Board Meeting Agenda July 2012 - Birmingham Children's Hospital

Board of Directors’ Meeting in Public 

Tuesday 31 July 2012 

AGENDA 

12.124 Apologies for absence 

09.00 5 mins 

Elaine Simpson, David Eltringham, David 

Melbourne, Vin Diwakar 

12.125 Declaration of interests 

12.126 Minutes of public Board meeting held on 29 

09.05 5 mins Enc 01 

May 2012 

12.127 Matters arising from of public Board meeting 

held on 29 May 2012 

12.128 Chairman’s Report 09.10 10 mins Verbal 

Questions from the public 09.20 5 mins 

12.129 Chief Executive’s Report 09.25 25 mins Verbal 


STRATEGIC OBJECTIVE 

Every child and young person requiring access to care at 

Birmingham Children’s Hospital will be admitted in a timely way, 

with no unnecessary waiting along their pathway 

12.130 Monthly Position Statement – Phil Foster, Challenge 09.55 15 mins Enc 02 

Deputy Chief Finance Officer 

progress 


STRATEGIC ENABLER 

Our Brand & Reputation 

12.131 Developing the BCH Brand - Rob Checketts, Information 10.15 25 mins Presentation 

Director of Performance 


10.45 Break 15 minutes 

STRATEGIC OBJECTIVES 

Every child and young person cared for by Birmingham Children’s Hospital 

will be provided with safe, high quality care, 

and a fantastic patient and family experience 

12.132 Quality Report – Vin Diwakar, Chief Medical Challenge 11.00 15 mins Enc 03 

Officer & Michelle McLoughlin, Chief Nurse progress 


Every member of staff working for Birmingham Children’s Hospital will be 

looking for, and delivering better ways of providing 

outstanding care, at better value 

12.133 Clinical Handover – Vin Diwakar, Chief Challenge 11.20 30 mins Presentation 

Medical Officer 

progress 


Every member of staff working for Birmingham Children’s Hospital 

will be a champion for children and young people 

A report under this objective is scheduled for September 

We will strengthen Birmingham Children’s Hospital’s position as a provider 

of Specialised and Highly Specialised Services, so that we become the 

leading provider of Children’s Healthcare in the UK

A report under this objective is scheduled for November 

We will continue to develop Birmingham Children’s Hospital as a provider 

of outstanding local services: ‘a hospital without walls’, working in close 

partnership with other organisations 

A report under this objective is scheduled for July 

STRATEGIC ENABLER 

A local Operating Framework & Financial Plan to ensure we move from 

strategy to action 

12.134 Resources Report – Phil Foster, Deputy Chief 

Finance Officer and Theresa Nelson, Chief 

Officer for Workforce Development 

Challenge 

progress 

11.55 15 mins Enc 04 


GOVERNANCE 

12.135 Use of Trust Seal - Gwenny Scott, Company Approve 12.15 5 mins Enc 05 

Secretary 


12.136 Hospitality Register Review - Gwenny Scott, Review 12.25 5 mins Enc 06 

Company Secretary 


Next Public Meetings: 

Annual General Meeting: 27 September 2012 

Council of Governors Meeting: 22 November 2012 

Public Board Meeting: 27 November 2012

BOARD OF DIRECTORS MEETING 

Minutes of the public meeting held on 29 May 2012 at 9.00am 

in the Education Centre at Birmingham Children’s Hospital 

Present: Keith Lester KL Deputy Chairman 

Jon Glasby JG Non Executive Director 

Judy Green JAG Non Executive Director 

Colin Horwath CH Non Executive Director 

Zubair Khan ZK Non Executive Director 

Elaine Simpson ES Non Executive Director 

Sarah-Jane Marsh SJM Chief Executive Officer 

Michelle McLoughlin MM Chief Nursing Officer 

David Melbourne DM Chief Finance Officer 

Theresa Nelson TN Chief Officer for Workforce Development 

Dr Vin Diwakar VD Chief Medical Officer 

David Eltringham DE Chief Operating Officer 

Attending: Gwenny Scott GS Company Secretary 

Tim Atack TA Director of Performance and ICT 

Dr Jim Gray DJG Consultant Microbiologist 

Observing: David Naylor The Burdett Trust 

Minutes: Shelley Smith Executive Assistant 

Ref. Item Action 

12.079 Apologies 

None 

12.080 Declaration of Interest 

None 

12.082 Minutes of the public meeting held on 27 March 2012 

The minutes were agreed as a true and accurate record. 

12.082 Matters arising from meeting held on 27 March 2012. 

12.053. The Board will discuss how the Governors can support schemes practically 

[Making Every Contact Count]. 

MM confirmed this will be picked up as part of the governors’ walkabout process in 

July. 

12.083 Chairman’s Report 

KL welcomed David Naylor of The Burdett Trust, who was attending the 

meeting as an observer, and gave the following verbal report: 

This week BCH celebrates its 150 th birthday. The launch on Monday was a great 

success and was the first in a series of events, the majority of which are to say thank 

you to staff. 

JAG hosted a Civic Reception in the Council House and reported that it was 

extremely well attended by staff, and the Lord Mayor of Birmingham made all feel 

welcome. Two inspirational guest speakers represented the hospital: a Diabetes 

Specialist Nurse who pioneered the Hospital at Home scheme, and Ben 

MacSkimming, a 14 year old patient. 

A Volunteer Recognition Ceremony will be held in the marquee today to recognise 

the selfless support and vital contribution of volunteers to BCH. ZK and ES will be 

1


presenting the awards. 

On Thursday KL will be presenting awards at the Bands 1-4 Tea Party Graduation 

Ceremony. 

KL expressed his gratitude to the other non-executive directors for their continued 

support in Joanna Davis’s absence. It is particularly sad that JD is unable to attend 

the events this week and all at BCH miss her energy and enthusiasm. 

The Board noted the verbal report. 

There were no questions from the Public. 

12.084 Chief Executive’s Report 

The Chief Executive reported verbally as follows: 

• It is fantastic to be holding a Board meeting during our 150 th birthday week, 

the focus of which is to say a big thank you to staff. There are various events 

during the week, including pampering sessions, which so far are proving very 

popular. Over 800 staff have booked on an event. 

We have had positive media coverage of the celebrations from ITV and the 

Birmingham Mail, and the BBC is recording several interviews in order to 

screen a lengthy piece on Friday. 

• On 25 May we were visited by the Prime Minister, David Cameron who chose 

BCH as the location for his announcement about the national roll-out of the 

Friends and Family Test from April 2013, which has already been launched 

across the Midlands and the East Cluster. Mr Cameron had heard about our 

pioneering work on patient experience, including the Friends and Family app 

we have developed. 

Mr Cameron spent 2 hours visiting wards, talking to patients and staff and 

getting involved with things like taking blood pressure and helping children 

order meals with the Maple system. He also met with a group of lead nurses, 

discussing cultural leadership issues and how nurses fit into the organisation. 

He was particularly interested in Safe and Sustainable, the way we are 

managing the financial situation and the prominence that MM Chief Nurse 

has in the Trust. He remarked as he was leaving that this was the busiest 

Children’s Hospital he had visited. The visit was covered positively in the 

media. 

• We had another high profile visit in May from Earl Howe who was interested 

in our research into paediatric rare diseases. Many children with these 

diseases only make it to early adulthood, so it is vital that research is done 

during childhood, and he was interested in how this can be developed. He 

visited the CRF and MRI scanner, and we explained some of the special work 

the Trust has done, such as the development of special diet food packets by 

Anita McDonald which have proved invaluable for many families, especially 

those for whom English is not their first language. Earl Howe also spent time 

with Tim Barratt and the wider team on the CRF, looking at some of the more 

intense studies such as the first inhuman trial in Hunters Syndrome. He was 

hugely impressed, particularly with the dedicated ward and the lengths that 

2


we go to for patient care. He sent a thank you letter expressing how the visit 

has changed his perception about the approach and value of paediatric 

research. 

• SJM and Jane Powell, Health Advocacy Lead, took part in the SHA Making 

Every Contact Count launch day. Of the four organisations that presented we 

were the only West Midlands hospital and the only acute hospital that are 

using MECC. Most of the public health attendees were impressed with the 

level of work we are doing as an acute organisation and other organisations 

were keen to work with us on their own schemes. 

• JAG and SJM attended the Annual Memorial Service at St Chad’s Cathedral, 

which was a beautiful event for bereaved families, very well supported by 

staff, especially the Chaplaincy team. SJM read to the Board a letter of 

thanks from a Sikh family who had attended the service. 

• BCH hosted the Association of Paediatric Anaesthetics Annual Conference, 

which was attended by anaesthetists from all over the world. There was real 

warmth in the room for Birmingham and BCH and the President stated that 

BCH leads the way in paediatric anaesthesia, supporting other organisations. 

• David Barron, Cardiac Surgeon, was awarded the ITV1 Daybreak Health 

Heroes Award. Dr Hillary Jones made a surprise visit to the Trust to present 

the award live on national TV. David received more nominations than anyone 

else in the country. 

With all of these events, it feels as though we are starting to fulfil our objective of 

throwing our doors open and getting the BCH message as far as we can. 

The Board noted the verbal report. 


Every child and young person requiring access to care at Birmingham Children’s Hospital will be 

admitted in a timely way, with no unnecessary waiting along their pathway 

12.085 Position Statement 

TA presented the report with the following highlights; 

• Emergency Department (ED): whilst general waiting times have improved 

over the last two months we are still struggling to meet our local standard of 

triage and the national standard for average treatment times. 

• This month we admitted all emergency and tertiary patients, and we are now 

starting to measure non-West Midlands requests, all of which were also 

admitted. 

• CAMHS: 9 patients could not be supported directly; all were admissions for 

Ashfield Unit. 

CAMHS have seen a 40% increase in demand over the last few years, partly 

due to wider service changes which mean other organisations are no longer 

supporting older adolescents, so we have picked up that support. The 

Community CAMH Service is also seeing an increase in demand at a time 

3


when Birmingham City Council is reducing funding for some aspects of 

CAHMS and other related services. Both services are looking at current 

demand and where they need to be in five years. 

• Cancelled Operations continue to be a concern, with 38 operations cancelled 

on the day, which was 2.1% of our activity, and a further 25 operations 

cancelled the day before. The reasons generally relate to a lack of PICU and 

theatre capacity. Gill Derrick, Clinical Director of Specialised Services has 

produced a detailed analysis which demonstrates that most cancelled 

operations are driven by urgent demand. Urgent unplanned patients are 

prioritised to the front of the planned list, which means we cannot always 

complete the list. There can also be issues relating to complex patients, 

where an operation takes longer than planned. Less complex electives at the 

end of the list are then cancelled. 

Because we have focused on improving quality through specialist based 

theatre teams there is also less flexibility to more patients around. 

DE added that theatres run at maximum capacity and the challenge is to 

create sufficient headroom within the system to be able to respond to these 

urgencies. We could reduce the patient flow, but this would affect our 18- 

week wait performance which affects the patient experience in another way. 

There are two ways to resolve this problem: 

1. Build more operating theatre capacity, 

2. Look at operating in ‘retail hours’, later into the evening and on 

Saturdays as routine. We do currently do some Saturday lists, but as 

it is not routine we pay premium rates. 

Work on adopting retail hours has now begun, based on the analysis 

undertaken by the directorate. 

VD added that the Productive Operating Theatre work may also help address 

some of these issues. 

The Board raised the following points in relation to cancelled operations: 

o 

o 

o 

o 

Whether we can learn from practices of other organisations. 

Whether as a Board we should consider an acceptable minimum 

number of cancellations, particularly in view of reputational issues. 

The level of confidence that the expansion of PICU will start to 

address this issue. 

The issues relating to a patient with learning disabilities referred to in 

the report. 

The Executive Team responded as follows: 

o 

o 

A lot of organisations have looked to industry for learning around 

cancelled operations. Sherwood Forest Hospital for example has 

partnered with Unipart and they are starting to learn from their 

approach to business. This is something we can look at. 

We put the patient at the centre of our decision making about 

prioritisation. The Executive Team has discussed in depth with the 

specialists in the hospital a potential tolerance level and they are very 

4


concerned with the idea. There is a risk that a target would distort 

clinical prioritisation, which could create a clinical risk far greater than 

the reputational risk. 

o 

o 

The impact of increased physical capacity takes time to be felt as 

specialist staff need to be recruited, trained and developed. 

The patient with learning disabilities was coming in for repeat tests 

and did receive treatment. 

• 18 weeks: we are meeting the elective standard, but this has been a real 

challenge. Despite increased theatre capacity and productivity, the size of the 

surgical waiting lists hasn’t moved over the last twelve months because 

demand has increased by 9%, predominantly from the non Birmingham area. 

Future demand modelling suggests an increase by 20% over the next seven 

years. 

PICU: 10 West Midlands patients and 4 non West Midlands’s patients could 

not be supported by PICU in April, although we did support 9 non West 

Midland’s patients. 

SJM stated this indicates PICU capacity pressures are not just a local issue 

as London, Wales and Gloucestershire are asking BCH for relief. We need to 

acknowledge to staff that we recognise that we do not think we have yet 

sorted the capacity problem and the physical expansion alone will not resolve 

it. KL expressed that he would like to be more visible around the hospital, 

and it may be beneficial to arrange to visit some of these areas. 

The Board noted the performance and the plans for improvement. 


Every child and young person cared for by Birmingham Children’s Hospital will be provided with 

safe, high quality care, and a fantastic patient and family experience 

12.086 Patient Safety Report 

VD presented the report to the Board with the following highlights: 

• VD explained the background to 3 incidents last year which were regarded as 

‘Never Events’. They involved the retention of an item after surgery without 

the patient’s knowledge or consent. These related to the removal of devices 

that were inserted just beneath the skin for intravenous antibiotics. On 

removal a tiny piece become detached and was not removed. In the majority 

of these types of case it is better to leave the item in place as is does not 

cause any harm and may cause more harm to remove. 

As a result of these incidents, Tony Lander, Clinical Director for Surgery, has 

revised the process to ensure the operating surgeon is familiar with the 

device and all its parts, and that the possibility of a piece remaining after 

removal is explained to the patient when consent is taken. Since those steps 

have been in place there have been no further events. This issue has gained 

national attention and there is now a focus on these types of cases across 

the NHS. 

• Mortality: no concerns. 

5


• Respiratory arrests, Acute Life Threatening Events and Unplanned 

Admissions to ICU: The data shows an increase in Cardiac Arrests, as we 

are now including arrests in ICU. We will be separating this data from arrests 

on wards to provide clarity. On the wards they have monitoring to prevent 

cardiac arrests, so we should see a low incidence but on PICU there are 

occasions where the heart may stop suddenly due to the severe nature of the 

patient’s condition or where the patient is recovering from surgery. As yet we 

don’t fully understand the measures we can put in place to prevent those 

cases from happening. This is the same in children’s hospitals worldwide. 

• Pressure sores: we are focusing on reducing grade 2 pressure sores and we 

are working to ensure we have the correct data to make sure the grading is 

done correctly. 

• We had two incidents on PICU over recent months, where antibiotics were 

not administered until a few hours after diagnosis. In response, as part of a 

National Campaign called ‘Surviving Sepsis’ we are piloting an Antibiotic 

Care Bundle in ED before roll out to more complex clinical areas. The 

process is appended to the report. 

KL queried the selection of ED for the pilot rather than a more complex area 

where the incidents occurred. VD responded that it was important to test the 

scheme in a lower risk environment to ensure it is safe. 

• Handover: VD and his team will be speaking at the National Patient Safety 

Congress on the work they are doing to improve the quality of handover. 

This is a good opportunity to highlight the Trust’s work on patient safety and 

for BCH to learn from other organisations. 

The Board received and noted the report. 


12.087 Paediatric Safety Thermometer 

MM gave a presentation to the Board, with the following highlights: 

The Safety Thermometer was launched across the region in March 2012. This is a 

tool which measures harm in 4 areas on one day each month: 

• Pressure sores 

• Urinary Tract Infections 

• VTE 

• Falls 

We piloted the scheme last year and the clinical teams felt that the process could be 

valuable. The SHA have now agreed to support the development of a Safety 

Thermometer more pertinent to paediatrics. 

MM’s team worked with Governance and VD’s team to identify our top 4 areas of 

harm and how they could be measured. The SHA then hosted an event to open the 

debate to a wider national audience. All organisations identified pressure sores and 

extravasation injuries as vital areas, and additionally agreed a measure for ‘no 

avoidable pain’. The group also discussed medication omissions but it was felt that 

more time is needed to produce a definition for this measure. The group therefore 

agreed that the fourth measure will be the paediatric early warning system (PEWS) 

6


as some children’s units do not have this working well yet. 

The group also debated the possibility of introducing age categories to reflect the 

range from neonatal to adolescent patients. However, it was agreed that this would 

complicate the process and at this stage the tool should be a single Paediatric Safety 

Thermometer for patients under the age of 18. 

An expert reference group has now been set up to set the definitions for the 

thermometer and the Trust’s informatics team is working with the SHA to develop an 

electronic process to reduce the levels of administration involved. 

BCH will be one of 10 national pilot sites for the new process, which will commence 

in September 2012 before full roll-out in March 2013. 

The Board discussed the following matters: 

• The benefit to us of measuring PEWS as we already do this well. 

This is a national initiative so needs to be relevant to the majority. Other 

trusts don’t have the same level of monitoring as BCH and we have set an 

objective to take a leadership role for children and young people. We have 

other additional ways of measuring harm such as the Nursing Care Quality 

Indicators (NCQIs) which we will continue. 

• How mental health services are being included. 

An adult mental health group is developing a separate process and MM’s 

team and the CAMHS team are working with them to develop 4 safety 

measures. 

• Any risks connected with the process. 

There are potential reputational risks when the results are in the public 

domain. 

• How performance will be improved on the back of data. 

As a Trust we are ahead, as we have implemented the NCQIs and we have a 

process already in place for pressure ulcers. We will be sharing good practice 

with other organisations. 

• The way the outcomes will be linked with other data, such as incidents, and 

reported to Board. 

This will come through to the Board as part of the Quality Report, which 

will integrate all safety and quality data. 

MM 

• The leadership and cultural challenges involved in introducing this kind of 

process. 

The Board received and noted the report. 


7


12.088 Infection Control Annual Report 

MM and DJG presented the report to the Board with the following highlights: 

• Last year was the start of a new era for infection control. We had previously 

put a lot of time and resource into getting the basics right. Last year we felt 

ready to set some challenging objectives, particularly around reducing central 

line infections, which is one of the most common types of healthcare 

associated infections we see, and reducing antibiotic usage. 

• These stretch objectives have been met with room to spare. We aimed to 

achieve 25% reduction in line infections and we achieved 33%; we aimed to 

achieve 10% reduction in antibiotics and achieved 14%. 

• There is a lot more we can do and we have set a further objective that no 

child will experience an avoidable infection at BCH. First we have to define 

what is ‘avoidable’. 

• There is also more we can do on antibiotic usage, ensuring there is no delay 

in getting antibiotics and discontinuing them as soon as appropriate. 

• The DoH mandatory surveillance changed focus last year from MRSA which 

has a low prevalence in paediatrics, to MSSA, which is in the top three 

causes of bacteraemia within BCH and most other children’s hospitals. The 

target concerned us but by working with parenteral nutrition and 

gastroenterology we were able to meet it. Learning from this work will be 

applied to Haematology/Oncology. 

The Board discussed the following points: 

• How we compare to other hospitals and is there anything we can learn from 

them. 

We have been consistently the best performing of the paediatric hospitals in 

relation to the DoH measures. It is difficult to compare ourselves on MSSA 

with other hospitals because the figures in the public domain are unclear. 

• The need to continue to embed the message that infection control is 

everyone’s responsibility and that by taking simple measures we can meet 

our targets. 

• Whether further improvements can be made in relation to blood culture 

contamination. 

Unnecessary laboratory investigations are bad for the patient and for the 

hospital. This is a cultural issue and DJG’s team is working with clinicians to 

make use of labs more appropriate. 

• Whether there is any cause for concern about infection control compliance 

connected with our capacity pressures. 

There are no concerns. We have a larger population of infected patients than 

most organisations and have a cultural appreciation of infection as a risk. All 

infections are monitored weekly and any hospital acquired investigations are 

investigated through root cause analysis. 

