HIGHLAND NHS BOARD - DOC by HC12020823378

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									                                                                        Highland NHS Board
                                                                            3 February 2009
                                                                                   Item 3.8
PERFORMANCE REVIEW GROUP

Report by Roger Gibbins, Chief Executive

   The Board is asked to:

      Note that the Performance Review Group met on Monday 5 January 2009 with attendance
       as noted below.
      Note the Assurance Report and agreed actions resulting from the review of the specific
       topics detailed below and the Balanced Scorecard (attached).


Panel:
Mr Garry Coutts, Chair
Dr Ian Bashford, Medical Director
Mr Quentin Cox, Chair, Area Clinical Forum
Dr Roger Gibbins, Chief Executive, NHS Highland
Ms Elaine Mead, Chief Operating Officer

In Attendance:
Ms Margaret Brown, Head of Service Planning
Miss Irene Robertson, Board Committee Administrator

Apologies:
Dr Ian Bashford
Mrs Ann Bethune
Mr Stuart Caldwell
Mr Ian Gibson

Respondents:
Dr David Alston, Chair, North Highland CHP
Mr Bill Brackenridge, Chair, Argyll & Bute CHP
Ms Pam Courcha, Chair, Raigmore Hospital
Ms Sheena Craig, General Manager, North Highland CHP (videoconference)
Mr Stuart Denholm, Clinical Director, Raigmore Hospital
Ms Susan Eddie, General Manager, Raigmore Hospital
Mr Derek Leslie, General Manager, Argyll & Bute CHP (videoconference)
Mrs Gillian McCreath, Chair, South East Highland CHP
Mr Okain McLennan, Non-Executive Director, on behalf of Mrs Ann Bethune, Chair, Mid Highland
CHP
Mrs Gill McVicar, General Manager, Mid Highland CHP
Dr Eric Baijal, Director of Public Health (items 5 & 6)
Mr Jim Docherty, Clinical Lead, Day Case Centre Project (item 1)
Mrs Anne Gent, Director of Human Resources (items 2b & 2c)
Mr Malcolm Iredale, Director of Finance (item 8)
Mrs Christine McIntosh, Cancer Network Manager (item 3d)
Ms Heidi May, Director of Nursing (item 3b)
Mr Bill Reid, Interim Head of eHealth/Head of eHealth Implementation Services (item 7)
Mrs Donna Smith, General Manager, Surgical & Anaesthetics Directorate, Raigmore Hospital
(item 1)
Mrs Margaret Walker, Smoking Cessation (item 5)
Mr Andrew Ward, Commissioning Officer, Day Case Centre Project (item 1)




                 Working with you to make Highland the healthy place to be
1     TOPICS DISCUSSED

       1) Review and Update of Assurance Report:-
           Referral Management
           Sickness Absence
           KSF & PDP
           Waiting Times – Inpatients/Outpatients/Day Case
           Annual Review Action Plan Update

       2) Overview of Balanced Scorecard:-
          a) Delayed Discharges
          b) Healthcare Associated Infection (HAI)
          c) Waiting Times - Diagnostics
          d) Breast Cancer

       3) A&E Attendances

       4) Smoking Cessation

       5) Alcohol Brief Interventions

       6) CHI Update

       7) Finance


2     DATE OF NEXT MEETING

The next meeting will be held on Monday 2 March 2009 in the Board Room, Assynt House,
Inverness at 1.30pm.




                                              2
IMPROVEMENT COMMITTEE – ASSURANCE REPORT
Meeting on 5 January 2009


1    TOPIC: DAY CASE CENTRE PROJECT
A dedicated day surgical facility is required to enable NHS Highland to achieve several specific performance measures and deliver on waiting
time targets. The Committee received a presentation detailing progress to date with the project and outlining the next steps.

Issues/Risks                          Assurance                                  Actions
Financial implications – ability to   Progress to date is in line with the       The project to progress to the tendering stage. Action: A Ward
deliver project within estimated      project plan and the design has
budget.                               been completed in line with the            The Committee to be advised on progress.
                                      original brief.                            Remit to Asset Management Team to manage the contingency.
                                      Ongoing review and scrutiny of             Full business case to be developed for submission to NHS Highland
                                      costs by Asset Management.                 and the Health Department which will require to identify costs.

                                                                                 Action: S Eddie




2    REVIEW OF ASSURANCE REPORT
Issues considered had been identified as ‘high risk’ and likely to miss targets.

Issues/Risks                          Assurance                                  Actions
Sickness Absence                      Some improvement shown in last             Develop audit approach to review and reflect on successful initiatives,
NHS Highland not on trajectory to     month’s figures, demonstrating             both internally and externally. Action: A Gent/GMs
achieve 4% target by March 2009       positive impact of interventions.
                                      Ongoing action in the operational
                                      units to address issues.

