clinical standards and patient experience outcomes whilst improving were
inconsistently being delivered.
• Operational management of the wards was inconsistent.
• Roles and responsibilities between Matron, Ward Manager and General managers
was unclear.
The investment approved was £700k. This was to fund the following:
• 2 Assistant Heads of Nursing intended to pick up divisional nursing operational
tasks/projects. Previously undertaken by Matrons.
• 5 Additional Ward Matrons
• 6 Band 5 Staff Nurses
• 3 band 3 A&C
Ward Matrons/Senior Sister/Charge Nurses
Fully in place by end July 2013 with a couple of acting or temporary arrangements pending
things like stroke reconfiguration and bed closures (in 2012/13 TSPs originally)
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Assistant Heads of Nursing
Both in post from October 2012 (internal/external appointment)
Administrative support for Matrons/Sisters
Originally delayed pending potential redeployment of at risk staff, but fully in post from
January 2013.
1

¾¿ÀÁÀ Â6/13) 124 (a)
Following Board approval there was also a significant communication process involving
nursing, medical and management colleagues in which new roles and structures were
discussed.
This was described in the original paper and included:
• Clinical
• Operational measures
• Workforce
3Ã
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Many of these measures were already included in the ward performance monitoring process
and have therefore been reviewed on a regular basis by the Senior Nursing team.
• There was some initial opposition/challenge from some general management and
medical colleagues
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• Winter capacity expansion and a failure to close beds as planned has meant that the
full delivery of the new ward model in Medicine has not been achieved. Since
October 2012 there has been circa 70 100 additional beds open that had not been
planned for in the new leadership model.
Leadership for these beds has come from existing Ward Matrons and acting up
arrangements for Ward Sister/Charge Nurses. Had these beds been factored into
the plan it would have equated to a further 2/3 Ward Matrons and 4 Ward Sisters.
• Winter pressures has also made it difficult at times to adhere to the principle of
keeping ward leaders as close t to the bedside as possible. Over the winter the
tendency to revert back to systems requiring all Matrons to focus on capacity issues,
even outside of their own wards, led to some undermining of the model.
• Norovirus managing the affects of norovirus at ward level was a massive task for
nursing leaders over the winter period with numerous ward closures and decants,
cohorted staff and difficulties with visitor closures.
Clinical
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The Trust had been successfully reducing the amount of hospital acquired, avoidable
pressure damage but mid 2012 this had plateaued and we were struggling to achieve further
improvements.
We believe the introduction of 3 specific measures in August 2012 have been instrumental
in further reductions:
Eradicate campaign
Accountability meetings
Ward Leadership effect
Of most significant relevance in the absence of any grade 4 avoidable hospital acquired
pressure damage for 12 months.
The financial and operational impact of pressure damage is well evidenced and therefore the
benefit to the organisation as well as the individual patient of achieving these reductions is
significant but impossible to quantify.
2

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Trends in avoidable falls with serious injury have also been reducing in the Trust for some
time but this has been especially noticeable since the ward leadership model was
introduced. Falls with injury not only have a significant impact on the individual patient but
also impact hugely in terms of length of stay and costs.
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Malnutrition risk assessment via MUST tool has shown an improving picture over the past 12
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The number of patients suffering avoidable weight loss has increased slightly in Medicine
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‚ƒ„ƒ …6/13) 124 (a)
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Generally the Safety Thermometer results have remained fairly static all year at around
93.5% harm free care. Given the pressures over the winter months and high levels of
vacancies it is surprising that this % has been maintained. We believe it is a sign of well
managed and led wards.
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It is difficult to evaluate the ward leadership model in relation to infection control. As far as
reportable infections is concerned the Trust has a good performance. Norovirus over the
winter months however created significant additional challenges for ward leaders around
the safe operating o0f their wards, staffing arrangements and visitor handling. Undoubtedly
having additional senior nurses in post assisted with these added pressures but it has not
been possible to evaluate in a clearly measurable way.
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Compliance with standards has improved since the ward leadership model was introduced.
At the beginning of 2012 compliance was around 65% and is now consistently above 80%.
‡ˆ7 Friends & Family Test
There has been a gradual improvement in Ward FFT results over the year and especially
since August 2012. (March 2013 includes ED data).
¡¢£¢¤¢¥¦¤ ®¯¦ª°± ®¯²ª°± §¯³ª°± ´µ¨ª°± ·¸ª°± ¹¥£ª°± ¡µ·ª°± ®¬¦ª°º »µ¼ª°º «¬©ª°º
Trust Overall 55 57 58 58 60 63 64 65 67 66 69 63
Medicine & EC 58 59 65 60 60 62 63 67 69 67 66 59
§¨©ª12 «¬­ª12
Surgery A & CC 52 52 51 56 58 65 62 65 67 66 72 67
Surgery B 73 75 73 76 86 95 95 95 100 89 83 77
W & CH 51 62 57 45 56 36 67 47 31 44 66 40
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ÃÄ9 ÏÇÐÍ ÑÒÐÓÔÐÕÇÖ×Ò ØÒÙÉÒÚÎ
Detailed ward review results are reported in the Quality Report and via divisional review
processes but in summary:
Ü ÝÕÒÐÞÒÖ×Ë ßÇÐÒ
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Red Amber
April 2012 3 20
June 2012 10 14
October 2012 7 20
Jan 2013 2 32
April 2013 2 25
Surgery A
Red Amber
April 2012 11 23
July 2012 7 19
October 2012 5 26
Jan 2013 12 19
April 2013 10 15
The majority of red ratings in both divisions relate to budget and workforce measures.
ÃÄàá ßÔÕâÈÇÉÖÊÎ
Data is difficult to obtain that demonstrates nursing complaints by ward but for the first 6
months in 2012 there was an average of 18 formal complaints per month associated with
adult inpatient wards. From August 2012 to date this has fallen to 13 per month.
The intention is to devolve complaints to divisions and directorates and the Matrons are
fully anticipating taking on a lead role in responding to formal complaints.
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ãäåæå ç6/13) 124 (a)
éêëë ìíîïðñòóôðõ
There have been a number of Must Do operational changes that the Matrons have either
led or been instrumental in making happen.
• Board rounds every day on every ward
• Senior ward nurse on ward rounds
• EDD for every patient on EBMS
• Nurse participation in discharge conference call
Having sufficient supervisory nursing leadership has been essential in embedding these
processes into the majority of our wards.
In addition there is now greater evening and weekend cover on the wards from Matrons and
ward Senior Sisters/Charge Nurses. This is reported to make the sites feel safer and gives
better access to information for relatives. I am advised that out of hours incident,
resuscitation and inappropriate emergency calls have reduced in recent months but data is
not currently available.
Most Matrons now do daily Matron ward rounds where they check patients progress,
checking chart accuracy, progress with treatment/discharge plans and general well
being/comfort of the patient. The Matrons and Ward Sisters in many areas also have ward
clinics for relatives/carers.
÷óïøùóïúî
éêëö
• E-roster is now in place in most wards but as with many workforce measures over
the past few months it is very difficult to assess the impact of e-roster because
workforce management, especially in Medicine, has been so challenged as a result
of changes in bed plans and norovirus.
A good measure of effective staff rostering is to consider how headroom is utilised
over time. If rostering is done well then headroom will be utilised evenly because
absence will have been planned well.
Data showing this is available but has not been included in this report. In summary,
of the 21 wards who have using e-roster for some time, 10 have significantly
improved their rostering practice and the others have not yet shown improvement.
• Bank & agency rates have continued to rise throughout the year thought to be
attributable to capacity/bed pressures, norovirus and robust adherence to the Trust
Specialling Policy.
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6000
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4000
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• Mandatory training and PDR rates are unsatisfactory across many ward areas. MT
was ceased for ward staff for several months over the winter and it was also agreed
to not focus on PDRs in favour of safely staffing wards.
• Sickness absence information by ward is reported in the Quality Report but in
summary:
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Number of wards
10% 6% 4%
May 2012 7 13 10
March 2013 4 8 16
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There is no formal mechanism currently for collecting staff feedback other than the national
staff survey which is annual and will not reflect any impact of the ward leadership model
until the end of this year. Evaluation from the Matrons and Ward Senior Sister/Charge
Nurses has been very positive lets hear from them.
I know my team and their capabilities so much better now
By being present on a daily basis has allowed me to understand the needs of the patients
and carers better and to respond more rapidly
Exciting and rewarding thank you
No reds on ward review yippee! I feel I have finally really achieved something good
Pressures are now shared
Great to spend time with relatives
The staff are saying loudly that they feel more supported
Short term sickness at an all time low because its managed but also staff want to come to
work now
Matron presence really reassuring
I feel very lucky and proud to be part of such a strong and cohesive leadership structure
Shame some of the capacity pressures pulled us away from the wards where we were most
needed
Some of the General Managers think we have been given an easier option!
I think Band 7s should be supervisory full time as well as the Matrons
Still nowhere near enough admin support.
2Q12 would have been worse if we had not made investment R this
KLMNOP
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This has been a difficult evaluation to complete for reasons already described, ie changes in
bed plan, norovirus impact and poor ward level data for some areas. The results are mixed,
but from my assessment is positive in terms of impact on patient care, safety and experience
(especially given the unprecedented winter pressures). However, results are less positive in
terms of financial and workforce measures. There is no doubt that the nursing leadership of
the organisation fully support the model and would wish to see it continue especially in
association with the current bed expansion plans.
The Board is recommended to accept this evaluation and continues to monitor the impact
via the Quality Report and Ward Performance review processes.
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SWBTB (6/13) 125
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£4,600,000 agreed with the Local Area Team of NHS England.
The cash balance of £44.6m is ahead of plan by £1.9m as at 31 st May.
£§ £¥£§¨
The Trust Board is requested to RECEIVE the contents of the report and ENDORSE any actions taken to
ensure that the Trust remains on target to achieve its planned financial position.
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Performance Management Board on 18 June 2013 and Finance & Performance Management Committee on 21
June 2013
Page 1