The Board congratulated DJG and MM on the successes; approved the report 

and confirmed support of the plans to develop infection prevention and control 

in line with the Trust’s strategic objectives. 

8


There were no questions from the public. 

A local Operating Framework & Financial Plan to ensure we move from strategy to action 

12.089 Resources Report – month 1 position 

David Melbourne presented the report to the Board with the following highlights: 

• This is the first of a new style report which aims to bring all the threads 

together. The Finance and Resources Committee has agreed to meet more 

regularly to enable the production of a monthly summary report and a 

quarterly, more detailed report for the Board. 

• Activity: There has been a significant increase in elective activity at 20% 

higher than last year. Outpatient activity has also increased, though 

unplanned activity is a little lower. 

• Monitor: at quarter 1 we are predicting green in all Monitor risk ratings, albeit 

there are no finance figures yet. 

• Workforce: we are developing a narrative on the implications for staff of the 

increase in activity. There was a small decrease in staff from March to April. 

Sickness absence has reduced to below the Trust 3% target. Productivity 

has improved significantly. Non-consultant appraisals are disappointing, 

though some of this maybe related to access to the system. TN added that 

the new appraisal system was launched last month, which is essential to our 

engagement with staff. 


• The approach to a more lightweight report was commended. 

• Adding forecast data would improve the report by acting as an accuracy 

gauge and to highlight potential risks. 

• The full performance data will not be included next month but a patient 

experience section will be introduced. 

The Board noted and approved the new format of reporting, and noted the 

performance concerns and the progress against the 2012/13 CIP programme. 

There were no questions from the public. 

12.090 Capital Programme 

David Melbourne presented the Capital Programme 2012/13 to the Board, with the 

following highlights: 

• The report sets out the challenges we have had to face in managing our cash 

balances and meeting our short-term and long-term ambitions. The Board 

has approved a Financial Strategy that requires us to develop cash balances 

to ensure we can meet our goal of a new hospital facility. 

• The financial plan for the year sets aside capital of £10.5 million, the majority 

of which is already committed to a range of schemes already approved. 

• A Capital Prioritisation Framework has been developed by the Capital 

Planning Group to guide investment decisions. This has been applied to the 

range of schemes set out in the report, which will come to the Board for 

approval over the next 18 months. 

9


KL added that the Finance and Resources Committee has looked very closely at this 

and as chair of that Committee he was happy that there was a robust and rigorous 

process. The Board needed to consider the following: 

1. Whether it approved to the £10.5 million being invested. 

2. The process for allocation. 

3. The allocated schemes. 


• The framework was robust and gave confidence. 

• The need to develop a timeframe for borrowing and investments on the 

current site if we move to a new site. 

The Board: 

Approved the approach taken to developing the Capital Programme. 

Approved that £10.5 million be set aside for investment in capital projects. 

Approved the allocation of the £10.5 million to the schemes identified. 


Governance 

12.091 Report on the use of the Trust Seal 

GS presented the report to the Board. 

The Trust Seal has been used this month on the leasing of premises to provide office 

accommodation, freeing up space in the hospital main site to enable expansion of 

the PICU and provide additional capacity for CAHMS, KIDS and fundraising. 

The Board approved the use of the Trust Seal. 


Date of next Public Board Meeting: Tuesday, 31 st July 2012. 

10

Board of Directors 

Public Meeting 


Item 12.130 Enc 02 

Strategic Objective/ Enabler 

Every child and young person requiring access to 

care at BCH will be admitted in a timely way, with no 

unnecessary waiting along their pathway 

Report Title 

Strategic Objective 1 - June 2012 Performance Report 

Sponsoring Director 

Director of Performance & ICT 

Author(s) 


Previously considered by 

Executive Management Team 

Situation 

This report provides the June update on this Trust strategic objective supporting improving 

our patient experience. The report highlights where performance is not being met and any 

concerns or improvements. 

The attachments provide further details on our current and comparative performance. 

Background 

June overall has seen an improvement in our performance standards, set against a 

reduction in demand, in part due to the Whitsun half-term holiday. 

Access Standards 

ED waits reduced, however, we continue to not meet 2 key standards: 

• The local Emergency Department (ED) triage objective was not met (all within 15 

minutes), the 95 percentile performance being 30 minutes. 

• The ED treatment time standard (average within 60 minutes) was not met, our 

performance being 60 minutes. 

All ED emergencies were admitted. 

A total of 3 tertiary admissions (all from the West Midlands) could not be supported and had 

to be admitted to out of region tertiary paediatric centres. 6 patients that were admitted had 

to wait over 24 hours before a BCH bed was provided.

CAMHS Tier-4 (Child & Adolescent Mental Health Service) 

The West Midlands service is provided by BCH and other providers (some private) with BCH 

providing the assessment of all requests. 

7 patients could not be supported by BCH CAMHS. 

Flow 

3 patients’ discharge was delayed due to non-hospital reasons and all 3 patients have 

discharge plans. 

Cancelled Operations remains as the key performance concern with 23 patients or 1.2% of 

all operations cancelled on the day due to hospital reasons. This is above the national 0.8% 

standard. The reasons for this are broken down as: 

No PICU (Paediatric Intensive Care Unit) bed 11 

Operation overrun 9 

Staff sickness 2 

More urgent patient 1 

No patients with Learning Disabilities had their operation cancelled and the ethnic 

breakdown of the 23 patients is: 

15 - white/British, 1 – asian/asian British Indian, 3 - asian/asian British Pakistani, 1 - 

mixed white/Caribbean, 1 – not stated, 2 – white/any other white 

A further 4 patients had their operation cancelled by the hospital before the day of the 

operation. 

Whilst the 18-week standards were met, a total of 46 patients had to wait over 18-weeks for 

treatment to start. During the month, 1 urology patient was treated at their 34 th week, the 

delay in part due to not being fit for previous operation dates. At the end of June 1 ENT 

patient (33 rd week) and 1 cardiology patient (35 th week) have requested to wait longer. 

The total surgical elective waiting list is 15% higher than this time last year (due to demand). 

When the plans to increase capacity come to fruition, this will lead to a short-term drop in 18- 

week performance as we treat all the patients waiting > 18 weeks. 

The local 90% CAMHS 18-week standard was not met, performance being 88.8%. With 

support from commissioners, additional staffing is being recruited to reduce waiting times. 

PICU (Paediatric Intensive Care Unit) 

The West Midlands (WM) PICU service is provided by BCH, University Hospitals of North 

Staffordshire NHS Trust and the KIDS (Kids Intensive care Decision Support) service run by 

BCH. 

PICU has remained under significant demand. A new KIDS activity graph is included that 

demonstrates the increase in demand over the past year. 

2 WM patients could not be supported with 1 patient going to Leicester and 1 out of region. 

1 non-WM request could not be supported, however a total of 5 non-WM requests were

supported (1 by BCH PICU, 3 by BCH non-PICU beds and 1 by North Staffs PICU). 

Assessment 

Waits and cancellations generally improved in June. Key actions to improve performance 

include: 

Emergency Department (ED): 

• The Emergency Care Pathway project has been re-energised with a new Project 

Manager and additional support to ED. 

• Supported by new Trauma Centre funding, an additional ED consultant and additional 

senior registrars have been recruited. The staff will be fully in place by January 2013 and 

will provide enhanced senior medical input into ED including 24-hour dedicated ED 

senior registrar cover. 

• Additional Advanced Nurse Practitioners have been appointed. 

• Development of the ED estate, including improvements to treatment rooms and waiting 

areas. 

• Plans have been developed to expand the general paediatric team to provide extended 

evening and 7-day consultant support to the Paediatric Assessment Unit and ED. 

PICU Capacity: 

• The first 4 of the 9 additional PICU beds open in September, with the remaining beds 

opening over the following year as new staff become fully PICU trained. This takes PICU 

up to 31 beds. 2 flex beds have opened in the interim. 

• In the autumn a new High Dependency support service is in place, providing support to 

all ward areas. 

• We aim to have in place by the winter a new enhanced 4-bedded Medical High 

Dependency Unit, co-located by PICU, to manage patients currently supported by PICU. 

This development is being discussed with the NHS Specialist Commissioning Team. 

We continue to work with commissioners to review the ongoing growth in demand, and 

establish short and long term plans to increase our capacity to support this demand and 

ensure our standards are met. 

Recommendations 

Trust Board is asked to note the performance and plans for further improvement. 

Key Risks 

Risk Description Controls Assurances 

Insufficient capacity in place 

to meet service demands 

Appropriate escalation 

systems in place 

Capacity plans being 

renewed and developed. 

This includes modelling 

capacity/demand between 

now and 2020 (new hospital) 

Daily, weekly and monthly 

reporting in place. 

Revised capacity plans being 

produced.

PICU capacity task group 

established 

Key Impacts 

Strategic Objectives 

This reports covers progress against meeting the strategic 

objectives linked to supporting improving our patient 

experience. 

CQC Registration (state 

outcome) 

Not directly 

NHS Constitution 

Yes – treatment within 18-weeks is a requirement within the 

NHS Constitution. 

Other Compliance (e.g. 

NHSLA, Information 

Governance, Monitor) 

Many of the indicators are local or national standards 

monitored by the Department of Health, Monitor and our 

Commissioners. 

Equality, diversity & human 

rights 

No 

Trust contracts 

Some of the planned improvements support delivery of QIPP 

initiatives and non-delivery of NHS standards can result in 

financial penalties 

Other 

Meeting the strategic objectives raises the profile of Trust 

locally, regionally and nationally

Strategic Objective Report 

Every child and young person requiring access to 

care at Birmingham Children’s Hospital will be 

admitted in a timely way, with no unnecessary 

waiting along their pathway 

June 2012 

Tim Atack 


1

Our Performance Dashboard – June 2012 

2

ACCESS 

Emergency Department – Transfers Out 

No patients were transferred out during June. 

3

Emergency Department 

4

Tertiary Referrals 

IP Tertiary 

•There were 161 referrals for specialist beds at 

BCH. 

• 3 patients were unable to get a bed at BCH 

• 6 patients had to wait over 24 hours to be 

offered a bed at BCH. 

• 18 patients were deemed to no longer require 

a bed at BCH 

5


( ) = not hospital delays/out of region patients/referred from home patients 

6

CAMHS Referrals 

Delayed Discharges 

7 patients could not be supported by 

BCH CAMHS 

3 patients discharge is delayed due to 

non-medical reasons. All patients are 

due to be discharged in July or August 

7

FLOW 

Cancelled Operations 


23 for June (1.22%) above the national 0.8% target. 

The ethnic breakdown of the patients is: 

15 - white/British, 1– asian/asian British Indian, 3- asian/asian 

British Pakistani, 1 –– mixed white/Caribbean, 1 – not stated, 

2 –white/any other white. 

No patients with Learning Disabilities were cancelled. 

A further 4 patients had their operation cancelled by the hospital 

before the day of the operation. 

8


9

18-weeks 

The standards were met for June 90.2% admitted, 98.6 % non-admitted and 98.4% 

incomplete patients, however a total of 46 patients were not treated within 18-weeks due 

to a lack of hospital capacity. 

Patients waiting over 30 weeks 

1 urology patient was treated at their 

34 th week, the delay in part due to 

not being fit for previous operation 

dates. 

1 ENT patient (33 rd week) and 1 

cardiology patient (35 th week) have 

requested to wait longer. 

1 urology patient (34 th week) waiting 

for treatment, in part due to not 

being fit for treatment 

10

18-weeks - CAMHS 

The local 90% standard was not met in June, actual performance was 88.8%. Additional 

staffing (funded by commissioners) is being recruited to address waiting time concerns. 

11

PICU Demand 

PICU has remained under significant demand 

which has impacted on both the ability to 

admit emergency patients and support complex 

elective surgery. The financial implications of 

this are explored in more detail later. 

A total of 2 WM patients could not be 

supported with 1 patients going to Leicester 

and 1 out of region. 

A further 1 non-WM requests could not be 

supported, however a total of 5 non-WM 

requests were supported (1 BCH PICU, 3 BCH 

non-PICU beds and 1 other WM PICU). 

12


Category Performance Indicator Performance Target 

Discharge 

Delays 

Discharge 

Delays 

No patient will leave the emergency 

department without being seen 

Lead 

Chief 

Officer 

R A G Apr-12 May-12 Jun-12 YTD 

Last year 

position 

Median time from arrival COO 9 9 8 9 11 

95th percentile COO >15 15 32 34 30 32 42 

Single longest total time COO 250 75 399 250 107 

Median time from arrival COO >60 - 4 4 4 4 5 - 0 0 0 6 3 9 4 

% of patients COO >0 0 0 3.04 1.86 4.2 0.22 

Number of patients COO 7 23 6 36 53 

% of patients COO 5.2 11.7 3.7 7.3 2.9 

Number of patients COO >0 0 0 7 3 10 NA 

% of patients COO >0 0 0 3.6 1.86 2 NA 

Number of patients not 

admitted to a CAMHS bed 

COO 9 4 7 23 75 

% of patients not admitted to 

a CAMHS bed. 

COO 47.4 36.4 53.8 51 48.2 

FLOW 

Delayed discharge total patients Total patients COO 2 1 3 6 NA 

Delayed discharge total bed days Total bed days COO 60 31 81 172 NA 

Comments 

Every child and young person requiring access to care at Birmingham Children’s Hospital will be admitted in a timely way, with no unnecessary waiting 

along ACCESS their pathway 

ED deflections Number of patients deflected COO 0 0 0 0 0 

Emergency 

Department 

Tertiary 

Referrals 

Tertiary 

Referrals 

CAMHS 

No patient (All patients) will wait more 

than 15 minutes for initial full 

assessment 

No patient will wait more than 1 hour to 

start of definitive treatment from a 

decision making clinician 

No patient will spend more than 4 

hours in total in the emergency 

department 

Tertiary Refusals (Number/%) 

Tertiary Referrals - Patients that did 

not get a bed within 24 hours of asking 

Tertiary Tertiary Refusals (Number/%) 

Referrals - ALL 

Patients that requested a BCH T4 

CAMHS bed and were not admitted 

following a gateway assesment 

Excludes non-BCH 

catchment 


catchment 

ALL requests

Strategic Objectives continued … 


Cancelled 

Operations 

Cancelled 

Operations 

RTT Waiting 

Times 

Diagnostic 

Waits 

PICU 

Provider cancellation of Elective Care 

operation for non-clinical reasons 

either before or after Patient admission 

Breach of clause 40.5 (Admitted patient 

and had operation cancelled for non clinical 

reasons. The provider needs to offer them a 

date within 5 operational days which falls within 

28 days from cancellation.) 

Lead 

Chief 

Officer 


Last year 

position 

Comments 

FLOW 

Number of cancellations COO 38 39 23 77 347 June 2011 - 20 

% of cancellations COO 1.5 - 0.8 2.1 1.96 1.22 1.76 1.6 

100% compliance COO 90 - 90 90.7 90.3 90.2 90.4 91.6 

% of non admitted over 18 weeks 95% non admitted COO >95 - 95 99.3 99.3 98.6 99.1 98.9 

% of incomplete over 18 weeks 92% incomplete COO >92 - 92 97.7 97.7 98.4 98 97.9 

CAMHS - number of non admitted over 

18 weeks 

COO Trend 

33 31 64 

CAMHS - % of non admitted over 18 

weeks 

90% non admitted COO 90 88.6 87.6 88.8 88.6 

Diagnostic waits number >6 weeks COO 0 0 0 0 

Diagnostic waits % >6 weeks Operating Standard 99% COO


Lead 

Chief 

Officer 


Expanding our Hospital at Home Services 

CPO 

Local strategy for children’s general services 

CMO 

Working in partnership to develop new and innovative 

COO 

CAMHS models 

ENABLERS 

Our ‘people strategy’ so everyone knows what role they have to play and how they will be supported 

People Strategy 

CWD 


Resources report 

CFO 

A strategy to deliver a modern environment, fit for an ambitious 21st century hospital 

New Hospital Project 

CFO 

Brand and Reputation 

150 years celebrations 

CEO 

Last year 

position 

Comments 

Every child and young person cared for by Birmingham Children’s Hospital will be provided with safe, high quality care, and a fantastic patient and family 

experience 

Every member of staff working for Birmingham Children’s Hospital will be looking for, and delivering better ways of providing outstanding care, at better 

value 

Emergency Care pathway 

COO 

June-Sept 

Research Output profile 

CMO 

Sept – Nov 

Equipping staff to create value 

CWO 

Nov-Jan 

Better use of staff and physical resources 

CFO 

Feb-March 

Every member of staff working for Birmingham Children’s Hospital will be a champion for children and young people 

National Strategy for Children’s specialised services 

CEO 

June-July 

Making every contact count 

CNO 

Oct-Dec 

YPAG 

CNO 

Dec-March 

We will strengthen Birmingham Children’s Hospital’s position as a provider of Specialised and Highly Specialised Services, so that we become the 

leading provider of Children’s Healthcare in the UK 

Safe & Sustainable Designation 

CMO 

June – July 

National Centre for rare diseases 

CMO 

Sept-Nov 

Children’s surgery review 

CMO 

Jan-Feb 

We will continue to develop Birmingham Children’s Hospital as a provider of outstanding local services: ‘a hospital without walls’, working in close 


Jan-March 


July-Sept 

June 

Monthly 

April 

May?



31 July 2012 

Item 12.131 Enc 03 

Every child and young person cared for by Birmingham 

Strategic Objective Children’s Hospital will be provided with safe, high quality care, 


Report Title 


Contributors 


Quality Report 

Dr Vinod Diwakar, Chief Medical Officer & Michelle 

McLoughlin, Chief Nurse 

Associate Chief Medical Officer (Safety), Governance 

Services, Corporate Nursing, Education & Learning 

EMT 

Situation 

The enclosed report provides a monthly update on key clinical safety topics. 

Background 

The report is collated from a number of information sources and provides assurance that key 

risks to quality and safety are being escalated and monitored until sufficient action has been 

taken to address the concerns. 

The report includes information on key risks, serious incidents, mortality data, cardiac arrest, 

respiratory arrest and other acute life threatening events. Information on Never Events and 

other safety information is included by exception. 

The report also includes other key information about quality, including infection control rates, 

Safety Thermometer outcomes, formal complaints, PALS and other patient experience data. 

Assessment 

Please see the enclosed report for a discussion of the key risks. 

Review the enclosed report. 

Recommendations

Key Risks 


Failure to correctly identify the 

greatest risks to the quality of 

care and safety of our 

patients. 

• Directorate 

Governance systems 

• Board Assurance 

Framework 

• Risk Register 

• Safety Strategy 

• Safety Dashboard 

Key Impacts 

• Monthly Board Safety Report 

• Mortality Review 

• Monitoring of incident 

trends 

• Monitoring of complaints 

trends 


The information provided in this report contributes to the 

delivery of our strategic objective that Every child and 

young person cared for by Birmingham Children’s Hospital 

will be provided with safe, high quality care, and a fantastic 

patient and family experience. 


outcome) 

All, but particularly: 

Standard 16 Assessing & monitoring the quality of service 

provision could be affected by a failure to manage risks 

highlighted by the report. 


None 




This report includes key quality information which should be 

considered by the Board. Failure to do so could impact on 

maintaining NHSLA level 3 compliance for Standard 1 

(Governance). 


rights 

None 

Other 

None

Quality Report: 

Safety & Patient Experience 

July 2012 

Vin Diwakar, Chief Medical Officer 

Michelle McLoughlin, Chief Nurse

The BCH Vision of Quality 

Strategic Objectives which reflect our commitment to Quality, Safety and a fantastic patient Experience. 

Every child and 

young person 

requiring access to 

care at Birmingham 

Children’s Hospital 

will be admitted in a 

timely way, with no 

unnecessary waiting 

along their pathway 

Every child and 

young person cared 

for by Birmingham 

Children’s Hospital 

will be provided 

with safe, high 

quality care, and a 

fantastic patient and 

family experience 

Every member 

of staff working 

at Birmingham 

Children’s 

Hospital will be 

looking for, and 

delivering better 

ways of 

providing care, 

at better value 

Birmingham Children’s 

Hospital’s leaders will 

work hard to strengthen 

its position as a provider 

of Specialised and Highly 

Specialised Services, so 

that it becomes the 

national provider of 

Children’s Healthcare 

Services in the UK 

Birmingham 

Children’s 

Hospital will 

continue to 

develop as ‘a 

hospital without 

walls’, working in 

close partnership 

with other 

organisations 

Birmingham 

Children’s 

Hospital will be 

a champion for 

children and 

young people. 

