ࡱ>  {}nopqrstuvwxyz'` bjbj{P{P ::E^x lll8lD("xzzzzzz$h[hl]3z]3]3  $1<1<1<]3h lx1<]3x1<1<T~nl pi&5L8\=<68p8 lT 1<X&D,;d]3]3]3]3d$Hd    SHAPE \* MERGEFORMAT  Annual Plan 2011/12 Contents Page Introduction ................................. 3Past Year Performance ................................. 5Our priorities and Plans for the Future ................................. 24Risk Analysis ................................. 48Declarations and self-Certification ................................. 50Appendices ................................. 52 1. Introduction to the Trust Our hospital first opened its doors in 1852 as the Hospital for Sick Children. With only 10 beds, it was the first hospital in the UK dedicated to children. Today Great Ormond Street Hospital (GOSH) is an international centre of excellence in child healthcare. Working with the University College London (UCL) Institute of Child Health (ICH), we are one of the largest centres for research into childhood illness in the world and a significant trainer of childrens health specialists. The children treated at the hospital often have complex, rare or highly specialised illnesses or disabilities. They are referred to us by other hospitals that do not have the expertise or specialist care needed. Since its formation the hospital has been dedicated to children and their specific and often unique healthcare needs. It is this single-minded approach to specialist childrens care that drives the hospitals vision and strategy. Great Ormond Street Hospital, together with London South Bank University (LSBU), trains the largest number of childrens nurses in the United Kingdom (UK). We also play a leading role in training paediatric doctors and other health professionals. The hospital does not have an Accident and Emergency department and chiefly accepts specialist referrals from other hospitals and community services. Interesting facts about the Great Ormond Street Hospital GOSH has the UKs widest range of health services for children on one site, a total of 49 different specialities. Many of the hospitals services are designated by the National Commissioning Group (NCG) as national services. That means we receive funding nationally to treat children from all over the UK who need our specialist care. We are the countrys largest centre for childrens heart operations and we are one of the largest heart transplant centres for children in the world. We are the countrys largest centre for childrens intensive care. We are the countrys largest centre for childrens brain operations. For example, we carry out about 60 percent of all UK operations for children with epilepsy. With University College London Hospitals (UCLH) we are one of the largest centres for children with cancer in Europe. We are the UKs only academic Biomedical Research Centre specialising in paediatrics. We are the countrys largest centre for paediatric craniofacial surgery. We are a leading member of UCL Partners, an alliance for world-class research benefiting patients, joining UCL with four hospitals. We are the countrys largest centre for children with kidney problems. Great Ormond Street Hospital has developed gene therapy for life threatening immune diseases; new, gentler ways of delivering bone marrow transplants in very sick children; new surgery to cure children born with extremely narrow windpipes; and a host of other new treatment and techniques used around the world. We employ more than 3,500 staff. We have more than 200,000 patient visits a year (outpatient appointments and inpatient admissions). More than half of our patients come from outside London. 2 Past year performance 2.1 Chief Executives summary 2010/11 has been a challenging but successful year for GOSH. In 2009/10 we reviewed the annual planning framework with a specific focus on developing a set of three year strategic objectives each with a series of executive-led critical workstreams and actions to ensure close monitoring and successful delivery. Our well established goals that focus on Zero harm, No waste and No waits continue to underpin our objectives which run, like a thread, through every part of the organisation and inform everything we do. We have made good progress against the second year of our three year programme with 61 out of 78 actions being rated as achieved against the milestones set. In 2010/11 we retained full Care Quality Commission registration demonstrating that we have continued to meet essential standards of quality and care across all our services. This has been supported by our safety programme that aims to minimise incidents and risks through both reflective organisational learning and a proactive programme focussing on areas of harm that can occur in children. This includes, for example, understanding the nature of harm through the implementation of the paediatric trigger tool and review of patient records; improving medication administration; and decreasing hospital acquired infection rates such as MRSA, central line and surgical site infections. Our drive to deliver the highest quality of services is also demonstrated in the significant progress we have made in the identification and publication of our clinical outcome measures. All our specialties have now identified at least two clinical outcome measures, some of which we have already published on our internet site. A plan to measure, analyse and publish all identified outcome measures over the next year is firmly in place. Last year the Trust made a formal decision to apply for Foundation Trust (FT) status. We strongly believe that becoming an NHS FT will allow us to retain our independence and thus be able to protect our exclusive focus on childrens healthcare needs. We want this because we believe it will help us deliver better care for children and their families, and increase the number of children we can help at GOSH, in the UK and across the world. Furthermore, we recognise additional benefits for our families that arise from FT status. Becoming a membership organisation helps us to work even better with our key stakeholders and to seek new ways to actively involve young people and their families in our decision making. We have already recruited more than 7,000 members, and we have begun to use them in a variety of ways to help us improve our services. Greater financial flexibility as an FT will additionally allow us to seek wider funding options for our work and support our mission to deliver world-class and pioneering clinical care and research and to collaborate with others to share that knowledge. We submitted our FT application to the Department of Health in February 2010 and we are now preparing for the final Monitor assessment process. One of our key aims of 2010/11 was to ensure that we achieved better than average satisfaction scores in the national staff survey by ensuring that all staff work in a supportive team environment with good education and training opportunities. We achieved better than average scores across a large number of satisfaction measures. Our staff members told us that they felt valued by work colleagues, that there was a strong quality of job design and that they received good support from immediate managers. Our staff members also told us they were very pleased with the level of education and support available and reported strong overall job satisfaction. However, staff did report lower than average satisfaction rates against the quality of work they were able to deliver. The feedback from the report will support our workforce development plans over the coming year. Last year I outlined our ambitious estate and capital redevelopment programme, which will see the construction of the Morgan Stanley Clinical Building and the refurbishment of the Cardiac Wing replacing part of the ageing Southwood building. The new centre will allow us to treat up to 20 per centmore children and will contain: new kidney, neurosciences and heart and lung centres; sevenfloors of modern inpatient wards for children with acute conditions and chronic illnesses; state-of-the-art operating theatres enabling us to carry out more operations on children with complex conditions; and enhanced diagnostic and treatment facilities offering faster and more accurate services for patients. Tele-medicine and tele-education facilities will be installed, enabling peer practitioners around the world to observe surgical interventions and other treatments via video linkup. I am please to report that the operational commissioning effort for the Morgan Stanley Clinical Building that is due to be handed over by the contractor in December 2011 has started and services will begin to move to the new facility between March and May next year. Furthermore the enabling works for the next stage of the project, stage 2B, are planned for August 2011. We set an ambitious savings target of 17m across the organisation for 2010/11, of which we realised 11.7m, over 1m more than we had achieved in 2009/10. By making good progress against our efficiency savings and by increasing our income through treating more patients we were able to deliver our planned financial surplus. We will continue to strengthen our efficiency savings programme and develop schemes on a Trust wide basis in order to achieve the stretching targets we have set ourselves in the coming years. We are also working closely with the University College London Partnership (UCLP) to ensure that we are able to leverage maximum efficiency benefits from the programme. This annual plan sets out our priorities and plans for the current year and details how we will manage the associated clinical, governance and financial risks.  Dr Jane Collins Chief Executive 2.2 Progress against our objectives We have made good progress against our 2010/11 objectives. For the year we had 78 actions grouped into 22 work streams. These were identified as necessary to move us towards achievement of our strategic objectives. We have reviewed these actions at the end of the year. Of the 78 actions 61 were rated Green, 14 Amber and 3 Red. Those rated Red include actions relating to Advanced Access to outpatients, which has progressed slower than planned, compliance with infection control standards (specifically C.difficile) and Business Process Management (BPM) which did not gain Board approval. The tables below outline our progress against both our strategic objectives and our key deliverable measures. 1. Consistently deliver clinical outcomes that place us amongst top 5 Childrens Hospitals in the world. WorkstreamAction RAGMaintain our focus on Zero HarmContinue the development of systems to decrease adverse drug events by concentrating on high risk medications and high risk areas in the Trust with the aim of a 50% reduction in adverse drug events in each high risk clinical area. Progress during year focused on Paediatric Intensive Care Unit (PICU) and the Cardiac Intensive Care Unit (CICU), with good progress on CICU. Work to create a dedicated medicines management post has been slow to move forward and progress in other high risk areas across the Trust has been slow.AmberAchieve 50% reduction in each specific hospital acquired infections including Central Venous Line infections (CVL), Surgical Site infections (SSI) and Ventilator Associated Pneumonia (VAP) from current baseline over the next year.Much progress has been made against collecting baseline data for SSI. We have continued to make good progress in reducing infection rates in the targeted areas but CVL rates were above the target we set ourselves.AmberContinue weekly Executive walkabouts and audit actions quarterly.Executive walkabouts are happening every week. A new model for the monthly review of new and outstanding actions has been agreed.GreenReview the Intensive Care Outreach team (ICON) pilot and the current 'Hospital at Night Team' and build on the successes of these two services to deliver integrated support for the sickest children on our ward.ICON has been agreed as a permanent service. The Standard Operating Procedure for the Hospital at Night team has been finalised and the General Paediatric Consultants have been appointed.GreenMaintain Child Protection structures and processes to support safe child protection practice. Child protection supervision policies to be fully implementedProgressing as per plans. No priority actions. Haringey SIT visit very successful. Plans for GOSH SIT and Haringey OFSTED in January on track.GreenAchieve compliance with infection control national standards.For the year the Trust has reported 11 cases against a year trajectory of 9. Therefore we have not achieved the CDI Target as currently set. The DH have not yet agreed to a paediatric target different from adult. The DH advisory committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) will be presenting our opinion on this again soon. A single case of MRSA was reported in the year against a target of 2.RedSpread the Situation, Background, Assessment, Recommendations and Decision (SBARD) communication tool and the Children's Early Warning Score (CEWS) throughout the Trust to ensure it is used by all staff.Considerable work has been done to agree a Trust approach to CEWS. Awareness has been raised and the tool has been disseminated across clinical areas. Further work has been identified to improve the level of observation, interpretation and action for all staff.AmberEnsure Safety First is a key agenda item for all appropriate meetings.Safety is a top agenda item on the Trust Board (TB) and Management Board (MB) agendas. The Trust has agreed that at least 25% of all main committee work is related to quality issues - this is already in place for the TB, MB and the Clinical Governance Committee..GreenIntroduce surgical check list before 100% theatre sessions.At the end of February 62% of surgical cases had all elements of the surgical safety checklist completed. There has been a steady upward trend over the year. GreenEstablish the level of harm as determined by the paediatric trigger tool.This has been completed. Monthly monitoring is ongoing.GreenImplement the Priority Actions for Health Plan for phase 2 (Jan - June 2010) and phase 3 (July 2010 onwards) identified in the safeguarding plan for HaringThis task has been incorporated into Task 2016 which details the overall strategic management of safeguarding children and young people across all GOSH sitesGreenReport Clinical Outcomes/Patient-Reported Outcome Measures (PROMS) through operational performance reviews and agree actions to improve.Action plans have been developed for the clinical units to aid with the development and publication of the outcome measures in each of the units. All units March performance reviews have included a sample of outcome measures currently available and at the end of March 2011 some of these outcome measures will be available on the external website.AmberContinue to monitor new National Institute for Clinical Excellence / National Service Framework (NICE/NSF) guidance through the Quality and Safety meetingsThe NICE and NSF guidance continue to be monitored through the Quality and Safety Committee on a quarterly basis.GreenDevelop benchmarking standards with international best practice across all units.An outcomes database is in development to incorporate publications, presentations and research on clinical outcomes which will identify areas where there is explicit benchmarking standards. A system previously identified a suitable to support this process was found to be unviable.AmberTo develop and publish a trust wide Quality Account by June 2010 in line with the Department of Health (DH) Quality Account Toolkit Advisory guidance.The 2010 Quality Account was published in June 2010. Good progress is being made and we are on track to produce the quality account 2010\11 in June 2011.GreenTo finalise our Quality and Innovation (CQUIN) measures with our lead commissioners and start reporting against these by May 2010.CQUIN measures have been in place for most of the year except where it has been agreed with commissioners that they needed to be redesigned.Green 2. Consistently deliver an excellent experience that exceeds our patient, family and referrers' expectations WorkstreamAction RAG2.1 Develop a consistent monitoring system to measure expectations, and whether we meet these.Implement Patient and Public Involvement/Engagement StrategyProgress is on schedule; all 2010-11 