Velindre NHS Trust Annual Performance Report

Transcription

1 Velindre NHS Trust Annual Performance Report 20-20

2 Contents Page Performance Report Overview Chief Executive Statement 3 About Us 6 Vision, Ambitions & Strategic Objectives 6 1. Delivering Against our Duties 7 2. Development Activity Trust Organisational Development Strategy Performance Summary Performance Analysis Sustainability Performance Appendix 1 Performance Trend Analysis 20- Summary 66 Appendix 2 Progress against our Three Year Plan 81 Appendix 3 Equality Annual Moniring Report 88 2 P a g e

3 Performance Report overview Chief Executive Statement - Mr. Steve Ham Velindre NHS Trust is a unique organisation within NHS Wales, delivering highly specialised services that are broad, complex, focused on excellence and keeping our patients and donors at the heart of everything we do. Underpinning everything about our business is our commitment Quality, Care and Excellence, ensuring patients, donors and the hospitals we supply all benefit from the highest standards of care, innovation and professionalism across the dedicated range of services we deliver. Like the rest of NHS Wales, we are facing the combined challenge of rising costs and increasing demand, while striving continue improving the quality of care and patient / donor outcomes. Inevitably, how maintain these improvements, while continuing meet the needs of our population for Cancer, Blood and Transplant Services, is firmly at the forefront of our thinking and planning for the coming year. Our commitment, however, is make sure we maintain our focus on providing an excellent service and I am confident I speak for the whole Trust when I reassure you that we are up the challenge has been a busy, productive and successful year for us and how we move forward in delivering services in the future is an area we intend build on during It is our collective ownership of measures that will enable us show how successful we are in delivering our services in new and innovative ways, both in the coming year and beyond. We recognise that the new Well-being of Future Generations (Wales) Act 2015 will have a transformative effect on our organisation. The Act has allowed us consider the impact of what we do from a new, distinct perspective. Embedding the principles of sustainable development will likely lead us in exciting new areas and innovative, invigorating partnerships. The Act sets an expectation that we will work in different ways. We will embrace the opportunity that the Act provides seek greater collaboration with other bodies. New strategic and operational relationships will result in the more effective integration of services and, also, long term improvements the well-being of the Welsh population. We have included within our three year plan and within this performance report our first wellbeing statement and set of well-being objectives. We anticipate that our objectives will evolve in future years as our appreciation of the wide reaching effects of the Act develops and as the sustainable development principles at the heart of the legislation are more thoroughly embedded across the organisation. 3 P a g e

4 This Performance Report and our Annual Quality Statement, provide wide ranging details about our performance. Some of the highlights this year include: The introduction of a pan Wales Blood Service. In May 20, the Welsh Blood Service ok over responsibility for collecting blood donations in North Wales, making it a truly national service for the whole of Wales for the first time. Coordinating the merger was a huge challenge, and that the transition was seen through so smoothly and professionally is testimony the commitment and hard work of staff on all sides. To find out how our service will operate as a national service please visit the Welsh Blood Service website via the following link: We have developed a Strategic Outline Programme (SOP), which was submitted Welsh Government, outlining our ideas on how cancer services in South East Wales could look in the future. Welsh Government has given approval for us take this programme forward, which is excellent news and, help shape a shared vision on how we should develop these plans, we are now engaging with a range of stakeholders involved in cancer services in South East Wales. The Programme Business Case (PBC) is being finalised. Further information is available from the Velindre Cancer Centre website via the following link: I am delighted report that in June 20, the Trust, in accordance with the set statury duty, had its Integrated Medium Term Plan (IMTP) covering the period approved by the Welsh Government. Having an approved IMTP in place is a key way of demonstrating all of our stakeholders that the organisation possesses the requisite level of maturity plan and deliver our services with confidence over a three year period. The IMTP is refreshed on an annual basis and approved by our Board in March each Year. The IMTP for reflects on progress against the key priorities, performance and ambitions from the year 20-20, confirming that delivery/progress against objectives was broadly in accordance with forecasts. This was submitted Welsh Government in March 20. You can find our latest plan using the link below; Delivering Excellence: our three year Integrated Medium Term Plan (IMTP) In respect of our financial performance we reported a small surplus position for the year ended 31 st March 20, as reflected in the Annual Accounts section of the Annual Report. I am also pleased report that we had yet another extremely successful year in with the Velindre NHS Trust Charity raising circa 2.7 million. Our focus on excellence has seen us continue improve the high quality services we provide our patients and donors. The details contained in this report show that we are maintaining 4 P a g e

5 and improving our performance in a range of vital areas however there is more do and areas that need further attention. We will need challenge ourselves and we intend be bold. We will continue develop our Cancer Services in the context of the Transforming Cancer Services (TCS) programme and the Blood and Transplantation services building on the establishment of a national service for Wales. Our plan also highlights the importance we attach innovation, research and development. Work in these areas will have a positive effect on the health of the Welsh population and will continue raise the profile of both Wales and the Trust. Our staff, volunteers, fundraisers and partners are firmly committed delivering our goal of Quality, Care and Excellence. I am certain that by focusing on providing the best possible patient and donor care in the most efficient way, we can continue meet the challenges ahead in Signed: Mr. Steve Ham Chief Executive Date: P a g e

6 About us Established in 1994, Velindre NHS Trust (the Trust) provides a range of specialist services at local, regional and all Wales levels. We provide two core services which includes Velindre Cancer Centre and The Welsh Blood Service. We also host a number of organisations on behalf of Welsh Government and NHS Wales. You can find out more about our Service Divisions and Hosted Organisations in the Accountability section of the Annual Report document. Vision, ambitions and strategic objectives We aim clearly articulate our organisational vision, ambitions and strategic objectives deliver high quality services and care for our patients, donors, staff and stakeholders. Our vision is that: Velindre NHS Trust will be recognised locally, nationally and internationally as a renowned organisation of excellence for patient and donor care, education and research We have developed a set of overarching objectives that will enable us achieve our vision. These are: Equitable and timely services; Providing evidence based care and research which is clinically effective; Supporting our staff excel; Safe and reliable services; First class patient /donor experience; and Spending every pound well; Our vision and our objectives, alongside a range of national and local policies drive our planning process. Last years approved Integrated Medium Term Plan provided a strong foundation for the development of a clear set of actions for the next three years. Underpinning our vision and overarching objectives we are in the process of embedding our four core Organisational Values - BE Accountable, BE Bold, BE Caring and BE Dynamic. We believe that by adopting these values in the heart of the organisation we will enable a culture that supports transformational change achieve world class services for our patients and donors. 6 P a g e

7 1. Delivering against our Duties National policy and drivers The focus and direction of the Trust s Integrated Medium Term Plan is determined by a range of drivers which bring gether national policy, Local Health Boards local needs assessment (in their capacity as commissioners of our services) and the need comply with statury requirements. There are a number of important national strategies and policies which guide the development and delivery of the services we provide and these are not all named explicitly within the plan; we have instead focused on a few fundamental policies and principles in our Delivering Excellence: our three year Integrated Medium Term Plan (IMTP). 7 P a g e

8 1.1 Equality, Diversity & Human Rights This last year has seen recognition of the progress made by the Trust in achieving its Strategic Equality Objectives. These objectives set out how the Trust will meet its duties under the Equality Act 2010, building on its commitment improve the lives of both its staff and service users and set out actions promote equality in health services. Equality Objective/Outcome Action People are and feel respected; this includes staff, patients, donors, carers and family members. The Trust has worked in partnership with other Local Health Boards and Third Secr organisations promotes and provide awareness sessions, information, training and workshops for key awareness events such as Carers Week, Black Hisry Month, Lesbian, Gay, Bisexual, Transgender (LGBT) Hisry Month and Sensory Loss Awareness Month. Development of short film for International Women s Day Dignity training rolled out all staff. Domestic Abuse training and awareness available all staff. Velindre Cancer Centre Dignity Group support dignified care. Cares information and training provided. Provide personalised care and treatment for patients. Provide appropriate support for patients with Dementia and cognitive impairments. Provide Mental Health First Aid training key staff. Development of staff equality training film with Iris in the Community. Total Recurl was developed and made by Velindre Staff. Velindre Trust is Snewall Diversity Champions, raising 32 places within the workplace index. 8 P a g e

9 Equality Objective/Outcome Action We communicate with people in ways that meet their needs (whether this is via written communication, face face, signage, Welsh or other community languages including British Sign Language) Improve collection of language information and communicate effectively with patients, their carers, donors and families in the language of their choice. Access Matters group improve all areas of access and communication at Velindre Cancer Centre including signage. Development of British Sign Language (BSL) online training for staff. Development of technology meet the needs of patients and donors with Sensory Loss i.e. Patient Buzzer, British Sign Language (BSL) Avatar project. Development and publishing Welsh Bilingual strategy. Improve accessibility and information on Trust, divisions and hosted websites. Development of Velindre Equality Facebook page share good news sries and access staff support groups. Equality Objective/Outcome Action People receive care and access services that meet their individual needs. Equality and dignity questions be included in the monthly patient surveys Partnership project using English as Second Language (ESOL) classes provide Cancer and Health information Transforming Cancer Service Equality Impact Assessment recommendation engage with community groups in the design and refurbish facilities explicitly meet the needs of patients, donors and visirs. Focus groups help and equality built in design reference groups Welsh Blood Service Use of accessible bleed chairs on sessions Welsh Blood Service Review data categories look at accurate recording of gender include transgender data. Review and development of a further six books in the Caring for my family with cancer children s books. To include more diverse families. Bilingual, audio and British Sign Language Versions of the books launched. 9 P a g e