Clinical Quality is our organising principle. It has always 

been our mission to provide outstanding care and 

treatment to all children and young people who choose 

and need to use our services, and to share and spread new 

knowledge and practice, so we are always at the forefront 

of what is possible. Our vision is to be the leading provider 

of healthcare for children and young people, giving them 

care and support – whatever treatment they need – in a 

hospital without walls 

The physical capacity of the estate is the biggest challenge 

to this vision. Thus, our clinical quality strategy is founded 

on capital investment in our estate, modernisation of care 

pathways, equipping our staff with the skills to use our 

existing resources more safely, effectively and efficiently, 

and partnership working to deliver healthcare for children 

and young people closer to their home wherever possible. 

We have built in a relentless focus on the experiences of our children, 

young people and families at every level. 

We want to be a place where safety is everyone’s top priority and 

have set the following 3yobjectives to reflect this: 

• Continue development of tools to prevent predictable and 

preventable cardiac and respiratory arrests, reduce extravasation 

injuries and medication incidents, improve time from decision to 

administration of antibiotics, and prevent Grade 2 pressure sores 

• Reduce risks in the handover of patients between services and 

caregivers during their inpatient stay 

• Develop a Trust wide quality outcomes dashboard 

• Introduce new methods of collecting and responding to the 

experience of our patients and families in real time using web 

technology

High Risks 

One high clinical risk is recorded on the risk register, this relates to the cardiac waiting list. 

Specialty 

/Area 

Issue 

Consequence 

Likelihood 

Action 

Cardiac Services 

RISK No: 1234 

There are a number of patients 

defined as clinically urgent that are 

awaiting cardiac surgery. Continued 

capacity issues in PICU mean that 

these patients cannot be offered 

dates for their operations. 

4 4 There are a number of ongoing actions to manage this risk, and the length of 

the waiting list has decreased over the last two weeks. 

Continued close monitoring of patients and availability of PICU beds. 

Reassessment of patients by cardiologists. Reprioritisation of patients based 

on changes to clinical condition. Restrictions on out of region referrals. 

Waiting list management has been reviewed by NHS IMAS to ensure that this 

is optimal. Additional PICU beds will open in September 2012 which will 

increase capacity. There are also longer term plans to explore the potential to 

expand the PIC network and to explore a further increase the number of PIC 

beds at BCH over the next 10 years. 

A critical care outreach team (PACE), an increase in MHDU beds and increased 

Consultant General Paediatrician posts will also increase PICU capacity for 

cardiac patients.

Learning from Incident 

Investigations (Closed cases) 

Two Serious Incident Requiring Investigation (SIRI) were completed in June 2012. 

Investigation 1 

This case involved a noted increase in diarrhoea 

and vomiting symptoms on Ward 5, and was 

treated as an outbreak of Norovirus. 

The investigation was unable to identify the Root 

Cause of the outbreak and no failures in care were 

identified. 

The review did identify a number of areas of good 

practice. 

Investigation 2 

This case also involved an outbreak of diarrhoea and vomiting symptoms, and 

was treated as an outbreak of Norovirus. This case involved Ward 9 (surgical 

ward). The outbreak lasted 10 days but affected fewer patients and staff than 

the outbreak on Ward 5. 

Again, the investigation was unable to identify the Root Cause of the outbreak. 

The only possible contributory factor identified was the fact that we were not 

able to carry out a rolling cleaning programme on this ward due to the layout 

of the ward. 

In future we will consider ‘zoning’ patients to allow this. 

Areas of good practice identified by these two investigations included: 

•High levels of cleaning - stepped up as required. 

•The responsiveness of our domestic team was excellent. 

•Visiting restrictions were adhered to and hand hygiene of visitors was very good. The use of posters had a big impact. 

•The quality and regularity of internal communication was excellent. 

•Introducing alcohol gel in Ronald McDonald House (Parent accommodation) as well as in-house parent accommodation. 

•Restricting movement of staff and patients between wards 

•Communication with external agencies (the PCT and the HPU) was excellent, as was the support that was provided by these agencies.

Learning from Incident 

Investigations (New Cases) 

There have been two new Serious Incidents Requiring Investigation since the last report. 

Both involved care delivered in the Emergency Department (ED). 

12/13:12 

A patient presented at the ED with a swollen leg. It was not possible to reach a diagnosis that day, 

therefore the patient was reviewed in a clinic 2 days later. Unfortunately, a diagnosis was still not 

possible, as an MRI scan was required and the patient would need a general anaesthetic for this 

scan. The patient was handed over to the general paediatrics team. 

There appeared to be delays in carrying out the MRI scan, and this was not completed for a 

number of weeks. The patient is now under the care of the Trauma and Orthopaedics team. It is 

not clear if the delay has led to the patient suffering additional harm. 

There were no 

new Never 

Events in June 

2012 

12/13:18 

A patient attended the ED with upper respiratory symptoms. This patient was an ex pre-term 26 week gestation baby with chronic 

lung disease, on home oxygen with a congenital cardiac condition of Atrial Septal Defect (ASD), pulmonary valve stenosis and 

moderate pulmonary hypertension. Following review and assessment by a medic, the patient was discharged home. 

The patient was found unresponsive at home the following day, and could not be resuscitated. We will review whether there are 

any concerns with the discharge. (Please note that this case is included under the Mortality Details section)

Mortality 

Mortality data is presented in a number of ways, and an overall picture can only be gained by using a 

number of indicators. These are: 

•Absolute number of deaths per time period. 

•Number of deaths per time period per 1000 admissions. 

•Standardised mortality ratio. 

•Cumulated sum (CUSUM) charts. 

•Review of individual deaths. 

Inpatient deaths per 1000 admissions 

This is a simple calculation to overcome any 

variations in admission numbers over time 

(e.g. the hospital may have more admissions in 

the winter months) or between hospitals of 

different sizes. Data can be compared 

between organisations by this method as it 

allows for different admission numbers but it 

is limited as a tool for comparison as there is 

no modification for case mix. The graph on the 

right shows the number of inpatient deaths 

per 1000 inpatient admissions at BCH since 

March 2011. Please note that the figure below 

does not include deaths which occurred in the 

Emergency Department. 

14 

12 

10 

8 

6 

4 

2 

0 

Absolute Number of Deaths 

The simplest way to represent mortality is as an 

absolute number of deaths in a particular time 

period; however it does not take into consideration 

either the number of admissions to the hospital or 

the case mix of patients. It is useful only as a sense 

guide to other data as it has not been modified in 

any way. Data cannot be compared between 

organisations in this format. 

Deaths 

Deaths per 1000 Admissions

Standardised Mortality Ratio (SMR) 

In order to account for differences in case mix for different organisations the idea of standardised 

mortality ratios has been developed. This attempts to account for differences in patients, such as 

diagnosis, age and pre-existing medical problems, and allows for comparisons between hospitals. 

A standardised mortality ratio (SMR) is the ratio of the actual number of deaths in a hospital within a 

given time period, to the number that might be expected if the hospital had the same death rates as a 

larger reference population (e.g. all English Hospitals). 

The SMR scores can be presented in a number of ways. 

Run Chart 

This shows how the standardised 

mortality rate of a hospital changes over 

time. If there are a small number of 

deaths in each time period then the 

month to month variation can be quite 

wide (as is the case with BCH where 

there are on average 4-12 deaths a 

month). 

The spikes in April and May 2011’s SMR 

have been reviewed and did not raise 

any concerns. The SMR over the last year 

has returned to normal levels.

Bar chart presenting data comparing a number 

of hospitals: 

This shows the position of an individual hospital in comparison 

with its peer group. It is easy to understand but does not give 

much information about whether our outcomes are unusual. The 

graph presented below shows 6 month’s worth of data rather 

than 12 as previously presented. This means that the impact of 

the increased SMR in April and May 2011 has reduced and our 

SMR has fallen from 140 to 124. 

August 2011 - February 2012 

BCH 

Funnel plot 

This shows the standardised mortality ratio on the Y axis, and the 

number of expected deaths on the X axis. Control limits can be 

applied, so that it is possible to see how likely that the variation 

from a score of 100 is by chance only. In the example below an 

amber dot occurs if there is between a 0.3% (1 in 330) and 5% (1 in 

20) likelihood that the score is different from 100 by chance and a 

red dot if there is less than a 0.3% likelihood that the score is 

different from 100 by chance. Such warnings should be investigated 

as to cause. 

The funnel plot below is presented using 6 month’s worth of data 

which means that the increase in SMR which resulted from the spike 

in April and May 2011 has decreased and we have returned to the 

green section of the plot.

Deaths in the Paediatric Intensive Care Unit (PICU) 

CUSUM Charts 

Another way of representing outcome data is by cumulated sum charts. These can be used where there is 

a score available to give a risk of mortality for each individual patient. Currently this method is in use at 

BCH for intensive care and cardiac surgery patients. 

The charts use data from all patients, not just deaths, so are more powerful than SMR in detecting 

problems. 

For BCH, the PICU CUSUM 

is a good reflection of 

overall hospital mortality 

as over 70% of deaths at 

the hospital occur on 

PICU. There is no 

evidence of systemic care 

failures which could have 

contributed to deaths on 

PICU.

Respiratory Arrests, ALTEs and 

Unplanned Admissions to PICU 

Explanation of Data 

Unplanned admissions to PICU are a measure of 

how well we are monitoring patients on the wards. 

Good monitoring on the wards means that we will 

pick up deteriorating patients more quickly 

therefore allowing us to admit them to PICU when 

required. A combination of high levels of 

unplanned admissions and low levels of cardiac 

arrests, respiratory arrests and acute life 

threatening events (ALTEs) means that we are 

monitoring and escalating clinical deterioration in a 

timely manner. 

Number 

40 

35 

30 

25 

20 

15 

10 

5 

0 

Jul-11 

Aug-11 

CRQAC Data: Arrests/ Unplanned PICU Admissions 

Sep-11 

Oct-11 

Nov-11 

Dec-11 

Jan-12 

Feb-12 

Mar-12 

Apr-12 

May-12 

Jun-12 

Cardiac arrests 

Respiratory 

Arrests 

ALTES 

Unplanned 

admissions to PIC 

PIC Cardiac 

Arrests 

August 2011: PICU 

cardiac arrests 

included in data set 

Details of Cardiac Arrests 

There were 4 ED reported cardiac arrests in June 2012. However, all of these were out of hospital arrests. 

There were no ward based cardiac arrests in June. 

PICU based cardiac arrests – May 2012 

In line with the revised review process for PICU cardiac arrests, the arrests that took place in May have now been 

reviewed at the PICU Mortality and Morbidity (M&M) meeting. 

All 3 cases were found to be not predictable and not preventable.

Monitoring Infection control 


• MRSA bloodstream infections: zero 

• MSSA bloodstream infections: one post-48hour 

case 

• E. coli bacteraemia: zero 

• Glycopeptide-resistant enterococci: zero 

• C. difficile: zero 

However, one case of C.diff was diagnosed in 

another hospital within 24 hours of discharge 

from BCH. The rationale for testing for C.diff in 

this case is currently not understood as the 

patient was reported not to have symptoms 

indicative of C.diff 

E-Coli - Pre 48 hours 

MSSA - Pre 48 hours 

4 

3 

2 

1 

0 

2011/… 

2012/… 

5 

4 

3 

2 

1 

0 

2011/12 

2012/13 

E-Coli Post 48 hours 

MSSA - Post 48 hours 

4 

5 

3 

4 

2 

3 

1 

0 

2011/12 


2 

1 

0 

2011/12 

2012/13

Safety 

Thermometer 

The monthly point prevalence of the four 

adult harm groups (Pressure ulcers, 

Catheter associated Urinary Tract 

Infections, Falls, VTEs) continues. 

Graph1 

We now ensure that when a pressure 

ulcer is identified a clinical expert reviews 

the care. So far, care has been 

appropriate in all cases. The slight 

increase in prevalence of pressure ulcers 

(Graph 1) could be attributed to an 

increased awareness amongst nursing 

staff. 

The percentage of harm free care has not varied 

over time and remains high, although it should be 

remembered that this is an adult tool not 

sensitive to a paediatric case load (Graph 2). 

Graph2 

Development of a paediatric version of this safety 

tool continues. The four paediatric harms have now 

been agreed by an expert reference group and are: 

extravasation, Paediatric Early Warning Scores, pain, 

and pressure ulcers. Testing will commence in 

August 2012 .

Complaints 

Key facts: 

•16 Formal Complaints in Q1 

•111 Formal Complaints Received in 2011/12 

•33 individual issues were identified within the 16 complaints received in Q1. 

•In Q1, 1 complainant made a referral to the Ombudsman 

Frequency of Complaints over 6 years 

40 

30 

20 

10 

0 

No of Formal Complaints 

Complaints per 1000 admissions in the last 12 months 

14 

12 

10 

8 

6 

4 

2 

0 

Complaints 

Complaints per 1000 

Admissions

Complaints According to Theme 

Quarter 1 

5 

6 

5 

6 

Waiting, delays, 

cancelations and access 

to services 

Staff Attitude 

2 

1 

2 

Outpatient delays & 

cancellations 

Inpatient delays & 

cancellations 

Access to services 

Quality of treatment 

Admission Discharge & 

Transfer 

11 

Communication 

Other 

2 

1 Nursing 

3 

Medical 

Patient's 

Status,Discrimination 

AHP 

Pattern over 15 months 

30 

25 

20 

Waiting, delays & 

cancellations 

Staff Attitude 

2 Oral 

Communication 

3 Written 

Communication 

15 

Quality of Treatment 

10 

5 

0 

Q4 1011 Q1 1112 Q2 1112 Q3 1112 Q4 1112 Q1 1213 

Communication 

Other 

2 

1 Quality of Nursing Care 

2 

Quality of Medical Care 

6 

Quality of overall service 

Appropriateness of 

Treatment

Some Complaints Issues 

Quality of Nursing Care 

•Nurse behaving in an ‘inappropriate 

manner’ 


•‘Lack of supervision throughout’ 

•Concerns about misdiagnosis of fracture 

•Concerns raised about problems 

following surgery 

Oral Communication 

•Poor communication regarding feeding 

•Lack of communication with the child by a 

Consultant 

Written Communication 

•Conflicting information given about 

endoscopes 

An Example of how we 

classify Complaints 

A family’s concerns are 

summarised below*: 

•An HDU bed was only made 

available when the family 

raised concerns 

•Concerns were raised about 

the length of time alarms 

were continually sounding on 

the ward 

•Ratio of nursing staff during 

breaks 

•Overheard nursing staff 

complaining about working 

conditions 

•Concerns about the volume 

of feed being administered 

*Please note that this 

complaint has been 

investigated as a SIRI 

Waiting, delays, 

cancellations & access to 

services 

•Surgery cancelled on 2 occasions 

•Concerns that lack of qualified staff 

caused delays 

•Concerns about delays in listing a patient 

for cardiac surgery 

Nursing Attitude 

•Concerns raised about unhelpful 

comments made by nursing staff 

•Nursing staff felt to be dismissive 

Medical Attitude 

•Father felt that a doctor had been rude, 

did not listen and acted unprofessionally

Actions Arising from 

Complaints 

Key Facts: 

44 individual recommendations made resulting from complaints responded to in Quarter 1 


At the time of writing: 

32 actions have been closed 

12 actions remain open 

Action Type by 

Directorate 

All actions arising from 

complaints are followed up 

by the Governance Services 

Unit on a quarterly basis. 

The Investigating Manager 

is asked for confirmation 

that each action has been 

completed and, where it 

has not proven possible to 

do so, provide details of 

alternative actions taken.

Complaints Aligned to Trust Values 

0 

Breakdown by Complaint 

0 

5 

9 

5 

10 

16 

10 

15 

20 

1. Commitment/Trust 

2. Trust 

3. Trust/Commitment 

4. Trust/Respect/Compassion 

5. Trust/Respect/Commitment/Compassion 

6. Commitment/Trust 

7. Respect/Trust 

8. Commitment/Compassion/Respect/Trust 

9. Commitment/Compassion/Respect/Trust 



12. Respect/Trust/Commitment 


14. Respect/Trust/Commitment 

15. Trust/Compassion 

16. Trust/Commitment

PALS Contacts 

70 

60 

50 

40 

30 

20 

10 

0 

Our PALS service was redesigned in 2011 to make it 

easier for families to raise issues. Our analysis does 

not reveal any systemic deterioration in clinical care 

Waiting, delays & cancellations 

4 

6 

6 

15 

Outpatient delays & 

cancellations 

Inpatient delays & 

cancellations 

Admission discharge 

and transfer 

Access to services 

Oct-10 

12 

Nov-10 

Dec-10 

Jan-11 

Feb-11 

Mar-11 

Apr-11 

May-11 

Jun-11 

Jul-11 

1 Quality of Nursing 

6 

Care 

Quality of Medical 

Care 

Aug-11 

Sep-11 

Oct-11 

Nov-11 

Quality of Treatment Staff Attitude Communication 

8 

5 

6 

Dec-11 

Jan-12 

Feb-12 

Mar-12 

Apr-12 

May-12 

Jun-12 

Attitude of Nursing 

Staff 

Attitude of Medical 

Staff 

Attitude of AHP 

14 

18 

Oral 

Written 

Other 

1 

Attitude of other 


Oral Communication 

Outpatient/Inpatient delays and cancellations 

e.g. concerns about treatment received, including misdiagnosis 

e.g. lack of information about delays, treatment, procedure and 

conflicting information between medics 

e.g. delays and cancellations of appointments, cancellations of surgery 

and difficulties in obtaining surgery date

Net promoter question (NPQ) 

Or Friends and Family Test 

From 1 April 2012 until 31 March 

2013 we are required, as part of 

this year’s patient experience 

CQUIN, to ask 10% of all our inpatients, 

with a length of stay 

greater than 24 hours, on their 

day of discharge: 

How likely is it you would 

recommend this service to 

friends and family? 

The responses can be: ‘extremely 

likely’ ‘likely’, ‘unsure’, ‘unlikely’ 

and ‘not at all’. 

‘Extremely likely’ is considered a 

promoter; ‘likely’ and ‘unsure’ are 

passive and ‘unlikely’ and ‘not at 

all’ are detractors. A score is 

determined by the number of 

detractors being subtracted from 

the number of promoters. As the 

guidance directs the question to 

be asked of over 18s this in reality 

is asked to parents and carers. 

The information is then reported to the Commissioners on a monthly basis, where a monthly net 

promoter score is calculated and compared against all acute trusts across the West Midlands and East 

Cluster. The CQUIN guidelines also direct that the result is reported to Board on a monthly basis along 

with other patient experience information, and the minutes of that meeting, demonstrating response 

and challenge are submitted on a monthly basis. 

The final target of the CQUIN will be aligned to a maintenance or an improvement on the net promoter 

score, dependent upon the first quartile score. 

74 75 

41 

9 

April 2012 

31 

5 

May 2012 

All responses received YTD by month 

118 

23 

2 



August 2012 

September 


October 


November 


Promoters 

Passive 

Detractors 

December 


January 

2013 

February 

2013 

March 2013 

In addition to asking the 

parents/carers a question has 

been developed with young 

people to ask of children and 

young people: I would tell my 

friends and family this is a good 

hospital. 

With the responses being: I agree 

a lot, I agree a bit, I’m in the 

middle, I disagree a bit, I disagree 

a lot. 

To date a smaller number of 

children and young people have 

been asked but of this number 

90% have said they would agree a 

lot and 10% agree a bit.

In order to provide our children and young 

people with a means of communicating that 

is familiar to them and which appeals to 

them, we have developed the BCH ‘Feedback 

App’. 

This contemporary approach to collecting 

patient feedback will be trialled in August on 

Wards 8 and 5. Users will also be given the 

option to answer the Friends and Family Test 

via this method. 

