112 Monitor 18 Weeks Report

Monitor 18 Weeks RTT Performance /CQC Compliance: Board of Directors 25 January 2012 1/45
Monitor : 18 Weeks RTT Performance & CQC Compliance

Agenda Item: 9 Reference: B11-12/159
Report to: Board of Directors

Meeting Date: 25 January 2012
Lead Director: Russ Favager, Director of Finance and Performance
Tina Long, Director of Nursing & Midwifery
David Rowlands, Medical Director

Lead Officer: Sandra Shannon, Acting Director of Operations
Melanie Maxwell, Associate Medical Director (Q&S)
Governance: Link to WUTH
Strategic Goals

To improve patient access

Excellence in patient safety

Link to Core Values Dedicated to excellence in all we do

This paper provides an update in relation to the Monitor regulatory
visit in February 2012 which will focus on 2 key areas:

18 Weeks RTT Performance
CQC moderate concern in relation to Outcome 9
(Management of Medicine)

18 weeks

The main reasons for under performance are:

Historic over reliance on waiting list activity
Increase in GP referrals and reluctance of commissioners to
fund additional activity above contract
Delays in recruitment to substantive medical posts to increase
activity in core time
Delays in negotiating new rates/agreements for flexible activity
Data quality and management information issues

Actions taken to improve performance are:

Additional resources to increase capacity through waiting list
initiatives
Recruitment of substantive medical staff
Transfer of activity to other providers
Increased focus on data quality issues and development of
detailed capacity and demand management tool
Focus on trust wide validation
External support: Elective Care Intensive Support Team
(ECIST) ; Waiting list management expert

Wirral University Teaching Hospital NHS Foundation Trust Agenda Item: 9
Ref: B11-12/159


CQC Moderate Concern Outcome 9 (Management of
Medicine)

In January 2012, the Care Quality Commission (CQC) raised a
moderate concern in relation to Outcome 9: Management of
Medicine. This report provides the background to the decision
making process within the Trust regarding the declaration of
compliance and details the evidence used within this process
Recommendation: To Approve
To Ratify
To Note
Comments

Next Steps: 18 weeks: to continue to implement the ECIST action plan to ensure
sustained achievement of 18 weeks.
CQC: a meeting is being requested with CQC to understand its judgement
on its moderate concern grading to support future work; to
commission KPMG to review its process for assessing CQC
Compliance.

Section 1

This section is an assessment of the impact of the proposal/item. As such, it identifies the
significant risks, issues and exceptions against the identified areas. Each area must contain
sufficient (written in full sentences) but succinct information to allow the Board to make
informed decisions. It should also make reference to the impact on the proposal/item if the
Board rejects the recommended decision.

What are the implications for the following (please state if not applicable):
Quality & Safety N/A
Financial (inc
Value for Money)

If 18 weeks is not agreed, the Trust will face financial penalties as well
as an additional loss of income if contract level of activity is not achieved.
Risk (including
legal)
There is a reputational risk if the organisation does not deliver 18 weeks
by end of January if agreed, in addition to the risk to CQC registration

Workforce Increased substantive and temporary recruitment of staff is required to
undertake additional activity
Equality & Human
Rights

N/A
Equality Impact Assessment (EIA) Attached
N/A
Other

Ref: B11-12/159


Section 2

This section gives details not only of where the actual paper has previously been submitted
and what the outcome was but also of its development path ie. other papers that are directly
related to the current paper under discussion.

Report History/Development Path

Report Name Reference Submitted to Date Brief Summary of Outcome

If you require any additional information, please contact the Lead Director/Officer.
Agenda Item: 9
Ref: B11-12/ 159


Monitor Regulatory Meeting
18 weeks RTT Performance & CQC Compliance

Introduction

1. This paper provides an update in relation to the Monitor regulatory visit in February 2012
which will focus on 2 key areas:

18 Weeks Referral to Treatment Times (RTT) Performance
CQC moderate concern in relation to Outcome 9 (Management of Medicine)

2. In both cases, the paper provides the background to the current position, identifies the
issues and the actions taken to improve performance or address compliance.

Section 1: 18 Weeks RTT Performance

Background

3. This paper provides background to the Trust 18 week position over the last 12 months in
advance of the 18 week escalation meeting to be held on 13 February 2012

4. Specifically the paper aims to address a range of key issues/ questions including:

How the 18 week position deteriorated to such a significant level
Whether all reasonable action was taken to identify and rectify the deterioration
Governance processes and information problems- annual declaration to Monitor.
What actions are being taken to improve performance
What assurance is in place regarding sustained future performance

5. In summary, the position is as follows:

Historic reliance on waiting list initiatives to deliver contract activity
Cessation of waiting list activity in November 2010 at the request of commissioners who
only wanted the financial value of the contract delivered and acceptance by
commissioners that 18 weeks would not be delivered
Late in 2011/12, contract negotiations agreement was reached with commissioners for
additional waiting list activity to achieve 18 weeks
Negotiations with consultants took place in Spring 2011 to increase activity. Alternative
methods of increasing activity through use of Limited Liability Partnerships (LLPs) were
explored. There were also a number of discussions with consultants regarding
appointing additional substantive consultants with the aim of increasing activity within
core capacity rather than waiting list initiatives. Due to the time it took to gain
agreement for additional consultants as well as problems with NHSLA cover for the LLP
delayed the start of additional lists within the timescale planned
At this time, the organisation was also dealing with ongoing problems related to
vascular service provision, resulting in the departure of the Chief Executive after a vote
of no confidence. There was a lack of organisational focus on 18 weeks during that
time
Throughout this period, data quality issues due to the implementation of a new patient
management information system meant that waiting lists were inflated and the Trust
was unable to obtain an accurate picture of 18 weeks performance.

Ref: B11-12/159


Historic 18 weeks performance

6. The graphs below show the deterioration in performance increase in waiting time for
admitted pathways since November 2010 when additional activity was stopped. In
December 2010, there were 2919 elective admissions compared with 3628 in Dec 2011, an
increase of 24%.

Reasons for decline in 18 week performance

Cessation of Waiting List Activity

7. Traditionally within the Trust, the annual activity contract levels were set at the levels of the
previous year outturn performance level. This had always included a significant level of
waiting lists activity and therefore could not be delivered within core activity only.

8. In June 2010, performance management of the 18 weeks waiting times target by the
Department of Health ceased following the revision to the Operating Framework.

9. In November 2010, commissioners requested that over performance against contract
should cease and activity levels be brought back to plan for the remainder of the contract
year as at 31 March 2011. The pressure on elective activity in terms of a growth in referrals
of approximately 17% was raised formally with commissioners and a risk was highlighted
that slowing the rate of elective activity would compromise delivery of the 90% target for
admitted patients as a Trust and for individual specialties. It was estimated that at contract
year end there would be over 6000 patients waiting for surgery, an increase of 1500.

10. In December 2010, NHS Wirral requested that all waiting list initiatives stopped apart from
cancer patients and in exceptional circumstances. They confirmed that they would not fund
the full level of activity required to deliver 18 week targets.

11. In response the Chief Operating Officer/ Deputy Chief Executive wrote to the PCT Chief
Executive and confirmed that waiting list initiatives had virtually ceased and highlighted that
the Trust could not guarantee achievement of 18 weeks on a Trust bottom line basis.

12. In the 2011/12 contract, commissioners agreed to pay for additional activity to support the
Trust to achieve 18 weeks RTT and this would be monitored on the bottom line position not
individual specialties. WUTH estimated that approximately 4.5 million worth of additional
activity was required to ensure RTT targets for 2011/12 on a Trust bottom line.

13. A final agreement of 3.3 million was reached. It was acknowledged that the 18 weeks
target for admitted patients would not be achieved in quarter 1 of the 2011/12 contract and
therefore no financial penalties would be applied. However, in quarter 2 financial penalties
would be applied where appropriate, excluding orthopaedics but financial penalties would
be applied in full from the start of quarter 3. Initially this additional activity was profiled to
commence from July 2012 and to be completed before end of March 2012 with 18 weeks
being back on track by end of September. However, due to a number of factors described
in this paper the target was not achieved at the end of September 2011.