10 Equality Objective/Outcome Action Improved engagement with public, patients and Donors Equality and dignity questions be included in the monthly patient surveys. Partnership project - Cancer Education via English as Second Language (ESOL). All Wales Blood Service work with community groups, improve awareness and increase donations. Work in partnership with Local Health Boards, Community Health Councils and the third Secr identify need and patient and donor experiences. Trust ok part in community events such as Health Fairs, Pride and 3 rd Secr events. Transforming Cancer Services stakeholder and engagement event continuing take place. Action Staff are paid fairly Analysis of staff equality data assist in identifying actions if pay gap exists or a need for specialist training and positive action programmes. Ensure all new positions undergo job evaluations. Workforce and Organisational Development look at Talent Management and succession planning. Ensure all staff receive Personal Development Plans in a timely manner. Support personal and professional development. Review staff survey responses measure improvements. As a result of all this work the Trust has been recognised and shortlisted for a number of awards, such as: Awards Nursing Times Cancer Nursing. Patient Experience Network (PEN) National Awards. Corporate Health Standard Platinum. Shortlisted Iris in the Community Short Film Awards. Royal College of Nursing Institute (RCNi) Cancer Nurse Awards (May 20). Excellence Wales Awards (May 20). We have also taken the opportunity inlcude our equality annual moniring report data and information at Appendix 3 of the Performance Annual Report. 10 P a g e

11 1.2 Welsh Language Supporting people use their language of choice We know that communication tailored an individual s needs is an essential part of providing good quality and safe care. Sometimes we care for patients and donors who speak a different language, or use sign language. We use the Wales Interpretations and Translation Service (WITS) help us. We have a Welsh Language Scheme support provision of bilingual services patients and donors who wish communicate in Welsh. During 20/ we have continued promote Welsh Language across our services. We ran Welsh language Meet and greet courses in partnership with Cardiff University, and some of our staff started a one year Welsh language course. We have focussed on the Welsh Language Strategic Framework, More than just words and the introduction of the new Welsh Language Standards ensure we can begin provide an active offer service those who need Welsh language services. We see this as part of our commitment continuously strengthen our ability provide individualised and patient and donor centred care. We also ran an intense Welsh Language course for over 15 members of staff ensure Welsh language services can be increased. 11 P a g e

12 1.3 The Wellbeing of Future Generations Act - Our approach the Well-Being of Future Generations Act & Our Well-Being Statement In April 20, the Well-Being of Future Generations (Wales) Act came in effect. We see the Act as an opportunity ensure our services are not only fit for the future but that everything we do is framed (without impacting current services) for the long term, considering prevention, integration, collaboration and involvement. Below, we have taken the opportunity publish the Trust s well-being objectives. Our objectives have been developed in accordance with the sustainable development principle defined in the Act and are intended demonstrate how we will contribute the realisation of the shared well-being goals. In a time of economic austerity and other constraints, the Act has provided us with an opportunity take sck and consider what we can do help make Wales a better place in which live in the decades come. We believe that the objectives that we have set will challenge us, individually and as an organisation, think differently, develop novel ways of working and, simply, do more. The Act should promote tangible change in how we, and other public bodies across Wales, operate. We are a provider of key, specialist health care services. Fulfilling this crucial role has always been our principle focus, but we already do so much more. As the Chief Medical Officer (CMO) for Wales has remarked in his annual report for 2015-, Rebalancing healthcare, the NHS in Wales has a far broader role than the delivery of healthcare services. 12 P a g e

13 We recognize that we are a major employer and we care about the well-being of our colleagues and their families. We care about the communities in which we live and work and the impact that we have on our environment. The Act and our own objectives give us licence challenge the status quo and challenge ourselves, as never before, think differently about what we do and the potential consequences of our activities for future generations. Our Well-Being objectives 1. Reduce health inequalities, make it easier access the best possible healthcare when it is needed and help prevent ill health by collaborating with the people of Wales in novel ways 2. Improve the health and well-being of families across Wales by striving care for the needs of the whole person 3. Create new, highly skilled jobs and attract investment by increasing our focus on research, innovation and new models of delivery 4. Deliver bold solutions the environmental challenges posed by our activities 5. Bring communities and generations gether through involvement in the planning and delivery of our services 6. Demonstrate respect for the diverse cultural heritage of modern Wales 7. Strengthen the international reputation of the Trust as a centre of excellence for teaching, research and technical innovation whilst also making a lasting contribution global well-being 13 P a g e

14 How our objectives were developed We strive do more than just treat disease. Our desire constantly improve the quality of the care that we provide and increase the scope of that care is fundamental what we do. This concern has also been an important motivating facr in the development of our wellbeing objectives. We also wanted use the process of developing our objectives as an opportunity address our wider role in society. We aspire deliver holistic care our patients and donors, but we want do more support families and wider communities. This ambition is in line with the sustainable delivery principle. We considered that an important step in our development process was identify the extent which the sustainability principle was, in reality, already a key impetus for us, whether or not we would actually describe such motivating facrs in the same terms as the Act now does. Recognising the extent which we already work in a sustainable way helped us arrive at a new appreciation of the potential power of our individual and collective actions if they could be directed in a clear, concerted manner. The new way of thinking that the Act promotes will help us channel our efforts maximum effect, but the realisation that sustainability is not an alien concept has been and will continue be useful in communicating and embedding the new ways of working across the Trust. Health Welsh Blood Service Anaemia Management Caring for Carers, Patient Knows Best & Every Contact Counts Environment Obtain Building Research Establishment Environmental Assessment Method (BREEM) sustainability rating of Outstanding for all future building developments Positive impact of better transport planning Wales and the World Collaboration overseas - work in Ghana, Peru, Uganda and elsewhere Palliative care course in collaboration with Cardiff University 14 P a g e

15 Work which already supports the well-being goals Our determination do more support the health of our patients, our donors, their families and their communities illustrates the contribution we already make and will continue make the achievement of several of the well-being goals. By treating ill health, we help people remain in, and return, employment. This is fundamental the well-being of our population, as illustrated by the Chief Medical Officer s recent report, and also directly supports the realisation of a prosperous Wales. Allowing people continue contributing in a positive manner society will support the vision of a Wales of cohesive communities. Our efforts support the children of families affected by cancer, provides just one example of our concern for the long term health and well-being of the people of Wales. The Rebalancing healthcare report references an extensive evidence base that points the potential harm that adverse childhood experiences can cause both individuals and the wider community in the long-term. This, in part, motivated colleagues at the Velindre Cancer Centre produce the children s book, Caring for my Family with Cancer. We intend produce more in this series, translate the books in other languages and release an audio book. We are confident that the series will prove be a valuable resource in promoting the well-being of young people dealing with often traumatic events. This work lends weight our efforts create a healthier Wales, but we hope that it will have longer-term benefits, contributing wards a resilient Wales and a Wales of cohesive communities. We are a major employer. The well-being of our staff and their families is important us. We want create more highly skilled jobs across our organisation. Our renewed attention on research, development and innovation can be a focus for improved collaboration with other health care providers and educational institutions. We intend develop a Centre for Learning on the site of our new cancer centre and we will also host Health Technology Wales. Our approach should attract investment and serve as a catalyst for job creation which will also help the effort create a prosperous Wales. It is our intention that this work will directly benefit the health of future generations in Wales and beyond. The achievement of our ambition be acknowledged internationally as a centre for research excellence will help boost the nation s reputation and is absolutely in line with the vision of a globally responsible Wales. The Welsh Blood Service already has extensive international links and colleagues from Velindre Cancer Centre have conducted health needs assessment work in Uganda in collaboration with Public Health Wales. This work has provided valuable learning that, in turn, has benefited not only the people of Uganda, but our own population and serves illustrate the value of cooperation. We are acutely aware of the positive impact that we can have on our environment. Currently, we operate an extensive estate and we have ambitious plans build a new cancer centre. This is a large scale investment with long term implications for our patients, our staff and the communities in which we work. We intend pursue this development in an environmentally sensitive manner, adhering the strictest environmental guidelines and employing innovative 15 P a g e

16 construction techniques. We also want involve the local community in the development process. What next? Over the course of the next year, we will work raise awareness of the well-being goals, our own well-being objectives and embed the principle of sustainable development. Legislation is an important lever for effecting change, but making the well-being goals reality will take more. We will encourage behavioural and cultural change. In everything that we do, in the case of every relationship, we want ensure that a sustainable approach is our default position. We are determined make sustainability the norm. The Act is ground breaking and it is helping create an exciting new public service environment in Wales. As we embark on our journey, we expect make false steps, take wrong turns, but the safeguarding of our future is just o important an issue for us not be ambitious in promoting the well-being agenda. Our intention is focus our initial efforts on a set of the goals that relate areas in which we can have an immediate impact. The ambitious scope of our objectives and the imperative think in a genuinely long-term manner inevitably means that these objectives will evolve over time. We are determined develop new partnerships and it is likely that our own perception of what we can do improve well-being in Wales will change as a result of these new relationships. As an organisation, we continue actively contribute the formation of a new national sustainability network which is developing out of the existing Sustainable Development Coordinars Cymru peer resource for local authorities and national parks. This and other fora have served as useful spaces in which we have been able initiate positive conversations on collaboration and partnership working with other public secr bodies, particularly those from outside the healthcare ambit. We have already begun explore the possibilities for collaboration with other public secr bodies in Wales. Positive initial discussions have been held with Cwm Taf University Health Board with a view cooperating on the development of a health promotion agenda. We have also opened discussions with Public Health Wales. In addition the novel schemes be delivered in conjunction with other healthcare organisations which are beginning take shape, we are excited by the potential that the Act offers for partnership with bodies operating in other fields. We have had positive conversations with the Pobl group, a major provider of housing, care and support services across south Wales, about possible co-operation. We have also begun take forward work with the National Museum of Wales. With the Museum, we hope share learning on volunteering and explore possibilities for advancing work in social prescribing. Our intention is that this activity will have the effect of helping reduce the dependence of the population on services provided by NHS Wales by promoting well-being in ways that we haven t previously attempted, with partners that we may not have considered working with P a g e

