1. Balanced Score Card Review of July 2015 Data

2. Balanced Scorecard Finance Patient Access Quality & Safety Human Resource Management

3. Finance

4. Finance Report - July 2015 Actual outturn YTD July 2015 Group budget €164.2m (2014 €159.9m) Group actual expenditure €164.1m (2014 €167.7m) Group actual surplus €138k ( 2014 deficit: €7.8m) CUH Budget €154.2m (2014:€148.6m) CUH /SMOH actual expenditure €154.6m (€156.0m) CUH /SMOH actual deficit €375k (2014 €7.4m) Mallow Budget €10.0m (2014:€9.7m) Mallow actual expenditure €9.5m (2014 €10.3m) Mallow actual surplus €514k ( 2014 deficit €560k)

5. Forecast 2015 Group Budget €282.58m (2014 €284.9m) Group projected expenditure €282.2m (€284.2m) Group Projected Surplus €358k ( surplus 0.7m) CUH Budget €265.3m (2014:€262.8m) CUH projected actual €265.4m (€265.2m) CUH projected Deficit €79k (€2.4m) Mallow Budget €17.3m (2014:€17.5m) Mallow Projected Actual €16.8m (€16.8m) Mallow Projected Surplus €461k

6. CUH Summary Budget v Actual Expenditure June 2015 Pay €kNon-Pay €kIncome €kTotal CUH-106-777831-52 SMOH -55-0 CUH-SMOH-106-782836-52 Mallow66-8211094 Total-40-86494642

7. CUH Budget v Actual Pay YTD - June 2015 Budget €k 2015 Actual €kVariance €k% Variance2014 Actual €k v 2014 Variance €k Medical/Dental31,81832,095-270-1%31,271-824 Nursing/Midwifery43,22743,834-607-1%44,018184 Paramedical15,96915,925440%15,96843 Housekeeping5,9846,598-614-10%6-240 Catering1,9721,97020%2,06596 Portering32,878652%3,011133 Administration8,8378,908-71-1%8,889-19 Other Staff1,7362-103-6%1,751-88 Total112,486114,047-1560-1%113,330-716

8. CUH Actual Non-pay Expenditure €k YTD July 2015 v 2014

9. CUH Group –Surplus / (Deficit) percentage %

10. CUH Debtor days – July 2015

11. CUH AGENCY COSTS €k 2013 – July 2015

12. CUH Agency Costs – June 2015

13. CUH Average Nursing & HCA Agency WTE’s per Week 2013-15 CUH Average Specials /Other Nursing & HCA Agency WTE’s per Week 2014-15

14. Cost Containment Plan

15. Patient Income 2013 – July 2015

16. Mallow Budget v Actual YTD June 2015

17. Patient Access

18. CUH Weekly INMO Trolley Report Week ending 14 th August 2015

19. Daily Trolley Numbers – June – August 2015 (23/8/2015)

20. Ambulance Turnaround Times (June)

21. ED – 6hr & 9hr Target (17 th August) (9hr – 77.4% - 6hr – 59.6%) R

22. Delayed Discharges - 2015 January – August (18 th August)

23. Inpatient – Day case Waiting Lists

24. Total Waiting List – 14/08/2015 Wait category 0-3 Months 3-6 Months 6-8 Months 8-12 Months12-15 Months15-18 Months18-24 Months24-36 MonthsGrand Total ACTIVE383221751427767311997 PREADMIT176411073361247 SUSPENSION404 2321 52 5992668515183723821296 ACTIVE2061043368211031446 PREADMIT1072817 2 145 SUSPENSION17 1 1 19 3301323575221231610 929398120226105844131906

25. 18 Month Breaches (54)

26. 18 Month Breaches by Speciality

27. 15 Month Breaches - December 2015 (313)