Ref: B11-12/159


14. In the annual declaration to Monitor of performance against healthcare targets and
indicators for 2011-12, the Trust declared a risk against the referral to treatment time, 95
percentile for admitted patients and received a risk score of 1 against this.

Data Quality Issues

15. In November 2010, the Trust went live with a new PAS system (Cerner Millennium) in
Outpatients as part of a phased complete replacement of the old PAS (TDS7000). There
was a successful transfer of outpatient appointments from the old system to the new, no
patients were lost and all appointment times were kept.

16. At the same time, inpatient waiting lists and the registration of all patients was moved to
Millennium. This required a transfer of patients across to create waiting list entries in the
new system. Staff had to ensure that the correct outcome was recorded at the end of an
outpatient appointment and, when selecting patients for admission to hospital, use the
transferred record from the old system rather than create a new record and, at the point of
admission, complete the record with the correct pathway status.

17. It was, therefore, expected that there would be some increase on the overall lists, and there
was also a substantial change in process for clerical staff. However, there were a number
of unintended negative consequences of the transfer.

User error of new system: despite training and support, the operational changes
required were not always applied by users. This led to both patient duplications and
entries where the pathway status was not completed, thus inflating the size of the list.
Systems were in place to monitor the size of inpatient and outpatient waiting lists,
although not the RTT uncompleted pathways.

The number of patients on the still waiters list and patients with incomplete pathways
were significantly inflated. This made accurate management of waiting lists in time
order very difficult. In addition, it was difficult to accurately monitor and predict 18 weeks
RTT performance.

High Validation requirements: due to the inflated waiting list, there was a significantly
higher requirement for validation of all 18 week breaches prior to submission of quarter
end position. There was a variability to the accuracy and extent that validation was
complete before month end.

18. The principal failures that led to this position were:

Insufficient appreciation of the scale of error
insufficient capacity in our on-going training & support
Lack of a systematic approach to planning and forecasting of 18 weeks.

19. There were also ongoing issues with the effectiveness of activity scheduling, partly as a
consequence of the implementation of Wirral Millennium. This caused some data
management problems in terms of producing a continually updated, robust Prior Targeting
List of who needs to come in and by when. As the Trust struggled to increase activity as
much as possible and, therefore, sought to maximise the effectiveness of our planning and
scheduling, this revealed a range of weaknesses in our systems.

Other Key Issues

20. In 2010, the commissioners across Cheshire and Merseyside undertook a review of
vascular surgery. A recommendation was made to appoint the Countess of Chester
Hospital as a Vascular Centre. Following which, a number of concerns were raised by
clinicians regarding the process and outcome. A Trust-wide vote of no confidence was
Ref: B11-12/159


taken by consultants and, as a consequence, the Chief Executive made the decision to
resign from post. The Deputy Chief Executive was appointed Acting Chief Executive. The
complex clinical and political debates diverted attention from 18 weeks performance.

Actions taken to improve performance

21. From April 2011 a plan was agreed to achieve 18 weeks RTT by the end of September
2011 through the following workstreams:

1. Increase capacity through additional premium rate activity
2. Increase core capacity with the appointment of additional medical staff
3. Transfer patients to other providers
4. Improve capacity and demand management and monitoring

Additional Activity

22. Additional activity was planned through by increasing core capacity with additional medical
staff and waiting list initiatives.

23. Discussions commenced with consultants in a number of specialties in relation to
increasing the number of substantive consultant posts to enable increased activity within
core capacity. Agreement was eventually reached to appoint additional senior medical staff
in orthopaedics, ophthalmology, gastroenterology, colorectal, anaesthetics and radiology.
Unfortunately, the appointments of both locums and permanent medical staff did not
progress as quickly as anticipated, partly due to availability of suitable candidates.

24. Discussions also took place with consultants to increase internal activity at a cost that was
better value for money than previously paid by the Trust through the LLP model.
Unfortunately, this ran into significant problems related to NHSLA insurance premiums
resulting in a delay in starting the extra activity and a requirement to return to traditional
waiting list initiatives from quarter 3.

25. From Q4 between 25 -30 additional lists have been undertaken each week.

Transfer of patients to other providers

26. In conjunction with our commissioners, over 500 patients were offered a choice of
transferring to other providers. Unfortunately, this had limited success with a return rate of
70%. This was predominantly due to a reluctance by patients to travel further afield than the
Wirral to receive treatment.

27. A second phase of offering patients transfer to a Wirral based private hospital commenced.
To date 270 patients in the specialties of ophthalmology, pain and orthopedics have
transferred to a private provider in Wirral.

Improved Capacity and Demand Management

28. The ongoing problems with data quality and activity scheduling made effective planning and
forecasting of 18 weeks very difficult. In recognition of the increased information support
required, the Trust invested in the appointment of 3 additional information analysts to work
operationally within divisions and these staff were in post late Summer 2011. A detailed
capacity and demand management tool was developed to enable a greater degree of
scrutiny and more proactive management of 18 weeks. Clinical Service Leads are also
engaged in managing and monitoring performance against 18 weeks.
Ref: B11-12/159


Improvement in Data Quality

29. A Trust-wide validation exercise was undertaken to validate the full out-patient waiting list
and still waiters list. In the outpatient waiting list, a total of over 11,000 entries were
validated up to December 2011 with a total of 2864 incorrect entries removed.

30. We have also started to review every entry on our still waiters (incomplete pathway list) and
from 23 January will substantially increase this activity as we have contracted an external
company with experience of both Cerner and validation. A system of monthly validation for
both outpatients and still waiters is ongoing.

31. Appendix 1: provides an update on progress against the various waiting list issues
identified.

32. We have also agreed to bring in an information expert on waiting list management to review
our systems and advise on a way forward to deliver a sustainable set of mechanisms with
early warning going forward.

33. A total of 150 clerical staff were also retrained in the application of the 18 week clock stop/
start rules and also given detailed guidance on how to apply this within Cerner Millennium.
A report has been developed to track user errors so that individuals can be identified if they
are unable or unwilling to apply the correct processes.

34. Following escalation of this issue in Q3 the incomplete pathways were discussed at the late
November Information Governance (IG) meeting, 2011. This then directly led to the work to
begin to properly report this matter. Incomplete pathways as opposed to individual waiting
lists, had not previously been reported. At the January, 2012, IG meeting a full discussion
took place and confirmation of the actions to validate the lists fully, to further improve the
training and to put in place information mechanisms to highlight error in recording at each of
the key stages on a weekly basis. We will look at the lessons to be learned as part of this
work and bring recommendations back to the IG Committee to further strengthen this
process.

External support from the Elective Care Intensive Support Team

35. In December 2011, the Trust invited the DH Elective Care Intensive Support Team (ECIST)
in to assist in identifying any areas for improvement. A number of recommendations were
made and a detailed action plan produced by the Trust with the aim of ensuring sustained
achievement of the 18 week RTT target.

36. The ECIST Report and the Trusts 18 week Action Plan are included in Appendix 2 and 3
respectively.

Conclusion

37. The current 18 week plan is based on an assumption that the Trust will deliver 18 weeks by
the end of January 2012 as a Trust bottom line but not within individual specialties. This
will require 90% of patients admitted from 1 February 2012 to be within 18 weeks of
referral.

38. Appendix 4 shows the Trust-wide trajectory of progress against 18 week RTT. The graph
shows that the Trust is on track to deliver the target of 90% by the end of January 2012.
Monitoring of progress is undertaken in the weekly surgical performance meeting and
reported to Executives, Hospital Management Board and the Board of Directors.

Ref: B11-12/159


Section 1: 18 Weeks RTT Performance

APPENDICES:

Appendix I: Progress against Waiting List Issues

Appendix II: ECIST Report

Appendix III: Trusts 18 week Action Plan

Appendix IV: Trust-wide trajectory of progress against 18 week RTT
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APPENDIX I

Waiting List & 18 Weeks Review Position Update 10 January 2012

1. This is an update on progress against the various waiting list & 18-week related issues.

External Assurance

Planned Patients on the Elective IP/DC PTL

2. A discrete piece of work required in response to the D Flory letter to NHS on 25/11/2011.
This is to ensure that:

the use of the Planned category of waiting patients is not being used inappropriately
Planned patients are not waiting longer than they should.