17 previously. This is in keeping with the Chief Medical Officer s call for a greater emphasis on public, community and individual involvement in the maintenance of good health outlined Rebalancing healthcare. Our ambition has been informed by the Act and we are confident that our work in these areas will contribute wards the realisation of the well-being goals. Measuring our progress We believe that it is important acknowledge that our objectives represent only a first attempt define how we will support efforts made across the public secr realise the vision described by the well-being goals. This is a reality about which we want be tally transparent. We recognise that measuring progress against our objectives may present some challenges in the short term. The work realise the well-being goals set out in the Act will likely take place over decades. The impact of some of our sustainable activity, particularly with a longer-term scope, may be difficult interpret. We are, however, intent on developing a robust sustainability component that will integrate meaningfully with our existing performance management framework. This will help us understand our working environment, the possible effects of proposed actions and will offer our stakeholders an acceptable level of transparency. In measuring progress against our objectives we will, where appropriate, adopt indicars that we already collect. Elsewhere, we will consider how best appraise our progress and will develop new measures where possible. Matrices and ols have been developed by organisations concerned with sustainable development in the UK and elsewhere which aid reporting on sustainability focused performance. The adoption of existing ols or the development of our own are approaches that we intend explore, most likely in partnership with other bodies. In the short term, we intend identify a number of new projects and areas of work in the coming year that we will be able develop as case-studies which can be used illustrate and interrogate progress against our well-being objectives. 1.4 Community Health Councils (CHC) The Trust maintains excellent working relationships with all Community Health Council s within South East Wales as demonstrated by examples such as involvement with the Transforming Cancer Services Programme, complaints resolution etc. There is Community Health Council (CHC) representation at Trust Board which invites contribution service delivery and objectives as discussed at these meetings. The Executive Team attends Cardiff & Vale CHC meetings on a regular basis. P a g e

18 The Trust, in particular the Velindre Cancer Centre, is also subject regular unannounced visits from the Community Health Councils (CHC s) as well as planned Hospital Environment Assessment Team audits. The results of these have, on the whole, been very positive. 1.5 International Health Development The Trust hosts the South Wales Sierra Leone Cancer Care Group which consists of staff from oncology, palliative care and paediatric cancer services from across South Wales. Through the South Wales Sierra Leone Cancer Care Group a partnership between Velindre Cancer Centre and Connaught Hospital in Freewn, Sierra Leone, was established in Visits Sierra Leone spped during the Ebola outbreak but restarted early in 20. Grant funding was secured enable five visits for the delivery of training programmes about cancer care, pain management, ultrasound and chemotherapy. A Burkitts lymphoma treatment pathway has been developed, the National Cancer Registry at Connaught Hospital in Freewn established, and members of the Group have worked with the surgical department at Connaught Hospital develop a procol for the management of breast cancer. We supported the following staff, through Hub Cymru grants, provide training on cancer care health workers in Sierra Leone: 8 Consultants 4 Nurses 1 Pharmacist 1 Radiographer 5 visits 1.6 Long Term Expenditure Trends Long term expenditure trends have been included in the Accountability Report section of the Annual Report on page P a g e

19 2.0 Development Activity 2.1 Supporting children and young people Last year we ld you about our award winning children s book Caring for my family with cancer. This year we have established a specialist service aimed at supporting children and young people when a parent, care giver or family member has cancer. The Service, established in partnership with One Wales and Macmillan Cancer Support, focuses on helping parents and care givers continue support and care for their children whilst also coping with the impact of cancer. We know from research studies that many people with cancer find it very difficult talk about their diagnosis and treatment plans. Fear of saying the wrong thing, or fear about causing upset and distress can make it hard for families do this. 2.2 Research and Development The delivery and management of high quality research is a strategic priority within Wales, and viewed by the Trust as the second priority after clinical care. Research drives changes in healthcare, enabling us translate innovation in practice and provides our patients with the best in care and quality, often allowing access treatments that would otherwise not be possible. As a research active centre, we are key contriburs the local and national cancer recruitment targets. Velindre Cancer Centre holds a diverse portfolio of research across various disease sites, a mix of commercial and non-commercial studies. As of December 2015, there are 102 open studies (approximately 1/3 are commercial) and 387 recruited participants. The Research & Development (R&D) team support our Investigars achieve 100% of the Welsh Government Key Performance Indicar: provide NHS permission open recruitment within 40 days of submission. Work is ongoing, in collaboration with internal departments and external stakeholders, continue improve process and working practice ensure an efficient, effective, high quality service is provided. Examples of continuous improvement include working collaboratively with R&D offices set up overarching agreements that have reduced time start recruiting, and cross-organisational support for the handling of tissue samples; both changes reduce timeframes and open up swifter access for all patients. 2.3 Early Phase Trials Participation in Early Phase trials provides patients with access novel treatments, often in situations where there are no other treatment options. This service is a first for Wales; previously, Welsh patients have needed travel English Cancer Centres access these treatments. As of December, the early phase team recruited 35 patients in 11 trials, and are planning further expansion, and collaboration with colleagues at other centres. 19 P a g e

20 2.4 Radiotherapy Research within Radiotherapy, and Medical Physics, continues develop in both the clinical area and in the technical side. A number of new projects have opened, and are in development. Dr Tom Crosby, Consultant Oncologist, was invited bid for a charitable donation from the Moondance Foundation, and successfully secured 1.5 million, which was then matched by the Velindre Charity. The money will be used support a multi-professional team undertake Research & Development, service improvement, and establish new treatments and therapies. It is anticipated that the funding will innovate radiotherapy treatment. 2.6 Digital Health: Information Management & Technology (IM&T) During 20/20 the Informatics departments across Velindre NHS Trust have delivered a number of successes in terms of application enhancements, infrastructure resilience changes, establishment of core principles and processes for the management of business intelligence, and the introduction of new skills sets. Welsh Blood Service Following the successful implementation of the Blood Establishment Computer System (BECS) in May 2015, the Welsh Blood Service (WBS) became a national service in May 20. The transition of services from NHS Blood & Transplant WBS required a significant IM&T programme be delivered utilising various IM&T resources and skill sets in order deliver: New BECS functionality for the provision of a sck holding unit in North Wales Migration of approximately 90,000 donor records from NHSBT systems Development of an in-house Hospital Web Ordering Solution Development of an in-house Donor Appointment System Development of an aumated algorithm for donor eligibility Reconfiguration of a Donor Contact Centre Transition of the WBS website a mainstream content management system Deployment of a new IM&T infrastructure in North Wales, working in collaboration with Betsi Cadwaladr University Health Board (BCUHB) In addition this the Welsh Blood Service continued in its provision of ongoing project management and software development support for the implementation of the all-wales Laborary Information Management System (LIMS) for Blood Transfusion, Hiscompatibility and Immunogenetics and Welsh Bone Marrow Donor Registry modules. 20 P a g e

21 Velindre Cancer Centre Velindre Cancer Centre has also continued make good progress against infrastructure and project plans for the period, which are delivering improvements for staff, patients and the public who visit the hospital. During 20/20 the Cancer Centre has support the upgrade of core infrastructure for its primary electronic patient management system, Canisc. This is a substantial programme of work that has spanned two financial years and will be completed in Quarter 2 of 20/2018. Additional successes during 20/20 were as follows: Delivery a new data communication room within the Cancer Centre Refresh of infrastructure and cabling its network nodes rooms in the Cancer Centre Design stage of the Acute Oncology Mobile Application Meeting the amended Welsh Government targets for timely completion of clinical coding Completed design, build and initial rollout at VCC of central Managed Print Service, improve printer standardisation; printer security; rationalisation of devices; reduce ner scking; ner consumption and the volume of prints that are printed but not collected Readiness work underway support the Welsh Imaging Archive System Pilot Implementation of management processes support the National Intelligent Integrated Audit Solution (NIIAS) Change of patient address details proforma implemented ensure patient demographics held by the organisation remain accurate and kept up date Business Intelligence Business Intelligence has been an ambition for both divisions of the Trust for a number of years. In 20/20, the appointment of key individuals in divisional leadership roles has seen significant progress in this area. The key highlights are: Completed Procurement and initial build of the Trust Data Warehouse Service provide a modern information service backbone Initiated Data Warehouse Service design for delivery of dashboards Initiated designs and builds of regular Data Extracts from Canisc Data Warehouse Service in order maintain accessibility our legacy data and establish dashboard views of hisric data 21 P a g e

22 Infrastructure enhancements Supported by a significant capital investment from Welsh Government, the informatics team have been able enhance devices across the Trust, improve its IT security provision and develop enhanced resilience for some of its core services. The key highlights are: Agreed national design and procured for Wales Microsoft Office licensing as first steps wards revenue licensing model and cloud services (move away from hisrically capital funded licenses) Procured Web Content Filtering service refresh and extend existing service functionality Continued IMT infrastructure replacement programme improve network resilience and wireless access as support for handheld computing/mobile design and mobile telephony; Continued Trust IMT Equipment Replacement - Procurement of PCs, lapps 22 P a g e

23 3. Trust Organisational Development Strategy 3.1 Workforce Planning Our Organisational Development (OD) Strategy, Building Excellence, outlines how over the next 3-5 years the Trust will develop a culture that enables each of us be great and achieve the delivery of ambitious and exciting service change plans. Through conversations with staff we know we need a values driven culture where world class services are delivered by a workforce that understands the difference it makes the donor and patient experience. The Trust will deliver this through its resilience and flexibility, and a culture that encourages ambition and improvement and is agile and responsive change. With patient/donor care central everything we do, we have articulated through our Integrated Medium Term Plan (IMTP) a future that involves significant change the scope and expectations of service delivery. With change comes the opportunity modernise and redesign services and the workforce, and further strengthen collaborative relationships with patients and stakeholder organisations. Through the application of the prudent healthcare principles across the Trust, moving forward we will continue excel in the delivery of care and clinical services that are uniquely ours, while understanding how use the skills of our staff and available resources most effectively continue improve. During 20, the Trust has established Think Tanks or cross functional working groups form the backbone the implementation of the Building Excellence Strategy. They are a chance for every member of staff get their thinking cap on and directly help influence the transformational agenda required across the Trust over the next 3-5 years. One of the seven think tanks is Workforce Planning, this group will be tasked with identifying what excellence looks like in this area by researching evidence based best practice both within the NHS as well as exploring what other high performing public and private secr organisations do. 3.2 The sry behind our values Between April and July 2015, the Trust met with 145 staff in team meetings, received 4 online Building Excellence questionnaire submissions, 250 online Staff Pulse Survey submissions, and carried out interviews with 96 staff as part of our Invesrs in People reaccreditation process. Everything that staff have ld us has been distilled in four organisational values, these values are for all staff, whether staff are working at the Welsh Blood Service, Velindre Trust HQ or Velindre Cancer Centre. We are working explore new ways of working and making the best use of people and advanced roles provide better services. 23 P a g e