28. 15 Month Breaches by Specialty

29. Outpatient Waiting Lists

30. Patients in breach of the 18m deadline- 30 th June

31. Patients Currently in Breach 0f 12mth Target

32. Medical Patients to be seen by the 31/12/2015 (1,382)

33. Surgical Patients to be seen by the 31/12/2015 (5,244)

34. Women and Children Patients to be seen by the 31/12/2015 (2,329)

35. Scope Waiting List

36. Scopes Routine – June 2015 R

37. Medical ALOS (June Dashboard) G

38. New Patients Treated with Radiation Oncology - July 2015

39. Reason for Treatment Delay - July 2015

40. Quality & Safety

41. Time to Surgery (June Dashboard) G

42. ALOS – Excluding LOS over 30 days (June Dashboard) G

43. Cancer KPI – Breast-Lung-Prostate -Jan – July

44. Serious Reportable Events (SRE’s) 11 SREs communicated in 2015 7 communicated in July & August 3 environmental events serious disability for patient associated with a fall whist in hospital 3 care management events Maternal death, serious disability associated with a diagnostic error & stage 3 pressure ulcer after admission 1 surgical event Unintended retention of a foreign object post surgical procedure

45. Reportable Events

46. Re Reportable Events portable Events

47. Patient Experience - Complaints Complaints received - July 2015 1.73% of complaints investigated within 30 working days 9 Safe and Effective Care 6 Access 2 Dignity and Respect 2 Communication and Information 1 Accountability

48. 5 Treatment and Care 2 Medication 3 Appointment 1 Human Resources 1 Hygiene 1 Parking 1 Accessibility / Resources 1 Admission 1 Delivery of Care 1 Alleged inappropriate behaviour 1 Communicatio n Skills Patient Experience - Complaints

49. Risk Register Risk Register update in June 2015 49 Open Risk Assessments on register Update & amendments made to 11 risk assessments Closed 6 previously identified risks - CUH 16, CUH 31, CUH 44, CUH 45, CUH 46, CUH 49 Reopened 1, CUH 39 - Theatre Staffing Four new risks identified CUH 52, CUH 53, CUH 54, CUH 55 6 risk assessment escalated to CEO South / South West Hospital Group for consideration of additional controls CUH 17, CUH 39, CUH 52, CUH 53, CUH 54, CUH 55

50. Reducing Healthcare Acquired Infection (MRSA) (June Dashboard) G

51. Reducing Healthcare Acquired Infection- C diff (June Dashboard) G

52. Reducing Healthcare Acquired Infection (June Dashboard) G

53. National Early Warning Score National Early Warning Score programme extending to include sepsis recognition and treatment National sepsis screening tool and pathway Implementation on implementation Audit results indicate a decrease in compliance - a number of measures identified for improvements Mandatory online education nurses, NCHDs and consultants- you must do it to work here Commitment that NEWS score will be used in all patient handover e.g. ward, virtual hospital, bed management Commitment to ISBAR Support for an electronic tool Irish Maternity Early Warning Score - New Modified IMEWS Chart rolled out in CUMH, ISBAR sticker for IMEWS developed and in use

54. NEWS Implementation (June Dashboard) G

55. IMEWS Implementation (June Dashboard) G

56. HIQA Reports - Portlaoise Presentation at EMB and Executive Quality & Safety Committee Self assessment report submitted against S/SWH Group template Filling of permanent Director of Midwifery post, Clinical Director post and experience Risk Manager post Critical Care Capacity

57. Human Resource Management

58. Sick Leave – July 2015

59. Staffing & Costs

60. EWTD Compliance

61. Capital Projects ProjectStatus MRI UnitCompleted and operational Paediatric Unit Phase 1 - build programme commenced in July Phase 2 – submitted for capital funding Mental Health UnitCompleted and operational Acute Medical Assessment Unit – Phase 3 & Endoscopy Unit Completed and operational Radiation Oncology Unit  Planning permission granted  Enabling works to commence in November 2015 Cystic Fibrosis/ Respiratory WardWard refurbishment completed – operational from October Blood Sciences ProjectDesign Team appointed – request for managed service approved Oncology Service  Expansion of Day Unit – plan signed off – submitted for Philanthropic funding (ACT)  Refurbishment of Ward 2D – capital funding in place  Medical Oncology Centre – developing Statement of Need Ophthalmology Transfer – phase 2Project group in place HelipadInterim helipad in place - final solution being assessed by CAA. Step Down UnitDiscussion has commenced on Procurement Process

62. Key Issues Recruitment of Nursing staff – 31 beds closed Recognition of Budgetary performance Dependency on patient income 2016 Estimates Undergraduate Training costs - €6.5m per annum Management of Unscheduled Care Implementation of Change Programme Initiatives Scheduled Care Implementation of plan to meet waiting list targets –Hospital Group approach to maximise capacity