This approach will be a ‘live’ way of gaining 

patient experience feedback with comments 

appearing on the BCH Internet site. 

The App is available from the ‘App Store’ or 

from ‘Google Play’ now. 

We are publicising the App through poster 

displays, leaflets and life size cut outs in the 

clinical areas.

Patient Experience Database (PED) 

Feedback is entered on to the PED from a variety of 

sources including: feedback cards (both paper and 

electronic), text, email, ward manager walkabouts, 

verbal comments, thank you cards and letters, and 

websites such as NHS Choices and Patient Opinion. 

Social network sites, facebook and twitter are also 

being monitored and responded to. 

A feedback App is to be piloted this month as an 

additional tool for children, young people and 

families to give feedback and rate the hospital as 

part of the ‘friends and family test’ 

The data in the graphs is from the development 

from Informatics who are further developing the 

PED reports to create clear, concise reports of 

activity; these will be introduced into formal reports 

as they become available. 

Parents consistently offer the highest number of 

comments using the methods that are recorded on 

the PED. Interestingly when numbers fall there 

appears to be a correlation between parent and 

young people’s feedback. A young person has been 

recruited to help support the Young person’s 

‘friends and family test’ and also increase feedback 

from both children up to 10 years and young 

people 11 years and over.

PED Results 

87% of the positive comments relate to either quality of care or attitude of staff, with a further 5% relating to communication and information 

- a hugely positive picture. It is encouraging to see 5% (n 77.25) of the positive comments relate to toys and entertainment, a slight increase to 

the last report. 

The highest need to improve comments related to facilities and accommodation. A combination of parent and patient remain very similar at 

37%. The comments regarding parent facilities are predominantly about eating, drinking and sleeping ,and issues impacting on being able to 

do these in the clinical areas. 

The need to improve comments on toys has a higher percentage than the positive comments but to balance this the actual number of 

comments is higher, 39 positive versus 32 need to improve. 

The number of need to improve comments relating to food and drink remains relatively high at 14%; the majority of comments were about 

choice for patients but with a few comments about vending machines being made available out of hours for parents. It is anticipated that the 

introduction of MAPLE (Menu Acquisition Portal Live Entry) for ordering food, which is currently being rolled out across the organisation, will 

help to address the issue of choice. YPAG undertook a quality walkabout relating to MAPLE in July, the outcome of which will be included in 

the next report. Additionally two YPAG members are working with the Head of Facilities to support the development of MAPLE.




Item 12.134 Enc 04 


A local Operating Framework & Financial Plan to 

ensure we move from strategy to action 

Report Title Resources report period 1 st April 2012 – 30 th June 2012 


Chief Finance Officer 

Author(s) 

Chief Officer for Workforce, Director of Performance & 

ICT, Deputy Chief Finance Officer 


Discussed with Chair of Finance and Resource 

Committee 

Executive Management Team 

Situation 

This report is to communicate the various aspects of Trust performance in the financial 

year to date, period ending 30 June 2012, and to identify any key risks that are evident 

within the organisation. 

The contents of this report will form the basis of the Trust’s Quarter 1 (Q1) Return to Monitor. 

The Trust is also required to report its predicted status for Governance and Mandatory 

Services. 

Background 

The Trust is required to comply with the finance related legal issues contained within our 

Terms of Authorisation as well as other key financial targets. This includes: 

• Not breaching the Private Patient Cap (a legal requirement); 

• Not breaching the Prudential Borrowing Limit (a legal requirement); 

• Not utilising the Working Capital Facility; 

• Performing at or above plan for Monitor’s financial metrics leading to an overall 

Financial Risk Rating of 4 or 5; and 

• Minimising triggering the additional financial indicators introduced as part of the 


• Compliance Framework, which may result in formal discussions with Monitor. 

The Trust is also required to report its predicted status for Governance and Mandatory Service

Delivery against these targets is driven by: 

• The volume and mix of demand experienced by the Trust. 

• How the Trust uses its most valuable resource, its staff, in responding to that 

demand. 

The report explores each of these areas in turn and the impact on the financial position 

and performance. 

Assessment 

The Trust has seen demand for its services increase in the first three months of the 

financial year, whether that is compared to plans agreed with commissioners or with 

levels last year. However, activity in June was lower for most areas, with average income 

per spell also reduced. This cumulative increase is being experienced in most areas, 

from outpatients and the emergency department to planned care, with only emergency 

admissions lower than last year. Unlike last year, a significant increase in demand is also 

being experienced from the Birmingham area. 

This increase in demand has brought into sharp focus the short to medium term capacity 

issues faced by the Trust. Meeting this demand will increase pressures felt by staff. 

Sickness rates are at 3.1%, above the 3% which indicates that the impact may be a 

contributory factor in increased absence levels. Engaging with staff, especially during 

periods of pressure, is important and appraisals are one indication of how well this is 

working in the Trust. Whilst the reported appraisal rate has increased to 67% from 55% in 

the last month it is still short of the 90% target. There is a continued focus through the 

performance management system to improve this. 

Due to the reductions in activity, income was lower in June and that has had an impact 

on the financial performance, which was just below the budget but ahead of our Monitor 

target at £2.3 million. Notwithstanding this, there are some significant pressures in 

Specialised Services, Medicine and Estates, all of which require addressing in order to 

avoid further financial difficulties later in the year. In these areas support is being 

provided to develop recovery plans, and all areas of the Trust have been asked to refresh 

year-end financial forecasts. 


The Board note the emerging risks associated with increased demand and the knock on 

effect on the capacity of the Trust and consequent impact on resources. 

The Board of Directors is asked to approve Governance (Green), Mandatory Services 

(Green), Safety Assurance Systems in place (Green) and Financial Risk rating (“4”) for 

inclusion in the Monitor Q1 Return, which must be submitted by July 31.

Key Impacts 


Staff and finance are key enablers to meeting the Trust’s strategic 

objectives. 


outcome) 

N/A 


NHS Constitution has a pledge regarding 18-week waits. 




Monitor metrics are considered in the report. 


rights 

N/A 


N/A 

Other 

N/A

Resources Report 


David Melbourne 

Theresa Nelson 

Tim Atack 

Chief Financial Officer 

Chief Officer for Workforce 


1

Reporting on resources use 

1. Summary of Monitor Declarations 

2. Volume and mix of activity 

3. Our performance dashboard 

4. Access 

5. Flow 

6. The impact on our workforce 

7. The financial consequences 

2

Summary for the month. 


Activity was lower in June in most areas compared with the same time last year and this has generally 

translated into a reduced financial performance. PIC remained extremely busy and highlights the 

impact of changes in the case-mix of patients on the flows in some patient pathways through the 

hospital. For the year to date the Trust is still above last years out-turn level of activity and plans agreed 

with commissioners with only emergency admissions falling below target. 

Staff numbers increased as a result of a combination of delivering the increased activity and some early 

recruitment of staff in Specialised Services in anticipation of service expansion later in the year. 

Appraisal rates continue to improve and the sickness rate has slightly increased compared to month 

two it is now above three percent. This will continue to be monitored closely to assess whether there is 

a trend. 

Due to the reductions in activity income was lower in June that has had an impact on the financial 

performance which was just below the budget but ahead of our Monitor target at £2.3million. 

Notwithstanding this, there are some significant pressures in specialised services, medicine and estates 

all of which require addressing in order to avoid further financial difficulties later in the year. In these 

areas support is being provided to develop recovery plans and all areas of the Trust have been asked to 

refresh year end financial forecasts. 

For our Q1 Monitor declaration we are reporting a Green rating against all the latest Monitor Finance 

and Governance risk ratings 

3

Monitor assessment and declarations. 

Our overall performance position remains broadly 

positive. 

Our key concern remains cancelled operations which is 

also being monitored by commissioners. 

For our Q1 Monitor declaration we are reporting a 

Green rating against the latest Monitor risk ratings. 

Monitor Quarter 1 2012/13 (predicted) 

Finance risk rating 

Governance risk rating 

Mandatory Services risk rating 

Safety Assurance System in place risk rating 

G(4) 

G 

G 

G 

Monitor Quarter 4 2011/12 (confirmed) 

Finance risk rating 

Governance risk rating 

Mandatory Services risk rating 

Safety Assurance System in place risk rating 

G(4) 

G 

G 

G 

4

Emergency activity profile. 

June 2012 saw a 5.2% increase in Emergency Department (ED) activity compared to June last year 

however there was a 6.0% decrease in emergency admissions. The 2012/13 contract plan is based on 

the 11/12 outturn and YTD ED is 4.7% higher and emergency admissions 0.3% lower than last year. 

However the mix of emergency admissions has shifted between specialist commissioning to PCT cluster 

commissioning that has a consequent financial impact 

Whilst June performance improved, the Trust continues to not meet its local standard of all patients 

triaged within 15 minutes (the 95 percentile performance was 30 minutes) and the national standard 

of average treatment start times within 60 minutes of arrival (actual was 69 minutes). Plans are in place 

to further reduce waits in ED. 

5

Planned activity profile. 

June 2012 has seen a 8.9% decrease in planned 

activity compared to last year. This is due to the 

Whitsun break (with an additional bank 

holiday) moving from May to June and the 

additional Diamond Jubilee celebrations. In 

addition five lists were lost as a result of the 

BMA day of action. 

The 12/13 contract plan was based on 11/12 

outturn plus a ~3.5% non recurrent increase in 

activity to reduce waiting times. YTD activity is 

6.9% higher. 

As a result of higher than expected demand 

total waiting list numbers have increased by 

10% and there continues to be pressure on 

meeting the 18-week admitted standard. 

Options to reduce the size of the waiting list 

and waiting times are being explored. 

6

Outpatients (OP). 

June 2012 saw a 11.6% decrease of new OP activity and a decrease in follow-up OP activity 11.4% 

compared to last year, due to the Whitsun break. The 12/13 plan is based on 11/12 outturn. YTD 

activity is 7.9% higher for new OP and 0.2% higher for follow-ups. 

7

Our Performance Dashboard – June 2012 

8

ACCESS 

Emergency Department – Transfers Out 

No patients were transferred out during June. 

9


10


IP Tertiary 

•There were 161 referrals for specialist beds at 

BCH. 

• 3 patients were unable to get a bed at BCH 

• 6 patients had to wait over 24 hours to be 

offered a bed at BCH. 

• 18 patients were deemed to no longer require 

a bed at BCH 

11


( ) = not hospital delays/out of region patients/referred from home patients 

12

CAMHS Referrals 

Delayed Discharges 

7 patients could not be supported by 

BCH CAMHS 

3 patients discharge is delayed due to 

non-medical reasons. All patients are 

due to be discharged in July or August 

13

FLOW 



23 for June (1.22%) above the national 0.8% target. 

The ethnic breakdown of the patients is: 

15 - white/British, 1– asian/asian British Indian, 3- asian/asian 

British Pakistani, 1 –– mixed white/Caribbean, 1 – not stated, 

2 –white/any other white. 

No patients with Learning Disabilities were cancelled. 

A further 4 patients had their operation cancelled by the hospital 

before the day of the operation. 

14


15

18-weeks 

The standards were met for June 90.2% admitted, 98.6 % non-admitted and 98.4% 

incomplete patients, however a total of 46 patients were not treated within 18-weeks due 

to a lack of hospital capacity. 

Patients waiting over 30 weeks 

1 urology patient was treated at their 

34 th week, the delay in part due to 

not being fit for previous operation 

dates. 

1 ENT patient (33 rd week) and 1 

cardiology patient (35 th week) have 

requested to wait longer. 

1 urology patient (34 th week) waiting 

for treatment, in part due to not 

being fit for treatment 

16

18-weeks - CAMHS 

The local 90% standard was not met in June, actual performance was 88.8%. Additional 

staffing (funded by commissioners) is being recruited to address waiting time concerns. 

17

PICU Demand 

PICU has remained under significant demand 

which has impacted on both the ability to 

admit emergency patients and support complex 

elective surgery. The financial implications of 

this are explored in more detail later. 

A total of 2 West midlands (WM) patients could 

not be supported with 1 patient going to 

Leicester and 1 out of region. 

A further 1 non-WM requests could not be 

supported, however a total of non-WM 

requests were supported (1 BCH PICU, 3 BCH 

non-PICU beds and 1 other WM PICU). 

18

Workforce Dashboard 

BCH NHS Foundation Trust - HR Workforce Key Performance Indicators 

Retention & Turnover 

Sickness Absence 

Other Workforce KPI's 

Whole Time Equivalent (WTE) Monthly Sickness Absence % 

Medical Appraisals Completed 

Previous 

Month 

Latest 

Months 

Difference 

Trend 

Previous 

Month 

Latest 

Months 

Implications on our workforce. 

Total staffing increased by 47.48 wte compared 

to May 2012. 

Overall staffing increased in the past year due to 

planned increases in PICU and Theatre capacity. 

The largest increase in numbers is within 

specialised services as a result of these service 

expansions. 

The patient access team has moved from 

Corporate to Clinical Support in June which 

explains this change in staff numbers 

3050.00 

3000.00 

2950.00 

wte 

2900.00 

2850.00 

2800.00 

Workforce WTE (including Bank) 

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 

2011/12 2012/13 

Directorate May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 

D1 Clinical Support Services 389.44 393.03 390.56 390.92 390.76 388.64 390.51 388.61 390.81 384.90 389.69 389.89 390.42 410.04 

D2 Medical Directorate 627.33 636.01 640.22 645.74 650.38 639.21 643.52 644.11 648.57 646.55 638.88 640.80 639.33 653.69 

D3 Specialised Services 687.51 692.17 697.24 702.15 705.68 715.94 728.02 717.60 730.12 730.31 725.83 729.86 744.50 762.30 

D4 Surgical Directorate 399.38 400.00 399.99 392.51 399.91 400.87 409.56 397.29 402.11 405.85 403.35 391.46 393.21 403.55 

D5 CAMHS Services 323.27 325.37 324.07 321.93 316.81 308.92 310.59 310.79 313.91 314.45 318.20 318.26 312.76 311.59 

D6 Corporate 460.09 463.10 466.17 467.77 453.79 454.19 450.94 451.03 472.33 474.77 468.71 471.48 468.07 454.61 

Total 2887.01 2909.69 2918.25 2921.02 2917.33 2907.78 2933.15 2909.44 2957.85 2956.83 2944.66 2941.75 2948.29 2995.77 

In-Month Movement 22.67 8.56 2.77 -3.69 -9.55 25.38 -23.72 48.41 -1.02 -12.17 -2.91 6.54 47.48 

20

Implications on our workforce. 

May sickness has increased to 3.1% which is above 

the Trust 3% target however the annual cumulative 

rate is continuing to drop. (Data is reported one 

month in arrears). The top four reasons recorded 

for sickness absence are: 

• Anxiety. 

• Gastrointestinal reasons. 

• Muscular related. 

• Cancer related. 

Appraisal performance continues to rise, 66.8% for 

June and on track to exceed our 90% standard by 

the end of September 

Sickness data is reported one month in arrears 

21

Workforce summary. 

April – June 2012 

Staff numbers have increased by 1.2 per cent year on year yet as indicated in the previous analysis 

increases in demand has fed into the Trust treating significantly more patients over the same period. 

However, the pay rather than staff numbers is the key determinant of the measure of workforce 

productivity and this has remained at the the level required for the delivery of Trust plans. (see analysis 

below). 

During a period of increased demands on staff sickness levels have not deteriorated and are slightly 

above our 3% standard. The major theme recorded for sickness absence is anxiety and stress albeit case 

review indicates that this can often relate to personal domestic circumstances. 

Effectively managing the workforce during these difficult periods requires regular good quality 

engagement and conversations with staff. One measure of this is the regularity of annual appraisals; 

these levels have improved to 67% and further improvement is expected over the coming months. This 

is an area of focus both within the Trust and by the Cluster and SHA. 

Updated workforce plans have been produced, raising a number of long terms challenges (i.e. 

reductions in trainees and junior doctors, potential retirements) that are also opportunities for new 

work force solutions. The workforce plans are being actively worked through within each Directorate 

and plans are in place to monitor these through a number of workforce forums. 

22

Financial Performance Summary 

Monitor Financial Performance Framework 

Criteria Metric Plan Actual Status Direction 

of Travel 

Financial Performance 

Underlying Performance EBITDA margin 3 3 Income and Expenditure 2,304 2,347 43 

Achievment of Plan EBITDA, % achieved 5 5 Cash Balance 34,464 32,179 -2,285 

Financial Efficiency Return on Assets 5 5 Capital Programme 2,598 2,138 -460 

Financial Efficiency I&E surplus margin 5 5 CIP 2,254 1,914 -340 

Liquidity Liquidity ratio 4 4 

Issue 

Plan 

£'000 

Actual 

£'000 

Variance 

£'000 

Status 

Direction of 

Travel 

Overall 4 4 Year to date surplus is performing slightly ahead ahead of the Monitor Plan but is now below the 

The Monitor Risk Rating is per the Plan of 4. This is forecast to continue through to year-end 

Foundation Trust Requirements 

(Monitor assesses financial risk on a scale from 1 (high risk) to 5 (low risk) 

FINANCIAL PERFORMANCE REPORT 

Month 03 - Period Ending 30 June 2012 

Issue Measure Plan Actual Status Direction 

of Travel 

Income and Expenditure 

Revised Plan (£26k). 

Cash Balance 

At the end of June w as behind plan due to low er creditors, higher debtors, delays in raising some S 

and the nature of the Trust's contracting portfolio. 

Capital Programme 

Prudential Borrow ing Limit Not to exceed £38.3m £2m £2m The Trust is performing below its original plan to Monitor w ith the strategic investment schemes 

Private Patient Cap Not to exceed 1% 0.4% 0.2% 

progressing w ell. This remains w ell w ithin the 75-125% parameters set by Monitor. 

Working Capital Facility Not to use Not Used Not Used CIP 

All categories are performing to or w ithin plan although from an I&E perspective a close w atch needs to The year to date performance is ashortfall of 15% or £340k. 

be maintained on Private Patient income 

The concern w ith the CIP delivery is that this w as a shortfall against a low plan w ith actual delivery 

being underpinned by performance monies and slippage from 11/12 schemes. 

23

Income and Expenditure against Plan 

The Trust is performing slightly above the plan 

submitted to Monitor but below the revised plan. 

June has been a difficult month financially with 

pressures exerted on both income and expenditure. 

Capacity pressures are being reflected in the activity 

being undertaken. The average income per spell has 

reduced in June whilst the Trust has already “lost” 

£0.4m in the Marginal Reduction in Emergency Tariff 

(MRET) due being paid at 30% for overperformance. 

There are real financial pressures in both Medicine and 

Specialised Services. With the Marginal Performance 

Adjustment being in place for the first time this year, 

SSD has felt the full weight of the Cardiac 

underperformance. However, with waiting list costs 

(circa £0.12m despite surgical underperformances), 

medical staff, CIP, PICU and junior doctor pressures 

being exerted the deficit has risen to £1.3m, a rise of 

£0.7m. A fuller briefing has been prepared on this. 

The EBITDA position is marginally above the Monitor 

Plan but below the revised plan. As a % against plan, 

this is the lowest EBITDA performance since 2008/09. 

2012/13 I&E to June 2012 Annual 

Plan per 

LTFM 

Revised 

Annual 

Plan 

YTD Plan 

per LTFM 

Revised 

YTD Plan 

YTD 

Actual 

Variance 

£'000 £'000 £'000 £'000 £'000 £'000 

Income from activities 193,902 194,107 49,233 48,108 48,526 419 

Other Income 24,268 25,356 6,067 7,104 7,048 -56 

Operating Expenses -204,006 -204,307 -51,001 -50,843 -51,269 -425 

EBITDA 14,165 15,155 4,299 4,369 4,306 -63 

Interest Receivable 265 265 67 66 147 81 

Depreciation -5,400 -5,400 -1,350 -1,350 -1,356 -6 

Profit/(Loss) on Asset Disposal 0 0 0 0 0 

Impairment 0 

PDC Dividend -2,520 -2,520 -630 -630 -670 -40 

Interest Paid -326 -326 -82 -82 -79 2 

Net Surplus/(Deficit) 6,183 7,173 2,304 2,373 2,347 -26 

Brackets indicate adverse 

Apr - June 

May In-month 

variance 

Income 

Variance 

Pay 

Variance 

Non-Pay 

Variance 

Total 

Variance 

Variance 

£000 

Moveme 

nt £000 

Clinical Support Services -9 -82 27 -64 -23 -42 

Medical Directorate -107 -160 -66 -333 -260 -73 

Specialised Services -103 -438 -748 -1,288 -570 -718 

Surgical Directorate -42 -10 23 -29 7 -36 

CAMHs -20 64 -27 17 9 8 

Corporate 224 -139 -180 -95 -21 -74 

Total Operational Budgets -56 -765 -971 -1,793 -858 -935 

Bad Debts 0 0 0 0 

Operating Leases 61 61 41 20 

Teaching & Research 0 0 0 0 

Reserves and Provisions 500 750 1,250 250 1,000 

Total Other Budgets 0 500 811 1,311 291 1,020 

Total Budgets -56 -265 -160 -482 -567 86 

24

Specialised Services 

The table opposite outlines the position against budget of the 

services within the Directorate. 