targets were met. Year 3 of the action plan has been agreed and will be implemented in 2011-12.Green2.2 Continue to reduce waiting times further through our no waits programmeComplete the roll out of Advanced Access OPD across all specialtiesTarget was for all specialties to have graduated by December 2010. By January 2011 19 out of 35 had achieved this. Responsibility for delivery has now been devolved to the Clinical Units and recovery plans are being confirmed and reported via Transformation Board. We now expect that this work to continue over the summer.RedEnsure we have a robust action plan to continue to meet all national access targets as described in the Trust Access Policy18 weeks continues to be achieved. We are reporting a number of waits across some services of over 13 and 26 weeks.Green2.3 Improve the standard of customer service that we offer patients and familiesContinue to improve the patient and family experience and measure effectiveness, specifically focussing on areas highlighted in the Ipsos MORI survey.We have approved a Patient Experience strategy and action plan. The plan will be implemented in 2011-12GreenEnsure all staff receive an appropriate level of customer service training via inductions, update or bespoke events.Actions on targetGreen2.4 Improve our understanding of our referrers, and their requirements and improve our service to meet these requirementsAchieve contractual standards for discharge summariesPerformance for the completion of discharge summaries improved substantially in year and settled around 70%. Work continues although the support from PCTs around GP details is hindering the move to an electronic system.AmberUndertake an analysis of our referral patterns, market share and competitors across all specialties to better understand our key referrers.Market share information was presented quarterly. Meetings and action plans developed for specialties that are not achieving market share progress as planned. GreenReview this analysis in conjunction with our pattern of outreach clinics and consider a more formalised model of partnership with referring hospitalsWe have had only one response to referrers newsletter request for outreach clinics. We are looking to develop more targeted outreach clinics in Cardiology. We need to formally review the potential for outreach in Neurology.GreenDevelop an action plan for improvement following the results of the Referrer Survey.Many actions were completed, including, publication of first newsletter, updated discharge summary templates, key referrers database and much improved timeliness. Projects underway include Trust wide bed management project, trial of PiMS cc list in two specialties and revising family information form. Generally good progress has been made. Green2.5 Continue to improve the patient environment through major upgrades, working closely with our charitable partnersContinue progress on redevelopment of new buildings within agreed timescale and budget. This includes the development of the Morgan Stanley Clinical Building due to complete in December 2011 and the continued development of the Phase 2b Full Business Case for final submission in July 2011.The operational commissioning effort for the Morgan Stanley Clinical Building - due to be handed-over by the Contractor in December 2011 - has started and services will move to this new clinical facility between March and May 2012. The Enabling Works for Phase 2B will start on site in August 2011 and the Full Business Case for Phase 2B itself will be submitted in September 2011, following authorisation as a Foundation Trust."GreenInvest within our 10 year capital programme to improve the patient environment within our existing buildings. Key deliverables will include at least one ward refurbishment; enhancement of out Patient facilities; upgrading public toilets in the Variety Club Building (VCB) and the start of renewing the patient entertainment system trust wide.Robin, Fox, Woodland and RANU wards were all refurbished along with level 1 outpatient facilities and public toilets in the variety Club Building. Work commenced in December on a programme of engineering and building fabric works to theatres and will run till September.Green2.6 Through the Foundation Trust process increase membership and develop a strategy to involve members effectivelyAchieve required membership trajectory.Membership target (8,000) achieved in December. Recruitment will continue.GreenFormally agree constitution including election.Our constitution has been approved by Trust Board and signed off by our solicitors.GreenIntegrate members into our management and governance processes.Work continues on streamlining approaches to membership. The engagement strategy is now drafted and work is underway to establish communication events for potential new councillorsGreen 3. Successfully deliver our clinical growth strategy WorkstreamAction RAG3.1 Deliver our planned in year growthDeliver our planned growth in line with population changes and specific growth across specialties as defined in our Integrated Business Plan (IBP).Some growth was witnessed in 2010/11. GreenMonitor compliance with new Access policy to minimise refusals.All refusals are being recorded and reported at Management Board. A Bed Management workstream commenced with a specific aim to minimise and eventually eradicate refusals.GreenSupported by the Transformation Team, deliver growth by redesigning processes to: Better utilise our assets; increase working hours e.g. Saturday; continue to reduce length of stay; improve theatre utilisation and increase day case rates.The devolved Transformation restructure is now in place. New teams working well and key project commenced in bed management. Surgical pathway project progressing well with good increase in theatre utilisation.GreenIdentify early in year and work up potential future National Commissioning Group (NCG) bids. This includes the timely submission of phase 1 and 2 proposalsWe have now had formal confirmation that services for Osteogenesis Imperfecta and Pseud-obstruction will be nationally designated for 2011-12. 8 stage 1 applications were submitted in December. The decision meeting has been postponed till April after which we should hear which are to be worked up as full cases. Green3.2 Revise future activity and growth plansRevise and update our IBP growth plan, considering general population increase, clinical and market share growth.The third iteration of our activity and capacity model has been completed and letters of support have been received from all key commissioners for our plans.Green3.3 Maintain IPP service growthReview IPP workforceRecruitment and retention improvements have enabled the opening of additional capacity within IPP and although there are continuing problems with recruiting band 6 nurses, the workforce turnover reduced from 23.9% to 12.9% during 2010/11. Sickness levels also fell from 4.1% to 4.0%. Recruitment continues via focussed recruitment campaigns as well as the Trust recruitment fares.GreenIncrease IPP physical capacityDuring 2010/11 IPP implemented an increase in open beds by 18.5%,taking total inpatient beds to 32. In additional two business cases have been approved which will enable an additional 3 beds to be opened in 2011/12 and a further 9 beds in 2012/13.GreenReview activity and improve efficiencyThe activity wasreviewed with particular focus on increasing accessibility to beds (patient numbers), increasing occupancy via improved bed management and increasing accessibility to outpatient facilities. All these targets have been achieved, as all types of patient activity has increased during 2010/11 when compared to 2009/10. Inpatient bed days have increased by 15.7%, day care bed days have increased by 5.3% and patients treated have increased by 3.4%. The outpatient attendances have also increased by 4.2%. GreenDevelop a formal IPP strategy and agree an action plan to deliver the strategy.The IPP strategy was agreed at Trust Board in January 2011.Green3.4 Position ourselves as a pan-London leader of networked paediatric services, providing co-ordination, training and education and setting standardsWork with the BLT to support the development of a paediatric trauma centreWe are working well with BLT. Still awaiting tender to be issued.Amber3.5 Position ourselves as a pan-London leader of networked paediatric services, providing co-ordination, training and education and setting standardsWork with local government partners and other statutory bodies to ensure Haringey community paediatric services are working in partnership for the benefit of childrenWork has gone to plan and we have achieved notable improvements in services in Haringey. The PCT has now re-commissioned the service with the Whittington Hospital to start in May.GreenWork with partners to implement the agreed North West London Paediatric Surgery network.The service has been established and is running under the oversight of the network board. GOSH are in attendance at each board meeting. Further milestones relate to establishing internal measures of success for the service and establishing a more formal SLA for 2011-12.GreenPending the outcome of consultation, work with North Middlesex University Hospital NHS (NMUH) to implement the new organisational model for paediatric services.This work has been completed. All Service Level Agreements are signed and subject to biannual review.GreenAchieve accreditation as a national paediatric cardiac centre through the new national processes, and plan to accommodate any further growth that arises from this process.GOSH is included in all the options. Public Consultation on options is now underway.GreenEstablish a north London tertiary paediatric network.Our response to the consultation is due shortly.Amber3.6 Position ourselves as a pan-London leader of networked paediatric services, providing co-ordination, training and education and setting standardsAchieve accreditation as a national paediatric neuro centre through the new national processes, and plan to accommodate any further growth that arises from this process.We received feedback from the national review on 8th October 2010. This confirmed that GOSH is the largest centre for Paediatric Neurosurgery in England, and provides the most comprehensive cover (in terms of dedicated paediatric neurosurgery staff). We continue to work within the review to gain benefits.Green 4. Currently partnered with ICH, and moving to UCL Partners with AHSC, maintain and develop our position as the UKs top childrens research organisation WorkstreamAction RAG4.1 Continue to develop partnership workingContinue to work with University College London Partners (UCLP) and leverage benefits from this.Positive working relations with UCLP continue, including close collaboration with other R& D units within the partnership.GreenAgree operational and management arrangements for Great Ormond Street Hospital / Institute of Child Health (GOSH/ICH) joint research activity administered A Service Level Agreement between ICH and the R& D office is to be signed off shortly, outlining operational and management arrangements.Green4.2 Develop and agree R&D strategies at clinical service levelAgree the Trust's R& D strategy and ensure Clinical Unit R& D strategies fit with this.Implementation of the strategy and closer working relations with clinical units is taking place.Green4.3 In year delivery (research)Strengthen our grant-writing infrastructure to increase our success in obtaining research grantsWe have recruited to the new research facilitator posts are expect to see improvements in the equality of research applications.GreenContinue to develop our R&D activities and ensure it is adequately funded. Carry out a review of the progress made in the first year of the Clinical Research Facility (CRF) and confirm strategy for the next five years.The review of the R & D Office is complete and the new structure will be implemented. Considerable staff change process is required and is underway. GreenAgree a financial plan for R&D which is consistent with The National Institute for Health Research (NIHR) priorities and facilitates development of successful research studies.Transition of responsibility for R& D office to GOSH has enabled the review of all financial processes, documentation of procedures and by the end of the year the general ledger will include more specific accounting structure for R& D. A financial plan for R& D will be completed once the work to identify the accountability for existing grants has been completed.AmberEnsure there is an appropriate funding transition for activities currently funded by GOSH Children's Charity.Applications have been made to the GOSH CC for the targeted valueGreen 5. To work with our academic partners to ensure that we are provider of choice for specialist paediatric education and training in the UK WorkstreamAction RAG5.1 To work with our academic partners to ensure that we are the provider of choice for specialist paediatric education and training in the UKCommissioning of high quality educational programmes from Higher Education Institute (HEI).GOSH remains the largest commissioning organisation for paediatric nurse education. Working in partnership with HEI's GOS continue to offer undergraduate modules, degree top up, postgraduate degree and doctoral programmes for all staff groups.GreenEnsure successful bids for Multi Professional Education and Training Levy (MPET) funding, Medical & Dental Education Levy (MADEL) and Non Medical Education and training (NMET) including additional recognition of specialist national paediatric activity.PGME have been successful in submitting two London Deanery bids to support Simulation training. GreenContinue to develop the use of new technologies for innovative delivery of educational programmesWe have continued to develop GOSHs Online Learning & Development Campus (GOLD). New packages support learning in Information Governance, Situation, Background, Assessment, Recommendation, Decision (SBARD) and Childrens Early Warning Scores (CEWS), ePanda and pain management. In addition we have launched an online community that has a membership of over 3,000 GreenUnderstand and fulfil a lead role within University College London (UCL) Partners and realise potential for training in child health by ensuring developments in the treatment of the patient are fed into the education and training prospectus for medical and clinical workforce.GOS part of sub-group being set up to look at Induction training across UCLP. In addition GOS and UCLH working together on designing a joint assessment centre to support UCLP Sterilization project.GreenDevelop our role as a leading education and training provider for other organisations e.g. North Middlesex University Hospital and Kuwait.NMUH SLA has now been signed off. The Kuwait contract has commenced and the first training programmes have been delivered.GreenRealise potential of Health Innovation and Education Cluster (HIEC) to ensure GOSH meets obligation to play a key national and international role in the development of child health professionals.GOS recognises it plays a key national and international role in developing child health professionals for the future whilst ensuring the continued professional development of existing staff. We have developed various learning material and delivery opportunities designed for national and international uptake and access. This has led to the successful commencement of a 3 year partnership with the Kuwait Health Ministry to provide learning to their Haematology and Oncology paediatric services. In addition, GOS medical and clinical leads regularly speak at national and international conferences. We have also opened up selected internal training programmes to external delegates. We have worked to maximise our role in UCLP and the North Central London, North East London and Essex HIEC through working with our partners to ensure we share the learning and good practice. We are currently working across UCLP to develop an integrated approach to the provision of statutory and leadership training across UCLP. Green 6. Deliver a financially stable organisation WorkstreamAction RAG6.1 Agree achievable CRES plan and ensure delivery through robust project and performance managementAgree robust plans for the delivery of the Cash Releasing Efficiency Scheme (CRES) programme and ensure that these plans are delivered through clear project managementTo date 11.9m of savings have been identified, of which 10.1m has been delivered (2010/11 target it 16.6m). 