SWBTB (6/13) 125 (a)
Financial Performance Report – May 2013
EXECUTIVE SUMMARY
• For the month of May 2013, the Trust delivered a “bottom line” surplus of £781,000 compared to a planned
surplus of £761,000 (as measured against the DoH performance target). Actual in month performance is
consistent with the year end target of 1.1% of turnover.
• For the year to date, the Trust has produced a surplus of £957,000 compared with a planned surplus of
£917,000 so generating an positive variance from plan of £40,000, again in line with the Trust’s target.
•At month end, WTE’s (whole time equivalents), excluding the impact of agency staff, were 200 below planned
levels. After taking account of the impact of agency staff, WTE’s were 66 above plan. Total pay expenditure for
the month, inclusive of agency costs, is £2131,000 above the planned level.
• The month-end cash balance was £44.6m. Year to date spend on capital is £0.8m.
Financial Performance Indicators - Variances
Measure
Current
Period
Year to
Date
Thresholds
Green Amber Red
I&E Surplus Actual v Plan £000 20 40 >= Plan > = 99% of plan < 99% of plan
EBITDA Actual v Plan £000 19 35 >= Plan > = 99% of plan < 99% of plan
Pay Actual v Plan £000 131 (109) 1% above plan
Non Pay Actual v Plan £000 (139) 23 1% above plan
WTEs Actual v Plan (66) (182) 1% above plan
Cash (incl Investments) Actual v Plan £000 2,765 2,765 >= Plan > = 95% of plan < 95% of plan
Note: positive variances are favourable, negative variances unfavourable
Performance Against Key Financial Targets
Year to Date
Target Plan Actual
£000 £000
Income and Expenditure 917 957
Capital Resource Limit 0 0
External Financing Limit --- 2,765
Return on Assets Employed 3.50% 3.50%
2013/14 Summary Income & Expenditure
Performance at May 2013
Annual CP CP CP YTD YTD YTD Forecast
Plan Plan Actual Variance Plan Actual Variance Outturn
£000's £000's £000's £000's £000's £000's £000's £000's
Income from Activities 392,331 32,532 32,397 (135) 65,407 65,392 (15) 392,331
Other Income 37,144 2,841 3,003 162 6,379 6,515 136 37,144
Operating Expenses (401,743) (32,684) (32,692) (8) (67,014) (67,100) (86) (401,743)
EBITDA 27,732 2,689 2,708 19 4,772 4,807 35 27,732
Interest Receivable 100 8 8 0 17 21 4 100
Depreciation, Amortisation & Profit/(Loss) on Disposal (15,291) (1,274) (1,274) 0 (2,549) (2,549) 0 (15,291)
PDC Dividend (5,707) (476) (476) 0 (951) (951) 0 (5,707)
Interest Payable (2,232) (186) (185) 1 (372) (371) 1 (2,232)
Net Surplus/(Deficit) 4,602 761 781 20 917 957 40 4,602
IFRIC12/Impairment/Donated Asset Related Adjustments 0 0 0 0 0 0 0 0
SURPLUS/(DEFICIT) FOR DOH TARGET 4,602 761 781 20 917 957 40 4,602
The Trust's financial performance is monitored against the DoH target shown in the bottom line of the above table. Some adjustments are technical, non cash related items
which are discounted when assessing performance against this target.
1