The key points to note are: 

Cardiac 

• activity underperformance has led to a £0.24m funding reduction; 

• £0.05m CIP shortfall; 

Theatres 

•activity underperformance has led to a £0.16m funding reduction; 

• £0.12m of WL costs have been incurred without generating surgical 

overperformance; 

•£0.10 CIP shortfall; 

Livers 

• £0.10m loss due to no small bowel transplants being undertaken; 

• £0.07m junior doctors pressures; 

PICU 

• Nursing variance of £0.10m due to maternity leave and 

supernumerary trainees in advance of bed openings. 

• Junior Medic pressures £0.07m 

Service 

YTD Budget 

£k 

YTD Actual 

£k 

YTD Variance 

£k 

YTD % 

Variance 

Cardiac Services 1,995 2,422 -427 -22% 

Theatres & Anaesthetics 3,465 3,901 -436 -13% 

Liver Services 1,892 2,110 -218 -12% 

PICU 3,394 3,596 -202 -6% 

SSD Management 74 78 -4 -5% 

KIDS 553 554 -1 0% 

Total 11,373 12,661 -1,288 -11% 

YTD Budget 

£k 

YTD Actual 

£k 

YTD Variance 

£k 

YTD % 

Variance 

Income -530 -428 -103 -19% 

Pay 8,865 9,302 -438 -5% 

Non-Pay 3,038 3,786 -748 -25% 

Total 11,373 12,661 -1,288 -11% 

780 

Workforce WTE (including Bank) 

Adjustments for underperformance have been predominantly been 

charged against non-pay, which gives a disproportionate position 

against the £3.0m budget. 

wte 

760 

740 

720 

700 

Staffing levels have increased in each of the last 3 months. This is 

expected as any PICU expansion would exceed any CIP workforce 

reductions. However, mean salaries have also risen over the same 

period, which, when combined with CIP delivery shortfalls and 

income pressures, generates a significant cost pressure. 

680 

660 

640 


2011/12 2012/13 

25

Medicine 

The table opposite outlines the position against budget of the cost 

categories within the Directorate. 


• CIP £0.10m shortfall – relates to sickness absence reductions, nonpay 

consumables and R&D contribution. 

• £0.09mMedical staff coverage of maternity leave and rota 

shortfalls; 

• £0.06m BMT and Anthony Nolan storage. 

Other issues to note are: 

• Costs incurred in deliver emergency activity not covered by income 

due to the Emergency Care Threshold 30% adjustment; 

• Minor shortfalls on coding CIPs. 

Estates 

The table opposite outlines the position against budget of the 

services within the Estates Department. 


• Unmet CIP £0.05m; 

• Agency costs covering Senior Managers and Tradesmen £0.13m; 

• Contracts and Consultancy £0.05m. 

Medicine 

YTD Budget YTD Actual YTD Variance YTD % 

£k £k 

£k Variance 

Income -519 -413 -107 -21% 

Pay 7,575 7,735 -160 -2% 

Non-Pay 4,336 4,402 -66 -2% 

Total 11,391 11,724 -333 -3% 

3050.00 

3000.00 

2950.00 

wte 

2900.00 

2850.00 

2800.00 

Medicine Workforce WTE (including Bank) 


2011/12 2012/13 

Estates 

YTD Budget YTD Actual YTD Variance YTD % 

£k £k 

£k Variance 

Income -31 -43 12 39% 

Pay 309 436 -127 -41% 

Non-Pay 707 851 -144 -20% 

Total 985 1,244 -259 -26% 

26

Profitability against Target 

The EBITDA (Earnings Before Interest, Taxation, Depreciation and 

Amortisation) Margin is 1.4% below target due to the 

tight financial position at Month 3 but remains 

fractionally above (0.16%) the Monitor Plan level. 

Both positions have worsened since Month 2. 

In Month 2 gains on income offset expenditure 

pressures. In Month 3, it is income where the 

pressures have been exerted. The mix of activity 

including low cardiac workload due to PICU 

pressures, a lower income per spell and the 

reduced income recovery through the Emergency 

Care Threshold have impacted upon the Trust. 

Of concern is the relatively light CIP performance 

against a low target. A failure to improve this 

position will result in further deteriorations in 

financial performance. 

The I&E Surplus Margin shows a slight 

improvement on the Monitor Plan, but like the 

EBITDA performance, this is marginal. 

9.0% 

8.0% 

7.0% 

6.0% 

5.0% 

4.0% 

3.0% 

2.0% 

1.0% 

0.0% 

5.0% 

4.5% 

4.0% 

3.5% 

3.0% 

2.5% 

2.0% 

1.5% 

1.0% 

0.5% 

0.0% 

EBITDA Margin 

7.7% 7.7% 

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 

4.3% 4.2% 

I&E Surplus Margin 

Actual 

Plan for 

Year 

Actual 

Plan 

for 

Year 

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 

27

Financial Workforce metrics 

Given the financial positions previously reported it is expected that 

workforce metrics will be close to the plan for the year. Both elements of 

the Clinical Income:Pay ratio are performing below plan. At this early stage 

of the year figures pro-rata’d to year-end can give exaggerated results but 

the June position does highlight the tightness of the Trust’s margins, 

especially if CIP schemes are not delivered. This is particularly the case for 

Clinical Income. 

The Trust however is also experiencing an increase in both the median 

salary (a mandatory Annual Report requirement) and the mean salary 

(although June’s position was slightly down on May’s). These are 

measures that will need to be contained given that workforce CIPs are a 

mix of reducing posts and reducing average costs, and discussions with 

Clinical Directorates point to workforce reduction schemes being put on 

hold in light of capacity issues. 

33.0 

32.0 

31.0 

30.0 

£k 

29.0 

28.0 

27.0 

26.0 

2012/13 Average Salaries 

Period 

Median Mean 

£m 

250 

200 

150 

100 

50 

0 

Clinical Income:Pay Ratio 

£194 £195 £189 £194 £198 £198 

£180 

£171 

£136 £139 £141 £141 £141 £143 £143 

£128 

0910 Plan 1011 Plan 1112 Plan 1213 Plan 1213 M3 1213 YTD 1314 Plan 1415 Plan 

Year 

Clinical Income £m Pay £m 

£m 

200 

199 

198 

197 

196 

195 

194 

193 

192 

191 

190 

Clinical Income per wte YTD 

2,996 

2,942 2,948 

£194 £197 £194 

Plan May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 

Year 

Clinical Income £m wte 

3040 

3020 

3000 

2980 

2960 

2940 

2920 

2900 

wte 

28

CIP 

CIP delivery is 15% below target at Month 2. This equates to £340k. The equivalent underperformance for the 

full year target of £10.8m would be circa £1.6m (a rise of £0.1m on Month 2). 

However, a straight line plan at Month 3 would require planned savings of £2.7m. The phased target is £2.3m. 

The underperformance is therefore against a back-ended programme, which amplifies the financial risk. 

Of the Directorates only Surgery is achieving its target although this is against a low target at Month 3. All 

Directorates, with the exception of Specialised Services have plans for their full CIP target. 

The concern is that in some areas the bulk of savings relate to performance monies or slippage relating to 

2011/12. This is the case in Medicine where £0.24m of the £0.29m achieved relates to Performance adjustment 

monies. Overall 30% of the savings identified to date are related to performance monies or slippage from 

2011/12. this means that there is a 20% shortfall against the 2012/13 specific schemes. 

Specialised Services’ shortfall is predominantly within non-pay, UHB SLA and Private Patient income. Corporate’s 

shortfall is driven by Estates. 

Directorate 

Clinical Support Services 

Medical Directorate 


Surgical Directorate 

CAMHs 

Corporate 

Total 

all figures £k 

Plan Actual Variance % Achieved % Plan M1-3 

302 301 -1 99.7% 19.4% 

427 290 -137 68.0% 17.4% 

646 524 -122 81.1% 23.3% 

331 340 9 102.6% 18.7% 

164 148 -16 90.1% 32.8% 

384 312 -72 81.1% 22.5% 

2,254 1,914 -340 84.9% 20.9% 

29

Cash and Capital 

Cash is 7% below plan at £32.2m. This is due to: 

• higher than planned payment of creditors in 

Quarter One (capital creditors reduced by £1m) 

combined with an increasing level of aged debt; 

• delays in recovering income due to the nature of 

our contracting portfolio (a higher level of cost per 

case activity); 

• delays in invoicing for some SLA work; and 

• the capital performance below. 

£k 

38,000 

37,000 

36,000 

35,000 

34,000 

33,000 

32,000 

31,000 

30,000 

29,000 

2012/13 Cash Position and Rolling Forecast 

The Capital plan was only agreed at the end of May 

so expenditure in Q1 will be lower than in previous 

years. Of the £10.5m programme £2.1m has been 

incurred in the year to date, which is slightly behind 

the target – although this is partly down to VAT 

reclaims of 2011/12 expenditure. 

The Trust remains within the Monitor 75-125% 

margins. 

£k 

14,000 

12,000 

10,000 

8,000 

6,000 

4,000 

2,000 

Actual 2012/13 Plan Rolling Forecast 

2012/13 Cumulative Capital Expenditure against Plan and Monitor 

Margins 

- 


12/13 Actual 12/13 75% 12/13 125% 12/13 Plan - Original 

30

Debtors and Creditors 

Debtors over 90 days have increased in June 

due to increased aged debts combined with a 

lower level of debt on the sales ledger. An 

action plan for recovering debts is being 

agreed with the Financial Controller. The 

Creditors position has improved in June as 

post annual accounts catch-up has taken 

place. The combination of these two 

measures obviously have an impact on the 

Trust’s cash position. the overall level of 

creditors reducing by 25% in May. The 

creditor position has improved following the 

clearance of significant debts with UHB. 

The Top 5 debts are a combination of R&D 

(Shire), Private Patient and NHS. The largest 

single debt, with Shire HGT, was paid in early 

July, so an improved position is expected in 

Month 4. 

30% 

25% 

20% 

15% 

10% 

5% 

0% 

% Debtors and Creditors over 90 days 


Debtors>90 days % Creditors>90 days % Target 

Top 5 Debts Over 90 Days Old 

Customer 

Shire HGT 

UHB NHSFT 

Private Patient - MK 

UHB NHSFT 

Birmingham Community Healthcare 

Scotland 

30 June 2012 30 May 2012 

Value Age 

(£k) (Days) 

Age 

(Days) 

Value 

(£k) 

140 381 110 381 

108 159 

347 139 317 139 

151 113 121 113 

252 69 222 69 

110 67 

861 769 

31

Financial summary. 

April – June 2012 

The Monitor Financial Risk rating is 4 per plan, with Liquidity remaining strong. 

The EBITDA and Income Surplus margins are within 0.2% of the plan. This highlights that there 

is minimal flexibility for failing to deliver on Income and CIP targets. 

Clinical Income performance is lower than plan in June. Although activity performance is 

strong in some areas, high PbR emergency overperformance combined with 

underperformances in some surgical specialties and Cardiac Surgery is resulting in the in-month 

financial deficit. Expenditure is worse than plan, which is a result of a shortfall on CIP combined 

with Estates cost pressures and in some Directorates, overperformance and workforce related 

costs. 

CIP is the key concern with only 85% of the plan achieved to date but there are inherently 

greater risks than this headline figure. 

The variances from target of Cash and Capital are within acceptable levels with closer 

monitoring of these and other working capital areas now planned and agreed. 

32

Birmingham Children's Hospital Performance Report - Month 3 - June 2012 

Monitor Quarter 4 2011/12 (confirmed) 

Finance risk rating G(4) Finance risk rating G(4) 

Governance risk rating G Governance risk rating G 

Mandatory Services risk rating G Mandatory Services risk rating G 

Safety Assurance System in place risk rating G Safety Assurance System in place risk rating G 


Every child and young person requiring access to care at 

Birmingham Children‟s Hospital will be admitted in a timely way, 

with no unnecessary waiting along their pathway 

Every child and young person cared for by Birmingham 

Children‟s Hospital will be provided with safe, high quality care, 


Every member of staff working for Birmingham Children‟s 

Hospital will be looking for, and delivering better ways of 

providing outstanding care, at better value 

Every member of staff working for Birmingham Children‟s 

Hospital will be a champion for children and young people 

We will strengthen Birmingham Children‟s Hospital‟s 

position as a provider of Specialised and Highly 

Specialised Services, so that we become the leading 

provider of Children‟s Healthcare in the UK 

We will continue to develop Birmingham Children‟s 

Hospital as a provider of outstanding local services: „a 

hospital without walls‟, working in close partnership with 

other organisations 

Enablers 

Our „people strategy‟ so everyone knows what role they 

have to play and how they will be supported 

A local Operating Framework & Financial Plan to ensure 

we move from strategy to action 

A strategy to deliver a modern environment, fit for an 

ambitious 21st century hospital 


National Measures 

Monitor Quarter 1 2012/13 (predicted) 

ED Triage within 15 minutes: 95th percentile < 15 minutes 30 

ED Time Seen within 60 minutes : median 69 

CAMHS Refusals 7 

Tertiary Refusals 3 

Tertiary Delays over 24 hours 6 

PICU 

Issues 

Every child and young person requiring access to care at Birmingham 

Children’s Hospital will be admitted in a timely way, with no unnecessary 

waiting along their pathway 

Access 

PICU Refusals: West Midland Patients. 2

June Red Rated Performance 

Category 

Performance 

Indicator 

A&E 

No patient (All patients) will 

wait more than 15 minutes 

Flow 

Tertiary 

Referrals 

Tertiary 

Referrals 

Tertiary 

Referrals - 

ALL 

Camhs 

Tertiary 

Refusals 

(Number/%) 

Tertiary 

Referrals - 

Patients that 

did not get a 

bed within 24 

hours of 

asking 

Tertiary 

Refusals 

(Number/%) 

Provider failure to ensure 

that “sufficient appointment 

slots” are made available 

on the Choose & Book 

system 

Performance Target 

95th percentile 

< 15 mins 

Lead 

Chief 

Officer 


Last year 

position 

COO 32 34 30 32 42 

Number of patients COO >0 0 0 6 3 9 4 

% of patients COO >0 0 0 3.04 1.86 0.22 


% of patients COO 5.2 11.7 3.7 7.3 

2.9 


% of patients COO >0 0 0 3.6 1.86 2 

Q1 trajectory to deliver 

0.03 by Q4 to be 

submitted Q2 – Q3 

delivery of trajectory Q4 

= 0.03 per month 


Contract 

COO >0.03 0.03 0.03 0.01 0.05 0.03 0.03 

NA 

Comments 

Also Quality Account indicator 

& Contractual obligation 


catchment 


catchment 

ALL requests 

CAMHS DNA Rate 

Less than 10% COO >10 -

June Red Rated Performance continued… 

Category 

Performance 

Indicator 


Lead 

Chief 

Officer 


Safety, Governance & Patient Experience 

Last year 

position 

Comments 

Internal BCH 

target 

Internal BCH 

target 

Population of 

the risk 

register 

Actions to 

address risks 

Risks greater than or 

equal to 16 have an 

action plan recorded 

on the risk register (%) 

All risks have 

completed actions 

sections (%) 

CMO

Monitor 

Monitor Governance Risk Rating 

Performance 

Category 


Indicator 

Growing a representative membership 

Lead 

Chief 


Last year 

position 

National target Overall numbers target 10,000 MCO Trend 

11,377 11,394 11,394 11,373 

Compliance framework - Targets, indicators and weightings 

Category 

Safety 

National target 


Performance 

Indicator 

C-Diff 

MRSA 

Patient Experience 


0 cases per year - locally 

agreed threshold 

1 cases or less per year - 

locally agreed threshold 

Lead Chief 

Officer 


Monitor 

Weighting 

Last 

year 

position 

CNO >1 - 1 0 1 0 1 1 1 

CNO >0 - 0 0 0 0 0 1 0 

90% admitted COO

Department of Health 

Category 

Performance Indicator 

Preventing people form dying prematurely 

National 

Target 

National 

Target 

Performance 

Target 

Lead 

Chief 

Officer 


Last 

year 

position 

Surgery COO

Department of Health continued … 

Category 


Performance 

Target 

Lead 

Chief 

Officer 

Helping people to recover from episodes of ill health or following injury 

Emergency 

Emergency Readmissions : 

National Target Readmissions COO 

after elective 

within 30 days 

National Target 


Emergency Readmissions 

:after elective (with 

exclusions) 


:after emergency 

admission 

Emergency 

Readmissions 


Emergency 

Readmissions 


COO 

COO 


69 

5.7% 

12 

0.99% 

125 

10.2% 

62 

4.9% 

3 

0.24% 

126 

10% 

53 

4.5% 

9 

0.76% 

95 

8.1% 

183 

5.0% 

24 

0.7% 

342 

9.4% 

Last 

year 

position 

NA 

NA 

NA 

Comments 

Exclusion Criteria: Regular 

Day Cases, Renal, Liver, 

Cancer Patients & Patients 

under 4 years. 


Emergency 


Readmissions 

:after emergency 


admission (with exclusions) 

COO 

13 

1.1% 

29 

2.3% 

9 

0.76% 

50 

1.4% 

NA 


Day Cases, Renal, Liver, 

Cancer Patients & Patients 

under 4 years. 

Ensuring that people have a positive experience of care 

National target 90% admitted COO >90 90 90.7 90.3 90.2 90.5 92.1 

National target 18 weeks 

95% non admitted COO >95 95 99.3 99.3 98.6 99.3 99.3 

National target 92% incomplete COO >92 92 99.7 99.7 98.4 99.7 98.2 

Diagnostic Tests within 6 


99% complete COO >99 99 100 100 100 100 81.2 

weeks 

Treating and caring for people in a safe environment and protecting them from avoidable harm. 



Health Care Acquired 

Infections 

Hospital related venous 

thromboembolism (VTE) 

No. of MRSA's CNO >0 - 0 0 0 0 0 0 

No. of CDiff CNO >1 - 1 0 1 0 1 1 

Risk Assesment CMO - - - 0 0 0 0 NA

Department of Health continued … 

Category 


Performance 

Target 

Ensuring that people have a positive experience of care 

95% of patients time 

National Target Total time in A&E 

total time in A&E < 4 

hours. 

Unplanned reattendance 

Indicators 

required for 

local use and 

information 

should be 

published 

locally. 



rate 

Left department without 

being seen 

Time to initial assessment: 

ambulance borne patients 

Time to treatment in 

department 

Cancer: two week wait 

from referral to date first 

seen 

Mixed Sex Accomodation 

Breaches 

Lead 

Chief 

Officer 


Last 

year 

position 

COO >95 - 95 97.8 97.6 97.5 97.6 98.1 

5 -

No update 

No update 

No update 

CQC Quality and Risk Profile 

STANDARD JUNE JULY AUG SEPT OCT NOV DEC JAN FEB MARCH APRIL MAY JUNE Commentary 

1: Respecting & involving 

2: Consent 

4: Care & welfare 

5: Meeting nutritional needs 

6: Cooperating with other providers 

7: Safeguarding 

2011 2012 

The only data available for this 

standard is the NHSLA level 3 

The only data available for this 

standard is the NHSLA level 3 

Additional information about 

serious case reviews not 

included 

8: Cleanliness & infection control 

„low green‟ (as green as can be) 

after having been „insufficient 

data‟. The change is due to new 

HPA data on MRSA and CDiff. 