1.8m worth of further savings are progressing and are likely to be realised as finance assess the end of year activity position.AmberAgree a robust 5 year CRES programme, with external scrutiny, to fit with our overall Integrated Business Plan.The Trust has agreed a robust 5 year CRES programme which is in line with the Integrated Business Plan, this been subjected to external scrutiny through the Foundation Trust application process. The focus will now shift to maintaining and updating this 5 year CRES programme. GreenManage services within budget, delivering efficiency e.g. reducing agency spend.Projected year end surplus was achieved as planned.GreenInvest within our capital programme to support increased revenue and decreased costs, including: Additional bed in Badger ward; additional outpatient capacity; reorganisation of Genetics and release of savings from the core lab development.A range of projects are being considered prior to start of the new financial year. New guidance has been issued in December 2010, This has stimulated a range of ideas which are currently Genetics have moved to York House and are currently going through a rationalisation programme( six Months) Badger Ward approved at October Management Board currently being briefed and designed. Amber6.2 Improve efficiency through rolling out Managing Variability ProgrammeContinue the roll-out of Variability and Flow (V& F) projects across the Trust, continuing to monitor the success of the cardiac project and completing Programme to be revised with engine room projects - surgical pathway progressing and bed management commencing.AmberEnsure issues with Service line Reporting (SLR) system are resolved by Quarter 1 and the system is fully implemented and in use by the units by Quarter 3.SLR and Patient Level Costings are now available centrally and SLR is being used by units to identify areas requiring financial improvementAmberEnsure performance monitoring requirements of the Commissioners contract are delivered and the financial penalties are minimised.This has been monitored with commissioners throughout the year.GreenComplete revisions of funding baselines for the remaining National Commissioning Group (NCG) services (Transplant, Neuromuscular, Extracorporeal membrane oxygenation (ECMO) & Bridge to transplantation (BTT).This was completed and increased funding secured.Green6.3 Ensure appropriate funding for our clinical services from commissionersWork within the GOSH charity to support their work to achieve the targeted level of fund-raising.At the end of the year total charity income for 2011/12 was 57.9 million nearly 10 million ahead of the original target. This performance was assisted by a number of significant one-off donations.Green 7. Ensure corporate support processes are developed and strengthened in line with the changing needs of the organisation WorkstreamAction RAG7.1 Make progress towards becoming a Foundation TrustSubmit Foundation Trust (FT) application by agreed timetable with SHA.Application documents were sent to Department of Health on 31 January 2011. The preparation for Monitor assessment has commenced. GreenEnsure the Trust has a robust Long Term Financial Model (LTFM) for use in the FT application process. Ensure all financial matters required to achieve FT status are delivered e.g. working capital facility; insurance programme.The various due diligence reviews of the LTFM by independent accountants have been completed successfully.Green7.2 Ensure that the Trust is compliant with regulatory requirementsEnsure that the Trust retains registered status with CQC.Work is ongoing to review an IT tool to support the process. Clinical Governance Committee and Audit Committee continue to seek assurance of compliance with the standards.GreenEnsure that Information Governance (IG) processes are strengthened and the self assessment score in the IG toolkit is improved.Head of IG appointed who is dedicated to improving IG processes. Information flows have been charted and used to identify IG risks. Critical systems have been identified and Information Asset owners and risk registers should be in place by end of March.GreenThe Public Health Action Plan is delivered in line with the Health and Adult Social Care Registration System.Progress towards our Public Health objectives has been slow but steady over the past year, mainly due to staffing and resourcing issues. However, work continues with the Pharmacy department to raise awareness of public health issues and medicines literacy. Preliminary work towards the coming year's key pieces of work - improving immunisation of our patients and understanding the father-friendliness our services - has been completed and we are on schedule to meet the time lines set.GreenWork towards achieving NHS Litigation Authority (NHSLA) level 3 Risk Assessment early in 2011.No date has been confirmed regarding the Level 3 assessment.GreenEnsure delivery of specific Information Governance requirements e.g. Pseudonymisation, NHS No, Data quality.Priority has been given to developing the pseudonymisation work plan and targets for all workstreams have been met but there will remain further work to do to ensure all critical systems have been addressed. A new training module on GOLD has been developed but it is likely the national targets wont be achieved during 2010/11 and so work will continue to increase no of staff completing IG training assessment in 2011/12.AmberEnsure that the Trust achieves best practice in Data Quality standards for all information supporting decision making.A Data Quality group was formed and met regularly during the year and a work plan established and followed. A new information tool was purchased to enable DQ processes to be carried out more effectively and is now working successfully.GreenDeliver all projects included as current year projects within the Information Technology (IT) investment strategy approved by Trust Board in March 2010.Currently on track Key projects include: - Server Virtualisation (Green) - Citrix Upgrade (Green) - Order Communications (Green) - ICT Storage and SAN migration (Green) - Asset tracking wireless (Green) - Microsoft Exchange (yellow due complexity of developing business case but progressing) GreenIf approved by Board, ensure Business Process Management (BPM) project progresses and meets all milestones in first year of implementation and there is a recognised improvement in Referral to Treatment (RTT) processes as a result of the pilot.Trust Board did not approve the project. The fact that there was no other health provider who had implemented such a scheme limited the assurance available. As a result, a revised ICT Strategy was presented in March.Red Key deliverable measures Year end positionEnsure GOSH retains full CQC registration by delivering key safety improvements and governance structures.AchievedPublish the Quality Account and demonstrate world-class benchmarked clinical outcomes.AchievedProgress Foundation Trust application.AchievedImprove congruency of clinical and R & D strategies.AchievedLeverage R&D and non R&D benefits from UCLPPartially achievedSecure advantages from the national paediatric cardiac & neuro surgery reviews.AchievedComplete the referrer survey and progress an agreed action plan.AchievedDeliver planned financial surplus through achieving income and efficiency goals.AchievedDeliver IT improvements to plan (including BPM if Trust Board approves).Partially achievedProgress Phase 2A building and 2B planning to meet future clinical needs.AchievedAchieve better than NHS average staff satisfaction scores by ensuring all staff work in a supportive team environment with good training and education opportunities.AchievedEnsure GOSH retains full CQC registration by delivering key safety improvements and governance structures.Achieved 2.3 Our financial performance The Trusts unaudited accounts report a retained surplus of 7.2M before impairments to property and 8.6M before these are accounted for this is broadly in line with the forecast position. Total revenue was 336.3M in 2010/11, an increase of 18.2M and 5.7% over the comparable values in 2009/10. It is important to note the North Middlesex service was discontinued effective May 2010. NHS Inpatient activity increased by 4.5% NHS day case activity increased by 0.9% NHS outpatient increased by 11.5% IPP inpatient activity increased by 15.7% on a bed day measure IPP day case activity increased by 5.3% on a bed day basis IPP outpatient activity increased by 4.2% Operating expenditure was 4.5% higher than 2009/10 at 323M The main changes relate to increased pay reflecting pay awards and agenda for change, higher drugs and clinical supplies, higher education costs, higher clinical negligence fees and higher costs of services bought from other NHS trusts net of reduced consultancy, depreciation and impairment charges. Impairment was recorded following a review of asset valuations totalling 1.4M net. Unaudited Position for 2010/11 outturn KRevenue from patient care activities283,881Other operating revenue52,426Operating expenses - pay-192,272Operating expenses non pay-130,719Operating Surplus13,316Investment revenue68Other gains and losses-633Finance costs-31Surplus for the financial year12,720PDC dividend-5,551Retained surplus for the year7,169Impairment1,448Position excluding impairment8,617  2.3.1 Cash Releasing Efficiency Schemes (CRES) We delivered 11.7m of efficiency savings across the organisation in 2010/11 against an ambitious target of 17m. We will continue to strengthen our efficiency savings programme and develop schemes on a Trust wide basis in order to achieve the stretching targets we have set ourselves in the coming years. We are also working closely with the University College London Partnership (UCLP) to ensure that we are able to leverage maximum efficiency benefits from the programme. In addition, we have improved the performance management of our CRES programmes, specifically in relation to greater analysis and more sophisticated reporting on the likelihood of schemes successfully delivering savings. 2.4 Improving quality 2.4.1 Care quality Commission (CQC) From April 2010, all health and adult social care providers who provide  HYPERLINK "http://www.cqc.org.uk/guidanceforprofessionals/introductiontoregistration/whoneedstoregister.cfm" \l "3" regulated activities were required by law to be registered with the CQC under the new regulations of the Health and Social Care Act 2008. To remain registered providers must demonstrate that they are meeting new essential standards of quality and safety across all of the regulated activities they provide. The new system will make certain that people can expect services to meet essential standards of quality and safety that respect their dignity and protect their rights. The system is focused on outcomes, rather than specific standards and processes, and places the views and experience of people who use services at the centre. The CQC assessments of quality and safety are based on a range of external sources of information, some of which we are required to provide from our performance management systems, which are considered with information from other external monitoring sources. These data items are drawn together to create a quality risk profile for the Trust, which provides an estimate of the risk of non compliance with registration requirements. To be registered, each trust must meet essential standards of quality and safety, which include: Involvement and information Personalised care, treatment and support Safeguarding and safety Suitability of staffing Quality and management Suitability of management GOSH is registered with the CQC with no conditions attached to its registration. The CQC has not taken enforcement action against GOSH during 2010/11. 2.4.2 NHS Performance Framework In April 2009, the Department of Health (DH) introduced the NHS Performance Framework to provide an assessment of the performance of NHS providers (that are not yet NHS Foundation Trusts) against a set of minimum standards. The Performance Framework identifies poor performance on an ongoing basis using a series of indicators from the domains of Finance and Quality of Service (which is comprised of Standards & Vital Signs, CQC Registration Status and User Experience) to trigger intervention as required. The Framework sets clear thresholds for intervention in underperforming organisations and a rules-based process for escalation, including defined timescales for demonstrating improved performance. Organisational performance is assessed against a series of indicators using the most current data available, and the results trigger intervention by Strategic Health Authority and PCT commissioners in the case of performance concerns. The table below sets out our performance over the year against the NHS Performance Framework indicators relevant to specialist paediatric hospitals. We have achieved all inpatient and outpatient waiting time and access targets. In terms of infection control we reported 1 case of MRSA in year against a year trajectory of 2. However, we did report 11 cases of C.difficile over the year against a locally agreed low trajectory of 9. It should be noted that the Department of Health advisory committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) will be presenting our opinion on the relevance of this standard for specialist paediatric hospitals soon. Performance IndicatorNumeratorDenominatorTargetTrust Performance Q1 Q2 Q3 Q4Cancelled ops - breaches of 28 days readmission guarantee as % of cancelled opsThe number of patients whose operation was cancelled, by the hospital, for non-clinical reasons, on the day of or after admission, who were not treated within 28 daysThe number of patients whose operation was cancelled, by the hospital, for non-clinical reasons on the day of or after admission5.0%MRSAActual number of MRSAPlanned number of MRSA1C difficileActual number of C difficile casesPlanned number of C difficile9Referral to Treatment - admitted - median<=11.1Referral to Treatment - 95th percentile<=27.7Referral to Treatment - non-admitted including audiology - 95th percentile<=18.3RTT - incomplete - 95th percentile<=36.131 day second or subsequent treatment - surgery ~Number of patients receiving subsequent/adjuvant treatment (surgery) within a maximum waiting time of 31-days during a given period, including patients with recurrent cancerTotal number of patients receiving subsequent/adjuvant treatment (surgery) within a given period, including patients with recurrent cancer94%31 day second or subsequent treatment - drugNumber of patients receiving subsequent/adjuvant treatment (drug) within a maximum waiting time of 31-days during a given period, including patients with recurrent cancer.Total number of patients receiving subsequent/adjuvant treatment (drug) within a given period, including patients with recurrent cancer98%31 day diagnosis to treatment for all cancersNumber of patients receiving first treatment within a maximum waiting time of 31-days during a given period, including patients with recurrent cancerTotal number of patients receiving first treatment within a given period, including patients with recurrent cancer96%Proportion of patients waiting no more than 31 days for second or subsequent cancer treatment (radiotherapy treatments)Number of patients receiving subsequent/adjuvant treatment (radiotherapy) within a maximum waiting time of 31-days during a given period, including patients with recurrent cancer.Total number of patients receiving subsequent/adjuvant treatment (radiotherapy) within a given period, including patients with recurrent cancer.94%  2.4.3 Monitor governance risk rating In preparation for operating as a Foundation Trust (FT) we have also considered how we would have performed against the governance risk requirements of the FT independent regulator, Monitor. Monitor use a scoring system for assessing governance risk taking account of service performance, clinical quality and patient safety, and mandatory services. The implications associated with each level of governance risk are set out in the tables below. Monitor rating matrix Green = a score of less