SWBTB (6/13) 125 (a)
Financial Performance Report – May 2013
Overall Performance Against Plan
• The overall performance of the Trust against
the DoH planned position is shown in the
graph. Net bottom-line performance delivered
an actual surplus of £781,000 in May against a
planned surplus of £761,000. The resultant
£20,000 positive variance is consistent with the
plan submitted to the NTDA.
Divisional Performance
•Divisional performance now includes contract
income performance for M1.
• Medicine division is overspending as a result of
additional capacity remaining open. A revised bed
plan is nearing completion as part of ensuring
sufficient capacity is in place ahead of next
Winter.
•Both Adult Community Services and Surgery (A)
divisions are experiencing slippage on their
Transformation savings plans.
Divisional Variances from Plan
Current
Period £000
Year to Date
£000 Budget
Medicine (305) (357) 87,295
Surgery A & Anaesthetics (55) (70) 62,434
Surgery B 120 131 24,310
Women & Childrens (8) (5) 43,866
Pathology 2 8 20,163
Imaging 48 66 16,962
Facilities & Estates (24) 15 36,168
Community - Adults (31) (65) 26,192
Operations & Corporate (16) (0) 44,587
Non Operational 288 308 28,329
2

SWBTB (6/13) 125 (a)
Financial Performance Report – May 2013
There has been a downturn in the level of Injury
cost Recovery Scheme income. Car parking and
catering income are also below plan.
The medical staffing overspend is a result of
agency spend in Surgery B, Surgery A and
Women & Children's.
Nursing costs (mainly agency) are overspent due
to additional capacity.
The consumables variance is mainly influenced
by the profile of orthopaedic prostheses.
Variance From Plan by Expenditure Type
Current
Period £000
Year to Date
£000
Patient Income (135) (15)
Other Income 162 136
Medical Pay (8) (184)
Nursing (76) (151)
Other Pay 215 226
Drugs & Consumables (91) 9
Other Costs (48) 14
Interest & Dividends 0 4
Capital Expenditure
• Year to date capital expenditure is £0.8m, mainly on Blood Sciences and on release of retentions. Scheme lead
officers are being asked to provide an up to date plan for expenditure through the year.
3

SWBTB (6/13) 125 (a)
Financial Performance Report – May 2013
Paybill & Workforce
• Workforce numbers, including the impact of agency workers, are 66 above plan . Excluding the impact of agency
staff, whole time equivalent (WTE) numbers are 200 below plan.
• Total pay costs (including agency workers) are £131,000 below budgeted levels for the month, reflecting support to
capacity issues. Nursing shows an overspend in month of £76,000.
•Expenditure for agency staff in May was £1,048,000 , maintaining the high spend seen in March and April with
medical staff at £0.3m and nursing at £0.6m. It is anticipated that a revised bed plan will alleviate these variations
together with recruitment efforts.
Analysis of Total Pay Costs by Staff Group
Year to Date to May
Actual
Budget Substantive Bank Agency Total Variance
£000 £000 £000 £000 £000 £000
Medical Staffing 12,819 12,397 606 13,003 (184)
Management 2,502 2,420 0 2,420 82
Administration & Estates 5,239 4,870 300 113 5,282 (43)
Healthcare Assistants & Support Staff 5,353 4,748 597 25 5,370 (17)
Nursing and Midwifery 15,462 13,694 674 1,246 15,613 (151)
Scientific, Therapeutic & Technical 7,189 7,032 103 7,135 54
Other Pay 154 4 4 150
Total Pay Costs 48,718 45,164 1,570 2,093 48,827 (109)
NOTE: Minor variations may occur as a result of roundings
4

SWBTB (6/13) 125 (a)
Financial Performance Report – May 2013
Balance Sheet
• The opening Statement of Financial Position (balance sheet) for the year at 1 st April reflects the statutory accounts
for the year ended 31 st March 2013.
• Cash balances at 31 st May stand at £44.6m in part reflecting slippage on the capital programme in 2012/13 and
2013/14.
Sandwell & West Birmingham Hospitals NHS Trust
STATEMENT OF FINANCIAL POSITION 2013/14
5
Opening
Balance as
at 1st April
2013
Balance as
at end May
2013
Forecast at
31st March
2014
£000 £000 £000
Non Current Assets Intangible Assets 924 884 1,421
Tangible Assets 216,669 214,637 227,997
Investments 0 0
Receivables 1,048 1,049 1,048
Current Assets Inventories 3,604 3,894 3,604
Receivables and Accrued Income 10,432 15,266 10,432
Investments 0 0
Cash 42,448 44,556 38,335
Current Liabilities Payables and Accrued Expenditure (43,040) (49,295) (43,039)
Loans (2,000) (2,000) (2,000)
Borrowings (914) (914) (914)
Provisions (10,355) (10,164) (10,049)
Non Current Liabilities Payables and Accrued Expenditure 0 0
Loans (3,000) (3,000) (1,000)
Borrowings (29,263) (29,141) (28,706)
Provisions (3,168) (3,168) (2,474)
Financed By
183,385 182,604 194,655
Taxpayers Equity Public Dividend Capital 160,231 160,231 160,231
Revaluation Reserve 34,356 34,356 39,120
Other Reserves 9,058 9,058 9,058
Income and Expenditure Reserve (20,260) (19,303) (13,754)
183,385 184,342 194,655