3. Results from the review so far:

Action Divisional staff continuing to validate the Planned waiters (NB how far?)
Action Trajectory for catching up on Overdue patients may be required: initial
response is we are working through in clinical priority order, and are not ignoring
patients waiting

18 Weeks Incomplete Pathways (Still Waiters)

4. WUTH is an extreme outlier both regionally and nationally in terms of the number of 18-
week patients apparently still waiting for treatment, and of those the number waiting over 52
weeks please see chart overleaf.

Ref: B11-12/159


5. Our initial focus on validation has been on the patients appearing to wait > 52 weeks.
Results so far:

Ref: B11-12/159


6. The total position for all still waiters as at 31 December 2011 is shown below.

7. As per the above at 31 December 2011, there was approximately 7,998 still waiters that
appear to have been waiting longer than 18 weeks, 51 of whom appear to have waited
longer than 52 weeks. NB. these patients will all have been seen, some on multiple
occasions, however the first definitive treatment does not appear to have commenced. The
validation of the still waiters, as a minimum focusing on the 52-weeks waiters, will be an
ongoing commitment. The DH view of a sustainable position is to have no more than 8% of
Ref: B11-12/159


incomplete pathways beyond 18 weeks, ie 92% under 18 weeks WUTHs December
position above is 65%.

8. An initial proposal is to establish a small team from outside the Trust to assist with working
through the current backlog of apparent still waiters beyond 18 week. However, the long-
term commitment has to be the establishment of robust processes across the Trust to
ensure all RTT pathways have accurate clock stops recorded.
Action Divisional staff / C&B Team to continue to validate the > 52 week waiters
Action Info Team to continue to explore alternative removal via data matching

Internal Processes

Outpatient Referrals on the OP PTL

9. The inaccuracy of the OP PTL is affecting WUTHs ability to manage OP waiting times, and
the important first phase of most 18-week pathways.

10. So far 10,883 entries on the PTL have been validated for the period Nov 2009 to Nov 2011,
with the following results:

11. Initial validation outstanding:

Action C&B Team to complete the outstanding validation (expected by 13/01/12)

Inpatient Waiting Lists

12. Some technical issues still need bottoming out to clarify whether / why:

patients who are being removed from the WL in Wirral Millenium (WM) still appear on
the PTL
TCI dates that are booked in WM do not appear on the PTL
patients who have already been done still appear on the PTL
Action JH/LG to follow-up with Jan Wood / SS

18 Weeks Delivery by 31 January 2012

13. As of 1 January, the Surgical Division still needed to book 726 elective WL cases into
January to clear the backlog by the end of the month. This may increase by a further 366
for long-waiting Outpatients likely to be seen in clinics who would also require surgery by
the end of January making a potential total of 1,092 cases not yet booked.

14. NHS Wirral has offered to try to move more WL cases in Pain, Ophtalmology (cataracts),
Max Fax, and T&O to Spire Wirral to help although the T&O cases would be performed by
WUTH consultants.

15. As part of the Surgical Divisions recovery plan, weekly performance is being projected
prospectively and reviewed retrospectively to ensure progress remains on-track. Detailed
below is the predicted and actual performance for w/e 8 January.
Ref: B11-12/159


16. For the above week, 307 admitted clock stops were expected with an associated RTT
performance of 62.5% within 18 weeks. The actual position was 311 admitted clock stops
with a performance of 72.7%. There were more <18 weeks admissions than expected this
is frequently the case with short notice urgent electives being arranged within the week.
However of more concern are any predicted admissions for breach patients that did not
take place, these are being investigated after the event on a weekly basis.
Action progress being monitored in weekly Surgical Performance meetings
Action Surgical Division to pursue transfer of more patients to NHS Wirral

Validation Processes

17. The number of different validation processes on waiting list related patients now required
on a weekly/regular basis has grown beyond a sustainable level for the resources currently
available. Whilst the scope & scale of some of the validation work should be time-limited,
much of it will also be needed for some considerable time and will be important if WUTH is
ever to implement a true RTT PTL process and flow.

18. Current validations required include:

The previous week/month non-admitted RTT breaches
The previous week/month admitted RTT breaches
Wales RTT long waiters
Still waiters : > 52 weeks
Still waiters : > 18 weeks
Planned elective WL (one-off, but monitoring overdue cases an ongoing commitment)
All patients on existing OP PTL (one-off)
All patients on existing elective IP/DC WL (one-off)

19. In addition, operational checks that would help maintain the accuracy of waiting lists are not
being routinely performed in all areas. Examples include:

Inappropriate referral recording
OP DNA management (rebook/discharge)
Overdue TCI management
Ensure Admin Event RTT clock stops are recorded for all pathways that do not end
with a patient contact
Deferred list management in WM
Ref: B11-12/159


Action JH//LR/ADOs to consider creation of more dedicated RTT admin team

External Input

20. Contact has been made with Rob Findlay from WL analysis company Gooroo. It has been
agreed to supply Gooroo with summary WL statistics in template form, for further analysis
and subsequent meeting to discuss.
Action JH/LG to populate the template for Gooroo.

Ref: B11-12/159


APPENDIX II
Intensive Support Team (IST) Diagnostic Review
Wirral University Teaching Hospital NHS Foundation Trust
1 December 2011

The IST was invited to Wirral University Teaching Hospital NHS Foundation Trust (WUTH) by the
Trust and the Cluster to review Referral to Treatment (RTT) performance.
Present:
Sandra Shannon, Acting Chief Operating Officer
John Halliday - Assistant Director of Information
Andy Ennis - Assistant Director of Operations - Surgery
Lakh Gossal - Senior Information Analyst
Tony Kinsella Primary Care
Nikki Waddie IST Manager
Michael Watson IST Analyst

Key themes identified by the Trust included the following:

1. The Trust has a history of delivering RTT performance through the use of waiting list
initiatives and other extra activity, which ceased in December 2010 as part of the Trusts
financial plan, leading to the current position.
2. A number of specialties now have a significant challenge around RTT standards.
3. The Trust has introduced Cerner in the past 12 months, which has highlighted some,
probably long standing, issues with data quality. In addition, the complexity of introducing
this new system was under-estimated by the Trust.
4. The Trust anticipated delivering against current performance standards by the end of Q3,
but now considers this could be achieved by the end of January 2012 at aggregate level.
5. The Trust has a large number of still waiters (patients without a clock stop who have
passed their first outpatient appointment) of some 13,000 patients who are not on either the
current outpatient or inpatient PTLs, of whom around 10,000 have waited over 18 weeks.
The majority of these patients are believed to be errors, who are not awaiting treatment
either as admitted or non-admitted patients, but the Trust cannot offer assurance on the
status of these patients. Validation of these patients will follow the current and ongoing
validation of the outpatient and inpatient PTLs, which it is anticipated will both be completed
by 12
th
December 2011. The Trust is committed to reviewing those still waiters over 52
weeks by the end of December 2011.
6. There are issues around data entry throughout the patient pathway, with clock stops in
particular not being appropriately recorded in outpatients by clinical staff and inpatient
waiting list entries not being correctly linked to the original referral by clerical staff. A re-
training programme for administrative staff has just been completed and the training of
nursing staff is currently taking place to address these issues and resolve concerns around
a paucity of understanding of the RTT rules. There was no discussion of plans to engage
clinicians in this process at this time.

Introduction:

The IST held general discussions around current performance and the challenge of meeting the
RTT performance measures and manage the backlog acquired over recent months. There have
been reductions in referrals (approximately 3%) representing a wider community commitment to
resolving the issues at WUTH. It was reported some activity has been taken out of the Trust and
some activity diverted through other organisations.

The Trust has agreed to provide some additional information, including a copy of the divisional
structure and performance data used in the weekly performance meetings. This data is
understood to be newly developed and still very much iterative.

Ref: B11-12/159


The main body of this report is divided into the key sections within the Diagnostic tool:

Leadership and Management
The Trust report a good rapport with the wider health community and there have been efforts made
to reduce pressure on the Trust by the apposite use of other providers including the channelling of
patients already on waiting lists to other organisations. This work has been led by primary care
colleagues.