than 1.0 Amber-green = a score from 1.0 to 1.9 Amber-red = a score from 2.0 to 3.9 Red = a score of 4.0 or more Risk rating categoryDescription (risk of significant breach of authorisation)GreenNo material concernsAmber-greenEmerging concernsAmber-redPotential future significant breach if not rectifiedRedLikely or actual significant breach  Monitor takes a proportionate approach where NHS FTs have increased levels of governance risk. For example, if the reason for the deterioration of a rating is a weakness in risk management processes, Monitor may require the Trust to provide a plan detailing how it proposes to address this. Failure to address issues on a timely basis (e.g. three consecutive quarters failure to achieve the same national requirement) may result in a red rating and could lead to a significant breach of the Authorisation and possible regulatory action. The table below describes our performance against the Monitor governance risk rating over 2010/11. Based on our performance we would have achieved a rating of Green over 1 of the quarters and Amber-Green over 3 of the quarters. This is due to not achieving our C. difficile trajectory. Targets - weighted 1.0 (national requirements)ThresholdsWeighting Monitoring periodQ1 Q2 Q3 Q4 Clostridium difficile year on year reduction (to fit with trajectory for the year as agreed with PCT)01Quarterly1011MRSA - meeting the MRSA objective 01Quarterly0000All cancers: 31-day wait for second or subsequent treatment comprising either:TBC1Quarterly0000Surgery94%0000anti cancer drug treatments98%0000radiotherapy (from 1 Jan 2011) 94%0000Maximum time of 18 weeks from point of referral to treatment in aggregate and by specialty for admitted patients90%0.5/1.0Quarterly0000Maximum time of 18 weeks from point of referral to treatment in aggregate and by specialty for non- admitted patients95%0.5/1.0Quarterly0000Maximum waiting time of 31 days from diagnosis to treatment of all cancers96%0.5Quarterly0000Screening all elective in-patients for MRSA100%0.5Quarterly0000Self-certification against compliance with requirements regarding access to healthcare for people with a learning disabilityN/A0.5Quarterly0000Overall governance ratingAmber -GreenAmber -GreenGreenAmber-Green 2.4.4 Commissioning of Quality and Innovation (CQUIN) The CQUIN payment framework makes a proportion of providers income conditional on quality and innovation. The framework aims to support a cultural shift by embedding quality improvement and innovation as part of the commissioner-provider discussion. Each provider on a national standard contract is entitled to earn 1.5% of contract value subject to achieving goals in a CQUIN scheme. For 2010/11 we agreed 13 CQUIN measures for the Trust with our commissioners. These are described in the table below. We achieved 7 of the measures over the last year, partially achieved against 1 and did not meet 5. We have now finalised and agreed a series of CQUIN measures for 2011/12 with our lead commissioners, which are detailed in appendix 1. SummaryAchieved EvidenceCommentsPatient SurveysAn increase of 5% who strongly agree or agree that they felt they could complain and they would be taken seriously over 09/10 inpatient survey resultsNoIPSOS MORI Inpatient Survey ResultsThe survey results showed a 1% reductionNot less than 90% who were very satisfied or fairly satisfied with their last visit to hospital over 09/10 inpatient survey resultsYesIPSOS MORI Inpatient Survey ResultsThe survey results were up 2% to 96%An increase in the % who were very satisfied or fairly satisfied with the quality and variety of food from 57% to 65%, excl. oncology patients, patients on TPN and patients that are on non-solid food regimes over 09/10 inpatient survey resultsNoIPSOS MORI Inpatient Survey ResultsSatisfaction increased by 3% to 60%Report 2010-11 Inpatient and Outpatient SurveysYesPresentation to CQRGPresentation Date to be Confirmed - Suggest CQRG on the 6th JunePaediatric Trigger ToolPublication of a report reviewing 160 cases auditing adverse eventsYesPresentation to CQRGPresentation Date to be Confirmed - Suggest CQRG on the 6th JuneDischarge Information% of discharge letters achieving the content criteriaYesInternal Trust Audit Report% of elective patients with an EDD within 24 hours of admissionYesInternal Trust Audit Report% of outpatient letters sent within 5 days of attendance and within the content standardsNoInternal Trust Audit ReportTPNIncrease in the percentage of children with severe intestinal failure who are receiving parenteral nutrition who have recorded measurement of nutritional blood tests (Cu, Zn, Se, vitamins A and E) in accordance with best practice guidelines. A systematic method of monitoring of complications from parenteral nutrition administration to be implemented during Q1 and reports on complications identified to be sent to the Agency quarterly thereafter. NoThe Trust has not reported this CQUINSurgical Site Infections Implementation of continuous (12 month from April 1 2010 to March 31 2011) surgical site infection surveillance (SSIS) for all inpatients and 30 days post-discharge in two specialties: spinal implant surgery and urology. Monitoring of cardiac surgery (open and closed) for inpatients for 3 months during 2010/11. Yes/NoReport from the Director of Infection ControlEstablished in neurosurgery, craniofacial surgery and tracheal and thoracic surgeryReduction in Urology SSI's from 8-6.NoReport from the Director of Infection ControlThe level of SSI's in urology remained at 8Central Venous Catheter Infections20% reduction in the rate of CVC related blood stream infections. Rates reduced to 2.4% per 1000 line daysYesReport from the Director of Infection ControlThe Trust reduced the CVC Infection rate from 3.26/ 1000 line days to 2.61/1000 line daysVentilator Associated Pneumonia on PICURemain 50% below baseline rate of 7YesReport from the Director of Infection Control2 episodes were detected in year 2.4.5 Managing risk InNovember 2009, Great Ormond Street Hospital was assessed by the National Health Service Litigation Authority against the Level 2 Risk Management Standards forAcuteTrusts. This is an NHS risk based insurance scheme that assists Trusts in the management of claims and litigation. The assessment provides an external, independentbenchmark for the processes in place to managerisk.Five key areas were assessedincludinggovernance, competence and capability of our workforce, the safety of the environment in which care is delivered, themanagement of clinical care including infection control andthe ways that we ensure we learn from experience. The Trust was successful inachieving Level 2 compliance, scoring 49 out of a possible 50 in total.This is an important achievement as it assists the Trust to demonstrate compliance with other regulatory bodies including the CQC. The Trust maintained Level 2 compliance in 2010/11 and will be applying for Level 3 in the near future. 3. Our Priorities and Plans for the Future Fig. 1 Summary of the planning process GUIDING PRINICPAL  GOALS  EXTERNAL CONTEXT     STRATEGIC OBJECTIVES SUPPORTING WORKSTREAMS AND ACTIONSCLINICAL UNIT STRATEGIES The diagram on the previous page summarises the process we went through as an organisation to identify our priority workstreams and supporting actions for the year ahead. We considered our purpose and values and the internal and external contexts in which we will operating during 2011/12. Together with a review of our past year performance we identified drivers, opportunities and threats and reviewed our own organisational capacity and capability to manage these effectively. We additionally confirmed that our strategic objectives remain fit for purpose going forward into the new financial year. The following sections outline the work that we undertook in relation to each of the areas above. Analysing the external environment PESTLE Analysis Strengths, weakness, opportunities and threats (SWOT) analysis Analysis of regulatory requirements and policy Drivers for change Strategic drivers Review and forecast of activity and demand Review of our internal capacity 3.1 Analysing the External Environment The Trust Board has considered a PESTLE analysis, identifying key changes to the political, economic, social, technological, legal and environmental landscapes that may potentially impact on the Trust. We have used this analysis to support and inform our strategic and development plans for the forthcoming year and in the longer term for our FT business plan application. InfluenceAnalysisCompetitive response Political (at DoH or more local levels, NHS reform, national reviews etc)GOSH is the most famous brand in the NHS and as such attracts much political and media attention. Current NHS policy is to localise services where possible and to centralise complex services where this delivers better clinical outcomes. This is highlighted by national Safe and Sustainable XE "Safe and Sustainable"  reviews in Paediatric Cardiac and Neurosurgery XE "Surgery"  and the London wide review of complex paediatric services. The Government has introduced a greater test for reconfiguration proposals, particularly involving primary care. The government also plan to move the vast majority of commissioning to GPs, and at this stage it is unclear what proportion of the GOSH income this will apply to. GOSH is acutely aware of the strength of its brand and will ensure that any strategic decisions reached that have the potential to impact on the brand are appropriately considered. If these involve a partnership arrangement with another organisation then GOSH will adhere to the Partnerships XE "Partnerships"  policy (see Annex 4-4). GOSH will actively participate in any local or national processes which review the provision of specialist paediatric services. To facilitate change GOSH will support and work proactively and sensitively with any other provider which may be adversely affected by any reconfiguration. GOSH will develop a close working relationship with new commissioning organisations.Economic (NHS funding, private / overseas, credit availability, wage rates etc)The economic situation means that the NHS will need to make efficiency savings of around 20billion to meet expected demands and increased costs. For GOSH this will manifest itself in reduction in tariff and pressure from commissioners to reduce activity levels. The latter is likely to have less of an impact on GOSH then other acute Trusts for several reasons: With the exception of NSCG, GOSH is a relatively small provider in financial terms and as such the focus of a commissioners drive is to reduce contract activity with their larger providers. The move towards centralisation of complex services will increase the demands for activity at GOSH, whilst actually saving the commissioners money by providing the right treatment in a timely manner. GOSH has a very broad specialty base across a very broad commissioner base and as such the commissioners needs to deliver demand management schemes or the rationalisations of treatments are highly unlikely to affect services provided by GOSH. The GOSH charity provides extensive funding (mostly capital) to the Trust and this support is expected to continue for the foreseeable future. GOSH also has the financial support of a sizeable R & D function, private and international business and other charities. The centrally imposed restrictions on NHS pay increases could lead to increased difficulties in the recruitment and retention of staff. One of the key GOSH competitive strategies is to improve efficiency. This will assist GOSH is remaining financially viable in a climate of declining tariffs and other economic challenges for providers. GOSH has increased resources to support the delivery of Cost Reduction and Efficiency XE "Efficiency"  Savings (CRES XE "CRES" ) and will maintain the delivery of these as a high priority for the organisation. The GOSH strategy is growth in services that it already provides. This strategy is the least challenging in ensuring the improvement of contribution of clinical services to counter the depression of tariff in a PbR XE "PbR"  led system. GOSH will retain its broad commissioner and specialty base thus spreading financial risk across the organisation and across the health economy.Sociological (cultural attitudes, demographics etc)The London and south east England population of 0-14 year olds will increase by an average of 1% per year according to ONS estimates. XE "ONS estimates"  This will lead to a proportionate increase in demand for specialist paediatric services.GOSH will continue to service the populations with the greatest underlying clinical need and actively reach out to support ethnic groups with intrinsically higher levels of complex paediatric health needs Technological (changes to treatments, new technologies etc)Technological changes will affect all specialties but this will be on a specialty by specialty basis. The likely overall impact of these will be increased work rather than any radical new developments that lead to the decline in demand for treatments at GOSH.GOSH is a member of the UCL XE "UCL"  Partners XE "UCL Partners"  AHSC XE "AHSC" , with a dedicated UCL departmental partner in the Institute of Child Health. This will ensure that GOSH is at the forefront of any technological developments that will change the way that healthcare is provided in GOSH services. GOSH has an ambitious R & D strategy (see Annex 3-4) which will ensure that GOSH retains and indeed enhances its position as the leading UK provider of paediatric research and development.Legal (EWTD, safety legislation etc)EWTD XE "EWTD"  is causing continuing problems with junior doctor staffing, in terms of maintaining adequate training opportunities, the ability to achieve safe and compliant emergency rotas and the ability to service the elective workload.GOSH is about to implement an innovative approach to the continuing challenges of the EWTD XE "EWTD"  on training grade medical teams by establishing a hospital wide general paediatric team to support key specialties within the Trust.Environmental (probably not much for services, maybe travel)Further demands for patients to be treated as close to home as feasible, with care closer to home being a pivotal stream of NHS philosophy.GOSH will continue to embrace and actively develop treatments closer to home this is exemplified by GOSH developing Europes first home haemodialysis service. 3.2 Regulatory Frameworks 3.2.1 NHS Operating Framework The 2011/12 NHS Operating Framework sets out the challenge of continuing to deliver high quality care for our patients, while beginning in earnest the transition to the new system envisaged in Equity and excellence: Liberating the NHS. The over-arching goal in this period will to build strong foundations for the new system by maintaining and improving quality, by keeping tight financial control and delivering on the quality and productivity challenge, and by creating energy and momentum for transition and reform. The framework additionally sets out the national priorities for 2011/12, including maintaining performance on key waiting times, continuing to reduce healthcare associated infections, and reducing emergency readmission rates. The DH will continue to develop the quality framework in 2011/12 in anticipation of the new role of the NHS Commissioning Board in driving quality improvement across the system and NICE will begin work on 31 new Quality Standards next year to add to the 15 already completed or in development. Meanwhile quality accounts will be extended to cover community services for the first time. The DH has made it clear that local commissioners should hold providers to Constitutional rights and contractual commitments. This includes achievement of a maximum waiting time of 18 weeks for admitted and non admitted patients in addition to recently published additional thresholds for the median and 95th percentile pathway waits. NHS London will also continue to monitor (and DH will continue to publish) waiting times for diagnostic procedures, which, as a key element of the 18 week pathway, should be no longer than 6 weeks. 