SWBTB (6/13) 125 (a)
Financial Performance Report – May 2013
Cash Forecast
• A forecast of the expected cash position for the next 12 months is shown in the table below. The projection will be
revised after detailed capital expenditure plans have been reviewed by project leads.
ACTUAL/FORECAST May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14
£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s
Receipts
SLAs: SWB CCG 20,479 20,684 20,684 20,684 20,684 20,684 20,684 20,684 20,684 20,684 20,684 20,684 20,684
Associates 7,502 7,884 7,884 7,884 7,884 7,884 7,884 7,884 7,884 7,884 7,884 7,884 7,884
Other NHS income 1,452 655 655 655 655 655 655 655 655 655 655 655 655
Specialised Service (LAT) 3,500 3,372 3,372 3,372 3,372 3,372 3,372 3,372 3,372 3,372 3,372 3,372 3,372
Education & Training 4,429 4,429 4,429 4,429
Loans
Other Receipts 1,045 1,620 1,620 1,620 1,620 1,620 1,620 1,620 1,620 1,620 1,620 1,620 1,620
Total Receipts 33,978 34,214 38,643 34,214 34,214 38,643 34,214 34,214 38,643 34,214 34,214 38,643 34,214
Payments
Sandwell & West Birmingham Hospitals NHS Trust
CASH FLOW
12 MONTH ROLLING FORECAST AT May 2013
Payroll 13,500 13,100 13,100 13,100 13,100 13,100 13,100 13,100 13,100 13,100 13,100
Tax, NI and Pensions 9,694 9,500 9,500 9,500 9,500 9,500 9,500 9,500 9,500 9,500 9,500
Non Pay - NHS 1,959 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,400
Non Pay - Trade 8,141 7,800 7,800 7,800 7,800 7,800 7,800 7,800 7,800 7,800 7,800
Non Pay - Capital 914 1,357 2,281 2,780 2,128 3,157 2,315 2,657 1,663 1,271 421 421 421
PDC Dividend 2,854 2,854
Repayment of Loans 1,000 1,000
Interest 20 15
BTC Unitary Charge 420 400 400 400 400 400 400 400 400 400 400 400 400
Other Payments 130 187 188 188 188 188 188 188 188 188 188 33,393 33,393
Total Payments 34,758 34,744 35,669 36,168 39,390 36,545 35,703 36,045 35,051 34,659 37,678 34,214 34,214
Cash Brought Forward 45,336 44,556 44,026 47,000 45,047 39,872 41,970 40,481 38,650 42,242 41,798 38,335 42,764
Net Receipts/(Payments) (780) (530) 2,974 (1,954) (5,175) 2,098 (1,489) (1,831) 3,592 (445) (3,463) 4,429 0
Cash Carried Forward 44,556 44,026 47,000 45,047 39,872 41,970 40,481 38,650 42,242 41,798 38,335 42,764 42,764
6

SWBTB (6/13) 125 (a)
Financial Performance Report – May 2013
Cumulative for Internal Reports
Risk Ratings
Measure Description Value Score
EBITDA Margin Excess of income over operational costs 6.7% 3
EBITDA % Achieved
Net Return After Financing
Extent to which budgeted EBITDA is
achieved/exceeded
Surplus after dividends over average assets
employed
100.7% 5
2.1% 4
I&E Surplus Margin I&E Surplus as % of total income 1.3% 3
Liquid Ratio
Number of days expenditure covered by
current assets less current liabilities
20.4 3
Overall Rating 3.4
Financial Risk Rating
•The table shows the Monitor risk rating score (out of 5) for the Trust based on performance at May.
•The liquidity score includes an assumed working capital facility.
Continuity of Service Risk Rating
•The proposed new financial risk rating position is shown below (out of 4).
Continuity of Services Risk Rating
Risk Ratings
Current Month
Year to Date
Forecast Outturn
Measure Description Value Score
Value
Score
Value
Score
Capital Service Capacity
Liquidity
Revenue available for debt service/capital
servicing costs
Cash for liquidity purposes * 360/annual
operating expenses
3.107 4 2.762 4 2.652 4
-2.286 3 -2.286 3 -6.483 3
Overall Rating 3 3 3
Performance Against Service Level Agreement Target
•The Trust main acute contract with Sandwell & West Birmingham CCG and Associates was signed in April as was
the Trust contract with Specialised Services commissioners at the Birmingham & Black Country Local Area Team.
Issues are being resolved with Sandwell Metropolitan Borough Council for services within its new commissioning
portfolio.
•Surgery B (ophthalmology) and Imaging are overperforming to date while Emergency Care , Surgery A (T&O) and
Women & Children (maternity services) are underperforming.
7

SWBTB (6/13) 125 (a)
Financial Performance Report – May 2013
Transformation Programme
•An update on TSP progress is provided separately. Key issues remain to be resolved around the final
determination of bed capacity as part of planning for next winter including reconfiguration changes considered in
12/13 (as paused). Final plans will form part of the bed configuration capacity.
Key risks
• The uncertainties associated with the new commissioning landscape are yet to settle, including specialised
services commissioning, the intentions of Sandwell MBC particularly in respect of school nursing, the
operation of the new maternity pathway tariff and exposure of the Trust to contractual penalties.
•The revised bed plan once finalised will impact operationally as well as on delivery of previously planned
Transformation Savings Plan targets. In the meantime additional capacity remains open.
External Focus
• Health sector regulator Monitor will be given additional powers to step in and tackle failing healthcare
providers as part of the Care Bill currently progressing through Parliament. A joint policy statement,
published by Monitor, the Department of Health and other health bodies as the bill makes its way through
the House of Lords, explains that Monitor will be able to impose additional conditions to a provider’s
licence if the Care Quality Commission has issued a warning notice to a foundation trust. Failure to
comply with these extra conditions would provide grounds for Monitor to remove, suspend or replace the
foundation trust’s directors or governors.
•The government has re-confirmed its commitment to education and training tariffs in a mandate issued to
Health Education England. New tariffs for non-medical education and training and undergraduate clinical
placements for hospital medical students are already being phased in (starting from April 2013). The
mandate sets HEE an objective of developing tariffs for postgraduate medical training programmes and
primary care medical education and training that better reflect the costs and benefits to employers of
trainees. Changes in reference costs, requiring organisations to cost training activities, rather than use
training income as a proxy for costs, are expected to provide a robust evidence base for future tariffs.
Recommendations
The Trust Board is asked to:
i. RECEIVE the contents of the report; and
ii.
ENDORSE any actions taken to ensure that the Trust remains on target to achieve its planned
financial position.
Robert White
Director of Finance & Performance Management
8