9: Management of medicines 

10: Safety & suitability of premises 

11: Safety, availability & suitability of 

equipment 

12: Requirements relating to workers 

13: Staffing 

14: Supporting workers 

16: Assessing & monitoring quality 

17: Complaints 

21: Records 

ending towards better /better /much better than expected 

neutral/similar to expected 

tending towards worse than expected 

Negative/worse/much worse than expected 

Insufficient Data 

No Data 

There is no data for this 

standard 

Improvement relates to addition 

of NHSLA level 3 data 





Improvement relates to 

improved data quality.

Quality Accounts 

Quality Account indicators (Trust Priorities) 

Category 

Reducing 

Infection 

Reducing 

Healthcare 

Associated 

Infections in 

Paediatric 

Intensive Care 

Overall BCH 

mortality 


Performance 

Target 

Lead Chief 

Officer 


MRSA 0 per year CNO >0 - 0 0 0 0 0 0 

Last 

year 

perfo 

rman 

Comments 

Local target with 

commissioners 0 per 

year 

MSSA 

Pre 48 hours CNO 1 2 0 3 16 YTD June 2011 - 9 

Post 48 hours CNO 1 4 1 6 11 YTD June 2011 - 2 

Below 1.4 

Reduce incidence of CVC 

infections per 

infections 

1000 CVC patient 

CNO 1.1 

Reduce and sustain the 

incidence of Ventilator 

days. Below 1.73 per 

1,000 ventilator CNO 0.7 

Associated Pneumonia (VAP) days 

No. of mortality's CMO 4 9 2 15 

Each patient mortality is 

See monthly safety 

investigated by a nurse and 

CMO 

report 

clinician 

Investigation information is 

provided to trust board 

CMO 

See monthly safety 

report 

Asthma 

Processes discussed at our 

Nurse and Doctor meetings 

Teaching sessions for new 

doctors 

Review our asthma care teams 

to ensure sustainability and 

resilience 

Amend the new care pathway 

documentation 

CMO 

CMO 

CMO 

CMO

Quality Account indicators (Trust Priorities) continued … 

Category 

Medication 

Incidents 

Staff survey 


Develop electronic prescribing 

for paediatric care 

Introduce Smart Pump 

technology for infusions 

Continue to develop staff 

awareness about medicine 

safety 

Continue to review all serious 

medication incidents to identify 

areas to improve 

Raise awareness about timely 

antibiotic administration through 

our Surviving Sepsis campaign 

Staff would be happy with the 

standards of care given to 

friends and family 

Staff feel that care of children 

and young people is the trusts 

top priority 

Performance 

Target 

Lead Chief 

Officer 

CFO 

CMO 

CMO 

CMO 

CMO 

Monitored through patient & 

Food and nutrition 

family feedback & food 

CNO 

walkabouts. 

Activities and play NCQI Performance CNO


Category 

ED transfers 

Peer Review 

Publications. 

Pressure Ulcers 

WHO Safe 

Surgery Checklist 

Nursing Care 

Quality Indicators 

Acute Life 

Threatening 

Events, Cardiac & 

Respiratory 

Arrests 


Fewer patients transferred out 

of BCH Emergency department 

Performance 

Target 

No patient 

transferred out of 

BCH 

Lead Chief 

Officer 


Last 

year 

perfo 

rman 

Comments 

COO >0 - 0 0 0 0 0 0 May 2011 - 0 

No. of Peer Reviews Research 

Publications 

CMO 271 

Number of Pressure Ulcers at 

Grade 3 and above 

Trend CNO 0 0 0 0 1 

100% compliance with checklist 

% of checks 100% 

completed 

CMO


Category 

Health Promotion 

Data Quality 

Category 

For records 

submitted to SUS 

for inclusion in 

HES 

Information quality 

for records 

management 

using the 

Information 

Governance Tool 

Kit 


25% of people who come to our 

main Outpatients Department are 

asked about health behaviours 

We will give brief advice about 

smoking to 50% of parents and 

carers who tell us they smoke 


alcohol to 70% of children and 

young people who tell us they drink 

alcohol 


smoking to 90% of children and 

young people who tell us they 

smoke 


% that had a valid patient NHS 

number 

% that had a valid general 

practitioner registration code 

Performance 

Target 

Performance 

Target 

Lead Chief 

Officer 


Last 

year 

perfo 

rman 

CNO 25 NA 

CNO 50 NA 

CNO 70 100 

CNO 90 83 

Lead Chief 

Officer 


Last 

year 

perfo 

rman 

Admitted patient 

care 

CFO 97.7% 97.8% NA 

Outpatient care CFO 98.8% 98.5% NA 

ED care CFO 96.2% 97.0% NA 

Admitted patient 

care 

CFO 100% 100% NA 

Outpatient care CFO 100% 100% NA 

ED care CFO 100% 100% NA 

CFO 

Comments 

Comments 

Performance 

reported 1 month in 

arrears.



Discharge 

Delays 

Discharge 

Delays 

No patient will leave the emergency 

department without being seen 

Lead 

Chief 

Officer 


Last year 

position 

Median time from arrival COO 9 9 8 9 11 

95th percentile COO >15 15 32 34 30 32 42 

Single longest total time COO 250 75 399 250 107 

Median time from arrival COO >60 - 4 4 4 4 5 - 0 0 0 6 3 9 4 

% of patients COO >0 0 0 3.04 1.86 4.2 0.22 


% of patients COO 5.2 11.7 3.7 7.3 2.9 


% of patients COO >0 0 0 3.6 1.86 2 NA 

Number of patients not 

admitted to a CAMHS bed 

COO 9 4 7 23 75 

% of patients not admitted to 

a CAMHS bed. 

COO 47.4 36.4 53.8 51 48.2 

FLOW 

Delayed discharge total patients Total patients COO 2 1 3 6 NA 

Delayed discharge total bed days Total bed days COO 60 31 81 172 NA 

Comments 

Every child and young person requiring access to care at Birmingham Children’s Hospital will be admitted in a timely way, with no unnecessary waiting 

along ACCESS their pathway 

ED deflections Number of patients deflected COO 0 0 0 0 0 

Emergency 

Department 

Tertiary 

Referrals 

Tertiary 

Referrals 

CAMHS 

No patient (All patients) will wait more 

than 15 minutes for initial full 

assessment 

No patient will wait more than 1 hour to 

start of definitive treatment from a 

decision making clinician 

No patient will spend more than 4 

hours in total in the emergency 

department 

Tertiary Refusals (Number/%) 

Tertiary Referrals - Patients that did 

not get a bed within 24 hours of asking 

Tertiary Tertiary Refusals (Number/%) 

Referrals - ALL 

Patients that requested a BCH T4 

CAMHS bed and were not admitted 

following a gateway assesment 


catchment 


catchment 

ALL requests

Strategic Objectives continued … 


Cancelled 

Operations 

Cancelled 

Operations 

RTT Waiting 

Times 

Diagnostic 

Waits 

PICU 

Provider cancellation of Elective Care 

operation for non-clinical reasons 

either before or after Patient admission 

Breach of clause 40.5 (Admitted patient 

and had operation cancelled for non clinical 

reasons. The provider needs to offer them a 

date within 5 operational days which falls within 

28 days from cancellation.) 

Lead 

Chief 

Officer 


Last year 

position 

Comments 

FLOW 

Number of cancellations COO 38 39 23 77 347 June 2011 - 20 

% of cancellations COO 1.5 - 0.8 2.1 1.96 1.22 1.76 1.6 

100% compliance COO 90 - 90 90.7 90.3 90.2 90.4 91.6 

% of non admitted over 18 weeks 95% non admitted COO >95 - 95 99.3 99.3 98.6 99.1 98.9 

% of incomplete over 18 weeks 92% incomplete COO >92 - 92 97.7 97.7 98.4 98 97.9 

CAMHS - number of non admitted over 

18 weeks 

COO Trend 

33 31 64 

CAMHS - % of non admitted over 18 

weeks 

90% non admitted COO 90 88.6 87.6 88.8 88.6 

Diagnostic waits number >6 weeks COO 0 0 0 0 

Diagnostic waits % >6 weeks Operating Standard 99% COO


Lead 

Chief 

Officer 


Expanding our Hospital at Home Services 

CPO 

Local strategy for children‟s general services 

CMO 

Working in partnership to develop new and innovative 

COO 

CAMHS models 

ENABLERS 

Our ‘people strategy’ so everyone knows what role they have to play and how they will be supported 

People Strategy 

CWD 


Resources report 

CFO 

A strategy to deliver a modern environment, fit for an ambitious 21st century hospital 

New Hospital Project 

CFO 


150 years celebrations 

CEO 

Last year 

position 

Comments 

Every child and young person cared for by Birmingham Children’s Hospital will be provided with safe, high quality care, and a fantastic patient and family 

experience 

Every member of staff working for Birmingham Children’s Hospital will be looking for, and delivering better ways of providing outstanding care, at better 

value 

Emergency Care pathway 

COO 

June-Sept 

Research Output profile 

CMO 

Sept – Nov 

Equipping staff to create value 

CWO 

Nov-Jan 

Better use of staff and physical resources 

CFO 

Feb-March 

Every member of staff working for Birmingham Children’s Hospital will be a champion for children and young people 

National Strategy for Children‟s specialised services 

CEO 


Making every contact count 

CNO 

Oct-Dec 

YPAG 

CNO 

Dec-March 

We will strengthen Birmingham Children’s Hospital’s position as a provider of Specialised and Highly Specialised Services, so that we become the 

leading provider of Children’s Healthcare in the UK 

Safe & Sustainable Designation 

CMO 

June – July 

National Centre for rare diseases 

CMO 

Sept-Nov 

Children‟s surgery review 

CMO 

Jan-Feb 

We will continue to develop Birmingham Children’s Hospital as a provider of outstanding local services: ‘a hospital without walls’, working in close 


Jan-March 


July-Sept 

June 

Monthly 

April 

May?

Contractual agreements and requirements 

Section B Part 8.1: Quality Requirements 



Lead 

Chief 

Officer 

R A G Apr-12 May-12 Jun-12 Quarter 

to Date 

YTD 

Last year 

position 

MRSA bacteraemia 0 post 48 hour MRSA CNO >0 - 0 0 0 0 0 0 0 

A&E measures 

Total time spent in A&E 

95% admitted and nonadmitted 

within 4 hours 

COO 5.5 - 5.5 - 15 - 60 -

Section B Part 8.1: Quality Requirements continued… 



Lead 

Chief 

Officer 


to Date 

Choose and Book 

C&B: % of services directly 

>95% by June 2012 COO

Section B Part 8.1: Quality Requirements continued… 


SUS 


Lead 

Chief 

Officer 


to Date 

YTD 

Last year 

position 

Comments 

Percentage of SUS data altered. 

% of SUS data altered in 

period between 5 

Operational Days after 

month-end 

CFO 

Requirements currently being 

clarified with commissioners. 

Locally Agreed KPIs 



Lead 

Chief 

Officer 


to Date 

YTD 

Last year 

position 

DNA 

Patient DNA New patient 11 -

Locally Agreed KPIs continued … 


Infection Control 


Lead 

Chief 

Officer 


to Date 

YTD 

Last year 

position 

PICU - 95% CNO

Locally Agreed KPIs continued … 


Complaints responded to within 

agreed timeline 

Commissioner complaints to be 

responded to within agreed timeline 

External Reviews: Commissioners 

should be informed of unplanned 

reviews. 

External Reviews: Reports of 

reviews to be shared with 

commissioners 

Resulting action plans and progress 

made to be shared with 

commissioners 


Lead 

Chief 

Officer 


to Date 

YTD 

Last year 

position 

95% CMO 95 100 100 100 100 100 100 

90% CMO 90 NA 

Within 48 hours of 

occurrence 

Within 10 working days 

of receipt of the final 

report. 

Within 1 month of receipt 

of report. 

CMO 

CMO 

CMO 

Schedule B Part 8.2: Nationally Specified Events 


Other National Indicators 


Lead 

Chief 

Officer 

NA 

NA 

NA 


to Date YTD Last 

Year 

CDIFF 1 CNO >1 - 1 0 1 0 1 1 1 

4 hour maximum time in A&E 

Operating standard of 

95% 

COO

Schedule B Part 8.2: Nationally Specified Events 


Patients seen within 2 weeks of an 

urgent GP referral for suspected 

cancer 

Patients with breast symptoms 

seen within two weeks of referral 

Patients receiving first definitive 

treatment for cancer within 62 days 

of an urgent GP referral 

Proportion of patients receiving first 

definitive treatment for cancer within 

62 days of a referral from an NHS 

Cancer screening Screening 

Service Proportion of patients receiving first 

definitive treatment for cancer within 

62 days following a consultant's 

decision to upgrade to patient 

priority 

Patients receiving first difinitive 

treatment within one month of 

diagnosis 

Patients waiting no more than 31 

days for second or subsequent 

cancer treatment - surgery 



cancer treatment - drug treatments 



cancer treatment - radiotherapy 

treatments 



93% 


93% 


85% 


90% 


85% 


96% 


94% 


98% 


94% 

Lead 

Chief 

Officer 


to Date 

Oncology 

YTD 

Last year 

position 

COO

Schedule B Part 8.2: Nationally Specified Events continued. 


Waiting times 

Patients seen within 18 weeks 

across for admitted pathways 

Patients seen within 18 weeks 

across for non- admitted pathways 



90% 


95% 

Lead 

Chief 

Officer 


to Date 

COO 0 - 0 0 0 0 0 0 3 

Wrongly prepared high-risk injectable 

medication 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Maladministration of potassiumcontaining 

solutions (modified) 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Wrong route administration of 

chemotherapy (existing) 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Wrong route administration of 

oral/enteral treatment (new) 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Intravenous administration of epidural 

medication (new) 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Maladministration of Insulin (new) Target 0 CMO >0 - 0 0 0 0 0 0 0 

Overdose of midazolam during 

conscious sedation (new) 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Comments 

Compliance with Eliminating 

Single Sex Accomodation

Schedule B Part 8.2: Nationally Specified Events continued 


Governance continued 

Never events (Schedule 3 part 4C) 

Suicide using non-collapsible rails 

(existing) 

Escape of a transferred prisoner 

(existing) 


Lead 

Chief 

Officer 


to Date 

YTD 

Last year 

position 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Falls from unrestricted windows (new) Target 0 CMO >0 - 0 0 0 0 0 0 0 

Entrapment in bedrails (new) Target 0 CMO >0 - 0 0 0 0 0 0 0 

Transfusion of ABO-incompatible blood 

components 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Transplantation of ABO or HLAincompatible 

Organs 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Misplaced naso- or oro-gastric tubes Target 0 CMO >0 - 0 0 0 0 0 0 0 

Wrong gas administered Target 0 CMO >0 - 0 0 0 0 0 0 0 

Failure to monitor and respond to 

oxygen saturation 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Air embolism Target 0 CMO >0 - 0 0 0 0 0 0 0 

Misidentification of patients Target 0 CMO >0 - 0 0 0 0 0 0 0 

Severe scalding of patients Target 0 CMO >0 - 0 0 0 0 0 0 0 

Maternal death due to post partum 

haemorrhage after elective Caesarean 

section 

Target 0 CMO >0 - 0 0 0 0 0 0 0 

Comments

Schedule B Part 14.2: National Requirements Reported Locally 


Price Activity Matrix (PAM) submitted monthly. 


HCAI Reduction Plan 

Contribution to the health economy strategic plan for HCAIs 

via attendance at health economy meetings 

Documented HCAI assurance framework/strategy – 

presentation of the Trust‟s internal action plan to the CQRG. 

Reporting outbreaks of infection – email from Trust to 

Infection Prevention Lead informing Cluster of outbreak 

MRSA bacteraemia and CDI deaths 100% within 2 working 

(part 1a&b) 

days. 

Demonstrate current cleaning standards within national 

cleaning guidance 

Compliance with Care Bundles (HII). In line with the 

Department of Health recommendations 

No. of ECOLI 

Lead 

Chief 

Officer 


to Date 

YTD 

Last year 

position 

Comments 

CFO Contracting Team 

NA Monthly Monitoring Sheets 

CNO 

CNO 

CNO 

CNO 0 - 0 0 0 0 0 0 0 

Cancer Registration Data Set (ISN) Reporting on Staging. 

COO 

Infection Team 

Cancer 

Waiting Data 

Violence-related injury to staff CWD NA 

Report on Incidents CMO Governance 

NA 

NA 

Quarterly - via Clinical Quality 

Review Group 

Submitted through Cancer 

Waiting Database one month in 

arrears. 

Reported Quarterly through BCH 

Non-clinical risk co-ordinating 

committee 

See Governance Report/ Sefety 

& Governance Page

Schedule B Part 14.2: National Requirements Reported Locally 


Data Quality 

Progress against milestones in Data 

Quality Improvement Plan 


Annual Report on progress on climate change adaptation, 

Mitigation and sustainable performance. 

Report Against Performance of Service Development and 

Improvement Plan. 

Lead 

Chief 

Officer 


to Date 

YTD 

Last year 

position 

A -GMP Organisation 

Code 

CFO 

NA 

B - Discharge Date CFO 100 100 100 NA 

C - NHS Number CFO 97.9 98.5 98.3 NA 

D - Contract Suffix CFO NA 

E- Discharge Ready Date CFO NA 

Schedule B Part 14.3: Local Requirements Reported Locally 

COO 

CFO 

European Working Directive Compliance CWD NA 

Patient Level Data SUS and Non- 

Sus 

Patient Transfers 

Non PBR variable data submitted 

Data Protection Act 

Detailing PCT, GP 

Practice & CCG 

No. of patients 

transferred out of BCH 

% of patients transferred 

out of BCH. 

HCS NON-pbr variable 

data 

Submission of toolkit self 

assesment scores 

CFO 

COO >0 - 0 0 0 0 0 0 0 

COO >0 - 0 0 0 0 0 0 0 

CFO 

Submit data. 

CFO Submit data. 

Level 2 

NA 

NA 

NA 

NA 

Comments 

Also Reported in Data Quality 

Indicators. 

Annual year end report (10 

working days after 31 st March 

2013) 

Reported via Contract Review 

Meetings. 

Writtten report required on areas 

of non-compliance 

Monitored via data submission 

to SUS 

State reason for tranfer. 

Submitted monthly to HCS as 

per contract timetable 

Bi-annual submission. Provided 

10 working days after 31st Oct 

2011 and March 31st 2012 

PBR Audit CFO Annual 

Waiting Times Report for all 

breaches.in relation to Cancer 

COO NA Reported via SCT. 

Services. 

RTT Waits and Numbers - 

Spreadsheet 

COO Submit data. 

NA

Schedule B Part 14.3: Local Requirements Reported Locally continued. 


HCAI - MRSA & CDIFF Exception 

Reports 

Safeguarding 


Monthly exception 

Reports 

Lead 

Chief 

Officer 


to Date 

YTD 

Last year 

position 

CNO 0 1 0 1 1 NA 

The number of DOLS 

authorised 

CNO 

NA 

% DOLS authorised CNO NA 

% compliance - 

safeguarding training 

CNO 99 98.2 98.2 97 

Comments 

Detailing breaches - anonymised 

Patient Level information/ GP 

Practice Code 

Reported via Clinical Quality 

Review Meeting. 

FNP Scorecard 

CAMHS - Caseload management 

CAMHS - Length of episodes 

CAMHS - Emergency Referrals 

CAMHS - Access 

PAN Birmingham Cancer Network 

% staff receiving 

safeguarding supervision 

Submit Dashboard 

monthly 

Policies and practices 

are in place for all staff 

ensuring caseload 

supervisions 

Report on length of 

episode in CAMHS by; 

diagnosis, severity and 

complexity 

CNO 

CNO 

COO 

COO 

Number of referrals COO NA 

Number of admissions 

from referrals 

COO 

NA 

Quarterly Report CAMHS 

Access across 16 

Localities as defined with 

Bham City Councils 

Children's Services. 

Position statement on 

compliance against 

tumour sites against IOG 

criteria 

COO 

CAMHS 

NA 

NA 

NA 

NA 

NA 

Reported via requirements as 

agreed with SCT. 