3.3 Monitor compliance framework We have considered the requirements set out in Monitors compliance framework in preparation for being authorised as an FT later in year. Monitors Compliance Framework sets out the approach Monitor will take to assess the compliance of NHS foundation trusts with their terms of Authorisation (the Authorisation) and to intervene where necessary. The most recent version of the Compliance Framework was published in March 2011 and includes the following revisions: Changes to board statements to reflect Monitors Quality Governance Framework; the inclusion, as in previous years, of relevant priorities from the Operating Framework for the NHS 2011/12, which was published on 15 December 2010, including new referral-to-treatment time measures and A&E clinical quality indicators; A refinement of our approach with regard to incorporating asset efficiency within our financial risk ratings; A revision of how Monitor will incorporate Care Quality Commission judgements in its governance risk ratings; The inclusion of NHS Litigation Authority Clinical Negligence Scheme for Trusts (CNST) levels in Monitors governance risk rating; The impact of material data submission failures or misrepresentations by NHS foundation trusts; and The regulatory consequences of a financial risk rating of 2. This revised Compliance Framework applies from 1 April 2011 and forms the basis on which annual plan submissions and subsequent in-year reports will be made in 2011 onwards. 3.4 Porters Five Forces Porters Five Forces analysis is a measure of the competitive intensity of a market. It analyses the potential influence that external factors could have upon the services we provide. Used along side our SWOT analysis (below) it reveals the areas and competitors that we must consider when devising our service strategy. Competitive ForceAnalysisCompetitive response Referrer Power (what power and likelihood is there of referrers changing allegiance)Referral to GOSH will almost always be decided by the referring secondary care clinician, with this decision being based on many factors, including clinical care, location, service provision, historical referrals routes, and quality of communication from the specialist centre. In the last referrer survey, GOSH rated extremely well for clinical quality, but had many areas of improvement with its communication to referrers and shared care providers. Ensuring GOSH maintains and grows excellent relationships with referrers and provides quality and timely communication links is the single most important factor in determining the future level of GOSH activity and hence overall viability. Referrer power is especially strong for international workload with many competitors especially in Germany and the US.GOSH has recently commissioned an external survey of referrers to GOSH, which highlights communication as being an area for improvement. GOSH take this very seriously and as such has included referrers experience as one of the key competitive strategies in this IBP. Additionally implementing an action plan from the survey is one of the Trusts key deliverables for 2010/11.Patient / Parent Power (what power and likelihood is there of patients / parents exerting choice)Although the development of patient choice is a key NHS priority, few of GOSHs services are directly affected because of the low levels of primary care referrals. However, the impact of patient (or parent) decision in tertiary care cannot be underestimated. With the explosion of information through the internet more and more patients are making informed choices about where to be treated. Targeted marketing for specialised services would result in more families requesting to be referred to GOSH.GOSH will continue to work with the charity to retain the hospitals high profile in the media. This is highlighted by recent BBC programmes set on GOSH and numerous positive press stories.Suppliers Power (what influence could inputs to the service have e.g. consumables and most importantly workforce)The key area of potential suppliers power is in the availability of appropriately trained staff, this affects most clinical staff groups. This has the potential to have a significant restriction on growth objectives.GOSH is well aware that the level of growth aimed for within the IBP will require the improved recruitment and retention of the key staffing groups. Strategies to deliver the workforce required is covered in the workforce strategy (see section 8)Threat of New Entrants (could another hospital move into this service either NHS or private)This depends on the specialty, but in the majority of areas this is unlikely. The set up costs and ongoing minimum infrastructure costs for viable safe specialist childrens services would be very prohibitive. The most likely new entrant would be an expansion of certain missing specialties from the paediatric portfolio at Guys.The greatest risk of this is the expansion of missing paediatric specialties at Guys. This risk is significantly reduced if GOSH and Guys being designated as specialist paediatric hubs north and south of the Thames. Additionally the GOSH activity plan does not aim to pursue additional workload from South London and surrounding area which can be provided by Guys.Threat of Substitution Products (could a new drug or less invasive treatment replace parts of the service)This will be completely dependent on each specialty and disease type within each specialty. However, across the whole medical spectrum gene therapy and stem cell transplantation are the developments most likely to cause a radical change in the delivery of healthcare. GOSH is at the forefront of developments in both these fields (e.g. Duchenne MD XE "Duchenne MD"  for gene therapy and tracheal stem cell transplantation) and any developments will gain workload at the Trust rather than present a risk of reduced activityGOSH is a world leader in development in the two most likely areas of product substitution - gene therapy and stem cell transplantation and any developments will gain workload at the Trust rather than present a risk of reduced activity 3.5 SWOT Analysis and response The table below details a SWOT analysis XE "SWOT analysis"  that has been completed by the Executive Team. The issues included are addressed to ensure that strengths and opportunities are being used to our advantage and threats and weaknesses are mitigated. These are shown in the tables below. StrengthsOptimise StrengthOpportunitiesOptimise OpportunityBrandStrong reputation / public loyalty and brand name for clinical excellenceEnsure that all partnership arrangements consider this aspect Partnership PolicyFoundation Trust membership provides opportunity to leverage brand reputation more effectivelyDedicate resources to FT application Open additional IPP resources to utilise strength of the brand. Clinical servicesOffer the widest range of paediatric services supported by specialist paediatric-focused infrastructure; critical mass of services in terms of staffing.No plans to decommission any specialties. Continued development of clinical services. Develop a General Paediatric team to assist with the management of complex multi specialty patients.Involving membership in the development of new ideas and plans for the hospital Growth of specialist services from other providers as part of rationalisation. GOSH 2010 Transformation XE "Transformation"  Programme National reviews of paediatric cardiac and neurosurgery servicesExtensive consultation during FT application and membership strategy Develop capacity to be able to accept workload from any reconfiguration. If reconfiguration does not occur then gain business through proactive marketing. Transformation XE "Transformation"  programme to progress as plannedStaffDedicated, highly sub-specialised clinicians working in multi-disciplinary teamsContinue to support staff with Education Strategy XE "Education Strategy" Recruitment strategy helps to grow sustainable staffing levels in the medium to long termMarket the Trust and attract candidates to posts at GOSH, specifically focusing on the world class opportunities in research, education, and training. ReferrersStrong referral base, supported by outreach and shared care arrangements Broad commissioner base Objective to increase market share for quaternary services, and in North London and surrounding area for tertiary services. Develop further formal shared care arrangements Review outreach clinics from the referrers survey supporting a strategy of tactical development for example in Neurology XE "Neurology"  Growth of specialist services, particularly those which generate surplus income through patient choice and stronger links with referrers Priority specialties identified from those with greatest opportunity to grow. Competitive strategy XE "Competitive strategy"  developed in IBPResearchResearch and Development, academic input and innovation demonstrated by Biomedical Research XE "Biomedical Research"  Centre award Member of the UCL XE "UCL"  Partners XE "UCL Partners"  Academic Health Sciences Centre (AHSC XE "AHSC" ) Maintain UCLP focusClear strategy for translational research attracts new funding streams Development of income-generating support services and R&D ventures Invest in additional resources in the R & D office to support researchers. Developed an R & D strategy to increase activity in the organisation.EducationEducational activity with Institute of Child Health, London South Bank University XE "London South Bank University"  and higher education institutions and internal blended learning approach Use UCL XE "UCL"  partners and the health innovation and education cluster (HIEC) XE "HIEC"  to develop the quality and range of educational services provided.Development of training services to offer to third partiesUpdate and review the training prospectus to ensure it remains relevant to the needs of staff, patients and partners. Review our prospectus for opportunities to develop commercial opportunities for the Trust. ResourcesGOSH Childrens Charity fundraising capacity Continue to support the efforts of the Charity with congruent aims, proactive marketing in GOSH and clinical engagementHospital redevelopment programme to expand capacity and facilitate new models of care Foundation Trust financial freedomsStarting development of 2B business case XE "Starting development of 2B business case"  Dedicate resources to FT application Reviewing 2 A redevelopment to ensure that capacity matches demand WEAKNESSESWeakness mitigations THREATSThreat MitigationsBrandInconsistent communication on priorities and development plansIBP and annual plan will become the single Trust plan and is being well communicatedFailure to achieve Foundation Trust status XE "Foundation Trust status"  and the potential for the hospital to lose its independence Performance issues lead to reputation damageDedicate resources to FT application High level emphasis on performance with regular board level reportingClinical servicesLarge patient population with multiple needsService development XE "Service development"  of general paediatric team to help manage patients with multiple needs ICON XE "ICON"  service development providing a rapid response to deterioration in children. CEWS XE "CEWS"  system development IBP outlines priority specialties for management and resource focusRisk from hospital acquired infection (includes decontamination & cleanliness)Transformation XE "Transformation"  project focus on reducing SSIs, VAPs and CLIs. Decontamination review and subsequent business case Key aspect of zero harm agendaStaffAvailability of staff. Recruitment problems in some key clinical and non clinical areas, exacerbated by central London location, creating clinical capacity issuesTrain and develop staff with the skills to work in acute paediatric settings. Continue to develop the range of staff benefits which encourage and reward staff who join GOSH and remain at the Trust.Competition for qualified staff from other providers Recruitment and retention XE "Recruitment and retention"  difficulties due to planned public sector pay rise constraintsRange of staff benefits targeted to address the reasons staff give for leaving, such as subsidised accommodation, childcare vouchers; on site nursery and play scheme; subsidised season ticket loans and cycle vouchers; social activities and awards to encourage staff to feel part of the GOSH family. ReferrersAbility to accept all appropriate referrals Timeliness of communication with referrersLaunch of Referrers Experience XE "Experience"  Programme Establishing sufficient capacity to cope with peaks and troughs of demand.Competition for national and regional market share Competition for international market shareReferrers experience programme Ensure world class outcomes Proactive marketingResearchMeasuring outcomes XE "Measuring outcomes"  for some specialist work Dedicated outcomes project and post holder.On-going need to bid for research fundingInvest in the R & D office R & D strategy to increase activity in the organisation Maintain leading role in UCLPEducationInsufficient capacity to respond quickly to service re-design Poor facilities for simulated learning Lack of integration of all learning opportunitiesDevelopment of transformation learning programme. Business case for simulated learning facility. Development of integrated learning programmes. Economic situation will affect funding and potential market development. Focus on statutory requirements distinctive services. Business development in markets less affected by the economic situation (e.g. Kuwait). ResourcesSpace constraints on Great Ormond Street site, including inflexible buildings Sub-optimal use of key resources (e.g. beds, theatres)Saturday operating XE "Saturday operating"  and procedures Extended cardiac surgery operating Continuation of Transformation XE "Transformation"  ProjectFinancial instability driven by changes to NHS funding systems Failure to meet efficiency improvement targets Requirement to reduce expenditure in the public sector due to recession Validity of PbR XE "PbR"  system for highly specialised childrens servicesMaintain active involvement in Childrens Hospitals Group Transformation XE "Transformation"  programme Efficiency XE "Efficiency"  is a competitive strategy 3.6 Strategic drivers 3.6.1 Equity and Excellence: Liberating the NHS Following publication of the White Paper Equity and Excellence: Liberating the NHS XE "Equity and Excellence: Liberating the NHS" , we have assessed how the proposed development will affect GOSH. The key changes for GOSH are: Focus on quality and safety; driven by commissioning Extension of clinical and patient reported outcome measures Extension of choice Development of the National Commissioning Board Removal of the private patient income cap The paper sets out how quality XE "Quality"  is expected to be rewarded financially. Tariffs will be refined and the implementation of best-practice tariffs will be accelerated. Key changes relevant for GOSH include a mandate in 2011/12 for national currencies for neonatal critical care; a review of the payments system to support end-of-life care (including options for per-patient funding); and an accelerated development of pathway tariffs. The CQUINs payment framework will also be extended and poor quality care may be penalised by fines, focussing in particular on an extended list of never events. The development of a National Commissioning Board (NCB) has been proposed, which has a role in commissioning national specialist services and regional specialist services as set out in the Specialist Services National Definitions Set XE "Specialist Services National Definitions Set" . The majority of our work will be covered by the Definitions Set with fewer of our services being covered by the GP consortia XE "GP consortia" . We expect that at least 81% of our activity will be commissioned by the NCB, and possibly over 90%, depending on interpretation of the definitions. In addition, the current private patient income cap for foundation trusts will be removed. This will provide us with an opportunity to increase our international work and thereby increase money to invest in our NHS services. 