24 3.3 Healthy Working Wales Corporate Health Standards We achieved Gold in the Healthy Working Wales Corporate Health Standards for many years, and this year we were very pleased be awarded a Platinum award. The Corporate Health Standard supports the development of policies that promote good practice assist businesses and organisations take active steps promote the health and wellbeing of staff. The Standard is awarded at different levels: Bronze, Silver, Gold and Platinum. It begins at bronze level recognising where activities and policies that comply with legislation and address key workplace risks employee health are in place. Platinum is reserved for exemplar employers who demonstrate business excellence and take full account of their corporate social responsibility. 20 NHS Wales Staff Survey: Staff answered more positively than in the last survey in 2013 on 90% of questions asked, and 78% of our scores exceeded the overall NHS Wales score. Key survey themes for the Trust include: We are particularly proud that 75% of staff would recommend the Trust as a place work, 93% say that if a friend or relative needed treatment, they would be happy with the standard of care provided by the organisation, and 87% of colleagues say that they are proud tell people they work for The Trust. The majority of scores relating line and senior managers have improved since 2013 e.g. 82% of staff say that their line manager treats them with respect (up from 76% in 2013); and 76% of staff say that senior managers are committed patient care (up from 66% in 2013). 84% of staff say that they know who senior managers are in the Trust, but only 32% say that communication between senior managers and staff is effective and we need address this. Many scores on health, well-being and safety at work have improved since 2013, but there are still areas for us review e.g. 13% of staff say that they have experienced harassment, bullying or abuse at work from their manager/team leader or other colleagues. Levels of work-related stress have improved slightly since 2013, so this is an area that we will maintain focus on in the coming year. 60% reported that they are able make improvements happen in their area of work. We are proud of our positive results, but remain committed focussing on areas that staff have said could, and should, be improved. 24 P a g e

25 4. Performance Summary 4.1 Velindre Cancer Centre Core activity during The following info graphics provide a snapshot of the core activity of Velindre Cancer Centre for the period The Velindre Cancer Centre provides specialist non-surgical oncology services patients from South East Wales, including chemotherapy, radiotherapy and specialist palliative care. 25 P a g e

26 4.1.2 Velindre Cancer Centre - Assessment of 20/20 Successes, key issues and risks 20/20 has been an extremely busy and successful year for the cancer centre; we have continued deliver excellent care and support our patients, their carers and their families despite increasing demand and pressure upon key services. This is a testament our hardworking, caring and dedicated staff who continue go the extra mile ensure high quality care; we are extremely proud look back over the year and see all of our achievements in improved patient care and treatment techniques. Velindre Cancer Centre: Summary of key achievements in 20/ Implementation of new radiotherapy techniques Improving patient accommodation and services Implementation of a second Stereotactic Body Radiation Therapy (SBRT) capable Linear accelerar Introduction of the STAMPEDE trial The PR07 trial Early phase trials CHHiP Development of key strategies Improved horizon scanning and commissioning of new drugs Implementation of new radiotherapy techniques: we have continued treat patients that would have previously travelled England for Stereotactic Body Radiotherapy (SBRT) and Stereotactic Radiosurgery (SRS), we have achieved our target of treating 35% radical patients with Intensity Modulated Radiotherapy (IMRT) and have increased the use of Image Guided Radiotherapy (IGRT) through clinical trials and local initiatives. Improving patient accommodation and services: we have completed the refurbishment of First Floor inpatient ward and have provided free Wi-Fi for all people within the Velindre Cancer Centre. Implementation of a second SBRT capable Linear accelerar: In Ocber 20 we successfully implemented a new linac with SBRT functionally. We are one of only a small number of cancer centres in Europe with this functionality. Introduction of the STAMPEDE trial: the outcomes of this trial identified a change in drug treatment (Docetaxel) that will improve outcomes with a recommendation change standard of care. 26 P a g e

27 The PR07 trial: the results of this trial reported benefit in survival and firmly establishes the role of radiotherapy in the treatment of men with locally advanced prostate cancer. Early phase trials: participation in Early Phase trials provides patients with access novel treatments, often in situations where there are no other treatment options. This service is a first for Wales; previously, Welsh patients have needed travel English cancer centres access these treatments. CHHiP: we have been involved in the largest ever study of prostate radiotherapy. Results have shown a significant improvement in outcomes through the halving of xicity and relapse rates, which have a significant impact upon patient outcomes and well-being. Development of key strategies: we have developed and published two key strategies which will help drive the service forward. Shaping the Future Together sets out five strategic aims and how they will be delivered: 1. Equitable and consistent care, no matter where. 2. Access state-of-the-art, world-class, evidence-based treatments. 3. Improving care and support for patients live well with cancer. 4. To be an international leader in research, development, innovation and education. 5. To work in partnership with stakeholders improve prevention and earlier detection of cancer. Shaping the Future of Radiotherapy sets out the Cancer Centre s ambition become an internationally recognised Centre of Excellence for Radiotherapy. The Strategy is underpinned by seven aims and sets out how they will be achieved: 1. Every patient has access the best treatment appropriate for them, which is timely and delivered in the most efficient and effective way possible. 2. The radiotherapy service will be at the forefront of technological advances through its continual assessment and adoption, for the benefit of all patients. 3. An integrated and empowered workforce that is motivated, values driven and innovative. 4. A service that is maintained and future proofed with effective and appropriate funding enable clinical, technological and research developments. 5. To expand radiotherapy research through effective leadership, resources and investment. 6. A high quality service which utilises comprehensive data, evidence based practice and research drive forward innovations. 7. Establish a culture of collaborative working and partnership that reflects and prioritises the values of the organisation. 27 P a g e

28 Improved horizon scanning and commissioning of new drugs: the unprecedented number of new additional drugs becoming available NHS Wales during 20/20 identified the need for improved horizon scanning and planning for the introduction of drugs, given their capacity implications. Ongoing challenges There are a number of challenges we face as an organisation, how we are addressing these can be found in our three year plan but they have an impact on how our services deliver and perform. Cancer incidence is increasing There is variation in cancer related outcomes throughout Wales and we need help close the gap There is growing demand for services and we must ensure that we have the ability treat and care for patients Treatments are becoming more complex and new advances are always emerging More people are living with and beyond cancer and need achieve best possible quaility of life and experience Resources are scarce and we must make the best of our resources We are working within a wider policy context and must ensure we are aligned There are a number areas that have not progressed as we had planned during 20/20 for various reasons. These include: Delivering chemotherapy at home and in the community - Whilst this piece of work was delayed at the start of the year, we are currently exploring the possibility of progressing procurement as a standalone organisation. Radiotherapy capacity: The most significant risk in the immediate medium term is the ability deliver the required levels of service for patients requiring 28 P a g e

29 radiotherapy. The increasing demands on the radiotherapy service, both in terms of patient numbers and complexity/time, cannot be met consistently within existing resources and through existing service models. The immediate risk is that with current radiotherapy resources we will be unable continue absorb the circa 4% annual increasing demand for radiotherapy in Wales and also the hisrical peaks in demand during September/Ocber and January/March. The impact of this will mean that we will be unable provide Radiotherapy treatment patients within the waiting time targets. Inability achieve these waiting times may compromise clinical quality, patient outcomes and patient experience as patients may be required wait longer for their treatment. Trust officers are currently pursuing a range of actions mitigate this risk and explore new and more efficient ways of working. The Trust developed a Business Case during 20/, in collaboration with Local Health Boards, for approximately 1 million per annum in revenue funding staff an additional Linear Accelerar (LINAC). This is still under discussion with commissioners. Increase radiotherapy access the appropriate rate for patients with cancer within our resident population - This work slowed down at the beginning of the year due competing priorities and limited capacity and resource take forward the work, however, a bid was submitted the Cancer Pathway Innovation Fund provide project support which was successful. Chemotherapy capacity: For several years demand for Systemic Anti-Cancer Treatment (SACT) has been growing, requiring increasing levels of capacity and resources deliver the service. This has proved challenging, but manageable within Velindre Cancer Centre (VCC) ways of working, including delivery of services within outreach settings. We believe that 20/2018 will be the year in which a step-change will occur, and that actual demand will outstrip the projected 5% per annum demand increase due the increasing number of approvals for new drugs/indications and the significant service implications associated with delivering these particular drugs. Until late summer of 2015, there was sufficient capacity in the service for VCC absorb the incremental increases in workload that were felt from the introduction of new drugs NHS Wales. However, as the SACT service is currently working capacity, absorbing increased demand without additional funding will not be possible without compromising patient safety, staff morale and service performance. There is therefore risk that Velindre Cancer Centre will be unable deliver new indications within the guideline period following publication given the lead in time secure funding and recruit staff. We are working with our partners in the challenging task of improving joint horizon scanning of new drug approvals, identifying opportunities deliver care closer 29 P a g e