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Page 1

SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST CORPORATE DASHBOARD - MAY 2013
SWBTB (6/13) 126 (a)
EXECUTIVE SUMMARY AND KEY EXCEPTIONS
KEY EXCEPTIONS
a
Stroke Care - a number of areas of reported Stroke Care performance improved during the month of May. Of particular note is the improvement in the proportion of stroke
patients who spend 90% or more of their time in hospital on a stroke unit (96.0%), and the proportion of patients admitted to an acute stroke unit within 4 hours of arrival
(85.7%). An improvement trajectory to support improvement in areas of lesser compliance has been implemented. There is also much focus on the continued
improvement of data quality and its availability.
b
CQUIN - of the 10 CQUIN schemes agreed for 2013 / 2014 as part of the Acute & Community contract with commissioners, the majority require a baseline assessment of
performance during Quarter 1, following which an improvement trajectory will be determined. The 4 schemes which cover specialised services are subject to formal
assessment each quarter. VTE assessment remains part of a CQUIN for 2013 / 2014. Performance since March has improved, and is currently reported as 92.5% for the
month of May, although this remains below the minimum operational performance threshold of 95%. A component of the nationally mandated Dementia CQUIN is to
identify, assess and refer on to specialist services any patient who potentially has dementia. Performance of at least 90% for each of the 3 categories is required, for each
of the 2 months year to date the Trust has met 2 (Assess and Refer) of the 3 categories.
c
Workforce - PDR and Mandatory Training compliance shows a modest improvement since April, improvement trajectories for both by Division, should have a further
positive impact upon June's performance. The need to focus on improving Sickness Absence rates, by focusing on 'hot spot' areas was emphasised at recent Divisional
Review meetings. Most recent Sickness Absence data for May indicates an improvement (reduction) from the previous month to 4.01%, primarily influenced by a fall in
short-term absence from 1.03 to 0.77%. The range by Division has also reduced to 0.00 - 5.47%.
d
Fracture Neck Of Femur - current data indicates that the percentage of patients admitted with a Hip Fracture during May, who were operated upon within 24 hours of
admission, reduced to 58.3%. A review of the reasons for the fall in performance and a rectification plan have been requested.
e
f
Emergency Care - performance against the 4-hour maximum wait target improved to 94.4% during the month of May, and to 93.4% for the year to date, with
performance into the early part of June continuing to meet the weekly and monthly improvement trajectory. The Trust met 2 of the 5 Emergency Care Clinical Quality
Indicators during May.
Mixed Sex Accommodation Breaches - breaches relate to patients who remain in ‘specialist beds’ such as Critical Care and Coronary Care. The number of breaches,
expressed as a percentage of completed Finished Consultant Episodes, is projected to be between 0.0 – 0.5%, whilst a revised policy is finalised and recording processes
are established.
g
Ambulance Turnaround - the percentage of Clinical Handovers completed within 15 minutes, and the Average Turnaround Time of Ambulances, both improved during
May. Similarly, the number of ambulances subject to 30 - 60 minute and greater than 60 minute delays in turnaround also improved (reduced), but continue to remain at
significant levels. Chargeable delays, now published by the West Midlands Ambulance Service for both categories of delay, are also indicated in the report.
h
Complaints - a suite of Key Performance Indicators (KPIs) against which to monitor complaints management has been identified. Data for the month of May is included.
CONTRACTED ACTIVITY PLAN
IP & DC Elective
IP Non-Elective
OP New
OP Review
OP Review:New
Em. Care Type I
Em. Care Type II
Adult Community
Child Community
Month Year to Date Year on Year Comparison (to date)
Actual Plan Variance % Actual Plan Variance % 2012/13 2013/14 Variance %
5037 4737 300 6.3 10051 8578 1473 17.2 10762 10051 -711 -6.6
4854 5014 -160 -3.2 9463 10102 -639 -6.3 9474 9463 -11 -0.1
14346 12334 2012 16.3 28062 24668 3394 13.8 28439 28062 -377 -1.3
30945 34843 -3898 -11.2 63809 69686 -5877 -8.4 66429 63809 -2620 -3.9
2.16 2.82 -0.67 -23.6 2.27 2.82 -0.55 -19.5 2.34 2.27 -0.06 -2.7
12874 16493 -3619 -21.9 25401 32247 -6846 -21.2 30260 25401 -4859 -16.1
2153 2530 -377 -14.9 4309 4947 -638 -12.9 5539 4309 -1230 -22.2
43995 41369 2626 6.3 43995 41369 2626 6.3 41538 43995 2457 5.9
14617 12528 2089 16.7 14617 12528 2089 16.7 11589 14617 3028 26.1
i
Activity - Overall high level Elective activity is currently exceeding the plan for the month and year to date, although is 6.6% less than that delivered during the
corresponding period last year. Non-Elective activity, consistent with the level delivered during the corresponding period last year is currently 6.3% less than the plan for
the year to date. Significant overperformance against the New Outpatient activity plan and a corresponding underperformance against the Review OP activity plan, gives a
FollowUp:New OP Ratio of 2.27 for the year to date, significantly less than the ratio derived from plan, and that for the same period last year. Type I and Type II
Emergency Care activity to date is considerably less than plan and for the corresponding period in 2012 / 2013. Adult Community and Child Community activity is currently
exceeding plan for the first month of the year by 6.3% and 16.7% respectively.
j
Referral to Treatment time & Diagnostic Waits - during May each high level, Admitted, Non-Admitted and Incomplete Pathway RTT target continued to be met.
Specialty specific exceptions were in Admitted Care (target 90%) where Trauma & Orthopaedics (66.04%), Plastic Surgery (86.52%) and Dermatology (84.74%)
underperformed. Non-Admitted Care (target 95%) underperformance is restricted to Urology (93.24%). Incomplete Pathway (target 92%) underperformance by speciality
relates to Trauma & Orthopaedics (82.68%) and Plastic Surgery (89.68%). The percentage of patients waiting in excess of 6-weeks for a diagnostic investigation /
procedure at the end of May remained below 1.0%.
k
Cancelled Operations - the proportion and number of Elective Admissions cancelled at the last minute for non-clinical reasons increased numerically and as a
percentage to 44 and 0.9% respectively during May. All patients were admitted within 28 days of the original breach date. Additional performance measures are included in
the report with improvement trajectories to year end to eliminate multiple cancellations experienced by the same patient and reduce the percentage of cancellations with 7
days or less notice given.
NATIONAL PERFORMANCE FRAMEWORKS
NHS PERFORMANCE FRAMEWORK - Summary
MONITOR COMPLIANCE FRAMEWORK - Summary
December January February March April May December January February March April May
Performing
15 16 17 16 15 16 Performing
14 15 15 15 14 14
Underperforming 3 2 1 2 2 3 Failing
2 1 1 1 2 2
Failing
1 1 1 1 2 0 No Data
0 0 0 0 0 0
Weighted Score 2.57 2.64 2.71 2.64 2.43 2.79 Governance Rating 2.0 1.0 1.0 1.0 1.0 1.0
There are 2 actual and 1 projected area of underperformance during the month
of May; Emergency Care 4-hour waits (actual) performance of 94.42%, ‘RTT
Delivery in all specialties’ and Mixed Sex Accommodation Breaches (projected).
The overall average weighted score for service performance for the month is
projected to be 2.79. CQC Registration Status remains Unconditional. As such
the Trust is projected to continue to attract a PERFORMING classification.
The Trust underperformed against the Emergency Care 4-hour wait target
during the month (performance 94.42%). Monitor's annual de minimis limit for
cases of MRSA Bacteraemia reflecting a governance concern is set at 6, and
as such the MRSA Bacteraemia reported (during April) for the year to date does
not contribute to the overall score for the month which remains 1.0 and attracts
an AMBER / GREEN Governance Rating. The Trust is projected to meet
performance thresholds for all high level Cancer targets.

SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST CORPORATE DASHBOARD - MAY 2013
Exec
Lead
RS
H Pts spending >90% stay on Acute Stroke Unit
% 86.0 82.1 70.6
83.3
96.0 90.2 83 83
K Pts admitted to Acute Stroke Unit within 4 hrs
% 54.0 42.9 42.6
69.4
85.7 90 90
K Pts receiving CT Scan within 24 hrs of presentation
% 100.0 93.3 89.8
93.2
89.7 91.8 100 100
3 Stroke Care
K Pts receiving CT Scan within 1 hr of presentation
% 57.7 48.2 51.4
61.5
65.4 50 50
H TIA (High Risk) Treatment 2%
Variation Variation Variation
No 0 - 2% >2%
Variation Variation Variation
a
No 0 - 2% >2%
63.1
Variation Variation Variation
4
13
1
No 0 - 2% >2%
Variation Variation Variation
No 0 - 2% >2%
Variation Variation Variation
No
Any
variation
variation
No
Any
variation
variation
11/12
Outturn
85.9
68.7
100
37.5
53.2
30.4
95
95
2
12/13
Outturn
85.6
59.1
91.8
52.0
69.8
75.9
37
76
1
MSSA Bacteraemia
No. 1 0 1 0 2 2 0 1 1 3 No. Only No. Only
12
15
R0
Infection Control E Coli Bacteraemia
No. 3 6 2 0 2 2 1 1 2 4 No. Only No. Only
50
48
F % 130.9 193.6 138.9 196.6 173.2 86 90
3
MRSA Screening
- Elective
F % 59.8 72.4 59.5 67.9 59.9 71 80
F % 80.7 82.3 76.8 79.2 82.2 86 90
MRSA Screening
- Non
Elective
Patient Not Matched
Best Practice - Patient Matched
Patient Not Matched
Best Practice - Patient Matched
F % 67.3 64.6 64.9 67.4 72.6 71 80
173.2*
No
Any
variation
variation
59.9*
No
Any
variation
variation
82.2* No
Any
variation
variation
No
Any
variation
variation
RS A 3 Risk Assessment
224 % 91.5 91.0 86.1
90.8
92.5 92.5 95 95 =>90 2000 ml)
Admissions to Neonatal ICU
RS
3 Obstetrics Adjusted Perinatal Mortality Rate (per 1000 babies)
Caesarean Section Rate
Numerator = 2869
Numerator = 991
Numerator = 2208
Numerator = 2356
No 51 42 53
56
56
55 660 =55/m
No 15 6 72 =6/m
No. 0 0 0
0
0 0
8 48 =4
% 10.6 12.8 12.2
10.5
10.0 10.2 =

Exec
Lead
RB 5 Cervical Cytology Diagnostic Report Turnaround
Days 50
>50 =>50 =>50 =>50 95 =>95 =>95

Exec
Lead
RB
H Clinical Handovers completed within 15 minutes % 74.8 75.6 71.3 76.4 85.1 81.4 82.0 86.9 84.89 =>85 =>85 =>85 0
In Excess of 60
minutes
All Journeys
All Journeys
H Chargeable Delays (WMAS report) No. 32 25 57 14 14 28 85
0 0 0 >0
F 14 No. of First Formal Complaints Received
No. 60 70 57 63 59 122 No. Only No. Only
No. of Link Complaints Received
No. 6 6*
0 0 0 >0
84.89*
29:06*
2863
146
g
13/14 Forward
Projection
11/12
Outturn
29:23
1256
834
12/13
Outturn
71.3
34:24
22089
2354
724
302*
K No. of Active Complaints in the System (formal and link) No. 302 No. Only No. Only
97*
No. of Days to acknowledge a formal or link complaint
KD K Complaints % 97 100 100 h 100 0
response date (% of total active complaints)
17*
K No. of responses sent out
No. 17 No. Only No. Only
K Oldest' complaint currently in system
Days 197 197* No. Only No. Only
RO H 8 Phased Data Collection Expansion - Maternity 137 %
By October with 30% response rate
By October with 30% response rate
Friends & Family Increased Response Rate (Emergency Care
RO H 8 175 %
Test
All Wards)
RO H 8 Improve Performance on Staff FFT
137 Score
Baseline Assessment during Q1 Baseline Assessment during Q1
Autumn Annual Staff Survey Autumn Annual Staff Survey
b
RS Recording DNAR Decisions
1105 %
Bi-Annual Ward Audit / Improvement Bi-Annual Ward Audit / Improvement
Elective Access
Contact Centre
Number of Calls Received
Average Length of Queue
Maximum Length of Queue
Number of Calls Received
No. 18309
12421
12509
12925
12188
25113 No. Only No. Only
0.23*
mins 3.19 1.06 0.25 0.23 0.23