3.6.2 Strategic national reviews The National Specialised Commissioning Group (NCG) is currently leading a number of service development programmes.These include: The Safe and Sustainable Childrens Cardiac Surgery Services Programme and the Safe and Sustainable Childrens Neurosurgical Services Review. The objective of the Cardiac Surgery Services programme is the delivery of a safe and sustainable service into the future. There are currently 11 childrens heart surgery centres in England. Approximately 30 surgeons conduct childrens heart operations across the country and between them they carry out around 3800 procedures a year. The review aims to reduce the number of centres providing care within England to ensure services have enough critical mass to be of the highest quality and sustainable. The Safe and Sustainable programme has based its agenda on the following core principles: The NHS must provide the very highest standard of care for all children in England who need heart surgery regardless of where they live or which hospital provides their care The care that every centre provides must be based around the needs of each child and family, taking account of the transition to adult services Other than surgery and interventional cardiology all relevant treatment (including follow-up) must be provided as close as possible to where each family lives NCG will develop a set of quality standards and ensure that services deliver the best care by meeting these standards The recommendations of the review are currently subject to public consultation. All four options for reconfiguration include GOSH as one of two centres in London, with the Royal Brompton discontinuing Paediatric Cardiac Surgery. The aim of the Neurosurgical Services Review is to deliver, within two years, robust proposals that will secure a safe, sustainable and world class service for children and their families. Similar to the Cardiac review it is likely that the number of centres providing neurosurgery will reduce. The Programme will initially: review current arrangements for childrens neurosurgical services including levels of need and activity in each of the 15 centres in England Develop criteria for a formal designation process that ensures that childrens neurosurgical services meet service specification standards, as well as meet national demand Develop service specification standards that will form a national quality framework within which childrens neurosurgery centres will be assessed Canvass the views of stakeholders on the future shape of childrens neurosurgical services The expectation is that the number of centres will reduce, with the probable outcome being around 5 centres nationally undertaking neurosurgery. Aside from GOSH, two other centres in London undertake paediatric neurosurgery; Kings and St Georges, with both undertaking small numbers compared to GOSH. We expect the outcome of the national review to rationalise the number of centres undertaking neurosurgery. 3.7 Demand and capacity analysis 3.7.1 Clinical strategy Our overarching clinical strategy focuses on treatment and care for complex conditions and on providing services which are available at a limited range of centres. GOSH is fully committed to providing health care locally where it can be done so safely and efficiently, and delivering cost effective care pathways to commissioners. The following schemes show examples of where this is being planned or delivered Established Europes first paediatric home haemodialysis service. This will deliver much improved clinical outcomes due to more frequent dialysis and better quality of life for the patients and families. GOSH are delivering this at the same cost as attending hospital haemodialysis. Undertaking numerous follow up outpatients by telephone and is continuously transferring more follow ups from clinic to telephone. Commitment to streamlining patient pathways and improving key performance metrics of this such as new to follow up outpatient ratios. Using non invasive expandable growth rods for some spinal surgery to radically reduce the number of inpatient procedures that a patient requires. Developing telemedicine clinics in a number of specialties to reduce both patient and clinician travel time and costs Our approach will be based on the development of clear clinical pathways, working in partnership with local services, and building on the well established GOSH strengths in providing nationally and internationally significant specialist paediatric healthcare services. The wider NHS / national benefits of our strategy are; Providing services for patients with the most complex conditions, who have limited (or no other) healthcare options. Saving costs for the NHS and other public services as we deliver the right high quality care in a timely manner avoiding waste and harmful delays in both diagnostic and therapeutic services. Offer the widest range of paediatric specialties on one site, which suit a complex case mix by delivering integrated care from one location. As the leading paediatric research provider, the concentration of complex cases at GOSH delivers the optimum environment for developing new techniques through translational research. Worldwide evidence suggests that higher volumes deliver better clinical outcomes for the most complex cases. With these criteria established we have undertaken a detailed market assessment of every specialty at GOSH to determine the external factors that will affect each particular specialty over the coming year and beyond. Based on the overarching principle of focusing on the most complex cases GOSH, has identified some priority specialties where the external need for GOSH to further develop its services is highest. 3.7.2 Priority specialty plans We have defined a number of priority specialties where the external environment determines that demands for services at GOSH will increase most. We aim to develop the capacity to meet these demands and ensure that we provide the paediatric population with the services it requires in the most efficient manner. The key specialties with a largest material change in terms of activity and income to GOSH are as follows; 3.7.3 Cardiac Surgery Whilst we are not anticipating additional clinical growth in cardiac surgery we do expect to increase our market share. The national Safe and Sustainable Paediatric Cardiac Surgery Review aims to rationalise the numbers of centres undertaking paediatric cardiac surgery across the country. In addition, The NHS London publication, Childrens and Young Peoples Project Londons Specialised Childrens Services: Guide for Commissioners also recommends a strategic direction of rationalisation of the number of providers of this specialist childrens service. The planned growth in cardiac services will increase the demand for all acuities of beds: ITU XE "ITU" , HDU XE "HDU" , and ward. To accommodate these plans the Trust has recently approved the first wave of expansion; 2 additional ITU beds and 4 additional HDU beds, which can be accommodated in the current footprint. The second phase of expansion will be accommodated by the Morgan Stanley Building due to open in 2012. 3.7.4 Neurosurgery GOSH is the largest provider of paediatric neurosurgery in the UK, delivering the highest quality of emergency and planned neurosurgery to children throughout the country, with a dedicated paediatric clinical team. Clinical growth is expected in neurosurgery for a number of reasons. New techniques are continuously being developed and a wider portfolio of surgical treatments is expected in epilepsy surgery, spinal surgery and surgical spasticity interventions such as intrathecal baclofen and deep brain stimulation. GOSH will also develop surgical spasticity services which are currently not provided at GOSH and is the formal neurosurgery support centre for the paediatric London trauma centre at Barts and The London Trust. In addition, the national Safe and Sustainable paediatric neurosurgery review aims to rationalise the numbers of centres undertaking paediatric neurosurgery across the country. The current demands for Neurosciences XE "Neurosciences"  beds (Neurosurgery XE "Neurosurgery" , Neurology XE "Neurology"  and Craniofacial XE "Craniofacial" ) are greater than the supply and will deteriorate further as demand increases. We will effectively increase number of beds available for neurosurgery beds by increasing the day case neurology capacity and moving appropriate craniofacial patients to surgical beds. However, we are still predicted to be short of bed capacity for neurosciences and are working on rectifying this by a combination of new working practices, smoothing the occupancy variation across the week and accessing additional bed capacity within the Trust. 3.7.5 Spinal Surgery The spinal orthopaedic service aims to provide a comprehensive multidisciplinary service for the care and management of children with both congenital and acquired spinal deformity. There is a considerable neuromuscular workload. In 2008 GOSH had to restrict referrals to the service due to patients waiting longer than the national inpatient standard of 26 weeks. GOSH is now fully accepting referrals and has good waiting times, whilst other providers are struggling to achieve waiting times targets for this specialty. The market share aims have been adjusted from the Trust wide objectives to reflect the non specialist paediatric nature of the service at Stanmore and the collaborative spinal services with Guys. Clinical growth will occur as more spinal surgery techniques are developed and currently underlying demand within the population is not being met due to a national lack of capacity. The NHS London publication, Childrens and Young Peoples Project Londons Specialised Childrens Services: Guide for Commissioners also recommends a strategic direction of rationalisation of the number of providers of this specialist childrens service. In response, we propose to increase the available spinal surgery beds by increasing the number of spinal cases undertaken as day cases and expanding the respiratory ward to be able to take spinal surgery patients who require non invasive ventilation. 3.7.6 Haematology / Oncology / Bone Marrow Transplant (BMT) GOSH provides comprehensive haematology, oncology and bone marrow transplant (BMT XE "BMT" ) services for all children in North London and for children under 1 across the whole of London. The service is well respected with a good established network of shared care providers. Research and development XE "Research and development"  output is extensive, with high numbers of publications. However, capacity problems exist which often delay or lead to the refusal of admissions from shared care providers. Referrals XE "Referrals"  have been diverted to other providers and the GOSH market share has contracted as a result of these capacity constraints, with an example being the loss of referrals from North Kent to the Royal Marsden hospital. The underlying clinical demand for services is expected to increase from a number of new / developing therapies: Radio isotope therapy Transplants for re-lapsed leukaemia Increased intensity of some treatment regimes Tumour vaccine therapy Increased range of specialties for which BMTs can be of clinical benefit Increased demand for metabolic and gastroenterology patients receiving BMTs Again, the NHS London publication, Childrens and Young Peoples Project Londons Specialised Childrens Services: Guide for Commissioners recommends a strategic direction of rationalisation of the number of providers of this specialist childrens service. Some of the other providers within the geographical zones also serviced by GOSH do not currently meet key clinical interdependences. To accommodate additional growth the service will expand its capacity in haematology / oncology / BMT XE "BMT"  to ensure that all referrals can be accepted and all shared care transfers can be accommodated in a timely manner. This physical expansion will be complemented by a reduction in the planned occupancy of the wards (to manage variation in demand) and by targeted service improvement work. In addition, the day case / outpatient ward undertook a specific Variability and Flow Management Project which increased capacity without the need to increase the physical space. 3.7.7 Gastroenterology GOSH is the largest provider of specialist gastroenterology services to North London and surrounding area and a provider of some quaternary services, e.g. auto immune gut disease, small bowel transplants (jointly provided with Kings) and neuromuscular gut disease. We anticipate that the demand for Gastroenterology XE "Gastroenterology"  beds will grow by approx 4 inpatient beds and a near trebling of day case beds over the next 5 years. This will be accommodated by a planned reorganisation of medical specialty beds over the coming years. Currently the 3 wards delivering these services are not used to their optimum capability and work is currently occurring to redesign patient pathways in the 5 specialties involved, which will then be followed by a review of the specialty delivery location and possible redistribution. A potential outcome will be the creation of a dedicated Gastroenterology facility which will accommodate all in patients, day cases and endoscopies with increased in patient beds. Currently there is one endoscopy suite and a co-located area has been identified to develop a 2nd suite in the next couple of years. 3.7.8 Specialist neonatal and paediatric surgery XE "Specialist neonatal and paediatric surgery"  (SNAPS XE "SNAPS" ) Referrals XE "Referrals"  for neonatal surgery are taken from units within the north London and surrounding region as well as other units within London. Tertiary XE "Tertiary"  referrals are received from throughout the United Kingdom as well as international referrals. The department of surgery provides a comprehensive service with special emphasis on the management of congenital abnormalities as well as diseases of the gastro-intestinal tract including oesophageal atresia, ano-rectal abnormalities, surgical oncology and minimally invasive surgery (Laparoscopy XE "Laparoscopy" ). Whilst no clinical growth is expected we do anticipate increasing our market share through The NHS London publication, Childrens and Young Peoples Project Londons Specialised Childrens Services: Guide for Commissioners, which recommends a strategic direction of rationalisation of the number of providers of this specialist childrens service. SNAPS XE "SNAPS"  has recently benefited from an extensive process review as part of a transformation project. The MVP project has generated a significant number of integrated care pathways which have contributed to a reduced length of stay for many of the common surgical procedures. This has resulted in a 15% reduction in length of stay (LOS) across SNAPS. In addition, there has been a focus on all stages of the pathway to and from surgery including booking, pre-op assessment and theatre utilisation which it is anticipated will also offer a significant gain. There are huge improvements in bed management, staff effectiveness through SBARD XE "SBARD"  handover and soon through ICPS and a general understanding of the growth that is possible within current capacity which we are rapidly reaching the maximum level of. 3.7.9 Paediatric and neonatal intensive care The intensive care unit at Great Ormond Street Hospital is the lead centre for Paediatric Intensive Care in North Thames and a recognised centre for training in Paediatric Intensive Care medicine. It is one of the largest units for children in the UK and Europe. There are two distinct units - the Neonatal Intensive Care Unit (NICU XE "NICU" ) and the Paediatric Intensive Care Unit (PICU XE "PICU" ) however they work closely together. The nursing and medical teams work closely together allowing great flexibility and are led by a team of eight consultants. Approximately 1,200 patients per year are admitted to PICU. Almost all children and infants admitted to PICU are ventilated (> 90%). We have a number of ventilators to allow different ventilator techniques appropriate to the care of the child. A full range of renal replacement therapies are also available should any child require it. Our patients come from the North Thames area and also further afield from all over the UK and abroad. This reflects the wide range of specialist services that can be provided for critically ill children in our unit. No clinical growth is expected, however we do expect to realise an increase in market share. The NHS London publication, Childrens and Young Peoples Project Londons Specialised Childrens Services: Guide for Commissioners recommends a strategic direction of rationalisation of the number of providers of this specialist childrens service. One of the other providers within the geographical zones also serviced by GOSH do not currently meet key clinical interdependences. Our current PICU XE "PICU"  / NICU XE "NICU"  footprint has 23 bed spaces and increased demand will be accommodated in these in the foreseeable future. 