30 home or at home where appropriate and further develop processes for modelling the implications of new drug approvals across patient pathways. An example of this is the planned introduction of docetaxel chemotherapy for patients with prostate cancer which has required the Velindre Cancer Centre write a business case seek funding from the local health boards. Junior Medical Staffing. The current levels of medical staffing are not considered optimal in relation the provision of training for all junior docrs, including new entrant levels (Senior House Officer (SHO). Work has commenced identify optimum staffing levels and operational day day activities that will assist in achieving the highest level of training and work experience for all staff. The situation is being monired monthly and plans are being developed fill the current gaps in the rota. However, despite a number of pressures on the service, the Cancer Centre has continued meet many of its performance ambitions for the year. Pressure ulcers: although low in number we have experienced an increase in pressure ulcers. We continue undertake a root cause analysis for each incident and monir themes that emerge. Hand hygiene: we will continue seek improve hand hygiene standards through close moniring and targeted action plans. 30 P a g e

31 4.2 Welsh Blood Service Core activity during The following info graphics provide a snap shot of the core activity of the Welsh Blood Service for the period The Welsh Blood Service collects voluntary donations from the general public across Wales which are processed, tested and distributed cusmer hospitals. The Welsh Transplantation & Immunogenetics Laborary, within the WBS, operates the Welsh Bone Marrow Donor Registry and provides direct support providers of Renal and Stem cell transplantation. 31 P a g e

32 4.2.2 Welsh Blood Service Assessment of Successes, key issues and risks 20/ has been an extremely busy and successful year. We have continued deliver excellent care and support our donors. Some of our achievements are noted below. Welsh Blood Service: Summary of Key Achievements in 20/ Implementation of a pan Wales Blood Service Delivered a safe and effective supply hospitals in Wales Delivered a Modern Donor Contact Centre Significantly increased Blood Stem Cell Donations Maintained Quality and Safety Listened from Donor Feedback The implementation of a pan Wales Blood Service: successfully achieved in May 20. This represents a major programme that has seen the Welsh Blood Service expand cover the whole of Wales with an increase in its geographic coverage by over 33%; increased the provision of our services an additional 676,000 people; serve the largest university health board in Wales; and sees us process approximately 25% additional units of blood at our Talbot Green headquarters. The benefits of this change are now coming fruition which include an annual saving of 500,000 for the NHS in Wales, has created jobs and more effective national planning across NHS organisations. Delivered a safe and effective supply hospitals in Wales: we have safely delivered the required amount of red blood cells, platelets and commercial products worth over 8m via a Good Manufacturing Practice (GMP) compliant cold chain hospitals. Delivered a Modern Donor Contact Centre: a project improve telephony and donor contact services support the recruitment and retention of donors throughout Wales has delivered a redesigned staffing model which provides multi-functional roles. This is improving the efficiency and effectiveness of the Welsh Blood Service (WBS) donor contact services and increasing the capacity for Welsh Language services. We also introduced 32 P a g e

33 significant technological advancements support this service change which included improved contact management systems, enhancements the website, and improvements our Information Technology (IT) infrastructure and the introduction of an electronic in house appointment system as the initial stages of a programme of ongoing digital development. Online Appointment Booking Service: in January 20 the Welsh Blood Service launched an Online Appointment Booking Service for blood donors. The new service has been well received by donors, and 2518 appointments were made using the system in its first full month of operation. It is hoped that the online appointment booking service will help bolster the number of new and returning blood donors, new platelet donors, and people willing sign up the bone marrow register. Significantly Increased Blood Stem Cell Donations: During the year we marked the 1000 th bone marrow donation collected in Wales since The achievement was celebrated at the Wales in the World event held at the Senedd. The Welsh Bone Marrow Donor Registry (WBMDR) supports patients world-wide. Currently, the WBMDR has over 64,500 potential donor volunteers on the register and receives around 24,000 search requests each year. Stem cells and bone marrow is exported over 30 countries across the globe. WBS Direcr Cath O Brien said: We are truly inspired and proud of our 1000 donors whose generous donations have helped so many patients in Wales and all over the world. This special event celebrated what is an amazing achievement by everyone involved with the Welsh Registry. Maintained Quality and Safety: we successfully retained all operating licenses and made good progress further extend our external accreditation. This is testament the dedication and commitment of our staff continually raise standards for quality improvement year on year. In addition, we have continued provide specialist advice and support a number of other NHS Wales organisations. Delivered Additional Testing: following new advice from the Advisory Committee on the Safety of Blood Tissues and Organs we introduced testing for Hepatitis E on a selection of our products, delivering an additional 11,000 tests. Listened and Learned from Donor Feedback: our donor feedback has been instrumental in changes we have made clinic opening times and has been used support the introduction of appointment systems at an additional number of our clinics. Donor feedback has also been facred in further improvements our new blood establishment computer system. Work is also continuing support embedding donor feedback in wider service improvements. For example, at Port Talbot we have extended our opening hours make it easier donate in the early evening. Being able make an appointment suits an increasing number of our donors and as a result we have introduced appointments for the first time at several venues such as Brecon and Carmarthen as well as launching a live on-line booking system. This system enables bookings be made 24/7 for all sessions with appointments and donors are able search venues by date and distance provide them the widest choice. 33 P a g e

34 The Welsh Blood Service R&D Strategy was approved by the Trust Board on 24th November 20. The strategy seeks advance donor care and transfusion and transplantation medicine through inception and participation in high quality health services research. The strategy has four themes: Donor Care and Public Health Transplantation Products Therapies. The WBS wants be an organisation where high quality research and development is performed as part of normal day--day activity and a programme of research and development. By the end of 20 we aim build Research & Development capability and capacity across the WBS, and set out a programme of collaborative projects in each of the above themes. A new Blood Health Plan has been developed provide renewed focus activity maximise the appropriate use of blood components and products. There are three core aims which lie at the heart of this plan. They draw on the principles of prudent healthcare and the unique characteristics of NHS Wales, a planned system with quality at its core: 1. Supporting individuals manage their health and wellbeing, avoiding unnecessary intervention. 2. Using evidence and transparent data drive service planning and improvement reduce inappropriate variation. 3. Avoid harm, placing safety and quality at the core of care. Ongoing challenges The Donor Panel is shrinking We must meet demand for blood and blood products We must meet stringent blood selection guidelines and regulary requirements Science and the scientific workforce is changing 34 P a g e

35 We recognise that there are still considerable challenges meet in ensuring the service remains fit for purpose now and for the future. Work needs be taken forward in a number of areas: Alignment of blood collection models: we will continue work fully align the service models for blood collection in north and south Wales embed a truly national service. Blood Establishment Computer System (BECS): further development is required streamline the system s current functionality and meet the ever increasing regulary burden. Declining Blood Donation Rates: we need address the decline in rates of blood donation that is being observed by the WBS, a phenomenon that blood services around the globe are currently experiencing. Key this is the need review the donor experience and update the technology we use engage with donors Mitigating and managing risk Where appropriate key risks are escalated the Trust Risk Register. Further information on the risk management strategy and key risks on the risk register as at the 31 st March 20 are contained within the Governance Statement section of the Accountability Report, see page 25 onwards. 35 P a g e

36 4.3 Listening and learning from patient / Donor feedback Velindre Cancer Centre We believe that patient experience is not just about a survey or a buzzword. This is about a shared commitment listening & learning across the whole organisation. It is fundamental that everyone understands and values the importance of delivering an excellent patient experience which is embedded within our culture. Real Time All-Wales Patient Experience Survey (face face interviews) I want great care Fundamentals of Care Observations of Care for Protected Mealtimes Evaluations & Taste Testing for Oral Nutrition Supplements Retrospective All Wales Radiology Patient Satisfaction Survey All Wales Patient Menu Survey Velindre Improvement Process Departmental Surveys Treatment Outcomes are measured by individual professionals and across Site Specialist Teams CHC and patient attendance at Trust Board Meetings Proactive / Reactive All Wales Patient Survey (online and hard copies be made available) Patient Experience website page be refreshed Patient Concerns Comment Cards Visirs comment books Patient Sries Patient Liaison Group Balancing 3 rd party surveys (e.g. Community Health Council, MacMillan) Walkrounds (e.g. Older Persons Commissioner, Community Health Council, Executive Walkarounds) VCC Facebook page VCC Twitter Channel 36 P a g e

37 Patients' Overall Experience 100% 80% 60% 40% 20% 0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Rated 9 or above % Target Someone Else s Shoes: The Velindre Cancer Centre launched a new audio podcast called Someone Else s Shoes. The podcast aims increase understanding and enable learning and opportunities for improvement through sharing patient, care and staff sries. In the first podcast David talked about his diagnosis and the importance of his faith. In the second, Linda shared her experience of A&E, radiotherapy at Velindre Cancer Centre, and the Macmillan Activity Programme. You can listen and subscribe here. You can view Welsh Blood Service patient and donor sries here. I have been attending Velindre since September, first for chemotherapy and now for radiotherapy. The care and kindness are second none, they really sum up the phrase Tender Loving Care. I ve just finished 20 sessions of radiotherapy. I was in LA5 and the team were amazing! They made me feel so relaxed and unafraid of the whole process. I really enjoyed seeing them every day. I will miss them dearly. Creating a good Patient Experience.. 1. Every role matters 2. Every interaction matters 3. Every perception matters 4. You matter 37 P a g e

38 We asked: Was there anything that we could change improve your experience? Patients said: Better TVs A map find my way around Display waiting times We did: Purchased TVs for the day unit; Introduced clear signage and maps Fitted display screens in the reception areas of the outpatient and radiotherapy departments that will be used show waiting times. Welsh Blood Service Our volunteer donors are the heart of the Welsh Blood Service - we could not provide our lifesaving blood donation programme without them. We know that secure their ongoing support we need ensure that each donor has a positive experience of our blood collection service each time they donate. How are we listening? At clinics - either face face with our staff or via compliment and concern cards. Social Media - Our Twitter and Facebook feeds have donors regularly interacting with the service. Website - Our website offers both a donor enquiry form and direct access the Welsh Blood Service. Donor Survey - A proactive donor satisfaction questionnaire sent donors via , 5 days after their attendance at a clinic. 38 P a g e