Exec
Lead
TRANSFORMATION PLAN (Continued)
January
Trust
February
Trust
March
April
May
Trust S'well
City
Trust
S'well City Trust
To Date (*=most
recent month)
TARGET
YTD 13/14
Exec Summary
Note
THRESHOLDS
13/14 Forward
Projection
11/12
Outturn
12/13
Outturn
Elective IP No. 726 671 723 722 791 1463 1728 10141
No
Variation
0 - 2%
Variation
>2%
Variation
10610 9596
Spells
Elective DC No. 4734 4409 4362 4255 4246 8588 6850 40198
53685 52875
Total Elective
No 0 - 2% >2%
No. 5460 5080 5085 4977 5037 10051 8578 50339
64295 62471
No
Variation
Variation
0 - 2%
Variation
Variation
>2%
Variation
Variation
RB
2
Outpatient
Attendances
Total Non-Elective No. 4778 4310 4810 4609 4854 9463 10102 60931
No 0 - 2% >2%
Variation Variation Variation
New No. 15090 13514 13214 13588 14346 28062 24668 152466
159051 171540
Review No. 32549 29500 29442 32513 30945 63809 69686 410406
421494 382248
i
No
Variation
No
Variation
0 - 2%
Variation
0 - 2%
Variation
>2%
Variation
>2%
Variation
55675
56982
Type I (Sandwell & City Main Units) No 0 - 2% >2%
No. 13086 12491 12703 5631 6896 12527 5743 7131 12874 25401 32247 184483
177201 171701
Emergency Care
Variation Variation Variation
Attendances
Type II (BMEC) No 0 - 2% >2%
No. 1831 1854 1986 2156 2156 2153 2153 4309 4947 28304
36362 26649
Variation Variation Variation
16 Community
Adult - Aggregation of 18 Individual Service Lines No. 45582 40519 41481 43995 43995 41369 540982
493163 538147
Children - Aggregation of 4 Individual Service Lines No. 14450 14059 13963 14617 14617 12528 165757
143400 155412
No
Variation
No
Variation
0 - 2%
Variation
0 - 2%
Variation
>2%
Variation
>2%
Variation
RB
RB
KEY ACCESS TARGETS
A 2 weeks
% 94.7 95.7 95.0
93.2
93.2 =>93 =>93
No
Any
variation
variation
A 2 weeks (Breast Symptomatic)
No
Any
% 97.4 94.9 93.2
96.9
96.9 =>93 =>93
variation
variation
A 31 Day (diagnosis to treatment)
No
Any
% 98.9 100 99.3
100
100 =>96 =>96
variation
variation
No
Any
A 31 Day (second/subsequent treatment - surgery)
% 98.1 100 98.9
100
100 =>94 =>94
variation
variation
No
Any
A 1 Cancer 31 Day (second/subsequent treatment - drug)
% 100 100 100
100
100 =>98 =>98
variation
variation
No
Any
A 31 Day (second/subsequent treat - radiotherapy)
% n/a n/a n/a
n/a
n/a =>94 =>94
variation
variation
No
Any
A 62 Day (urgent GP referral to treatment)
% 85.7 85.6 94.8
90.8
90.8 =>85 =>85
variation
variation
No
Any
A 62 Day (referral to treat from screening)
% 95.0 91.7 100
100
100.0 =>90 =>90
variation
variation
No
Any
H 62 Day (referral to treat from hosp specialist)
% 85.7 100 86.5
85.2
85.2 =>85 =>85
variation
variation
A Admitted Care (RTT 90.0 =>90.0 =>90.0 85-90 95.0 =>95.0 90 - 95 =92.0 =>95.0 87 - 92 =6 /
month month month
H Audiology D.A Patients seen in

KEYS TO DATA SOURCES, PERFORMANCE ASSESSMENT SYMBOLS AND INDICATORS WHICH
COMPRISE NATIONAL & LOCAL PERFORMANCE ASSESSMENT FRAMEWORKS
DATA SOURCES
INDICATORS WHICH COMPRISE THE PERFORMANCE ASSESSMENT FRAMEWORKS
FORWARD PROJECTION ASSESSMENT
1 Cancer Services (National Cancer Database) A NHS Performance F'work, Monitor Compliance F'work, SHA Provider M'ment Return & Local Priority / Contract.
Maintain (at least), existing performance to meet target
2 Information Department B NHS Performance F'work, SHA Provider M'ment Return & Local Priority / Contract.
Improvement in performance required to meet target
3 Clinical Data Archive C NHS Performance Framework & Local Priority / Contract.
Moderate Improvement in performance required to meet target
4 Microbiology Informatics D SHA Provider Management Return & Local Priority / Contract.
Significant Improvement in performance required to meet target
5 Histopathology Department E NHS Performance Framework only
Target Mathmatically Unattainable
6 Dr Foster F SHA Provider Management Return only
xxx
7 Workforce G
Monitor Compliance Framework only
PERFORMANCE ASSESSMENT SYMBOLS
8 Nursing Division H Local & Contract (inc. CQUIN)
Fully Met - Performance continues to improve
9 Surgery A Division K Local
Fully Met - Performance Maintained
10 Medicine Division
Met, but performance has deteriorated
11 Adult Community Division
Not quite met - performance has improved
12 Women & Child Health Division
Not quite met
13 Neonatology
Not quite met - performance has deteriorated
14 Governance Division
Not met - performance has improved
15 Operations Division
Not met - performance showing no sign of improvement
16 Finance Division
Not met - performance shows further deterioration
17 Nurse Bank
18 West Midlands Ambulance Service
19 Healthcare Evaluation Data Tool (HED)
20 Pharmacy Department
21 Imaging Division
Page 5 of 5

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Page 1

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Page 1

SWBTB (6/13) 129 (a)
FT Programme Monitoring Status Report
Amber
Activities Last Month
• Meeting held with NTDA (17.6.13) formal TFA to be agreed
by end of June 2013.
• Further development of Long Term Financial Model
• F T
Health Education West Midlands
Planned Next Month
• Compilation of evidence ahead of BGAF/QGAF self-assessment
• Begin development of new IBP
• Review progress on development of 2015/16 TSPs
• Detailed FT milestones developed in association with OBC
timescales
• Begin development of new LTFM
• W
July.
Issues for Resolution/Risks for Next Month
• Agreement from TDA on revised TFA milestones
• Continue to make progress on A&E target in line with rectification plan to NTDA
• Outline 15/16 TSPs to be developed
• 18 weeks data quality - current approach of historic validation and analysis under review. New plan to be confirmed.

