1. Balanced Score Card Review of September 2015 Data

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

3. Finance

4. Finance Report - September 2015 Actual outturn YTD August 2015 Group budget €188.2m (2014 €183.0m) Group actual expenditure €188.1m (2014 €191.9m) Group actual surplus €104k ( 2014 deficit: €8.9m) CUH Budget €176.7m (2014:€170.1m) CUH /SMOH actual expenditure €177.1m (€178.6m) CUH /SMOH actual deficit €421k (2014 €8.5m) Mallow Budget €11.5m (2014:€11.2m) Mallow actual expenditure €11.0m (2014 €11.8m) Mallow actual surplus €525k ( 2014 deficit €617k)

5. 5  Group Budget €282.58m (2014 €284.9m)  Group projected expenditure €282.2m (€284.2m)  Group Projected Surplus €379k ( surplus 0.7m)  CUH Budget €265.3m (2014:€262.8m)  CUH projected actual €265.4m (€265.2m)  CUH projected Deficit €97k (€2.4m)  Mallow Budget €17.3m (2014:€17.5m)  Mallow Projected Actual €16.8m (€16.8m)  Mallow Projected Surplus €476k Forecast 2015

6. CUH Group Summary – Budget v Actual Expenditure YTD September 2015 Pay €kNon-Pay €kIncome €kTotal CUH-2,382-5,9327,768-546 SMOH0-247349 CUH-SMOH-2,382-5,9567,841-497 Mallow37-375933595 Total-2,345-6,3318,77498

7. CUH Budget v Actual Pay YTD - September

8. CUH Group –Surplus / (Deficit) percentage % ( September )

9. CUH Actual Non-pay Expenditure €k YTD September 2015 v 2014

10. CUH Debtor days –September 2015

11. CUH AGENCY COSTS €k 2013 – September 2015

12. CUH AGENCY WTE – September 2015

13. CUH Agency Costs – September 2015

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

15. Patient Income 2013 –September 2015

16. Mallow Budget v Actual YTD September 2015

17. Patient Access

18. CUH Weekly INMO Trolley Report Week ending 16 th October 2015

19. Ambulance Turnaround Times (September) 90% of patients clinically transferred <60 minutes after the 1 st two weeks of the month to 94% at the end of September.

20. ED – 6hr & 9hr Target 12 th October) (9hr – 73% - 6hr – 56%) R

21. ED – 6hr & 9hr Target (Jan – Sept - Trend line)

22. Delayed Discharges - 2015 January - October (13 th October)

23. Inpatient – Day case Waiting Lists

24. Total Adult Inpatient Waiting List ( 22/10/2015)

25. Waiting List – 15 month Target (22/10/2015)

26. Outpatient Waiting Lists

27. OPD - Potential Breaches (4,499)

28. 28 Patients to be seen by the 31 st of December 2015 4417 Urgent patients waiting 0-12 months not due to breach 4499 Urgent and Routine patients due to breach the 15 month deadline of the 31.12.15: 1157 have been booked and capacity maximised to EOY 3342 Potential Breaches 2342 Gynae & Ophthalmology 523 Difficulties 163 Diabetes 74 Endocrine 90 Plastics 80 Vascular Surgery 23 Paeds Neurology ? NL 93 Gen Surg ?SIVUH but includes Children The remaining patients will be managed through additional out of hours clinics

29. 29 Medical Patients to be seen by the 31st of December 2015

30. 30 Surgical Patients to be seen by the 31st of December 2015

31. New and Return DNA Rate

32. Scope Waiting List

33. Scopes Urgent – September G

34. Scopes Routine - September R

35. Medical ALOS (August Dashboard) A

36. New Patients Treated with Radiation Oncology September

37. Reason for Treatment Delay - September 2015

38. Quality & Safety

39. Day Surgery Admission Rate (August Dashboard) G

40. Surgery – Length of Stay G

41. ALOS – Excluding LOS over 30 days (August Dashboard) A

42. Cancer KPI – Breast-Lung-Prostate -Jan – September

43. Quality Programme Clinical Care Indicators 1)Medical Readmission rates 2)Surgical readmission rates 3)Patient experience of nursing care 4)Staph Aureus rates 5)C. Difficile Rates 6)Training in hand hygiene (online or in person) 7)End of life care in a single room 8)Presence of family room on ward (and further standard or room) 9)Falls 10)Smoking cessation

44. Learning – Hold to Account Restructuring of Board Agenda Spend time at board meeting on discussing quality (and measure) Act - Restructuring of Board minutes to reflect recommendations Non executive quality walk rounds to meet clinical team on wards providing the care Results Dedicated time for the discussion of quality of clinical care at board meetings Quality of Clinical Care Indicators are analysed monthly by the Board 150% increase in the time spent discussing quality of clinical care at board meetings Improvement in quality of discussion & number of recommendations by the Board in relation to quality of clinical care

45. Risk Register Risk Register update submitted 22 nd October 2015 49 Open Risk Assessments on Risk Register Two new risks escalated to Group CEO: Risk Assessment 56 – Keogh Billing system Risk Assessment 57 - Delayed intervention for patients requiring Implantable Cardio Defibrillator (ICD) procedures.

46. Reducing Healthcare Acquired Infection (MRSA) (August Dashboard) G

47. Reducing Healthcare Acquired Infection- C diff (August Dashboard) G

48. Reducing Healthcare Acquired Infection August Dashboard) G

49. Human Resource Management

50. Sick Leave – August 2015

51. Staffing & Costs

52. EWTD Compliance ( Jan – Sept)

53. 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 WardOpening on 24 th October 2015 Education and Training CentreStatement of Need being developed 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 UnitProcurement Process for staffing being progressed

54. 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