39 @givebloodwales 53 rd donation day in Rhiwbina. Good service and great Staff! Thank you #feelgoodfriday The lady who was training put needles in on the th in Port Talbot did a cracking job, no bruise. Well Done. We asked: Was there anything that we could change improve your experience? We used donor feedback : Make changes clinic opening times Introduce an appointment system in some clinics Inform some improvements our new blood establishment computer system 39 P a g e

40 4.4 Learning from concerns During 20/ we investigated all complaints and concerns in accordance with the NHS Concerns, Complaints and Redress Arrangements (Wales) Regulations 2011, and shared our findings openly and honestly with patients, their families, donors and staff. As in previous years we noted that complaints about the Cancer Centre were often complex and related more than one issue. Many of the concerns about the Welsh Blood Service were about clinic opening and waiting times. 25 Trust Concerns Received During VCC WBS Corporate We view each complaint as an opportunity learn and improve our services. Examples of changes we have made following a complaint include: Increasing the availability of the chemotherapy pager service provide 24 hour access for patients with treatment related sympms or concerns Introduced a standard for blood glucose moniring in pancreatic cancer patients enable prompt detection and treatment of diabetes Enabled donor feedback and concerns be considered as part of an ongoing review of clinic efficiencies and accessibility. All lessons learned from concerns are reviewed by our Organisational Learning Committee. Within the Welsh Blood Service we have developed a donor compliments and concerns dashboard improve shared learning across all of our blood collection teams. 40 P a g e

41 5. Performance Analysis We have developed a wide range of measures which are routinely used monir the quality and performance of our core services. The core measures for Velindre Cancer Centre and the Welsh Blood Service are included in the tables below. Performance trends in respect of these targets are included in Appendix 1. The performance summaries are explored further with supporting narrative in the Trusts performance reports received by the Trust Board. These papers are available on the Trusts internet site via the following link: 41 P a g e

42 5.1 Velindre Cancer Centre (VCC) Performance metric Target 14/15 15/ / Radiotherapy % of patients commencing radical Radiotherapy within 28 days % of patient commencing palliative Radiotherapy within 14 days % of patient commencing emergency Radiotherapy within 2 days 98% 95% 98.5% 98% 98% 95% 98.5% 99% 100% 99% 100% 100% Linac Up-time 95% 96% 95% 98% SACT % of patients commencing nonemergency chemotherapy within 21 days % of patients commencing emergency chemotherapy within 5 days Death within 30 days of Chemotherapy rates 98% 98% 99% 99% 100% 95% 100% 100% <2% N/A 1.5% 1.6% Outpatient % of Outpatients seen within 20 mins n/a 43.5% 49% 50.2% % of Outpatients seen within 60 mins n/a 79% 88% 87.2% % of Outpatients seen within 90 mins n/a 87% 96% 96% Workforce Infection, Prevention & Control Velindre Cancer Centre Sickness absence rate No. of Velindre acquired infections MRSA No. of Velindre acquired infections MSSA No. of Velindre acquired infections C.Difficile 3.54% 3.61% 4.1% 3.7% No. of Velindre acquired Pressure Ulcers Patient Experience Hand hygiene compliance Inpatient areas Hand hygiene compliance Noninpatient areas % of patients overall experience rated 9 or above 95% 93% 81% 82% 95% 77% 88% 85% >80% N/A 85% 85% 42 P a g e

43 5.2 Welsh Blood Service (WBS) Performance metric 2014/ / 20/ Target Actual Target Actual Target Actual 7,300 new Bone Marrow Volunteer (BMV) registrations 100% of new Bone Marrow Volunteers (BMV) samples aged * 3,000 6,090 3,000 2,359 3,294 3,313 30% 56% 100% 100% 100% 100% 98% of commercial product requests met 98% 99% 98% 98% 98% 1 96% 90% deceased donor typing / cross matching reported within 6 hours 90% Anti-D & -c Quantitation results provided cusmer hospitals within 5 working days 90% routine antenatal patient results provided cusmer hospitals within 3 working days 80% samples referred for red cell reference serology work up provided cusmer hospitals within 2 working days Reduce number of reportable SABRE events from (8) (5) Maintain 100% close SABRE reports MHRA within 30 days 71% of blood donors scoring 5 or 6 out of 6 for satisfaction with overall service 100 % of concerns answered within 30 days 90% 100% 90% 100% 90% 100% 90% 97% 90% 98% 90% 97% 90% 97% 90% 96% 90% 99% 80% 86% 80% 88% 80% 82% % 100% 100% 100% 100% 100% 69% 74% 70% 75% 71% 89% 100% 97% 100% 100% 100% 100% <7% time expired platelets <7% 4.6% <7% 4.3% <7% 11.29% <0.5% volume of waste (red cells) <0.5% 0% <0.5% 0.1% <0.5% 0.5% <6% tal losses prior issue previously 5 <9% 8% <6% 5.2% <6% 4.4% 1 This was due a national shortage of a specific wholesale product 43 P a g e

44 5.3 Progress against our three year plan The Trust has made considerable progress and achievement with the objectives and priorities it set out deliver during 20/. Some areas such as Information Technology systems have progressed slower than we expected with some issues outside the Trust s direct control. These objectives have been strengthened and refined for the plan. Further detail is available in Our Three Year Plan which is available on the Trust Internet Site via the following link: Progress against our three year plan objectives are reported the Planning & Performance Committee and Trust Board in our Delivering Excellence Performance Report. These reports for are available on the internet site via the following link Progress against Performance Progress against: Equitable and timely access targets Performance during 20/ has been of a high standard and is in line with our continued intention deliver the best possible services. Areas not meeting set levels have been and are subject continued scrutiny and actions are being taken forward improve. Appendix 1 sets out the key measures and performance trend over 20/. Progress against: Waiting times and access services During the year we saw increased demand for radiotherapy and chemotherapy services provided in the Velindre Cancer Centre. Our staff worked hard meet the increase in demand and we are exploring new ways of working reduce waiting times and improve access our services. Progress against: Radiotherapy We achieved our target of seeing 100% of people referred for emergency radiotherapy within 2 days every month but we know that we didn t always see people referred for radical and palliative radiotherapy as speedily as we would have liked. We have been trying out different staffing models and extended opening hours test if they make a difference waiting times and will continue explore new ways of working in addition a business case for an additional Linear Accelerar (LINAC) increase our capacity. We are still having discussions with our commissioners increase capacity. 44 P a g e

45 100% Radical Radiotherapy 98% 96% 94% 92% 90% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % within 28 days % Target 100% Palliative Radiotherapy 98% 96% 94% 92% 90% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % within 14 days % Target 100% Emergency Radiotherapy 80% 60% 40% 20% 0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % within 2 days % Target 45 P a g e

46 Utilisation of Linear Accelarar (LINAC) time was good during 20/ and this ensured waiting times for patients were maintained whilst minimising disruption for patients where-ever possible. 100% Linear Accelerar Availability - PD Uptime 98% 96% 94% 92% 90% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- PD Uptime % Target 100% Linear Accelerar Availability - Linac Uptime 98% 96% 94% 92% 90% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Linac Uptime % Target 46 P a g e

47 Progress against: Chemotherapy The charts below show we have mostly been able start chemotherapy within the target time that we set for ourselves. We are always striving continuously improve our services. For example we are currently reviewing our pharmacy services see if a different way of working will help with the chemotherapy waiting times. The increase in approval of new drug and treatment regimens has increased pressure on the service but we have continued explore how we can deliver these services patients. 100% Emergency Chemotherapy 98% 96% 94% 92% 90% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % within 5 days % Target 100% Non-Emergency Chemotherapy 98% 96% 94% 92% 90% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % within 21 days % Target Progress against: Access therapy services During 20/ we have undertaken a review in therapy waiting times and are in the process of introducing a revised collection process focussing on patient outcome in addition access services. 47 P a g e

48 Progress against Safe and reliable services target Hospital Acquired Infections: We have continued maintain our low rates of hospital acquired infections. C.Difficile: Methicillin-Resistant Staphylococcus Aureus (MRSA): Methicillin-Sensitive Staphylococcus Aureus (MSSA): Compliance with our Skin Care bundle has been varied during 20 - however this is an area where we have been undertaking action and will continue work on. There are measures at Velindre Cancer Centre where further work is ongoing improve what we do but the overall services provided by the Velindre Cancer Centre and Welsh Blood Service continue be of a high quality, focusing on excellent patient and donor care. 48 P a g e

49 100% Hand Hygiene Compliance - In-Patient Areas 80% 60% 40% 20% 0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- First Floor ASU CIU % Target 100% 80% 60% 40% 20% 0% Hand Hygiene Compliance - Non In-Patient Areas Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- CDU RDU CTU Outpatients Radiology Radiotherapy % Target Progress against: Collecting enough blood Thanks the amazing support from our loyal and dedicated donors throughout the year we always collected enough blood and platelets meet the demand from hospitals in Wales. Progress against: Bone Marrow Donations In last year s Annual Quality Statement we ld you how pleased we were with the increasing number of people volunteering on the Bone Morrow register. The number of donations fell during 2015/ but we are pleased say that wards the end of 20/ we increased the number of people we recruited above our anticipated level Number of New Bone Marrow Volunteer Registrations - South Wales Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- New Bone Marrow Volunteers (BMV) registrations per month in South Wales Target (292 per month as of September ') 49 P a g e

50 Progress against: Welsh Blood Service meeting demand During 20/ demand for whole blood and platelets has been met. 100% 80% 60% 40% 20% % Red Cell Supply Meeting Demand 0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Collections Sck Importation from NHSBT % Target % Platelets Supply Meeting Demand 100% 80% 60% 40% 20% 0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % Platelets Supply Meeting Demand % Target Progress against: Meeting Transplant services requests Performance was met for this measure during 20/. 100% Turnaround Times (Deceased Donor Typing/Crossmatching Reported within 6 Hours) 50% 0% 20- Q1 20- Q2 20- Q3 20- Q4 % Deceased Donor Typing/Crossmatching Reported within 6 hours % Target 50 P a g e