3.7.10 Summary GOSH caters for the most complex patients in the paediatric health care needs spectrum and through the NHS strategic direction of rationalising highly specialist services it is logical that GOSH will be required to expand. Many of our activity plans are based on specific commissioning objectives e.g. The National Safe and Sustainable reviews and Healthcare for Londons Specialised Childrens Services. We firmly believe that increasing clinical activity at GOSH will assist commissioners in reducing total healthcare expenditure for the group of patients that we treat. 3.8 Trust objectives In response to our analysis of past year performance and review of the external environment in which we will be operating in we have revised and developed our workstreams and actions that will deliver our strategic objectives. The following tables set out our development plans for the future, describing our seven key objectives and associated workstreams and actions to deliver them. Each workstream has a responsible Executive lead and Committee to monitor progress. Clinical Units and Nursing have additionally developed their local plans to deliver the trust objectives. These are detailed in appendix 2. 1. Consistently deliver clinical outcomes that place us amongst top 5 Childrens Hospitals in the world WorkstreamActionAction: Continued / Revised / New Executive leadMaintain our focus on Zero HarmContinue the development of systems to decrease adverse drug events by targeted actions such as the expansion of the CIVAS service and other strategies aimed at concentrating on named high risk medications and named high risk areas in the Trust with the aim of a 25% reduction against the 2010 baseline.RevisedCo-Medical DirectorContinue our work to reduce specific hospital acquired infections including Central Venous Line infections (CVL), Surgical Site infections (SSI) and Ventilator Associated Pneumonia (VAP) from current baseline over the next year.RevisedCo-Medical DirectorMaintain child protection and broader safeguarding structures and processes to ensure effective safe guarding of all children and young people. RevisedChief Nurse and Director of Workforce DevelopmentDevelop and monitor new structure for managing and learning from Serious Incidents (SIs)NewCo-Medical DirectorEnsure effective provision of nutritional care for all patientsNewChief Nurse and Director of Workforce DevelopmentEnsure provision of safe services for the deteriorating and critically ill child.NewChief Nurse and Director of Workforce DevelopmentImprove our measurement of clinical outcomes and demonstrable continued improvement in outcomesGather and report outcome data and information to demonstrate the clinical effectiveness of the organisation and benchmark against comparable organisationsRevisedCo-Medical DirectorEnsure accountability for delivery of CQUIN targets are fully devolved operationally and monitored regularlyRevisedChief Finance Officer2. Consistently deliver an excellent experience that exceeds our patient, family and referrer expectations Continue to reduce waiting times further through our no waits programmeContinue to meet national and commissioning standards and improve the utilisation and efficiency of our resources.RevisedChief Operating OfficerImprove the standard of customer service that we offer patients and familiesEnsure the effective measurement and improvement of patient experience through agreement and implementation of a patient experience action planRevisedChief Nurse and Director of Workforce DevelopmentContinue to improve our relationships with referrers in order to achieve our market share objective Continue to implement the actions for improvement following the results of the Referrer Survey including producing a directory, holding referrer days alongRevisedCo-Medical DirectorInvest within our 10 year capital programme to improve the patient environment within our existing buildings and continue progress on redevelopment of new buildings within agreed timescale and budget. This includes the development of the Morgan Stanley Clinical Building (MSCB) due to complete in December 2011 and the continued development of the Phase 2b Full Business Case for final submission in July 2011.RevisedDirector of RedevelopmentPrepare to move into the Morgan Stanley Clinical Building including workforce redesign. NewChief Operating Officer3. Successfully deliver our clinical growth strategy Deliver our planned in year growthDeliver our planned growth in line with population changes and specific growth across specialties as defined in our Integrated Business Plan (IBP) RevisedChief Operating Officer Maintain IPP service growth Improve patient access and staff recruitment and retention to ensure IPP income target is achievedRevisedDirector of International PatientsPosition ourselves as a pan-London leader of networked paediatric services, providing co-ordination, training and education and setting standardsAchieve accreditation as a national paediatric centre for cardiac and neuro-surgery through the new national processes, and plan to accommodate any further growth that arises from this process.RevisedChief Operating OfficerWork with partners in the region to deliver paediatric tertiary care in light of NHS London proposals.RevisedChief Operating Officer4. Currently partnered with ICH, and moving to UCL Partners AHSC, maintain and develop our position as the UKs top childrens research organisation Deliver the Research StrategyRenew and deliver the Biomedical Research Centre in paediatricsNewDirector of Clinical Research and DevelopmentContinue to develop partnership working with ICH, University College London Partners (UCLP) and UCL BusinessRevisedDirector of Clinical Research and DevelopmentIncrease research activity and income for the Trust by 10%NewDirector of Clinical Research and DevelopmentIn year delivery (research)Continue to improve the mechanisms for the management of research within the Trust RevisedDirector of Clinical Research and Development5. To work with our academic partners to ensure that we are provider of choice for specialist paediatric education and training in the UK Deliver the Education & Training Strategy with our Implement the Trust's Education and Training Strategy through the delivery of an innovative and effective programme of blended learning using the on-line campus, classroom & work-based teaching and simulator learning.NewChief Nurse and Director of Workforce Development6. deliver a financially stable organisation Agree achievable CRES plan and ensure delivery through robust project and performance managementAgree robust plans for the delivery of the Cash Releasing Efficiency Scheme (CRES) programme and ensure that these plans are delivered. RevisedChief Operating OfficerDeliver surplus to plan.ContinueChief Operating OfficerImprove efficiency through our Transformation ProgrammeDeliver operational efficiencies through the devolved Transformation team and engine-room projects.NewChief Operating OfficerEnsure appropriate funding for our clinical services from commissionersWork with other specialist paediatric providers on work streams which will provide evidence to DH to support maintenance of specialist top up or targeted tariff design changes. RevisedChief Finance OfficerEnsure performance monitoring requirements of the Commissioners contract are delivered and the financial penalties are minimised.RevisedChief Finance OfficerSupport the charity to raise targeted fundsContinue to strengthen communication between GOSH and GOSH Charity at all levels to ensure fund-raising targets are metRevisedChief Executive7. Ensure corporate support processes are developed and strengthened in line with the changing needs of the organisation Make progress towards becoming a Foundation TrustComplete monitor assessment, attain authorisation status and establish an effective members council.RevisedChief Operating OfficerEnsure that the Trust is compliant with regulatory requirementsEnsure that the Trust retains registered status with CQC.RevisedChief ExecutiveEnsure that Information Governance (IG) processes are strengthened and the self assessment score in the IG toolkit is improved.RevisedChief Finance OfficerImprove efficiency of business processesImprove the quality and access to critical information relating to the Trust's strategic and operational objectives.NewChief Finance OfficerDeliver the first year of an agreed medium term IT strategy which ensures robust IT infrastructure and a credible and fundable replacement strategy for critical business applications.RevisedChief Finance OfficerContinue to develop management and leadership including Specialty Leads, Clinical Unit Teams and Trust Board.NewChief Executive In order to ensure that we are achieving the strategic elements of our plans the trust Board have developed 8 key deliverable measures for 2011/12 a series of must-dos. These include: 4.1 Key deliverable measures 2011/12  Key Deliverable1To achieve a 10% reduction in harm as defined by the global trigger tool 2To double the number of specialties that have clinical outcome measures published on our internet site 3Ensure the Morgan Stanley Clinical Building ready for occupation 4To meet our growth targets for both NHS and International and Private Patient activity 5To increase our research publications and income for the Trust by 10% 6To achieve excellent ratings in the Post Graduate Medical Education and Training Board and Quality Assurance Agency for higher education reviews 7To meet our budget 8To attain authorisation as a Foundation Trust  4.2 Performance management Progress against Trust objective workstreams and key deliverable measures will be monitored through the Management Board and Trust Board on a monthly basis. 4.3 CIMA strategic scorecard Following the development of the Trust strategic direction and key strategic objectives, and in order to help the Trust Board to fulfil their responsibility to contribute and challenge the strategy effectively, the organisation has adopted the CIMA strategic scorecard TM. The scorecard provides the Board with a monthly assessment of strategic issues by regularly summarising the key aspects of the environment in which the organisation is operating to ensure that the Board is aware of the ongoing changing competitor, economic and other factors; and identifying the (key) strategic options that could have material impact on the strategic direction of the organisation. The objectives of the scorecard are to: Assist the Board, in particular the non-executive directors, in the oversight of an organisations strategic process. In effect, it gives the Board the big picture. Provide an integrated and dynamic framework for dealing with strategy at Board level that focuses on the major strategic issues facing the organisation and ensures that the strategy is discussed at Board level on a regular basis. Provide strategic information in a consistent and summarised format to help directors to obtain sufficient grasp of the material so that they can offer constructive, informed input. Assist the Board in dealing with strategic choice and transformational change and the attendant risks. Provide assurance to the Board in relation to the organisations strategic position and progress. Assist the Board in identifying key points at which it needs to take decisions. Although the scorecard is primarily aimed at Board level for use as an agenda item at Board meetings, it offers considerable benefits to the organisations management: The discipline of having to prepare and update the scorecard helps management to keep its focus on the key strategic issues. It facilitates discussion within the management team and helps the team to refine its proposals prior to exposure to the Board. It can help to identify gaps in knowledge and analysis and can improve the quality of information presented to the Board. Because the scorecard improves the quality of the Boards contribution, this will lead to more constructive engagement with management. The strategic process and content are thus enriched. This makes for better governance and performance The scorecard uses four dimensions to assess the strategic position and identify strategic options and risks. These are summarised in the diagram below. CIMA Strategic Scorecard Strategic position This focuses on information that is required to assess the organisations current and likely future position. It covers externally focused information such as economic and market developments and market share as well as internal issues such as competences and resources. Strategic options Having set the scene with relevant background and information, the focus of the scorecard shifts towards decision making. Strategic options can be defined as those options that have the greatest potential for creating or destroying stakeholder value.Strategic implementation At this point, the emphasis of the scorecard is to identify key milestones for the Board and to monitor implementation of the agreed strategy. Decisions on appropriate action may be required if things are not proceeding as planned. Strategic risks This dimension underpins the others by focusing specifically on the major strategic risks that pose the greatest threat to the achievement of the organisations strategy as well as key issues such as the organisations risk appetite. The scorecard will bring all the high-level strategic information together in a summarised, but coherent form for the Boards use within a robust framework. This will be supported by a strong foundation of high quality management information which the Board can access if it is felt necessary to explore a particular issue in greater depth. 