The Trust has a relatively new management structure in place for the division of surgery, planned
to allow for career progression as well as functionality. The division is divided into 4 directorates to
assist in management of performance. New Clinical Service Leads have been recently appointed
and these individuals are taking an interest in performance through both the new format
performance meetings, but also through 1 to 1 meetings with directorate managers. The frequency
of these latter meetings varies according to pressures within the service. The CSL also have line
management responsibility for their consultant colleagues.

The CSLs have been supported by a series of leadership development initiatives, which are
ongoing.

Recommendations
1. The Trust works with the clinicians to ensure a good rapport between clinical and
managerial teams focused on the delivery of clinical care, within the RTT timescales.
2. The Trust reviews clinical engagement in the RTT process and compliance with accurate
completion of the clinic outcome forms (status sheets).
3. The Trust continues to optimise training of staff with regard to Cerner and consider the
development of standard operating procedures to support usage and ensure regular
training updates for staff. An e-learning package for annual updates may be something
which the Trust which to consider to support ongoing learning.

Reporting and Governance
WUTH has invested significant man hours in developing an understanding of its current position
particularly in relation to capacity and backlog. Capacity is measured against contract referrals for
the purpose of developing an understanding of the financial position in relation to clinical activity.
Contract activity is also used as a general guide to demand. The capacity is not measured against
actual demand and waiting list size is not monitored.

The capacity tool is also used to review the activity of clinical colleagues (noting annual leave,
study leave etc) proactively to initially understand and then minimise its impact of the utilisation of
clinic capacity. This Trust plans to use this information within the consultant job planning cycle,
which will commence in the New Year.

This system is new and its uses are continuing to develop with the directorate teams and clinical
service leads. It forms the basis of the performance data shared at the weekly performance
meetings, which in turn inform the Board reports. IST has asked to see the latter two forms of
report and also to receive an electronic form of the capacity tool.

The Trust does not produce breach reports. The team explained they believe they have a broad
brush understanding of the causes of breaches, most of these are associated with a deficit in
capacity and reflected the number are too significant to review at patient level. They are working to
resolve the overarching causes, but have not as yet performed any detailed analysis to allow them
to resolve other issues. The breaches do not form part of any Board reports, although sharing of
the data with clinicians and directorate managers is beginning to be embedded into the
organisation.

Recommendations
1. WUTH review their capacity against demand to reflect any imbalance in provision. IST has
offered to return to the Trust to demonstrate the outpatient and the inpatient models.
2. The Trust forward to the IST the reports used at both performance and board level for
review.
Ref: B11-12/159


3. The Trust develop a robust breach reporting system to facilitate improvements in service
delivery, clarify understanding of key areas of concern and inform the Trust Board of the
same with apposite actions planned to address issues highlighted.

Access and Choice

WUTH does not have an Access policy. The Trust have some supporting documentation, such as
a DNA document.

Recommendations:
1. IST to forward copy of sample Access Policy to the Trust
2. IST will review WUTH draft Access Policy and provide feedback
3. Dissemination and associated training with the implementation of the Access Policy. IST
will provide support with Access Policy training if requested / required.

Choose and Book:
There was no discussion around the use of Choose and Book during the meeting nor of the
process for booking patients, however the Trust did talk about the booking of patients on to
admitted pathways and, aside from clinical urgency, confirmed they booked in chronological order,
where patient choice allowed and always sought to make maximum use of the resources available.

Specialty Level Performance
There is insufficient capacity reported to the IST but there has not been a consistent and
standardised approach to demand and capacity (noted above) review across all services for
admitted and outpatient services. The teams have a large amount of data available to them to
assist in planning their activity, notably around capacity. WUTH talked about an action plan to
ensure delivery of the RTT standards by the end of January 2012 and the IST has requested a
copy of the plan. Pressures from non-elective care during the winter and the need to achieve
financial balance have added pressure on capacity but this is not reflected in the capacity
projections in the sample T&O capacity planner shared with the IST.

The team talked about reviewing the patient pathways, but reflected a generic approach to this
process, with a standard wait of 6 weeks for a first outpatient appointment. There was no evidence
of attempts to review pathways at specialty or at sub-specialty or to develop disease-specific
pathways reflecting the needs of the patients and the availability of resources. Pathways should
have clear milestones or trigger points to alert staff to the need to escalate problems. An
escalation process is required to support action against milestones.

There are a large number of patient listed as still waiters, who are not thought to require treatment
but where clock stops have not been applied. There is a need for a follow up system to prevent
further additions to this list. This is being addressed by the Trust (see notes above) but particular
attention should be given to those where there has been no direct patient contact (for example
results are reviewed and the patient is discharged).

Recommendations:
1. Capacity and Demand work undertaken as a proactive process continues and is developed
to allow maximum utilisation of capacity in terms of people, space and finances.
2. Clear pathways identified/agreed and milestones agreed within each.
3. The establishment of clear escalation processes in alignment with the milestones in each
pathway.
4. Consistent and accurate application of clock starts and clock stops.
5. Follow up of clock stops for patients where these occur outside points of direct patient
contact to ensure accurate and contemporaneous records.

Information Quality
In the short time available for the initial meeting it was not possible to go into the detail of how RTT
information is processed and manipulated to support PTL and other RTT reporting. It is clear from
discussions with the Trust that work is still underway within the Trust to improve information quality
Ref: B11-12/159


and if required the IST could conduct a more detailed review of processes including the treatment
of patient pauses, DNA restarts, inter-provider transfers etc.

Validation
The Trust is nearing completion of a full validation of both the admitted waiting list and the first
outpatient waiting list. The methodology explained to the IST is that individual patients are
identified as incorrect and then excluded from PTL reports; these patients are subsequently
corrected on Cerner in slower time in order to ensure that reports match the underlying data and
this is quite the correct approach. The Trust must ensure visibility of the number of patient records
still to be updated until such time as the full process is complete.

There is an urgent need to validate the large number of patient currently recorded as being on
incomplete pathways following first outpatient appointment. The Trust does not have a formal plan
for tackling the large numbers of patients in this cohort nor any attached timescales; there is,
rather, the intention to refocus resources dedicated to the current validation programme to this new
group. Given the very large patient numbers compared to that validation which has so far taken
place, plus the relative complexity of making adjustments on Cerner with longer and potentially
more complex pathways, it behoves the Trust to validate a representative sample of pathways
across the waiting times spectrum in order to formulate an understanding of the size of the task
ahead and potential timescales attached. It may prove worthwhile undertaking a cohorting
exercise through the application of auditable business rules in order to accelerate the process and
the IST could, if required, support this process.

Where the current validation has taken place no recording of the reasons for genuine (i.e. not due
to data quality) breaches has taken place and this represents a missed opportunity to better-
understand the underlying reasons for long waiting patients. Similarly it would have been useful to
quantify at a high level the reasons for the data quality errors encountered in order to better-focus
future training and ongoing validation efforts. The IST would recommend that the Trust put such
measures in place as part of plans for the validation of incomplete pathways.

RTT performance
The Trust has made a commitment to deliver aggregate admitted performance of 90% by the end
of January 2012 and has detailed plans to achieve this incorporating both current admitted backlog
clearance and conversion from the first outpatient PTL to the admitted waiting list. Whilst the
modelling for this seems credible, it excludes any patients currently on the unmonitored still
waiting list which will include patients currently awaiting a diagnostic test. The Trust is,
furthermore, currently seeing a growing first outpatient waiting list which suggests a significant
number of patients still to come onto the admitted waiting list which questions the sustainability of
admitted performance even if the 90% January target is achieved.

The IST was told that the LHC priority is sustainable admitted percentage performance, followed
by the remaining RTT standards including non-admitted and incomplete pathways. There was no
detailed discussion of measures the Trust has in place to meet these aspirations.