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Page 1

SWBTB (6/13) 130 (a)
SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST - NHS PERFORMANCE FRAMEWORK MONITORING REPORT - 2013/14
QUALITY OF SERVICE
Integrated Performance Measures
Indicator
Emergency Care Waits less than 4-hours
MRSA Bacteraemia
Clostridium Difficile
18-weeks RTT 90% Admitted
18-weeks RTT 95% Non -Admitted
18-weeks RTT 92% Incomplete
18-weeks RTT Delivery in all Specialities (number of treatment functions)
Weight
Performing (Score
3)
Performance Thresholds
1.00 95.00% 94.00 - 95.00% 94.00% 92.40% 0 0.00 94.42% 2 2.00
1.00 0 >1.0SD 1 0 0.00 0 0 3.00
1.00 0 >1.0SD 3 3 3.00 1 3 3.00
1.00 =>90.0% 85.00 - 90.00% 85.0% 92.2% 3 3.00 92.5% 3 3.00
1.00 =>95.0% 90.00 - 95.00% 90.0% 97.8% 3 3.00 98.2% 3 3.00
1.00 =>92.0% 87.00 - 92.00% 87.0% 95.6% 3 3.00 96.3% 3 3.00
1.00 0 1 - 20 >20 3 2 2.00 6 2 2.00
Diagnostic Test Waiting Times (percentage 6 weeks or more) 1.00 93.0%* 3 1.50
Cancer - 2 week GP Referral to 1st OP Appointment - breast symptoms
0.50 93.0% 88.00 - 93.00% 88.0% 96.9% 3 1.50 >93.0%* 3 1.50
Cancer - 31 day diagnosis to treatment for all cancers
0.25 96.0% 91.00 - 96.00% 91.0% 100.0% 3 0.75 >96.0%* 3 0.75
Cancer - 31 day second or subsequent treatment (surgery)
0.25 94.0% 89.00 - 94.00% 89.0% 100.0% 3 0.75 >94.0%* 3 0.75
Cancer - 31 day second or subsequent treatment (drug)
0.25 98.0% 93.00 - 98.00% 93.0% 100.0% 3 0.75 >98.0%* 3 0.75
Cancer - 31 Day second/subsequent treat (radiotherapy) 0.25 94.0% 89.00 - 94.00% 89.0% 100.0% 3 0.75 >94.0%* 3 0.75
Cancer - 62 day urgent referral to treatment for all cancers
Cancer - 62 day referral to treatment from screening
Delayed Transfers of Care
Mixed Sex Accommodation Breaches (as percentage of completed FCEs)
VTE Risk Assessment
0.50 85.0% 80.00 - 85.00% 80.0% 90.8% 3 1.50 >85.0%* 3 1.50
0.50 90.0% 85.00 - 90.00% 85.0% 100.0% 3 1.50 >90.0%* 3 1.50
1.00 5.0% 3.10% 3 3.00 3.20% 3 3.00
1.00 0.0% 0.0 - 0.5% 0.5% 0.00 - 0.5%* 2 2.00 0.00 - 0.5%* 2 2.00
1.00 90.0% 80.00 - 90.00% 80.0% 90.80% 3 3.00 92.50% 3 3.00
Sum (all weightings) 14.00
Average Score (Integrated Performance Measures) * projected 2.43 * projected 2.79
Score 2
Underperforming
(Score 0)
April
2013/14
Score
Weight x
Score
May 2013/14
Score
Weight x
Score
CQC Registration Status Performing Performing
The assessment of
Unconditional or no non-compliance /
Enforcement action by
enforcement action by outstanding conditions
CQC
CQC
from the initial
registration
Overall Quality of Service Rating Performing Performing
Assessment Thresholds for Integrated Performance Measures Average Score
Underperforming if less than 2.1
Performance Under Review if between 2.1 and 2.4
Performing if greater than 2.4

SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST - NHS PERFORMANCE FRAMEWORK MONITORING REPORT -
2013/14
Financial Indicators
SCORING
2013 / 2014
2013 / 2014
Criteria Metric Weight (%)
April Score Weight x Score May Score Weight x Score
3 2 1
Initial Planning
Planned Outturn as a proportion of
turnover
5 5
Planned operating breakeven or surplus
that is either equal to or at variance to
SHA expectations by no more than 3%
of income.
Any operating deficit less than 2% of
income OR an operating
surplus/breakeven that is at variance to
SHA expectations by more than 3% of
planned income.
Operating deficit more than or equal to
2% of planned income
0.05% 3
0.15
0.57% 3 0.15
Year to Date
YTD Operating Performance
25
20
YTD operating breakeven or surplus that
is either equal to or at variance to plan
by no more than 3% of forecast income.
Any operating deficit less than 2% of
income OR an operating
surplus/breakeven that is at variance to
plan by more than 3% of forecast
income.
Operating deficit more than or equal to
2% of forecast income
0.00% 3 0.6
0.01% 3 0.6
YTD EBITDA 5
Year to date EBITDA equal to or greater
than 5% of actual year to date income
Year to date EBITDA equal to or greater
than 1% but less than 5% of year to
date income
Year to date EBITDA less than 1% of
actual year to date income.
11.29% 3 0.15
6.69% 3 0.15
Forecast Operating Performance
20
Forecast operating breakeven or surplus
that is either equal to or at variance to
plan by no more than 3% of forecast
income.
Any operating deficit less than 2% of
income OR an operating
surplus/breakeven that is at variance to
plan by more than 3% of income.
Operating deficit more than or equal to
2% of income
0.00 3 0.6
0.00% 3 0.6
Forecast Outturn
40
Forecast EBITDA 5
Forecast EBITDA equal to or greater
than 5% of forecast income.
Forecast EBITDA equal to or greater
than 1% but less than 5% of forecast
income.
Forecast EBITDA less than 1% of
forecast income.
6.88% 3 0.15
6.46% 3 0.15
Rate of Change in Forecast Surplus
or Deficit
15
Still forecasting an operating surplus with
a movement equal to or less than 3% of
forecast income
Forecasting an operating deficit with a
movement less than 2% of forecast
income OR an operating surplus
movement more than 3% of income.
Forecasting an operating deficit with a
movement of greater than 2% of forecast
income.
0.00% 3 0.45
0.00% 3 0.45
Underlying Position (%)
5 Underlying breakeven or Surplus
An underlying deficit that is less than 2%
of underlying income.
An underlying deficit that is greater than
2% of underlying income
1.46% 3
0.15
1.07% 3 0.15
Underlying Financial Position
10
EBITDA Margin (%) 5
Underlying EBITDA equal to or greater
than 5% of underlying income
Underlying EBITDA equal to or greater
than 5% but less than 1% of underlying
income
Underlying EBITDA less than 1% of
underlying income
6.88% 3 0.15
6.46% 3 0.15
Better Payment Practice Code Value
(%)
2.5
95% or more of the value of NHS and
Non NHS bills are paid within 30days
Less than 95% but more than or equal to
60% of the value of NHS and Non NHS
bills are paid within 30days
Less than 60% of the value of NHS and
Non NHS bills are paid within 30 days
90.60% 2 0.05
92.60% 2 0.05
Better Payment Practice Code
Volume (%)
2.5
95% or more of the volume of NHS and
Non NHS bills are paid within 30days
Less than 95% but more than or equal to
60% of the volume of NHS and Non
NHS bills are paid within 30days
Less than 60% of the volume of NHS
and Non NHS bills are paid within 30
days
94.90%
2 0.05
94.40% 2 0.05
Finance Processes & Balance
Sheet Efficiency
20
Current Ratio 5
Current Ratio is equal to or greater than
1.
Current ratio is anything less than 1 and
greater than or equal to 0.5
A current ratio of less than 0.5
1.09 3 0.15
1.02 3 0.15
Debtor Days 5
Debtor days less than or equal to 30
days
Debtor days greater than 30 and less
than or equal to 60 days
Debtor days greater than 60
12.31 3 0.15
12.97 3 0.15
Creditor Days 5 Creditor days less than or equal to 30
Creditor days greater than 30 and less
than or equal to 60 days
Creditor days greater than 60
40.44 2
0.1
44.79 2 0.1
*Operating Position = Retained Surplus/Breakeven/deficit less impairments
Weighted Overall Score
2.90
2.90
Assessment Thresholds
Performing > 2.40
Performance Under Review 2.10 - 2.40
Underperforming < 2.10

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12.2 Monitor FT Bulletin April 2013 SWBFT (5/13) 051
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