KSF and PDP Implementation            87% of staff now have completed            Managers in conjunction with KSF Team to progress uptake of PDP.
Current level of recording of         KSF outlines.                              Action: Operational Managers
PDPs is only 14%




                                                                             3
IMPROVEMENT COMMITTEE – ASSURANCE REPORT
Meeting on 5 January 2009


2 Topic: Review of Assurance Report (cont’d)
Issues/Risks                   Assurance                                     Actions
Waiting Times –                15 week target achieved at                    Sustainability to be discussed at the Planning Group in January 2009.
inpatient/daycase/outpatients  December 2008. Congratulations                Action: GMs
waiting over 15 weeks and 12   to everyone involved.
weeks by March 2009            Work ongoing towards meeting                  TCI reports to be circulated to the Improvement Committee.
Ability to sustain targets.    12 week target.                               Action: M Brown

Annual Review Action Plan            Now part of the LDP process and         Update Action Plan and inform the Committee of the outcome of the
To ensure implementation of          will be subject to review in mid-       mid-year review. Action: M Brown
actions arising from the 2008        February 2009
Annual Review


3    TOPIC: REVIEW OF BALANCED SCORECARD
Issues considered had been identified as ‘high risk’ and likely to miss targets.

Issues/Risks                         Assurance                               Actions
Delayed Discharges                   North and SE CHPs reasonably            Situation and actions to continue to be monitored both locally and
Breaches of 6 week target            confident about meeting the             through the Highland and Argyll & Bute Partnerships.
                                     target.                                 Action: J Baird/GMs

Healthcare Associated                The numbers of SAB remain with          Evidence elsewhere indicates that actions will take at least 12 months
Infection (HAI):                     projected confidence intervals.         to achieve desired outcome. Refocusing action plan on blood culture
NHS Highland is unlikely to                                                  management and undertake evaluation and comparison of outcomes
achieve the target of 30%                                                    between the wards implementing the Scottish Patient Safety
reduction of SAB by 2010, and is                                             Programme bundles and those where the programme has not yet
not meeting trajectory figures so                                            been introduced.
far this year
                                                                             Breakdown of figures in each category (SAB/MRSA/MSSA) to be
                                                                             provided.

                                                                             Action: H May



                                                                         4
IMPROVEMENT COMMITTEE – ASSURANCE REPORT
Meeting on 5 January 2009



3 Topic: Review of Balanced Scorecard (cont’d)
Issues/Risks                      Assurance                                Action
Hand Hygiene – failure to achieve Training and support ongoing for         Undertake a programme of activity to raise general public awareness
90% compliance at last audit      audit commencing 14 January              of hand hygiene. Action: H May
                                  2009.

Waiting Times – Diagnostics         Overall, confident that 6 week         To ensure capacity across the area is maximised. Action: GMs
Diagnostic tests target not on      target will be achieved by March
trajectory for March 2009           2009.

Raigmore - Endoscopy capacity                                              Short term actions being taken with capacity support from Belford.
issue                                                                      Action: S Eddie

North CHP – Ultrasound -                                                   Bid to Planning Group. Action: S Craig
additional staff time required

Breast Cancer                       Actions being taken to recover the To explore utilisation of capacity elsewhere in Highland.
Improvement trend not               position                           Action: C McIntosh/GMs
maintained in Quarter 3


4    TOPIC: A&E ATTENDANCES

Issues/Risks                        Assurance                      Actions
Concerns regarding this target as   Meeting held with Scottish Awaiting guidance from Scottish Government regarding target.
a basis on which to measure         Government to identify LDP Action: M Brown
increased self management and       development target for 2009-10
primary care services




                                                                       5
IMPROVEMENT COMMITTEE – ASSURANCE REPORT
Meeting on 5 January 2009


5   TOPIC: SMOKING CESSATION
 The Committee received a presentation which showcased the excellent work being undertaken in South East Highland CHP

Issues/Risks                        Assurance                    Actions
Not achieving target                Good model of practice to be Service to be remodelled to match resource to demand, in order to
                                    shared                       achieve target by March 2010. Action: E Baijal/GMs
                                                                 LDP trajectory for 2009-10 to be reprofiled. Action: E Baijal


6   TOPIC: ALCOHOL BRIEF INTERVENTIONS

Issues/Risks                        Assurance                               Actions
Not achieving trajectory            Activity currently being measured       Update on percentage uptake and number of registrations to be
                                                                            prepared for next meeting. Action: E Baijal


7   TOPIC: CHI

Issues/Risks                        Assurance                        Actions
Roll out of Radiology target        Work ongoing to achieve delivery Action Plan is being developed through LDP process 2009-10.
                                    of target                        Action: B Reid


8   TOPIC: FINANCE
 The Committee received a presentation on the financial position

Issues/Risks                       Assurance                    Actions
Achievement of savings         and Savings plan on target to be Impact assessment of implementation of savings plan on service
impact on services                 achieved                     delivery required for 2008-09 and 2009-10. Action: M Iredale/GMs

                                                                            Report required on development of whole systems saving plan.
                                                                            Action: L Kirkland




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