PTLs
The summary admitted PTL seen by the IST is well-constructed in summary, giving a clear idea of
predicted aggregate performance and, importantly, basing assumptions on the premise that the
longest-waiting patients will be booked first. This is somewhat undermined, however, by the No
TCI section intended to illustrate the distribution of undated patients still waiting. Patients who
have already passed their RTT target date are sub-divided into those listed within 6 months and
those listed more than 6 months ago with the implication that those in the latter category be
prioritised; on the assumption that this reflects the order in which patients are being prioritised, this
may well result in patients being appointed out of turn and more in line with 26 week waiting
times. There is a rich variety of information across this PTL but it is unclear exactly how this is
used on a day-to-day basis and the IST would seek reassurance that it is properly understood and
applied by its target audience. The Trust assured the IST that patients are booked from Cerner
according to RTT waiting time, subject to case-mix, patient choice and clinical urgency, which
raises the question as to why the PTL reports do not seem to wholly mirror this.

Ref: B11-12/159


The first outpatient PTL shows clearly waiting times by specialty in a 13 week PTL style. The
decision to cohort patients into 3-week time-bands with an all-encompassing >13 week category,
however, may be under-emphasising some long waits as, once a patient exceeds 13 weeks, it is
not obvious exactly how much longer they wait. There is no indication of a first outpatient
milestone target either in aggregate or at specialty level and, again, it is not clear how this report is
actually used by staff to manage and prioritise long-waiting patients. The IST has sought
assurance that that despite the superficial resemblance to a 13 week stage-of-treatment PTL, the
waiting time calculations underpinning the report are consistent with RTT rules.

The Trust does not have an incomplete PTL showing patients in the period after first outpatient
appointment and these patients are not monitored by the Trust until such time as they might
appear on the admitted PTL. An approximate comparison of the current first outpatient PTL (27
th

November) and the most recent monthly performance summary (October) suggests the following:
of the 28,500 patients on incomplete pathways, 3,000 are on the admitted PTL and 11,000 are
on the first outpatients PTL. Of the patients awaiting a first outpatient appointment fewer than
2,000 are over 13 weeks. Even if some of these are also over 18 weeks this, in addition to the
admitted backlog of 1,000, would leave 10,000 of the 11,000 current incomplete pathways over
18 weeks remaining. In summary there are, according to Trust figures, around 10,000 patients in
limbo between their first outpatient appointment and possible listing for surgery who have already
waited over 18 weeks and there exists no mechanism for either reporting or managing these
patients within the Trust aside from the monthly corporate reporting of aggregate incomplete
pathway numbers.

Recommendations:
1. Complete current validation and maintain visibility and monitoring of patients remaining to
be updated on Cerner until all records match those reported.
2. Revise first outpatient PTL to give more emphasis to long waiters and to highlight waiting
times milestone standards.
3. Create and incorporate into performance management a full RTT incomplete PTL.
4. Urgently quantify the validation required to tackle the incomplete backlog and agree a
credible plan for delivery with commissioners.
5. Put measures in place to record reasons both for genuine breaches and for DQ errors.

Summary:
The Trust has been aware for some time of problems developing in meeting the RTT standards
and has submitted previous action plans to deliver activity. The team report a need to improve
collaboration between the consultant/medical staff and the management teams, although this is
also reported as improving with the increase in data available to review performance and
improvements are associated with the appointment of clinical service leads. However, the Trust do
not provide any breach reports for the Trust Board and a clear escalation process, which will allow
for proactive management of any potential breaches has not been established.

There are concerns around the education and training needs of staff across a range of disciplines
and grades. There has been no inclusion of medical staff in the training, although concern was
raised around their understanding of the need for accurate compliance with RTT reporting. Once
training has been completed, ongoing refresher training, possible in a format coterminous with
annual mandatory training in addition to any ad hoc requirements associated with development of
the IT systems, is required. The IST has requested some additional information from the Trust.
The absence of an Access Policy and clear pathways with trigger points compounds the deficit of
knowledge and complicates the issue.

There is validation on going to ensure accurate data on the outpatient and inpatient PTLs, but no
priority has been afforded to the still waiters list, which will need to be reviewed and validated to
ensure the Trust can initial achieve the RTT standards and then continue to sustain this position.

It is clear great strides in both the quality and quantity of performance information have been made
in recent months and this is to be applauded; there is still significant work to do, however,
especially around incomplete pathway management. It is, furthermore, important that the Trust
Ref: B11-12/159


ensure this information is used appropriately and is targeted at and understood by the correct
people.

Next Steps:

1. Administrative processes for review with IST support
Review the application of Clock Stops outside patient contact;
Development of an Access Policy;
Support education and training around new Access Policy and RTT rules;
Formalise Standard Operating Procedures for booking staff;
Discussion around the use of Choose and Book.

2. Capacity and Demand
To achieve sustainable levels of activity, demand and capacity models can be used with
the Trust to access their status;
The IST can support the Trust in the development of action plans to meet needs
identified;
The Trust to review and agree the prior approval process with PCTs.

3. Information and Performance Management
Formulate and enact a credible plan to validate still waiting patients the IST can
support the Trust with approaches to this exercise if required;
To review the fitness for purpose of current performance reports and implement full
RTT incomplete reporting;
To review the way in which managerial information is used to ensure proper
understanding and application;
The IST can support the Trust in reviewing current RTT information derivation and
processing if required.

IST Contact details:

e-mail: nikki.waddie@southwest.nhs.uk
mobile: 07799 861688

e-mail: michael.watson@southwest.nhs.uk
mobile: 07979 913789

Ref: B11-12/159


APPENDIX III
18 Week Action Plan V3

Summary Information
Description of reason for Action Plan:

This actions identified in this plan aim to provide assurance around sustained
achievement of the 18 week RTT target.

Governance Body
Responsible for
oversight:
Trust Board, HMB,

Director, CHD or ADO
Responsible:
Executive sponsor: S E Shannon
CHD P M Doyle

Is the reason for an Action Plan an organisational risk that should be added to the Risk Register?
YES If yes, follow Trust Standard Work for Action Planning. Please state clearly what the risk is:
There is a risk of the trust not achieving the 18 week RTT target by January 2012
If If
Action Plan Leadership
Action Plan Lead Name:
Andrew Ennis
Position/Division:
Associate Director of Operations, Surgical Division
Telephone Number of Lead:

Directorate Leadership/Action Plan Members:
Jane Wilson, Directorate Manager
Pam Leonard, Directorate Manager
Debbie Mirlrees, Directorate Manager
Lakh Goshal, Senior Information Analyst
John Halliday Associate Director of Information
Business Support Managers (BSM)
S E Shannon, Acting Director of Operations
Date Action Plan completed:
Updated 18.1.2012

Action Plan Background Information
Current Control Mechanisms:

Weekly performance meeting ]
Capacity and demand modelling tools.
18 week training programme
Are elements of the Action Plan measurable: Yes
How often is the Action Plan reviewed?
Weekly
Informal review to take place with IST at 6/52
Formal review to take place with IST at 3 months

Date action plan approved: 29.12.2011

Ref: B11-12/159


Issue Actions
Trust
Lead
IST
Lead
Date Due Trust Position/Progress Update
RAG
Leadership and
Management

1. Using the clinical leadership structure work with
clinicians to ensure shared ownership of the
delivery of clinical care, within the RTT
timescales.
Capacity and demand modelling tools and
current performance update to be shared with
CSLs for discussion with clinical teams.
Review and improve processes for completing
clinic outcome forms
Work with clinicians to ensure the accurate
completion of clinic outcome sheets
regular audit/ feedback to clinical and clerical
staff develop clearer guidance and crib sheets
for staff
AE
PMD

CSLs

BSMs

MW

1.4.12
Following feedback from the IST a number
of changes have been made to support
the operational effectiveness of the tool
and further support accurate 18 weeks
monitoring and planning.

The revised capacity and demand tool has
been shared with a number of clinical
service leads and is now being discussed
at specialty business meetings.

Reporting and
Governance

2. To review current core capacity against demand
to reflect any imbalance in provision.
IST to demonstrate the outpatient and waiting
list models to the trust
To compare the Trust and IST C&D modelling
tools to improve functionality.
To update capacity and demand tool to ensure it
accurately reflects the demand rather than
LG NW 6.1.12
and on-
going
The capacity and demand modelling tools
have been in use for some time but
following feedback from the IST there has
been some upgrade to the tools. They are
now being used as working documents
and may be further refined over the next
few weeks.