Quarterly Report - discussed at 

CAMHS performance 

management meeting, 

Bi Monthly. Discussed at 

CAMHS Performance 

Management Meeting. 

Bimonthly report. Discussed at 

CAMHS Performance 


Quarterly Report discussed at 

CAMHS oerformance 


COO NA Reported via SCT.



PAN Birmingham Cancer Network - 

Progress against Improving 

Outcomes Guidance 

Emergency Readmissions : after 

elective 

Emergency Readmissions :after 

elective (with exclusions) 


emergency admission 


emergency admission (with 

exclusions) 

QIPP Report 

Best Practice Tarriff - Paediatric 

Diabetes 

Equality and Diversity 

Lead Chief 


Officer 


to Date 

Progress Report COO NA 

Report and action plan to 

be collated by end April. 

Emergency 

Readmissions within 30 

days 

Emergency 


days 

Emergency 


days 

Emergency 


days 

QIPP Scheme reports for 

those that cannot be 

monitored via SUS 

BPT to commence in 

third quarter of 2012/13 

or as defined in SDIP 

Q1 - Publish Information 

on Staff & Service Users 

to demonstrate 

Compliance 

Q1 - Publish Equality 

objectives & send to 

commissioners 

Q4 - Progress Report on 

Equality objectives to be 

sent to Commissioner. 

COO 

COO 

COO 

COO 

COO 

CFO 

COO 

CWD 

CWD 

CWD 

69 

5.7% 

12 

0.99% 

125 

10.2% 

13 

1.1% 

62 

4.9% 

3 

0.24% 

126 

10% 

29 

2.3% 

53 

4.5% 

9 

0.76% 

95 

8.1% 

9 

0.76% 

183 

5.0% 

24 

0.7% 

342 

9.4% 

50 

1.4% 

YTD 

Last year 

position 

NA 

183 

5.0% NA 

Comments 


24 

0.7% NA Day Cases, Renal, Liver, Cancer 

Patients & Patients under 4 

years. 

342 

9.4% NA 


50 

1.4% NA Day Cases, Renal, Liver, Cancer 

Patients & Patients under 4 

years. 

NA 

NA 

NA 

NA 

NA 

Reported via SCT. 

Trust agreed Business Case. 

Recruitment in progress. Trust & 

commissioners are working in 

line with SDIP. 

Reported via Quality Review 

Meeting

Equality and Diversity 

Reported via Quality Review 

Meeting 

Q3 - Submit a list of all 

policies/decisions that 

have been subject to 

equality analysis. 

CWD 

NA 



Equality and Diversity - Workforce 

Training Report 

Equality and Diversity - New 

Information Requirement 

Executive leadership Safety 

Walkabouts 

Demonstrate learning from rule 43 

coroners 


% of staff trained in 

Equality & Diversity 


Communications & Care 

provision for pepole with 

Learning Disabilities 


Human Rights Act 1998 - 

to cover aspects of 

dignity and respect 

Submit bi-monthly 

progress returns using 

SHA EDS progress 

reporting template. 

Commissioners to 

receive at least 4 

summary reports 

Rule 43 letter, response 

from trust and any 

subsequent action plan 

Lead 

Chief 

Officer 

CWD 

CWD 

CWD 

CWD 


to Date 

YTD 

Last year 

position 

CNO/CMO 2 3 4 NA 

CMO 

NA 

NA 

NA 

NA 

NA 

Comments 

Mortality (HSMR relative risk) Quarterly Report CMO NA Monthly Safety Report 

Workforce Report CWO NA 

Statement of CAS alerts and rapid 

response reviews, outcomes, gap 

analysis and any action plans 

Reported via Clinical Quality 

Review Meetings 

Workforce Page of Performance 

Report 

CMO NA Governance Report

Commissioning for Quality and Innovations (CQUIN) 

Category 

Performance 

Indicator 

Heart Of Birmingham PCT 

HoB 1 

HoB 2 

HoB 3 A 

Safety 

Thermometer 

National 

(Weighting = 10%. 

Value = £178,078) 

Safety 

Thermometer 

Paediatric 

Specific 


Value = £178,078) 

Friends and 

Family Test 

Regional 


Value = £71,235) 


Lead 

Chief 

Officer 


to Date 

YTD 

Last year 

position 

No. of pressure ulcers per month CNO 0.99 1.74 2.44 NA 

No. of falls per month CNO 0 0 0 0 0 NA 

No. of UTIs in patients with catheters per month CNO 0 0 0.35 0.35 0.35 NA 

No. of VTE per month CNO 0 0 0 0 0 NA 

Sample Size CNO 302 287 287 876 876 NA 

Percentage of patients with harm free care CNO 99.01 98.26 97.21 NA 

Q1 Report on Paediatric specific outcomes, 

rationale for inclusion and adapted NHS Safety 

Thermometer Tool. 

Q2 Pilot the metrics (agreed Q1) and provide 

the pilot results and details of any refinements. 

Q3 Provide a report detailing surveyed 

outcomes for all months in quarter. 



10% of inpatient discharges, with patients 

surveyed at or within 48 hours of discharge 

CNO 

CNO 

CNO 

CNO 

CNO

Commissioning for Quality and Innovations (CQUIN) continued … 

Category 

Performance 

Indicator 


Friends and 

Family Test 

HoB 3 B Regional 


Value = £71,235) 

Weekly 

HoB3 C Reporting 


Value = £71,235) 

HoB 3 D 

HoB 4 

Performance 

Improvement 


Value = £71,235) 

Net Promoter - 

Paediatric 

Specific 


Value = £284,939) 


Board Minutes evidence patient experience 

reporting, including Net Promoter Score 

(Organisation, Specialty & Ward level. 

Evidence of weekly collation and review of the 

Net Promoter Score from Quarter 2 

Monthly Net Promoter Score shows either: 

(A) A 10 point improvement in Net Promoter 

Score 

(B) Achievement or maintenance of top quartile 

performance throughout 2012/13 

Q1 Provide a report demonstrating the 

developed questions appropriate for different 

age groups and an indication of the reporting 

mechanism that will be used through the 

organisation to inform the board. 

Q2 Pilot the developed questions and provide 

the pilot results and details of any refinements 

to the questions for roll-out across the whole 

organisation. 

Q3 Provide a report demonstrating that the 

questions are established and reported for 10% 

of inpatient discharges, with patients surveyed 

at or within 48 hours of discharge. Evidence of 

weekly data collection. Evidence of Board 

reporting and any changes implemented as a 

result 

Lead 

Chief 

Officer 

CNO 


to Date 

YTD 

Last year 

position 

NA 

Comments 

CNO NA Applicable from Q2. 

CNO 

CNO 

CNO 

CNO 

NA 

NA 

NA 

NA 

June has exceeded the 

SHA top quartile 

standard. May saw a 10 

point increase from April 

12. 

Q1 report ready and 

submitted.


Category 

Performance Performance Target 

Indicator 


HoB 4 

HoB 5A 

Net Promoter - 

Paediatric 

Specific 

continued 

Healthy 

Lifestyles - 

Smoking 


Value = £142,470) 

Q4 Provide a report demonstrating that the 

questions are established and reported for 10% 

of inpatient discharges, with patients surveyed 

at or within 48 hours of discharge. Evidence of 

weekly data collection. Evidence of Board 

reporting and any changes implemented as a 

result 

Q4 Smoking Status recorded children 

preadmission 90% 

Q4 Smoking Status recorded children 

outpatients 25% 

Q4 Smoking Status recorded parents 


Q4 Smoking Status recorded parents 


Q4 Brief advice to stop smoking children 


Q4 Brief advice to stop smoking children 


Q4 Brief advice to stop smoking adults 


Q4 Brief advice to stop smoking adults 


Lead 

Chief 

Officer 

CNO 

CNO 

CNO 

CNO 

CNO 

CNO 

CNO 

CNO 

CNO 


to Date 

YTD 

Last year 

position 

NA 

Comments 

Combined Q1 

update report 

produced and 

submitted 

Q4 Alcohol Status Recorded Children 

Preadmission 70% 

CNO 

HoB 5B 

Healthy 

Lifestyles - 

Alcohol 

(Weighting = 6.4%. 

Value = £113,976) 

Q4 Alcohol Status Recorded Children 

Outpatients 25% 

Q4 Patient drinking (Brief advice to stop 

drinking and referral to specialist services) Preadmission 

70% 

Q4 Patient drinking (Brief advice to stop 

drinking and referral to specialist services) 

Outpatients 70% 

CNO 83 

CNO 

CNO 

Combined Q1 

update report 

produced and 

submitted


Category 

Performance 

Indicator 



a) Evidence of board level commitment to 

implementation 

HoB 5C 

HoB 6 

Healthy 

Lifestyles - 

Making Every 

Contact Count 

(Weighting = 1.6%. 

Value = £1,976) 

CAMHS QNCC 


Value = £284,939) 

Lead 

Chief 

Officer 

CNO/CWD 


to Date 

YTD 

Last year 

position 

b) Board level lead / champion in place CNO/CWD NA 

c) Evidence of organisational policies and 

procedures in place, for example organisational 

health and wellbeing development strategy, 

suitable data collection and reporting 

mechanisms, use of induction 

d) Evidence of activity to support employees 

own health and wellbeing including 

implementation of NICE PH tobacco guidance 

for workplaces 

e) System to routinely record the number of 

NHS staff completing locally agreed training in 

delivering lifestyle brief advice 

CNO/CWD 

CNO/CWD 

CNO/CWD 

f) System to routinely record the number of 

referrals from NHS organisations to local stop 

CNO/CWD 

smoking services, as a key indicator for delivery 

of brief lifestyle advice from NHS staff. 

QNCC Standards Type 1 (Essential): These are 

standards that are critical to care. Failure to 

meet these standards would result in a 

significant threat to patient safety, rights or 

dignity and/or would breach the law 

Type 2 (Expected): These are standards that a 

CAMHS team providing a good service would 

be expected to meet. 

COO 

COO 

NA 

NA 

NA 

NA 

NA 

NA 

NA 

Comments 

Q1 update report 

produced and 

submitted. 

QNCC review is 

planned for Nov 

2012. 

Type 3 (Desirable): These are standards that 

an excellent team should meet or standards 

that are not the direct responsibility of the team. 

COO 

NA


Category 

HoB 7 

WMSCT - 

C1 

Performance 

Indicator 

Antimicrobial 

Stewardship 


Value = £284,939) 


M2 Audit report with evidence of selfassessment 

score and action plan. Arrange a 

peer review with BSOL Associate Director 

M6 Audit report with evidence of selfassessment 

score. Arrange a peer review with 

BSOL Associate Director. 

M12 Audit report with supporting evidence of 

self-assessment score. As part of this scheme 

arrange a peer review with BSOL Associate 

Director 

West Midlands Specialised Commissioning Team 

WMSCT - 

C2 

Safety 

Thermometer 


Value = £84,228) 

Clinical 

Dashboard. To 

implement the 

routine use of 

specialised 

services 

clinical 

dashboards 

(Weighting = 10%, 

Value = £168,456) 

Complete record of safety thermometer survey 

data every quarter reported directly to the NHS 

Information Centre. 

Q1 1. Identify dashboards lead & dashboard 

lead in each clinical area 

2.Summary of plans for implementation of the 

dashboards within timescale 

Q2 1.Routine reporting against quality 

dashboard requirements for all relevant 

services 

2. Brief update for each clinical area 

Lead 

Chief 

Officer 

COO 

COO 

COO 


to Date 

YTD 

Last year 

position 

NA 

NA 

NA 

Comments 

Report - 30/05/2012 

Current score = 2 


Payment is subject to 

achieving a score of at 

least 40. 


Payment is subject to 

achieving a score of at 

least 65. 

CNO NA See HoB 1 for data. 

CMO 

CMO 

Q3 1.Brief update for each clinical area . CMO NA 

Q4 1. Evidence that all relevant dashboards 

have been considered by front line clinical staff 

with evidence of consideration of current 

performance and identification of plans for 

improvement, where appropriate. 

CMO 

NA 

NA 

NA 

Q1 report produced 

and submitted.


Category 


Indicator 


WMSCT - 

C3 

Minimise the 

number of 

patients 

accidently 

extubated 


Value = £168,456) 

90% of patients who were accidently extubated 

to have their cases reviewed and reported on 


Lead 

Chief 

Officer 

COO 


to Date 

YTD 

Last year 

position 

NA 

Comments 


and submitted. 

WMSCT - 

C4 

CAMHS T4 - 

Education, 

training and 

meaningful 

activity requires 

Providers to 

develop 

strategies to 

respond to the 

variety of age 

groups treated 

in Specialised 

Services 

specifically in 

respect of 

education, 

training and 

meaningful 

activity 


Value = £84,228) 

Q1 1. Consult Service Users as a group about 

their wishes and feelings about educational and 

other daytime activities. 

Q2 1. report describing contacts and 

negotiations with providers of educational, 

training and therapeutic services (both internal 

and external as appropriate) to address the 

need to provide (or enable access to) 

comprehensive age appropriate provision. 

COO 

COO 

Q3 1. Overall strategy document which 

addresses the arrangement of this provision COO NA 

Q4 1. Internal audit of percentage of Service 

Users who have accessed in excess of twenty 

hours [for local determination] educational, 

training or defined meaningful activity during 

each week of Quarter 4. 

COO 

NA 

NA 

NA 



Narrative report of 

no more than 500 

words 

To detail milestone 

and timelines in 

year and includes 

sample individual 

timetables. 

Target percentage 

to be locally 

determined.


Category 


Indicator 


Q1 Narrative report detailing current practices, 

discussion with Human Resource advisors & 

results of a minimum of two group meetings 

with service users 

WMSCT - 

C5 

WMSCT - 

C6 

CAMHS T4 

Patient 

Involvement in 

Recruitment 


Value = £84,228 

CAMHS T4 

Feasibility 

study - 

conversion of 

bedroom 

facilities to 

single room 

accommodation 

for adolescent 

wards 


Value = £84,228) 

Q2 Narrative that details the date and content 

of discussion at the unit‟s Clinical Governance 

forum about the development of a strategy to 

enable patient involvement, and plans for the 

training of patients in this role. 

Q3 Details of the number of patients who have 

engaged in the training by end of Q3. 

Qualitative report on their reaction to the 

Lead 

Chief 

Officer 

COO 

COO 

COO 


to Date 

YTD 

Last year 

position 

Q4 Number of recruitment processes which 

featured patient involvement during Q3 and Q4. COO NA 

Q1 Completion of consultation exercise & a 

series of visits to other Tier 4 units. COO NA 

Q2 Consultations with other stakeholders to 

include CQC, QNIC, estates departments and 

planning authorities 

Q3 options paper to be considered at board 

level 

• Produce an options paper to be considered at 

board level by the Trust 

Q4 Report in the form of a feasibility study, 

options appraisal or business case to include 

the results on consideration at board level 

COO 

COO 

COO 

NA 

NA 

NA 

NA 

NA 

NA 

Comments 



Provide a copy of a 

Strategy and 

associated training 

material to be used. 

Narrative report of 

max 500 words 



Confirmation of the 

completion of the paper 

and its consideration at 

Board to be provided


Category 


Indicator 


WMSCT - 

C7 

Safety 

Thermometer - 

Paediatric 

Specific 

(Weighting = 5% 

Value = £84,228) 

Q1 report the proposed Paediatric specific 

outcomes, rationale for inclusion and adapted 

NHS Safety Thermometer Tool. 

Q2 report on the pilot implementation and from 

the lessons learnt, a revised set of metrics 


outcomes for all months in quarter 



Lead 

Chief 

Officer 

CNO 

CNO 

CNO 

CNO 


to Date 

YTD 

Last year 

position 

NA 

NA 

NA 

NA 

Comments 


and submitted.

Local Targets - Safety, Governance and Patient Experience 

Safety 

Category Performance Indicator Performance Target Lead R A G Apr-12 May-12 Jun-12 YTD 

Infection control 


Clostridium difficile 

infections 

1 cases in the 

financial year 

Last year 

position 

CNO >1 - 1 0 1 0 1 1 

Comments 

One case 

diagnosed in 

Coventry hospital 

within 24 h of 

discharge from 

BCH 

National target MRSA Bacteraemia 0 case per year CNO >0 - 0 0 0 0 0 0 

MSSA (Meticillin Pre 48 hours CNO T B A 1 2 0 3 16 June 2011 - 9 

National target Sensitive 

Post 48 hours (10% 

Staphylococcus Aureus) reduction) 

CNO 1 4 1 6 11 June 2011 - 2 

National target E-Coli 

Pre 48 hours CNO 0 1 0 0 5 June 2011 - 3 

Post 48 hours CNO T B A 2 0 0 2 13 June 2011 - 4 

Internal target Hand hygiene 

95% compliance with 

hand hygiene policy 

CNO 1 - 0 0 0 0 0 3 

Internal target 



All MRSA 

Patient to Patient 

Transmitted MRSA 

PICU 

National target Ward 11 

National target Ward 12 

Trend analysis CNO 8 13 13 21 101 

MRSA Admission 

Screening 

CNO 2 5 5 7 39 

New Isolates CNO 3 3 1 6 24 

Previous Isolates CNO 3 5 7 8 32 

0 cases per year CNO >0 - 0 0 0 0 0 0 

100% all admissions 

are screened 


are screened 


are screened 

CNO

Local Targets - Safety, Governance and Patient Experience continued … 


Net App 

Local target 

Local target 

Total number of 

inpatients in period 

Total number of 

responses in period 

Number of 

discharges within the 

period 

Number of responses 

in period 

Last year 

position 

CNO 1018 1063 1272 2081 NA 

CNO 124 111 143 254 NA 

Local target Number of Promoters CNO 74 75 118 193 NA 

Local target Number of Passives CNO 41 31 23 54 NA 

Local target Number of Detractors CNO 9 5 2 16 NA 

Local target Overall Score CNO 52.4 63 81.1 NA 

Local target Average SHA Score CNO 52 62 NA 

Safety Thermometer 

Percentage of Patients 

Local Target 

with Harm free Care 

% CNO 99.0 98.3 97.2 NA 

Local Target Sample Size Number CNO 302 287 287 NA 

Local Target Pressure Ulcers CNO 0.99 1.74 2.44 NA 

Local Target Catheters & UTIs CNO 0 0 0.35 NA 

Local Target VTEs CNO 0 0 0 NA 

Local Target Falls CNO 0 0 0 NA 

Comments 

SHA upper 

quartile is 71



Risk register 

Last year 

position 

Comments 


Population of the risk 

register 

Risks greater than or 

equal to 16 have an 

action plan recorded 

on the risk register 

(%) 

CMO



SIRIs continued.. 

Families are informed of 

Internal target the outcomes of SIRIs 


Families are informed of 

incidents that have been 

declared SIRIs 

within 28 days of the 

ratification of the final 

SIRI report 

within 7 days of the 

declaration 

Last year 

position 

CMO 100 100 100 100 

CMO 100 NA 0 95.8 

Comments 

Due to language 

issues with the 

family we have 

not yet informed 

them that there 

will be a SIRI 

investigation. A 

plan to inform 

them is being 

agreed. 