4.4 Financial Implications of our plans The financial plan for 2010/11 has been compiled on the basis of; Expected outturn activity Demographic growth Known and forecast demand for services NHS and IPP Known service changes I.e. Haringey transfer Operating plan assumptions these are detailed later Local and national tariff for PCT activity Agreed/estimated contract values with other commissioners IPP tariff prices MFF and Specialist top up 2010/11 rates Known or best estimates of other income sources A CIP target of 4% - higher internal target to mitigate risk to delivery Financial summary revenue statement Overall position000Actual 2009/10Actual 2010/11Plan 2011/12Plan 2012/13Revenue from Patient care activities267.5283.9286.5301.4Other operating revenue50.652.451.459.8Operating expenses(309.9)(323.0)(330.9)(357.5)Operating surplus8.213.37.03.7Other gains and losses0.03(0.6)00Investment revenue0.50.10.10Finance costs(0.03)(0)00PDC dividends payable(5.2)(5.6)(5.8)(5.7)Retained surplus for the year3.57.21.3(2.0)Impairments included (net)3.81.45.64.7Retained surplus excluding impairments 7.38.66.92.7 m2009/102010/112011/12ActualActualPlanEBITDA %8.5%8.3%8.3%Net surplus %2.2%2.5%2.0%ROA4.9%5.0%3.7%Private patient %8.0%8.89.7% Key points are: 2009/10 to 2010/11 GOSH at NMH service transferred back to NMH in May 2010 and is not part of the 2011/12 plan The Haringey paediatric service is not in the plan for 2011/12 although at the time of writing a formal agreement for the service to be transferred to another provider has not been agreed Growth in NHS activity, including demographic growth, is reflected in the plan Growth In IPP activity is reflected in the plan, this includes the FYE of the Kuwait education contract R&D funding reflects the best estimate of income from this income stream including any known allocations The 2010/11 tariff is modelled into all activity projections to determine planned income levels Key assumptions The assumptions that are derived from the NHS Operating framework are: Assumption % changebaselineInflation (Clinical income) - deflation-1.5 Relative to 2010/11 Income includes demographic growth1.0Quality performance payments known as CQUIN 1.0Pay inflation pay awards only apply to staff below 21K * 0.15% of overall pay bill0.15*2010/11 Tariff is modelled and reflected incl. emergency threshold and readmissionsNAContingency0.5CIP minimum (from cost reductions)4.0of total expenditure Income The Trust has modelled and reflected the effect of the MFF changes at 29% (31% previously) The Trust has modelled and reflected the Paediatric top up at 60% (78% previously) and its extension to additional HRGs The plans reflects the 1.5% deflation in priced activity Growth reflects 1% demographic growth Other growth is reflected based on known and forecast demand for certain clinical services New cardiac outpatient procedures are modelled and reflected in line with PBR guidance The divestment of the Haringey service is reflected No financial penalties become payable due to non-achievement of metrics or income lost from not achieving the CQUIN targets CQUINS is included at 1% to reflect risk to delivery Expenditure Pay inflation has been applied to salaries of 21K or less in line with the operating plan this equates to 0.15% of the pay bill Non-pay inflation: Drugs is included at 5% and all other non pay is at 2.9% CIP is applied at 4% although units have a higher target to deliver to ensure that at least the 4% is delivered Cost pressures have been funded to units where these are not activity related - activity related cost pressures are funded by increased levels of income to units Statement of Financial Position (SFP) mMar-10Mar-11Mar-12ActualActualProjectedTotal Fixed Assets258.1329.6344.6Stocks & Work in Progress5.25.25.0Debtors36.530.329.8Cash at bank and in hand8.532.625.3Total Current Assets50.268.160.1Creditors-37.6-53.9-42.8NET CURRENT ASSETS12.614.217.3TOTAL ASSETS LESS CURRENT LIABILITIES270.7343.8361.9Provisions for liabilities and charges-1.3-1.2-1.1Other non-current liabilities-7.7-7.3-6.9TOTAL ASSETS EMPLOYED261.7335.3353.9 The major movements on the SFP are: Continued expenditure on the phase 2 a Hospital development in addition to non-hospital development for buildings, IT and medical equipment Higher levels of creditors at year Reduced levels of debtors as old performance debt and Haringey and LPP debt is cleared by March 2011 Higher cash levels reflecting the creditor and debtor movements The current financial plan shows a small net outflow of funds in 2010/11 Summary Cash Flow ActualActual2009/102010/11Cash from operating activities15.838.7Tangible and non tangible assets-36.9-72.5PDC received15.415.0Other capital receipts12.948.5Proceeds from disposals0.5Dividends paid-5.1-5.7Net change in cash2.624.0 Investments in service developments The plan includes continued spend on phase2A of thee hospital redevelopment from 2011/12 this will be entirely donated with the last of the PDC now utilised The Trust will continue to invest in IT as well as ongoing maintenance and medical equipment investment this includes the investment required for Phase 2A medical equipment Capital expenditure Expenditure year to 31 March 2011Planned expenditure 2011/12'M'mHospital redevelopment15.00Hospital redevelopment - donated47.234.7Estates Maintenance8.57.7Estates - donated0.51.3IT 4.56.6IT - donated03.3Medical equipment0.30Medical donated1.53.5Total 77.5  57.1  5. Risk Analysis 5.1 Financial risk Key risks included within the planExplanation of the riskHigh/ Medium/ Low riskMitigating actionsDelivering CRESMediumThe trust will plan for CRES above required levels to mitigate risks.Insufficient skilled staff to deliver our strategic objectives HighContinuing to market GOSH as an attractive employer Developing in house succession and education and training programmes to grow our own Developing new roles and care pathways to reduce unnecessary dependence on hard to recruit roles CQUIN MediumThe value included in the plan is 1% and this is lower than the maximum that could be achieved of 1.5%. The Trust will also actively work to ensure targets are delivered.Ensuring the Trust is paid for the work carried out current contracts reflect lower levels of activity than the Trust anticipates it will seeMediumThe Trust is expecting to be paid for the work it does under tariff arrangements and will discuss with commissioners the likely and forecast performance with a view to ensuring that the commissioners are fully aware of the financial resources needed to satisfy for the work undertakenCommissioning risks including non payments for readmissions and reduced rates i.e. marginal ratesMediumA financial provision has been made within the financial plan. All risk areas will be monitored quarterly and audits carried out where agreed with the commissioners Opportunities There are likely to be opportunities from the Trust emerging from service reconfiguration within London. 5.2 Risks to services provided The Trust provides a full range of tertiary paediatric services across surgical and medical specialities. Current risks identified are: Difficulties in recruiting specialised staffing and skilled senior admin and clerical staff due to the competitive forces in central London Difficulties in obtaining adequate reimbursement for low volume highly specialised services through the standard NHS funding structures Loss of non-London activity to regional providers Lack of pace and clarity in the strategy to concentrate specialised services Restrictions in respect of the building programme to ensure that service disruption is kept to a minimum. The private patient cap could restrict growth in private patient care. Commissioners are seeking ways of restricting low priority treatments. GOSH only carries out treatments falling within these definitions if the child has multiple complex needs and it would be a significant clinical risk for such procedures to be carried out in a general hospital Contingency reserve 2011/12 The plan provides for a 0.5% contingency reserve. 5.3 Governance risk The Trust has a governance structure in place identified within the Risk Management Strategy and approved by the Trust Board. The strategy ensures appropriate structures are in place at all levels of the organisation to identify, mitigate and control risk and to manage for safety as well as risk reduction. It describes the operational framework that is required to deliver the strategy and how it links into the wider assurance and governance processes of the Trust. This is to ensure that quality assurance; quality improvement and patient safety are central to the activities of the Trust and fully embedded in the management processes. The governance structure identifies the roles and responsibilities of committees and groups that have responsibility for risk and the duties and authority of key individuals and managers with regard to risk management activities. It describes the process for Trust Board review of the strategic organisational risks from the risk register and the local structures to manage risk in support of this strategy. The Audit Committee and Clinical Governance Committee monitor both operational and strategic risks and assure the Trust Board that the necessary controls are in place and assurances sought. The Trusts Assurance Framework is based on a structured and ongoing assessment of the key risks to the Trust of not achieving its objectives. The Assurance Framework is used to provide information of the controls in place to manage the key risks and details the evidence provided to the Board indicating that the control is operating. The Assurance Framework is mapped to the Care Quality Commissions Registration Standards and to other internal and external risk management processes such as the NHS Litigation Authority Standards, Internal and External Audit recommendations and the Information Governance Toolkit. It is monitored and updated throughout the year by the Risk Assessment and Compliance Group and reported and challenged at both Board assurance committees. The safety of children in hospital is a Trust strategic objective with established links into the Assurance Framework, regular review of high level risks by the Executive team and local monitoring and reporting systems. Clinical and non clinical incidents are analysed by type, severity, location and frequency to identify patterns and to enable early identification of problems and action to be taken. In the event of a serious incident, the Trust engages with external agencies as required to investigate at an appropriate level. Reports are received by the Clinical Governance Committee on all aspects of clinical risk and risk reduction and to support proactive management and non clinical risks are reported to the Audit Committee. The operational framework sets out how this occurs and how this process integrates with other management, performance monitoring and assurance systems of the Trust. This is to ensure that effective risk management for improved safety is embedded in all elements of the Trusts work and enables early identification of factors whether internally or externally driven, which may prevent the Trust from achieving its strategic objectives of ensuring care is provided in a safe and effective way. The Trust is committed to this positive approach to the consistent management of risk, where managing for safety, in a culture that is open and fair, supports learning, innovation and good practice for the benefit of the child. Regulatory and legislative compliance is monitored through an audit and reporting process, to identify deficiencies and reduce any assurance gaps identified. Wherever possible, links to the performance management systems in the Trust are used to assess compliance. The Risk Assessment and Compliance Group oversees operational compliance and reports into the Management Board. Committee members sit on Management Board and ensure that compliance matters are addressed within the operational decision making process. 6. Declarations and Self-Certification 6.1 Board statements The board is required to confirm the following (subject to update in the final amended Compliance Framework): For clinical quality, that: The board is satisfied that, to the best of its knowledge and using its own processes (supported by any relevant Care Quality Commission metrics and including any further metrics it chooses to adopt), its NHS foundation trust has and will keep in place effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients. The board can confirm that its NHS foundation trust has met and will continue to meet the requirements for registration with the Care Quality Commission in accordance with the Health and Social Care Act 2008. For service performance, that: The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the application of thresholds) and national core standards and with all known targets going forwards; The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections (the Hygiene Code). For other risk management processes, that; Issues and concerns raised by external audit and external assessment groups (including reports for NHS Litigation Authority assessments) have been addressed and resolved. Where any issues or concerns are outstanding, the board is confident that there are appropriate action plans in place to address the issues in a timely manner; All recommendations to the board from the audit committee are implemented in a timely and robust manner and to the satisfaction of the body concerned; The necessary planning, performance management and risk management processes are in place to deliver the annual plan; A Statement of Internal Control (SIC) is in place, and the NHS foundation trust is compliant with the risk management and assurance framework requirements that support the SIC pursuant to the most up to date guidance from HM Treasury (see http://www.hm-treasury.gov.uk); and All key risks to compliance with its Authorisation have been identified and addressed. For compliance with its Authorisation, that: The board will ensure that the NHS foundation trust remains compliant with its Authorisation and relevant legislation at all times; The board has considered all likely future risks to compliance with its Authorisation, the level of severity and likelihood of a breach occurring and the plans for mitigation of these risks; and The board has considered appropriate evidence to review these risks and has put in place action plans to address them where required to ensure continued compliance with its Authorisation. For board roles, structures and capacity, that: The board maintains its register of interests, and can specifically confirm that there are no material conflicts of interest in the board; The board is satisfied that all directors are appropriately qualified to discharge their functions effectively, including setting strategy, monitoring and managing performance, and ensuring management capacity and capability; The selection process and training programmes in place ensure that the nonexecutive directors have appropriate experience and skills; The management team has the capability and experience necessary to deliver the annual plan; and The management structure in place is adequate to deliver the annual plan objectives for the next three years. Appendix 1 2011/12 CQUIN measures Appendix 2 Clinical unit and departmental annual plans Appendix 1 2011/12 CQUIN measures Primary Care Trust CQUIN measure Indicator SplitsFinancial ValueContract %Overall 2,020,7901.500Patient Experience: Undertake further inpatient and outpatient surveys and achieve improvement in key areas most notably communication with parents and patients during admission to hospital on issues such as medication side effects, patients fears and concerns and decision making 1100%202,0800.150Composite Score on Ipsos MORI Survey (Local):1a10%20,2080.015Implementation Plan and Monitoring:1b30%60,6240.045Composite Score on Ipsos MORI Survey (National)1c50%101,0400.075Qualitative Benchmarking1d10%20,2080.015Surgical Site Infections: Reduction of current rate of surgical site infection in 4 specialties and the establishment of surveillance in 5 new specialties2100%363,7420.270Reduction or maintenance of infection rate in 4 specialties2a50%181,8710.135Establish Implementation of 5 new specialties2b50%181,8710.135CVC Infections: Further reduction in the rate of central venous catheter (CVC) infections from latest reported rate of 2.8/1000 line days3100%363,7420.270Maintain CVC rate at 2010-11 Levels3a50%181,8710.135Improve CVC Infection Rate3b50%181,8711.135Nutrition Screening: To implement and evaluate GOSH nutrition flowchart; monitor patient outcomes using Z weight scores; full audit of height measurement 4100%363,7420.270Implement GOSH Flowchart4a40%145,4970.108Monitor patient outcomes using Z weight scores4b20%72,7490.054Full audit of height measurement4c40%145,4970.108Child protection: Strengthen the quality of the annual audit of child protection cases; achieve improvement in levels of group supervision for staff; increase the % of staff achieving level 3 training 5100%363,7420.270Record Keeping5a20%72,7490.054Supervision5b60%218,2440.160Level 3 Training5c20%72,7490.054Paediatric Trigger Tool: Continue to review 20 sets of case notes per month and undertake a peer review of the implementation of the tool 6100%363,7420.270Review process and continue to undertake tool6a100%363,7420.270TOTALS2,020,7901.500 London Specialised Commissioning Group Paediatric Haemophilia7Optimal dosage of prophylactic clotting factor for children with haemophilia A and B7a199, 662Paediatric and Cardiac Intensive Care8Reducing the % of unplanned readmissions into Intensive Care within 48 hours of the initial admission and reducing the number of accidental exubations8a199, 662Optimal dosage of prophylactic clotting factor for children haematology and oncology A and B9Reduce prescribing errors in haematology and oncology through improved training, improved patient information and drug pre-preparation. Also to map the usage of antifungal drugs and costs from Allogeneic BMT patients9a199, 662 Appendix 2 Clinical Unit and Nursing Annual Plans Cardio-respiratory Infection Cancer and Immunity Medicine and Diagnostic & Therapeutic Services Neurosciences Surgery International & Private Patients Nursing and Education  The NHS Litigation Authority (NHSLA) is a Special Health Authority, which was established in 1995. The NHSLA administers the Clinical Negligence Scheme for Trusts (CNST) and the Liabilities to Third Parties Scheme (LTPS) and Property Expenses Scheme (PES), together known as the Risk Pooling Schemes for Trusts (RPST).     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