51 Co-ordination and importation of national and international haemapoietic stem cell donations for patients transplanted in Wales performance continues exceed the target with all reports issued within the timeframe for this critical service which is delivered 24/7. 20/ saw a record number (38) of allogeneic transplants supported by the Hiscompatability & Immunogenetics (H&I) lab and Welsh Bone Marrow Donor Registry (WBMDR). Turnaround times remain on track and above targeted performance levels. Progress against: Red cells issued WBS has set itself a target of 60% of all red cells issued be less than 14 days old allow sufficient srage time for our cusmer hospitals manage appropriate sck levels. Performance lower than 60% is due higher collections and the transitional support being supplied by NHS Blood and Transplant leading high sck levels in preparation for go-live of the Pan Wales Blood Service Programme in May % 80% 60% 40% 20% Red Cells Issues less than 14 Days Old 0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Red Cells Issues % Target Part bags - work continues reduce part bags where-ever possible. There are various reasons that a donation may need be spped before reaching the required volume including venepuncture technique, donors feeling unwell or an equipment failure. 4.0% % Part Bags 3.0% 2.0% 1.0% 0.0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % Part Bags % Target 51 P a g e

52 Unsuccessful venepuncture, maintaining this target for venepuncture is essential in ensuring sufficient blood is delivered meet service need. This is an excellent achievement during 20/. 3.0% Unsuccessful Venepuncture 2.0% 1.0% 0.0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % Unsuccessful Venepuncture % Target Progress against: First class patient and donor experience target Our patient and donor feedback is largely positive. The Trust has worked improve the way it collects and receives feedback from those who use our services. Work understand, and collate themes allow improvement in areas is critical in terms of using patient views, comments and suggestions make changes and develop services. Only two months during 20/ was below required levels. Patients' Overall Experience 100% 80% 60% 40% 20% 0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Rated 9 or above % Target Concerns, incidents and severity - whilst numbers have been low the Trust takes its resonsibility learn from and take action from any concern or incident. 52 P a g e

53 200 VCC Concerns Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Incidents Complaints Claims Welsh Blood Service donor satisfaction durng 20/ has mostly been above the set level. The importance of learning from donor feedback remains paramount. 100% Donor Satisfaction 80% 60% 40% 20% 0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % Donors scoring 5 or 6 out of 6 for satisfaction % Target Progress against: Supporting our staff excel target Our workforce measures for sickness absence and Personal Appraisal Development Reviews (PADR) were not met during 20/; this is an important area that the Trust is working improve. Detailed analysis understand areas that need particular focus has been undertaken and actions are in place try and improve. These measures are also subject scrutiny at committee and Trust Board level. 53 P a g e

54 Trust (excl. hosted) PADR's 100% 80% 60% 40% 20% 0% May-15 Apr- Jun-15 May- Jul-15 Jun- Aug-15 Jul- Sept-15 Aug- Oct-15 Sept- Nov-15 Oct- Dec-15 Nov- Jan- Dec- Feb Jan- Mar- Feb- Apr- Mar- % Reviews Complete % Target VCC PADR's 100% 80% 60% 40% 20% 0% May-15 Apr- Jun-15 May- Jul-15 Jun- Aug-15 Jul- Sept-15 Aug- Oct-15 Sept- Nov-15 Oct- Dec-15 Nov- Jan- Dec- Feb Jan- Mar- Feb- Apr- Mar- % Reviews Complete % Target WBS PADR's 100% 80% 60% 40% 20% 0% May-15 Apr- Jun-15 May- Jul-15 Jun- Aug-15 Jul- Sept-15 Aug- Oct-15 Sept- Nov-15 Oct- Dec-15 Nov- Jan- Dec- Feb Jan- Mar- Feb- Apr- Mar- % Reviews Complete % Target Sickness rates - work is ongoing ensure sickness rates improve and that staff are supported across the Trust. 54 P a g e

55 Trust (excl. hosted) Sickness/Absence Rates 5.5% 5.0% 4.5% 4.0% 3.5% 3.0% Apr-15 Mar- May-15 Apr- Jun-15 May- Jul-15 Jun- Aug-15 Jul- Sept-15 Aug- Oct-15 Sept- Nov-15 Oct- Dec-15 Nov- Jan- Dec- Feb Jan- Mar- Feb- Velindre NHS Trust (excluding hosted) Corporate Services Velindre Cancer Centre Welsh Blood Service Progress against: Spending every pound well target The Welsh Blood Service measures under this area remained low which was positive during 20/. 20% Time Expired Platelets 15% 10% 5% 0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Time Expired Platelets % Target Volume of Waste (Red Cells) 0.6% 0.5% 0.4% 0.3% 0.2% 0.1% 0.0% Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- % Volume of Red Cells Waste % Target A summary of performance trends are captured in Appendix 1 of this report on page P a g e

56 6. Sustainability Performance The Trust recognises that in our day--day operations we impact upon the environment in a number of ways and therefore should report upon our potential impacts in a responsible manner. Sustainability reporting is an essential part of organisational governance in the public secr in Wales and the Welsh Government s aim is enable integrated reporting. For 20/ public bodies in Wales, which report under the FReM (Financial Reporting Manual), are required produce a FReM Sustainability Report. The environmental sustainability agenda is taken forward in a structured manner and supported by strong governance arrangements. The Direcr of Planning, Performance and Estates is the lead officer for environmental sustainability within the Trust. One of the Trust Board Independent Members is the Environment Champion and works closely with the Direcr of Planning, Performance and Estates and Trust Board progress this important agenda. The Assistant Direcr of Estates, Environment and Capital Development and the Environmental Development and Compliance Officer, provide the Trust with additional capacity and capability take forward the ambitious work programme. The planning and delivery arrangements related sustainability within the Trust are set out below. Trust Board Lead Direcr / Independent Member Planning and Performance Committee Quality and Safety Committee Trust Sustainability Group Divisional / Cancer Centre Quality and Safety Group Divisional / Hosted Organisation Energy and Environmental Forum The following tables, data and narrative set out the Trusts performance in sustainability for 20/ and compare it against previous years. In the reporting of emissions the revised 2013/14 20/ Defra grid average conversion facrs have been applied. This has been adopted enable more accurate annual emission comparisons and will continue in future reports following Defra guidance. 56 P a g e

57 The Trust recognises the need establish robust and accurate data enable it set realistic targets and manage data effectively. The Trust continues make progress in this area but recognises there is more work be done. Comparison of 20/ data against data prior 2015/ identified the following data anomalies: Additional data has now been included for NHS Wales Informatics Service (NWIS) and NHS Wales Shared Services Partnership (NWSSP) for both 2015/ and 20/, except NWSSP waste data for 2015/ due data availability issues. As this data has only been included in the 20/ report a number of indicars have shown a significant increase when an annual comparison has been applied. In order allow a direct comparison against the previous year s data, a comparison that excludes NWIS and NWSSP organisation data has also been included in the report (shown in brackets). Gas, water and waste data for leased buildings has been estimated due no information being available as part of the lease agreement. Green House Gas Emissions Non-Financial Indicars (1,000 tco2e) Total Gross Emissions Total Net Emissions Gross Emissions Scope 1 (direct) Gross Emission Scope 2 & 3 (indirect) , , , , , , , , Related Energy Consumption (million kwh) Electricity: Non Renewable Electricity: Renewable Gas LPG Other Expenditure on Energy 0.82m m m m 2 Financial Indicars ( million) CRC License Expenditure on Accredited Offsets e.g. GCOF Expenditure on Official Business Travel 0.95m m m m 3 57 P a g e

58 1 In the reporting of emissions the revised 2013/14 20/ Defra grid average conversion facrs have been applied. This has been adopted enable more accurate annual emission comparisons and will continue in future reports following Defra guidance. 2 For leased buildings with no information available on gas consumption, estimated figures have been used for cost, consumption and emissions. 3 Business mileage figure includes NWIS and NWSSP (as per previous year s submission). Finite Resource; Water Consumption Water supplied ,5 Consumption abstracted N/A N/A N/A N/A (Office) Per FTE N/A N/A N/A N/A Non- Financial Indicars (000m3) Water Consumption (Non-Office) supplied abstracted N/A N/A N/A N/A Financial Indicars ( million) Water supply costs (Office) Water supply costs (Non- Office 0.001m m m m 4, m 0.029m 0.030m 0.030m 4 For leased buildings with no information available on water consumption; estimated figures have been used for cost and consumption. 5 Water data provided for NWIS and NWSSP this year. As this data has only been included in the 20/ report a number of indicars have shown a significant increase when an annual comparison has been applied. However, an update has been provided within the submitted narrative, utilising the data collected and comparing last year s data with the same data set for 20/. 58 P a g e

59 Non-Financial indicars (nnes) Waste Total Waste ,7 Landfill ,7 Re-used / Recycled ,7 Composted Incinerated with Energy Recovery Incinerated without Energy Recovery , Total Disposal Cost 0.13m 0.105m 0.115m m 6,7 Financial Indicars ( million) Landfill 0.04m 0.026m 0.026m m 6,7 Re-used / Recycled 0.01m 0.038m 0.051m m 6,7 Composted Incinerated with Energy Recovery Incinerated without Energy Recovery 0.01m 0.041m 0.038m 0.053m 6,7 0.07m For leased buildings with no information available on waste disposal; estimated figures have been used for both cost and nnage. 7 Data collected during 20/ includes estimated waste information for the hosted organisation NWSSP. This data was not previously captured and therefore the figures provided in the Waste table for 20/ cannot be directly compared the previous years. However, an update has been provided within the submitted narrative, utilising the data collected and comparing last year s data with the same data set for 20/. 59 P a g e