Completion of SUI 

actions 

Actions arising are 

completed within 

specified timeframe (%) 

CMO



Internal BCH 

target 

Escalation of serious 

incidents 

All red graded Serious 

Incidents escalated 

within 24 hours of 

becoming aware of the 

incident (%) 

Last year 

position 

CMO

Local Targets - Safety, Governance and Patient Experience continued… 


Complaints 

Internal target Number of complaints CMO 7 1 8 16 111 





Timeliness of response 

Number of health 

service referrals to 

Ombudsmen 

Number of complaints 

requesting additional 

information after CEO 

response 

Manager contact with 

complainant 

100% within 25 days or 

negotiated timescale 

with the family 

Trend analysis 

Trend analysis 

When applicable, all 

relevant managers to 

make contact the 

complainant (%) 

Last year 

position 

CMO 90 95 100 100 100 100 100 100 

1 0 1 1 2 

0 0 0 0 0 

CMO 10 10 5 2 1 6 3 36 

formal complaints 

FOI 

Internal target Number of FOI's Trend analysis CMO TREND 18 28 19 65 273 

Number of FOIs 

National target responded to within 20 

working days 

100% CMO



Patient access 



Local 

commissioner 

target 

Local 

commissioner 

target 

Local 

commissioner 

target 

Call centre 

Convenience and 

choice (provider 

information on nhs.uk 

and availability of slots) 

90% all calls to be 

answered within 1 

minute 

80% all calls to be 

answered within 30 

seconds 

Last year 

position 

COO


Nursing Indicators 


Clinical Support Services 

Lead 

Chief 


Internal target MDC >95% CNO 95 100 100 

Internal target SDC >95% CNO 95 97 99 

Internal target Directorate overall >95% CNO 95 99 99 

Medical Directorate 

Internal target MHDU >95% CNO 95 97 90 

Internal target Ward 15 >95% CNO 95 96 86 

Internal target Ward 2 >95% CNO 95 93 

Internal target Ward 6 >95% CNO 95 92 


Internal target Haemaglobinopathy >95% CNO 95 98 96 

Internal target ODC >95% CNO 95 100 92 

Internal target Ward 15 HDU >95% CNO 95 97 90 

Internal target Ward 15 TCT >95% CNO 95 99 90 

Internal target WTCRF >95% CNO 95 99 99 



Internal target PICU >95% CNO 95 94 95 

Internal target Recovery >95% CNO 95 97 84 





Surgical Directorate 

Last year 

position 

Internal target Burns >95% CNO 95 99 96 

Internal target Haemodialysis >95% CNO 95 100 100 





Internal target NSW >95% CNO 95 95 96 


BCH 

Internal target BCH overall >95% CNO 95 95 92 

Comments 

Reported 

Quarterly 

Reported 

Quarterly 

Reported 

Quarterly 

Reported 

Quarterly 

Reported 

Quarterly

Data Quality 

Performance Indicator Contracting SUS DQ IG 

Toolkit 

OVERALL RATING 

Good 

Practice 

To Reach 

Green 

Apr-12 May-12 Jun-12 

YTD 

Last 

Year 

Data Quality Rating x x x x Combines below metrics 

Admitted Patient Care 

Administrative Category x x 

Admission Method 

Birth Date x 99% 100 100 100 

Critical Care Discharge 

x x 

Date 

99% 100 100 100 

Critical Care Start Date 

Decision to admit Date 

x 

x 

x 

x 

99% 

99% 

100 

NA 

100 

91.5 

100 

93.8 

Discharge Date 

99% 

x x 99% 

Commissioner x x 99% 

Consultant Code x x 99% 

x 

x 

99% 

100 

100 

98.7 

100 

100 

100 

100 

98.8 

100 

100 

100 

100 

98.7 

100 

100 

100 

100 

100 

98.7 

100 

100 

100 

93.8 

100 

100 

100 

100 

98.7 

100 

100 

100 

92.9 

100 

Valid Code required; denotes 

Private/NHS mapped prior to external 

Valid Admission Method; mapped prior 

to external submission 

Patients with valid DOB 

Valid Commissioner Code 

Valid Consultant Code check against 

National ODS File 

>= Episode Start date and

Data Quality continued… 


Toolkit 

Good 

Practice 

To Reach 

Green 

Apr-12 May-12 Jun-12 YTD Last 

Year 

Admitted Patient Care continued 

Intended Management 

x x 98% 99.3 99.6 99.5% 99.5% 99.6 

IPM record creation date 

>1 after admission date 

IPM record creation date 

>1 after discharge date 

Last Episode 

NHS Number (present) x x 

x 

x 

95% NA 92.4 92.5% 92.5% 92.6 

Operation Status x x 99% 100 100 100 100 100 Code identifies whether procedure 

Patient Classification x x 98% 100 100 100 100 100 Valid 

performed 

patient 

during 

classification 

episode 

PCT of Residence x 99% 99.5 99.6 99.5 99.5 99.2 Valid PCT Code 

Postcode 

x x Not NULL or invalid postcode (check 

100% 99.5 99.6 99.5 99.5 99.2 

against ODS file) 

Primary Diagnosis 

x x 99% 100 100 100 100 100 National file ICD10 

Sex x x 99% 100 100 100 100 100 

x 

x 

95% 

Primary Procedure x 99% 

Primary Procedure Date 

Site of Treatment 

x x 99% 

x 99% 

x 92% 

Source of Admission x x 99% 

Spell Start Date x 99% 

Trace Status on x x x 98% 

Treatment Function x x 99% 

Elective Waiting List 

Administrative Category x x 100% 

Birth Date x x 

Consultant Code x x 

x 

NA 

100 

98% 97.9 

99% 

99% 

100 

99.1 

100 

100 

100 

99.9 

100 

100 

100 

100 

60.7 

100 

98.5 

100 

98.0 

100 

100 

100 

99.8 

100 

100 

100 

100 

61.8% 61.8% 61.5 

100 

98.3 

98.3 

100 

100 

100 

99.9 

100 

100 

100 

100 

100 

98.3 

100 100 

98.3 

100 

100 

100 

99.9 

100 

100 

100 

100 

100 

98.1 

100 

97.2 

0 

100 

100 

100 

100 

100 

100 

100 

Patients with specified Intended 

Management Code 

Percentage of records entered same 

day as event 

Percentage of records entered same 

day as event 

Correct Last Episode number 

Valid NHS number for all inpatient 

admissions 

National file OPCS 

Date >= Episode StartDate,



Toolkit 

Elective Waiting List continued.. 

Count of Days 

x x 

Suspended 

Decided to Admit Date x x 

GP Practice x x 

Sex 

Trace Status on elective 

WL Suspensions with 

no comments 


Good 

Practice 

To Reach 

Green 

100% 

100% 

Intended Management x x 100% 

Intended Procedure 

98% 

NHS Number (present) 

x 98% 

Planned, no TCI date or 

x 

Admit by Date 

Original Decided to 

x x 

Admit Date 

100% 

90% 

Postcode x x 100% 

Attendance Disposal 

x 


Year 

99.3 

x x 99% 100 100 100 100 100 

x x x 98% 99.8 99.9 99.9 99.9 99.8 

x 

99% 100 99.1 97.4% 97.4% 99.7 

x 

x 

99% 

99% 

Commissioner x x 99% 

100 

100 

97.1 

98.3 

100 

100 

100 

96.9 

98.3 

99.1 

98.6 

48.1 

100 

100 

98.5% 

41.2 

100 

100 

97.0 

98.5 

41.2 

100 

100 

97.3 

98.1 

99.3 

98.7 98.6 98.5 98.5 98.6 

100 

80.3 

99.6 

100 

97.0 

98.5 

99.0 

100 

79.8% 

99.6 

99.0 

79.8% 

99.6 

100 

37.3 

Patients with positive integer (Days 

suspended) 

Patients with valid Decision to Admit 

Date 

Valid GP Code check against National 

ODS File, nulls mapped to unknown 

Patients with specified Intended 

Management Code 

Patients with valid intended procedure 

code 

Valid NHS number for all waiting list 

patients 

Patients with valid Original Decided to 

Admit Date 

Planned patients with no TCI or Admit 

by Date 

Good practice 


Departure Time x 99% 100 100 100 100 100 Valid departure time for all ED records 

ED Activity 'treatment 

complete' with no coding 

ED Activity with no 

telephone numbers 

ED IPM record modified 

after arrival date 

x 

99% 

80% 

99% 

80.5 

99.7 

100 

99.8 

100 

98.8 

27.6 

100 

99.9 

100 

100 

99.8 

100 

99.8 

100 

98.5% 

100 

86.4 

99.7 

100 

99.9 

100 

98.6 

Not NULL or invalid postcode (check 


Valid Gender Code 

Patients with NHS number trace 

Data Dictionary codes for ED 

attendance disposal 

All patients treated should have 

treatment code 

Safeguarding issue, all should have 

telephone number 

Data entered same day as event



Toolkit 

Good 

Practice 

To Reach 

Green 

Emergency Department continued.. 

First Investigation 

x 99% 

x x x 99% 

Attended or Did Not x x x 99% 

Birth Date 

x x 99% 


Year 

All records should have first 

100 100 100 100 100 

investigation where appropriate 

First Treatment x All records should have first treatment 

99% 100 100 100 100 100 where appropriate 

Patient Group x 99% 

PCT of Residence 

x 

99% 

Postcode x 99% 

Trace status on ED 

arrivals 

Referral/Outpatient 

Administrative Category 

Attendance Date 

Commissioner 

Consultant Code 

x x x Valid Consultant Code check against 

99% 100 100 100 100 100 

National ODS File 

Ethnic Category 

First Attendance 

x 

x x 

99% 

99% 

94.2 

100 

95.5 

100 

96.3 

100 

96.3 

100 

92.3 

100 

Valid ethnic group code, unknown 

invalid Specified First Attendance 

GP Practice 

x 

x 

x 

x 

x 

99% 

99% 

99% 

99% 

100 

99.4 

99.5 

99.8 

99.9 

99.9 

99.6 

100 

99.3 

98.5 

100 

99.1 

99.4 

99.7 

99.9 

100 

99.6 

100 

99.2 

98.4 

100 

99.3% 

99.6% 

99.8% 

100 

100 

98.9 

100 

99.3 

98.7 

100 

99.3% 

99.6% 

99.8% 

100 

100 

98.9 

100 

99.3 

98.7 

100 

99.5 

99.6 

99.8 

99.9 

100 

99.5 

100 

99.3 

98.5 

Valid PCT Code 



Patients with NHS number trace 

Valid Code required; denotes 

Private/NHS mapped prior to external 

submission 

All attended outpatient appointments 

Missing data mapped for external 

Patients submission with valid DOB 


Valid GP Code check against National 

ODS File, nulls mapped to unknown 

NHS number (present) 

on attended 

Operation Status 

x 

x 

x 

98% 99.0 99.3 99.5 99.5 

% 100 100 100 100 

99.0 

100 

Valid NHS number for all outpatient 

appointments 

Code identifies whether procedure 

performed during episode. 

Outcome of Attendence x x x 99% 96.3 90.5 87.2 87.2 91.8 Not specified code monitored internally 

Patients undeparted 

x 

Arrival time present but not departed 

where patient attended 

99% 96.5 89.9 87.1 87.1 91.5 

monitored internally 

on time



Toolkit 

Good 

Practice 

To Reach 

Green 


year 

Referral/Outpatient continued … 

position 

PCT of Residence x 99% 99.7 99.7 99.6 99.6 99.6 Valid PCT Code 

Postcode x x 100% 

Primary Procedure 

Priority Type 

Source of Referral for 

Outpatients 

Trace Status on 

Outpatients 

Treatment Function 

Code 

Registration 

Duplicate Registrations 

90% 

Referral Date x x 99% 

Sex x x 99% 

x 

x 

x 

x 

80% 

99% 

99.7 

100 

80.8 

99.7 

100 

99.3 

x x 98% 99.9 99.9 99.7 99.7 99.9 Patients with NHS number trace 

x x 99% 

99% 

99.7 

100 

79.9 

99.6 

100 

99.2 

99.1 

100 

99.1 

99.9 

99.6 

100 

80.7 

99.6 

100 

99.5 

99.3 

99.9 

99.6 

100 

80.7 

99.6 

100 

99.5 

99.3 

99.9 

99.6 

100 

79.6 

99.7 

100 

99.4 

99.2 

99.9 



National file OPCS 


submission 

Patients with no Referral Date, or with 

invalid date 

Valid Gender Code 


submission 

National file of Treatment Function 

Codes 

Duplicates against total registrations

Local Targets - Workforce 


Internal 

target 

Internal 

target 

Internal 

target 

All Staff to have an up to 

date PDR 

Lead Chief 

Officer 


Last year 

position 

3

Local Targets - Education 


Induction training 

Internal 

BCH target 

Corporate induction received 

by new staff 

Internal Local induction received by 

BCH target new staff 

Mandatory training 

Internal 

BCH target 

Conflict resolution 

Internal Information Governance 

BCH target training 

Internal 

BCH target 

Health and Safety Training 

Internal 

BCH target 

Fire training 

Internal 

BCH target 

Child Protection level 1 

Internal 

BCH target 

Moving and Handling training 

Internal 

BCH target 

Infection control 

100 % of staff who require it to have 

received training 

65% of staff who require it to have 













received theory training 



Lead 

Chief 

Office 

R A G April 12 May 12 June 12 

Last year 

position 

CWD

Local Targets - Efficiency and Operations 

Category Performance Indicator 

18 weeks 


Lead 

Chief 

Officer 


Last year 

position 

Internal Mean treatment times COO 10.4 10.6 11.1 10.2 

Internal Admitted 

Median treatment times COO 10.5 11.2 12.4 10.9 

Internal 95th percentile treatment times COO >23 18.3 92 

% 

COO 132 99 

Local Targets - Efficiency and Operations continued … 

Stages of treatment - Internal targets 

Local Inpatient 26 week wait 100% at the end of each month COO 5.6 6 4.6 3.6 3.1 3 3.4 3.7 Non-elective & emergencies. 

Internal 

target 

Inpatient length of stay 

Current Inpatients over 7 days COO Trend 

NA 

Current Inpatients over 30 

days 


days 


days 

COO 

COO 

COO 

Trend 

Trend 

Trend 

NA 

NA 

NA 

Internal 

target 

Pre-operative bed days 

70% elective patients operated 

on day of admission. 

COO




Item 12.135 Enc 5 

n/a 


Report Title 


Author(s) 


Report on the Use of the Trust Seal 

n/a 

Gwenny Scott, Company Secretary 

n/a 

Situation 

The Trust’s Standing Orders require that the use of the seal is authorised by the Board of Directors and 

entered in the Register of Sealings. The seal is used to execute deeds (e.g. conveyances of land) or where it may 

be required by law. 

The Company Secretary is Custodian of the Trust Seal. 

The seal was used on the following documents: 

Lease of premises at Unit 7 Rowchester Court. 

Background 

Assessment 

The lease of Unit 7 Rowchester Court is a renewal of the lease for 10 years with a five year break clause. The 

premises provide office accommodation for the Finance department. 

The Board is asked to endorse the use of the Trust seal. 

Recommendations




Item 12.136 Enc 6 

Strategic Objective/ Enabler n/a 

Report Title 


Author(s) 


Hospitality Register Review 

David Melbourne, Chief Finance Officer 

Gwenny Scott, Company Secretary 

n/a 

Situation 

In accordance with Trust policy and Standing Financial Instructions and with the Department of 

Health’s Standards of Business Conduct, the Hospitality Register is presented for review. 

Background 

The Department of Health’s Standards of Business Conduct for NHS Staff provides that NHS staff 

must ensure that decisions are not improperly influenced by gifts or inducements. The Trust’s policy 

and Standing Financial Instructions therefore require any gift or hospitality of a value of £25 or 

above to be registered in the Trust’s Hospitality Register, which must be maintained by the Director 

of Finance. 

Assessment 

The entries made in the Hospitality Register since December 2011 are set out in the attached 

appendix. 

The majority of the entries relate to fees and expenses for staff attendance at conferences paid 

by private companies. There are also a number of entries relating to donations by companies to 

the KIDS service. 

There is no indication of any improper influence resulting from these gifts, donations and 

hospitality. 


The Board is asked to review the contents of the Hospitality Register.

Key Risks 


Failure to record gifts or 

donations on the Hospitality 

Register may have a 

reputational impact. 

Regular review of the Register 

Bi-annual reports to Board.



outcome) 






rights 


None 

None 

None 

None 

None 

Potential 

Key Impacts

HOSPITALITY REGISTER 2012 

Date of Entry Name of Recipient Department Hospitality Description Approx Value Date of Receipt Sponsor/Received From 

19 December 2011 Chris Kendriksz IMD 

Attendance at World Meeting in San Diego including 

registration and hotel 

$1200 Feb 12 Actelion UK 

19 December 2011 Chris Kendriksz IMD Neuro-paediatrics meeting in Portugal 900 Euros Jan 12 Actelion UK Portugal 

19 December 2011 Chris Kendriksz IMD NPC Forum in Greece 1000 Euros Mar 12 Actelion Global 

28 December 2011 Catherine Stewart Clinical Nurse Specialist Train fare to London to attend one day workshop £155 04 January 2012 Biomarin Drug Co 

06 February 2012 Dr Suresh Vijay IMD 

07 February 2012 Angela Horsburgh Deputy Perfusion Manager 

19 March 2012 Dr Saikat Santra Clinical IMD 

19 March 2012 Dr Saikat Santra Clinical IMD 

20 March 2012 David Melbourne CFO 

Attendance at World Meeting in San Diego including 

registration and hotel 

Attendance at symposium for ECMO & Advanced 

Therapies for Respiratory failure incl flights, course 

and accommodation 

Travelling expenses for home visits carried out in Jan 

12 for sponsored study on Cholesterol Ester Storage 

disease 

Training day in Amsterdam for Gaucher disease 

including flights, course and refreshments 

Box of Costa coffee goodies including coffee, muffins, 

flasks and a voucher 

£3,100 8-10 Feb 12 Genzyme Corporation 

Course $720 

Accom $1843 

Flights £721 

26 Feb 12 to 1 Mar 

12 

Chalice Medical 

£268 January 2012 Premier Research Group 

Approx £417 23 March 2012 Genzyme Ltd 

Approx £35 21 March 2012 Compass 

12 April 2012 

Cathy Griffiths 

Darren Redfern 

Glynis Kane 

Clare Murray 

Procurement 

Labs 

Labs 

Labs 

Visit to Roche facility including taxis, lunch, drinks and 

dinner 

£25 per person 

per head 

4/5 April 2012 Roche 

13 April 2012 Catherine Stewart Clinical Nurse Specialist Train and hotel £300 1/2 Mar 2012 Shire 

16 April 2012 Phil Wilson KIDS Intensive Care Donation towards the Paediatric Critical Care Forum £500 June 2012 Smiths Medical Ltd 

14 May 2012 Phil Wilson KIDS Intensive Care Donation towards Paediatric Forum £600 May 2012 Par Aid Limited 

17 May 2012 Phil Wilson KIDS Intensive Care Donation towards Paediatric Forum £250 May 2012 SP Services UK 

17 May 2012 Dr Chetan Mehta Cardiology 

Attending Association of European Paediatric 

Cardiologists meeting in Istanbul - flights, accomm and 

registration 

£1300 approx 23-26 May 2012 St Judes Medical 

24 May 2012 Colin Horwath NED Lunch with Deloitte £25 23 May 2012 Deloitte

28 May 2012 Phil Wilson KIDS Intensive Care Donation towards Paediatric Forum £500.00 May 2012 Timesco of London Ltd 

01 June 2012 Phil Wilson KIDS Intensive Care Donation towards Paediatric Forum £600 June 12 Ferno UK Ltd 

08 June 2012 

Rosy Rogers, Louise Kiely, Sarah 

Hart 

Nursing/Facilities 

Attendance at Hefma Annual Awards dinner in Telford 

@ £195 per person 

£195 pp 24 May 2012 Sodexho 

15 June 2012 Kate Parkes Radiology 

18 June 20912 Kate Hall 

West Midlands Newborn 

Screening Laboratory 

Attending UKRC exhibition in Manchester, inc meal 

and hotel. 

TBA 26-27 June 2012 Agfa 

Flights to Finland and return (conference): £697.64; 

Accommodation for 4 nights, transport and £1,348 01 June 2012 Perkin Elmer 

subsistence, estimated at £650. 

22 June 2012 Phil Wilson KIDS Intensive Care Donation towards Paediatric Forum £250 01 June 2012 Elgin Medical 



Dr Suresh Vijay, Dr Anupam 

Chakrapani, Louise Simmons and 

Catherine Stewart 

Dr Suresh Vijay, Dr Anupam 

Chakrapani, Louise Simmons and 

Catherine Stewart 

IMD Flights to Amsterdam for conference (£170 each) £680 30 June 2012 SHIRE 

IMD 

19 July 2012 Michelle Bignall Clinical Chemistry 

Hotel and registration for Amsterdam conference 

(£500 each) 

Travel and accommodation for educational seminar in 

Perth, Scotland 

£2,000 30 June 2012 BioMarin 

£543 08 September 2012 Randox Laboratories Ltd

Board Meeting Agenda July 2012 - Birmingham Children's Hospital

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