Work has commenced un developing
more detailed breach analysis. This is
focused on high level trends for now but
as performance improves it will become
more detailed and patient specific

Ref: B11-12/159


Issue Actions
Trust
Lead
IST
Lead
RAG
contract only.
To further develop accurate predicted V actual
activity model
To develop more detailed breach analysis
process and identification of trends to inform
action

Access and
Choice

3. To develop a trust wide access policy that
covers all aspects of the 18 weeks pathway and
includes DNA and cancellation standards as
well as safeguarding guidance.
Use IST example as guide
To be reviewed and agreed by each CSL
To be approved/ ratified through trust
governance structure
Education and training to be provided to
all staff
Include monitoring KPIs in policy

SES
JH
NW 1.4.12 Currently the trust has a DNA policy and
the first draft of the access policy has been
drawn up. This will require a period of
consultation and ratification through trust
governance framework before
implementation.

Specialty Level
Performance
4. IST to support the Trust to Improve functionality
of current models in key specialties
AE
LG

NW 6.1.12
and
ongoing
As No 3.
Ref: B11-12/159


Issue Actions
Trust
Lead
IST
Lead
RAG
Acting Director of Operations to give support
Weekly review of specialty capacity and demand
management at weekly performance meeting

SES
5. Further improve specialty pathway management
in line with 18 week milestones
Agreed and identify pathways and individual
milestones within each for individual specialties
Establish escalation processes in alignment with
the milestones in each pathway.

LG NW 1.6.12 Priority will be to achieve 18 week
performance and improve forward capacity
and demand management so this work will
not start until after February

6. To increase core capacity through recruitment of
additional senior clinical posts.
Ophthalmology
T&O
Urology
ENT
Colorectal
Gastroenterology
AE

HR
dept
1.4.12 All posts recruited to but not all in post.

There will be a time lag from recruitment to
commencement. Colorectal consultants
have commenced and dates of all
remaining posts to be confirmed.

Ref: B11-12/159


Issue Actions
Trust
Lead
IST
Lead
RAG
Radiology

7. To increase anaesthetic capacity for extra lists
Undertake analysis of capacity and demand
Develop business case for extra permanent staff
Recruit locums
Management of sickness to continue long term
PMD
AE
Additional posts recruited to. Now able to
staff all core lists and requested additional
activity lists

8. Offer long waiters the choice of other providers
If waiting longer than 10 weeks for outpatient
appointment
If waiting more than 18 weeks for admission
from referral If capacity and demand predicts a
future capacity shortfall
PCT
AE
ongoing A number of patients were offered the
choice of alternative providers in Liverpool
but there was a 70% return rate to Wirral
as patients were unwilling to travel.

Focus continues to offer patients choice of
other providers but based on the Wirral.
Specialties include ophthalmology, pain,
orthopaedics and transfer of activity has
commenced.

Ref: B11-12/159


Issue Actions
Trust
Lead
IST
Lead
RAG

9. Ensure optimum utilisation of available capacity
Weekly monitoring of clinical and theatre
utilisation
Development of OPD C&D model and theatre
utilisation report
Accurate monitoring and management of
consultant leave to ensure minimum impact on
planned activity
DMs On-going Some loss of theatre capacity due to
sickness and vacancies but the C&D
models are improving this.

10. Minimise use of WLI in longer term
11. Move as much activity as possible to core
capacity though effective use of capacity and
demand
AE On-going At present WLI necessary in order to
achieve target but job plan reviews are on-
going to improve flexibility. Also additional
consultant recruitment continuing.

Data Quality 12. Improve accuracy of waiting list
Weekly validation to continue to ensure
consistent and accurate application of clock start
and clock stops and follow up of clock stops for
patients where these occur outside points of
direct patient contact
Validate still waiters and incomplete pathways
JH

DMs

NW 1.2.12 In progress, a number of patients have
been removed where these are due to
system errors and user errors. A weekly
review will identify where user error
continues

Ref: B11-12/159


Issue Actions
Trust
Lead
IST
Lead
RAG
and remove errors
Increase number of staff trained in validation

13. To continue to optimise training of staff with
regard to the 18 week clock stop and start rules
and their application in Cerner,
Develop standard operating procedures to
support usage
Develop annual training updates for staff,
consider e-learning package.

BSMs

1.4.12
In progress, so far 150 clerical staff have
been trained and all given guidance
document. There will be a number who
require further training. A weekly report
has been developed to identify individual
user errors.

14. Review planned waiters list
Ensure all patients appropriately on list
Ensure listed for date within clinically agreed
timeframe
TCI any patient currently over planned
review date
PL

6.1.12 In progress

15. Review all patients on still waiters list
Validate complete lists to date
Introduce monthly validation of current month
Ensure no on-going data errors through
DMs 1.1.12 Current list validated completely and a
monthly validation will continue going
forward.

Ref: B11-12/159


Issue Actions
Trust
Lead
IST
Lead
RAG
improved recording of clock starts and stops and
use of Cerner
16. Review all patients on outpatient waiting list
Validate complete lists to date
Introduce monthly validation of current month
Ensure no on-going data errors through
improved recording of clinic outcomes
NMc

DMs
1.1.12 Current outpatient list validated
completely. A total of 10883 patients have
been reviewed and 2864 incorrect records
removed.

A monthly validation will continue going
forward.

Assurance and
effective
performance
planning
17. To agree a trajectory for achievement of the 18
week standard for admitted patients as a trust

AE
DMs
1.2.12 Trajectory developed and being used as a
tool to inform action. Reviewed daily by
DMs and at weekly performance meeting.
Will be used on an on-going basis to
provide closer management and
monitoring of performance

Communication and Status Checks Plan

Please describe how you plan to communicate and status check on individual actions as well as the collective Action Plan:

To be reviewed at weekly surgical performance meeting. To be discussed at directorate performance meetings and specialty actions agreed with Clinical Service
Leads

A trajectory of planned and actual capacity and actual activity has been developed for the surgical division specifically. This is being used as the working tool for
Directorate Managers to identify where shortfalls or risks exist and therefore to take action. Therefore the trajectory will alter slightly on a week by week basis and
there is a timelag between the additional activity being booked on the system and the data extrapolated. However, the plan is based on an assumption that the
Trust will deliver 18 weeks by 1
st
February 2012 but not in all individual specialties. Those specialties of high risk will be offset by other specialties and that
medical and women and childrens divisions will deliver 100% rather than 90%.

Ref: B11-12/159


Please describe the anticipated outcome from the action plan:

To achieve Trust wide performance of 90% for 18 weeks RTT for admitted patients by the end of January 2012. 90% of patients admitted for treatment from 1
st

February 2012 will be admitted within 18 weeks of referral.

SIGNATURE OF ACTION PLAN LEAD Andy Ennis, Associate Director of Operations DATE 30 December 2011

SIGNATURE OF EXECUTIVE SPONSOR Sandra Shannon, Acting Director of Operations DATE 30 December 2011

KEY:

Complete and ongoing
Commenced and in progress
Not yet started

Ref: B11-12/159


APPENDIX IV

Ref: B11-12/159


Section 2: Care Quality Commission Moderate Concern Outcome 9 :
Management of Medicine

Background

1. In January 2012, the Care Quality Commission (CQC) raised a moderate concern in relation to Outcome 9: Management of medicine. This report
provides the background to the decision making process within the Trust regarding the declaration of compliance and details the evidence used within
this process.

2. A report was received from the CQC in January 2012 following our submission to CQC which included a range of evidence against a number of
standards where previously the Trust had declared non- compliance including management of medicines.

3. The report acknowledges that the Trust had submitted regular updated action plans in response to the original minor concerns regarding the
management of medicines and had also achieved the Wholesale Dealer Licence and improved storage compliance. However, the ward storage audit
undertaken in July 2011 and submitted by the Trust as evidence to the CQC still identified some issues and although we submitted action plans to
continue the improvement, a moderate concern was raised.

4. Specifically, the paper aims to address a range of key issues/ questions including:

How the Trust assessed compliance initially in the annual declaration to monitor.
The robustness of current processes for monitoring compliance against CQC regulations
What actions are being taken to improve and sustain compliance against Outcome 9.

5. In summary, the position is as follows:

January 2010 Trust declaration of non-compliance with a number of regulations. Evidence submitted to CQC. Unconditional registration given with
action plans agreed for outstanding areas of non-compliance.
June 2010 action plans reviewed and submitted to CQC
September 2010 unannounced CQC inspection outcome 9 rated as a minor concern.
Re-audit in April 2011 showed some outstanding storage compliance issues but a significant improvement across the Trust.
July 2011 an updated compliance report was sent to CQC with supporting evidence forwarded as requested in October 2011
January 2012 based on evidence submitted by the Trust, CQC raised a moderate concern in relation to outcome 9.

Historic Decision Making regarding Trust compliance with Outcome 9

Ref: B11-12/159


6. In January 2010 at initial registration, the Trust declared non-compliance with a number of regulations. For regulations deemed to be non-compliant,
action plans were developed and submitted to CQC. All identified risks were entered on to the risk register. CQC considered the evidence as
submitted and the Trust was given unconditional registration with a plan to provide CQC with evidence of compliance as it was achieved.

7. The compliance issues raised for Outcome 9 were:

Competency assessments for all new staff handling medicines
Investigate how to inform wards that a pharmacist has checked discharge medication
Compliance with national storage requirements
Registration with the Royal Pharmaceutical Society
Obtain Wholesaler Dealer Licence
Update policies and procedures (to be completed before registration was live)

8. In September 2010, an unannounced inspection took place on 3 wards in Arrowe Park Hospital. The outcome of this inspection in relation to Outcome
9 was minor concern:
9. In January 2011, the Trust received a draft report from CQC with the final report on 23 May 2011 which stated:
The trust declared non-compliance in relation to this outcome as only pharmacy staff have in place approved and standardised competence
assessments to undertake medicines handling duties. The current electronic system for the production of discharge prescriptions does not indicate if a
pharmacist review has taken place. The trust also identified concerns regarding compliance with national storage requirements of medicines on some
wards. There are also a number of policies and procedures which require updating in order to allow the Trust to register with the Royal Pharmaceutical
Society (RPS) and to obtain a Wholesale Dealers Licence to carry out its Service Level Agreement for pharmacy purposes.
A competence-based assessment for all new staff handling medicines is under development and is expected to be complete by 1/7/10 in accordance
with the originally-agreed action plan. The Clinical Director of Medicines Management and the Director of Information are to scope possible solutions
which would allow discharge prescriptions to indicate that a pharmacist review has taken place. This should be complete by 15/2/11 in accordance with
the originally-agreed action plan.
A Trust-wide audit of storage of medicines was undertaken in February 2010. An action plan will be developed by 30/6/10 and the process will be re-
audited to assess improvements by 28/3/11.
The review of Standard Operating Procedures and Policies to ensure compliance with the RPSs requirements is not yet due for implementation it is
expected to be complete by 30/6/10 in accordance with the originally-agreed action plan. The review of procedures and policies against the MHRAs
requirements is due for completion by 31/8/10, in accordance with the originally-agreed action plan.
We will continue to monitor the progress in the above actions as identified by the trust at registration and follow up as required to ensure they are
completed within the agreed time scales.
Ref: B11-12/159


The trust has introduced the use of red tabards to enable nursing staff to be easily identified by other staff and undertake the administration of
medicines without out interruption. On the day of the visit staff were seen to wear these tabards during medication administration. We reviewed patient
medication records and saw that all medications administrations were recorded as given or if not given this was recorded. The trust uses a
computerised system and the recordings are made on printed off hard copies by hand and also on the computer record system. We noticed that if a
medication is omitted the reason is not recorded on the hard copy but was recorded on the computerised record. One of the ward managers explained
to us how medications should be ordered and how administration is recorded.
During our visit we did not observe any medications being left at patient bedsides or stored inappropriately. The trust has also undertaken an audit of
medications left at bed sides which was made available to the inspectors at the site visit.

Action following receipt of the CQC report

10. In July 2011, an updated compliance report was sent to the CQC reporting that the medicine storage audit was underway and due to be completed as
scheduled and that the required documents to obtain Wholesale Dealers License (WDL) had been submitted. The WDL was subsequently obtained.
At this time, these were the only outstanding compliance issues.
Ref: B11-12/159


External assurance used within the decision making process

11 During the process of assessing compliance against Outcome 9, a number of external assessments were used as evidence of compliance.

July 2011-Trust NHSLA level 3 assessment

12. The standard for medicine management was passed at level 3 and comment was made that there was clear evidence that both sites had been
audited and that actions had been completed with ensuing changes in practice. This provided some external assurance to the Trust Board about our
medicine management systems.

Quality Risk Profile Reports

13. The regular reports from Quality Risk Profile (QRP) rated outcome 9 as green until the QRP system was overhauled when the Trust rating changed to
grey: insufficient information. This information was disseminated to the Trust Clinical Governance Programme Boards and Quality and Safety
Committee monthly when available, and in advance of each committee meeting.

Internal assurance used within the decision making process

14. In August 2011, the original evidence and progress against action plans were discussed at Executive Directors Group, Hospital Management Board,
Clinical Governance Programme Board and Quality and Safety Committee. The following factors were taken into account:

Trust and Divisional action plans on track to be delivered within stated timescales
Re-audit in July 2011 showed some outstanding storage compliance issues but a significant improvement across the Trust
All other actions were completed albeit outstanding the Wholesale Dealers License
External assurance had been given around medicines management from QRP and NHSLA systems
CQC had determined we had a minor concern at registration.

15. In October 2011, we provided the evidence to CQC to support our compliance statement including the audit report and action plans.

Actions currently being undertaken to ensure sustainable compliance

16. The following actions are being undertaken:

Divisional action plans have been reviewed. Significant progress has been made against the actions and any outstanding issues have clear
timeframes for completion
Matrons undertake monthly spot checks in each clinical area. These are graded as red, amber or green and are reported to Hospital Management
Board.
Ref: B11-12/159


Where clinical areas are still rated as red, this is due to major capital work that is required. Where this is the case, a full risk assessment has been
undertaken, actions have been put in place to mitigate the risk and this has been entered onto the Trusts Risk Register
Where clinical areas are still rated as amber, this relates to the completion of minor environmental work and the Trust has a programme of work in
place to complete these
The latest audit carried out in January 2012 has demonstrated significant improvements.

17. In addition to the above, the Trust is planning to commission its external auditors, KPMG to review its process for assessing CQC Compliance.

Ref: B11-12/159


Current system within the Trust to monitor CQC Regulation Compliance

18. The following points describe the Trust systems for assessing and monitoring compliance with CQC regulations:

Each of the sixteen patient-focused regulations is led by Executive Director whose portfolio includes that service area and managed day to day by
an operational manager.

A portfolio of documentary evidence is kept centrally for each of the regulations, updated regularly so that all evidence is dated within the past year

Provider Compliance Assessments are completed for each regulation in the format prescribed by CQC, using their Judgement Framework to score
each prompt. These are also regularly updated

An annual Management Review Panel is undertaken for each regulation. This includes the Executive and Operational Leads with the Associate
Medical Director, and the Head of Assurance. The panel reviews the CQC guidance and the Provider Compliance Assessment in detail and
assesses our compliance. The meetings have formal minutes with actions are assigned to individuals. This process has to date gone through two
cycles. Formal reports are generated quarterly and reported to Clinical Governance Programme Board and Quality and Safety Committee.

If a deficiency is identified, a risk assessment is undertaken and the risk entered on the risk register with an action plan. Risks are then managed in
line with our risk management policy and action plans monitored to completion through the divisional management boards. Where the risk score
remained unchanged for 12 months or an action was out of date then this is escalated to Hospital Management Board. In November 2011, it was
agreed to escalate risks to HMB which were at 15 or above to ensure that HMB is fully informed of increasing risks; escalation to Trust Board
occurs when the risk is significant ie 20 or above.

Actions to support improvement

19. The following actions are supporting improvement:

Gemba walks part of the Trust;s Kaizen continuous improvement programme to gain local-level intelligence about the patient experience and
any possible risks to CQC Compliance. These are undertaken by Executive and Non-Executive Directors, Governors, and Clinical Heads of
Division and Associate Divisional Officers.

A CQC self-assessment tool completed by lead nurses has been developed to support observational activities at ward level, which is explicitly
referenced to the Essential Standards of Quality and Safety. This is being piloted within the Women & Childrens Division.

The results of these Gemba walks and lead nurse self-assessments will feed into Divisional-level Review Panels which will mirror those operating
at corporate level.

Ref: B11-12/159


Each month the CQC's Quality and Risk Profile (QRP) for the Trust is reviewed. The QRP is summarised in a monthly briefing to the Clinical
Governance Programme Board and the Quality and Safety Committee of the Board of Directors.

A Trust-wide communication programme is on-going to raise awareness of CQC's role.

Ref: B11-12/159


Conclusion

20. The Trust assessment of compliance was made taking account of the above factors and acknowledging the progress made with action plans as well as
the external assurance received.

21. A judgement had been made based on the outcome framework and risk to patients.

22. The Trust was aware of all the issues identified by CQC and actions had been completed or were in progress. The culture within the Trust has always
been one of openness and transparency with well-established risk reporting and risk management systems in place. It was felt that there was sufficient
evidence assurance to support a rating of compliance with Outcome 9.

23. Reading the judgement framework, it is not clear why CQC has graded the Trust with a moderate concern and, therefore, a meeting is being requested
to understand this judgement to support future work.

Dr M J Maxwell FFPH
Associate Medical Director (Quality & Safety)

Ref: B11-12/159


Section 2: Care Quality Commission Moderate Concern Outcome 9 :
Management of Medicine

APPENDICES

Appendix I: Timeline for the Process of Assessment of Compliance Outcome 9

Ref: B11-12/159


APPENDIX I

Timeline for the Process of Assessment of Compliance - Outcome 9

Date Action
Jan 2010 Register non-compliance with action plan. This was discussed widely
at CGPB and also at Trust Board
8 Jan 10 CGPBCQC regulations discussed
19 Jan 2010 Risk 1433 entered onto the risk register - scored 3
12 Feb 2010 CGPB - Regulation leads with process for compliance monitoring and
QRP report
Jun 2010 Update to CQC -
Regulation 13
Medicines Management
The Trust declared non-compliance in relation to this regulation as only
pharmacy staff have in place approved and standardised competence
assessments to undertake medicines handling duties.

The current electronic system for the production of discharge
prescriptions does not indicate if a pharmacist review has taken place.

The Trust identified concerns regarding compliance with national
storage requirements of medicines on some wards.

There are also a number of policies and procedures which require
updating in order to allow the Trust to register with the Royal
Pharmaceutical Society (RPS) and to obtain a Wholesale Dealers
Licence to carry out its Service Level Agreement for pharmacy
purposes.

The Trust must implement the actions within the timescales stated.

Status Ongoing
A competence-based assessment for all new staff handling medicines
is under development and is expected to be complete by 1/7/10 in
accordance with the originally-agreed action plan.

Ref: B11-12/159


Date Action
The Clinical Director of Medicines Management and the Director of
Information are to scope possible solutions which would allow
discharge prescriptions to indicate that a pharmacist review has taken
place. This should be complete by 15/2/11 in accordance with the
originally-agreed action plan.

A Trust-wide audit of storage of medicines was undertaken in February
2010. An action plan will be developed by 30/6/10 and the process will
be re-audited to assess improvements by 28/3/11.

The review of Standard Operating Procedures and Policies to ensure
compliance with the RPSs requirements is not yet due for
implementation it is expected to be complete by 30/6/10 in
accordance with the originally-agreed action plan. The review of
procedures and policies against the MHRAs requirements is due for
completion by 31/8/10, in accordance with the originally-agreed action
plan.

9 Jul 2010 CGPB: First quarterly update
20 Sept 2010 E mail to Compliance officer ( IW) with update of action plan
Medicines Management competence-based assessment for all new
staff handling medicines (due 1/7/10). On-going / partially
implemented. The Director of Pharmacy has advised that good
progress has been made but some work is still on-going, and progress
is graded as amber. The current status is as follows:
All hospital staff undertake medicines management training
during induction and as part of mandatory refresher training
Dispensary Training Packs have been written for pharmacy
technicians
Discharge script single check training and competence
assessments have been developed for nursing staff at
discharge
Deputy Lead Nurse working on professional nurse induction
which will include standardised medicines management
competence assessments for all new nursing staff
Medicines prescribing training introduced at 2 weekly intervals
Ref: B11-12/159


Date Action
for all doctors in training full session plans not yet produced
but sessions are booked
8 Oct 2010 CGPB: QRP
12 Nov CGPB: Med Management updated action plan.
10 Dec 2010 CGPB: Quarterly report med management rated amber. References
Sept visit and no concerns having reviewed the documentation. (pre
draft report doesnt reference action plan update)
19 Jan 11 QSC - QRP and compliance discussed
21 Jan 11 CGPB: QRP CQC Safeguard review and CQC outlier report
discussed
10 Feb 2011 CQC review Panel held -
18 Mar 11 CGPB: QRP/ Quarterly review/ Action plan following Sept 10
Compliance review/ Lessons learnt from other Trusts (CQC doc)
23 Mar 11 QSC - QRP (reg 13 green)
15 Apr 11 CGPB: Meds reconciliation audit shows improvement and action
plan agreed
18 Apr 11 Exective Directors Group (EDG) Monitor Q4 Compliance Report
20 Apr 11 QSC told of CQC outlier letter ( UTI deaths)/Safeguarding report/ M1
unannounced inspection/ QRP (to March 11 Reg 13 green)
13 May 11 CGPB: MIAA report significant assurance on compliance
management QRP
May 2011
CQC update on action plan
C:\Documents and
Settings\MMaxwell\My

18 May 2011 QSC Final MIAA report evidence for compliance (significant
assurance)/ ongoing CQC compliance process discussed/ Draft CQC
inspection M1 report
10 June CGPB: Quarterly update/ culling casenotes discussed ( outstanding
compliance action)
22 June 11 QSC Quarterly CQC compliance review report
27

June 11 Executive Directors Group (EDG) Meeting: CQC Action Plan & letter
01 Jul 11 HMB noted concern from Monitor; need to update CQC
04 Jul 11 Executive Directors Group (EDG) Meeting: CQC/Monitor
11 Jul 11 Executive Directors Group (EDG) Meeting: CQC / Meds Management
Ref: B11-12/159


Date Action
Audit
15 Jul 11 CGPB: Discussion that action plans not completed yet/ CQC outlier
report response case note culling and med devices systems now in
place and working ( other compliance issues)
18 Jul 11 Executive Directors Group (EDG) Meeting: Monitor Q1 Compliance
Jul 2011
CQC update on action plan
C:\Documents and

20 Jul 2011 QSC mortality alert discussion/ update on outstanding compliance
issues.
22Jul 2011 HMB note progress with plans. COO to write to CQC re compliance
11 August
2011
Letter to CQC Compliance Officer (SD) explaining our current thinking
around compliance.
C:\Documents and

12 August
2011
HMB Compliance issues now resolved. August Board
15 August
2011
Executive Directors Group (EDG) Meeting: CQC Compliance Review.
Paper to August Informal Board
19 August CGPB: QRP/ Accountable officer report/ culling and med devices
issues resolved.
22 August
2011
Executive Directors Group (EDG) Meeting: CQC Compliance Review
30 August
2011
Executive Directors Group (EDG) Meeting: Feedback from Informal
Board re compliance
31 August
2011
Trust Board Paper ON CQC Compliance stating current

Position and asking Boards to sign off compliance.
S:\Groups\
CQCRegistration\CQC

5 Sept 2011 Executive Director Group (EDG) Meeting: feedback from Board
Ref: B11-12/159


Date Action
310811
9 Sept 2011 Letter to Monitor from GD confirms Board sign off. Recognises need
for some further improvement actions
C:\Documents and

10 Oct 2011 Executive Directors Group (EDG) Meeting: Proposed Changes to
CQCs Enforcement Regime. Paper to be submitted to HMB
14 November
2011
Executive Directors Group (EDG) Meeting: CQC compliance
21 November
2011
Executive Directors Group (EDG) Meeting: CQC Response- Gaps.
EDG noted
5 December
2011
Executive Directors Group (EDG) Meeting: Draft CQC Compliance
Report

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