60 6.1 Carbon Management In 2013 a Trust Carbon Reduction Strategy was developed in conjunction with the Carbon Trust. The implementation of the strategy aims reduce the carbon emissions created by the Trusts services over a five year period ( ). During 2014 the Trust entered in workshops with the Carbon Trust look at Behavioural Change within the NHS. Following these workshops it set a potential outlook for a utility consumption saving of 10% over a five year period ( ), based on a 2013/14 financial year baseline and in accordance with Section 3: Targets & Business Case of the Trust Carbon Reduction Strategy. The following table identifies the annual percentage target reduction in electricity, gas and water consumptions and emissions and provides an explanation as why each target has been set. This year s performance target is highlighted in green. Financial Year Percentage Target (%) Reason for Percentage Target % % % % % This target was set in November It is a low percentage due the target being set over half way through financial year 2014/15. Energy awareness strategies and targets with suitable moniring, being delivered by behavioural change. Energy awareness strategies and targets with suitable moniring, continual emphasis on behavioural change. Investment required maintain on-going savings. Diminishing savings as investment required further increase savings. Extra 0.5% ensure 10% overall five year target is achieved. 60 P a g e

61 6.2 Energy and Water Management During 20/ the Trust did not achieve an overall reduction in electricity consumption (nonrenewable and renewable), showing an increase of 3.72 % compared 2015/. The Trust s annual electricity consumption, excluding NWIS and NWSSP organisations, produced a net increase of 1.46 %, compared with similar data of the previous year. The current Trust target, as shown in the Annual Percentage Target Reduction table, is based on electricity consumption established in 2014/15, excluding NWIS and NWSSP organisations. The performance against this target shows an increase of %. During 20/ the Trust did not achieve an overall reduction in gas consumption, showing an increase of 9.47 % compared 2015/. The Trust s annual gas consumption, excluding NWIS and NWSSP organisations, produced a net increase of 5.41 %, compared with similar data of the previous year. The current Trust target, as shown in the Annual Percentage Target Reduction table, is based on gas consumption established in 2014/15, excluding NWIS and NWSSP organisations. The performance against this target shows an increase of 9.13 %. Facrs that have impacted on the Trust overall performance include: Additional Bangor and Wrexham All Wales sites at WBS. Addition of NWIS and NWSSP organisations in Trust reporting. Increased operational hours within divisions, in particular of linear accelerars (LINACS) providing patient radiation treatment and associated equipment at the Velindre Cancer Centre (VCC). Limited promotion and moniring of energy awareness and education within the larger divisions of the Trust (WBS and VCC). Continued use of older, less energy efficient equipment such as linacs and refrigerars. During 20/ the Trust did not achieve an overall reduction in water consumption, showing an increase of % compared 2015/. The Trust s annual water consumption, excluding NWIS and NWSSP organisations, produced a net decrease of 0.95%, compared with similar data of the previous year. The current Trust target, as shown in the Annual Percentage Target Reduction table, is based on water consumption established in 2014/15, excluding NWIS and NWSSP organisations. The performance against this target shows an increase of 0.31 %. 61 P a g e

62 Facrs that have impacted on the Trust overall performance include: Additional Bangor and Wrexham All Wales sites at WBS. Addition of NWIS and NWSSP organisations in Trust reporting. Increased water flushing regimes in VCC. Increased operational hours at VCC. The Trust will continue work wards achieving a significant reduction in its carbon emissions by focusing on the following: Reducing electricity and gas consumptions through embedding Don t Waste at Work energy and waste campaigns and improving meter reading and data capture at all divisions / hosted organisations. Staff, patients and visirs all have a role play in achieving these reductions. Reviewing extended hours of use and use of equipment at divisions and ensuring this is taken in account in future year comparisons. Replacement of inefficient boilers. A pilot energy saving lighting scheme has been installed at VCC reduce its operational impact on the environment. This scheme will be monired and if the predicted reductions are achieved it could potentially be expanded across VCC as well as other sites. The Building Management System at each site will be re-configured ensure energy efficiency is optimised. Ensure that gas heating is switched off during the summer period or BMS controls are amended correctly reflect summer temperatures. A PC shutdown software initiative has been trialled at The Trust Headquarters. The initiative involved an aumatic shutdown of all PCs at 8pm every night, in an effort sp energy being unnecessarily wasted overnight when PCs are not in use, prolonging the life of PC software as equipment is not on all the time and because it s the right thing do. After a successful trial, The Trust Headquarters will now be used as a case study with the hope roll the initiative out other Trust divisions and hosted organisations over the next twelve months, in line with our Environmental Management System. Water and gas moniring and leak detection good practice will continue over the next twelve months ensure future targets are achieved. Business cases will be developed for chosen installations and funding sourced, working with Welsh Government. Further reductions in energy consumption and emissions need be realised, alongside the behavioural change of staff, patients, donors, visirs and contracrs. 62 P a g e

63 6.3 Travel and Transport During 20/ the Trust s overall expenditure on official business travel increased by 9.2 % compared 2015/, 8, Trust overall official business mileage increased by 7.86 %, 1,843,1 miles. Facrs that have impacted on the Trust overall performance include: Additional staff across the various divisions and hosted organisations of the Trust. The Trust continues work wards achieving a significant reduction in its carbon emissions by requesting that all staff, visirs and contracrs consider the Travel Hierarchy when arranging travel for commuting, meetings, conferences and visits. This includes: Videoconferencing facilities are available across Trust sites, allowing people at two or more locations see and hear each other at the same time, minimising travel. Staff will be supported make better use of these facilities reduce unnecessary travel. Walking is good for your health, improves mood and boosts self-esteem. Many Trust sites are located within a short distance green areas such as the Taff Trail. Staff will be supported make better use of these facilities. A cycle work scheme has been introduced at the Trust make it easier for staff purchase a bike. Secure bike shelters and showers are also available encourage cycling work. These options will be further promoted staff reduce unnecessary use of vehicles. Bus and train services are included when directing staff, patients, donors, visirs and contracrs each division / hosted organisation, public transport must be made the first choice for staff conference travel. Car sharing will be further encouraged, as well as using the journey for multiple purposes where possible (e.g. delivery of reports and papers). Travel options will be made available all staff throughout the Trust through a site specific environmental awareness factsheet, with particular focus on staff that have not considered changing their travel habits before. In line with the roll out of ISO14001 certification across all Trust Divisions and Hosted Organisations, a Trust Travel Plan has been developed and launched. This includes details and achievements from the VCC, WBS and Trust Headquarters as well as hosted organisations. The Trust Travel Plan will actively encourage the reduction of single occupancy car journeys, with initiatives such as: Video conferencing / conference calls rolled out across all sites. 63 P a g e

64 Shared occupancy journeys, with a designated car parking facility for registered car sharers at its VCC site. Maintain the cycle work scheme for the purchase of bikes and providing good cycle facilities. Improve and increase the number of bike shelters and showers on site at VCC and WBSs. Support working from home. Look in the use of lower carbon options for transport. Actively encourage the use of public transport. Actively support the use of alternative fuel vehicles for travel, including LPG, Bi-Fuel, Hybrid, and Zero Emission. The Trust-wide Travel Plan will acknowledge the above principles gether with guideline documents such as the Active Travel (Wales) Act 2013, Wellbeing of Future Generations (Wales) Act 2015 and the Good Practice and Guidelines: Delivering Travel Plans, commissioned by the Department for Transport, in consultation with Communities and Local Government, give further impetus the use of travel plans as a means of promoting sustainable travel. The Travel Plan will also support the Trust Environmental Policy and associated procedures. The Trust Travel Plan will deliver a wide range of benefits. For developers, it will make a site more accessible and smooth the planning process. The benefits for local authorities include helping achieve wider local government objectives and managing demand across travel modes. The Travel Plan will assist in bringing a wide range of benefits the wider community such as: Reducing peak time congestion. Reducing harmful transport emissions and reducing energy use, therefore helping tackle climate change and provide environmental benefits. Improving public transport, accessibility and tackling social exclusion. Offering pleasant surroundings for pedestrians in and around Trust buildings. As part of the Trust Capital Build design process, all major construction schemes will be reviewed in line with the Welsh Government s Architectural Design Evaluation Toolkit (AEDET). As part of this process consideration is given and scores awarded for proximity public transport services. The Trust will work with both Local Authorities on the provision of its The Trust Travel Plan, ensuring that all public transport options, including cycling are integrated in new schemes. 64 P a g e

65 6.4 Waste Management Data collected during 20/ includes waste information for the hosted organisation NWSSP. This data was not previously captured and therefore the figures provided in the Waste tables for 20/ cannot be directly compared the previous years. The Welsh Government has set a target for all organisations recycle at least 70 per cent of waste by The Trust has set a target for 20/ of 57 % recycling of its waste materials, as it moves wards the 70 % goal. The Trust s chosen clinical waste contracr is now recovering residual waste (flock) from clinical waste treatment plants. Therefore the Trust will now include any alternative treated and energy recovery incinerated clinical waste as recycled waste. During 20/, the Trust did not achieve its overall annual recycling percentage target of 57 %, with a performance of %. However, the rate of recycling had increased by 2.99 % compared the previous year performance of %. The Trust s annual recycling rate, excluding NWIS and NWSSP organisations, is %, showing a net increase of 4.65 % compared with similar data of the previous year. The Trust will continue work wards increasing its recycling rate by focusing on a wide range of opportunities that include: The Trust Environmental Compliance Officer has been working closely with divisions within the Trust prepare for the implementation of a Bin the Bin initiative. The initiative involves removing desk-side bins and having central waste stations in an effort increase recycling, encourage source segregation of waste in line with government legislation, minimise the amount of waste bags used and encourage networking, movement and staff wellbeing. During full implementation over the next 12 months, each division will need overcome several obstacles including addressing staff concerns, promoting the benefits of the initiative and encouraging staff participation throughout the Trust. Full implementation of the initiative will aid in the continual improvement of the Trust s Environmental Management System. Continued implementation of the All-Wales NHS waste contract and improved data collection procedure, whilst promoting and moniring waste awareness and education across the Trust. The Trust Environmental Development and Compliance Officer working with the Estates and Operational Services departments at all divisions analyse the data capture method of waste weights ensure that the correct calculations are being used. The Trust Environmental Development and Compliance Officer is engaging with hosted organisations in developing initiatives and producing more accurate information. 65 P a g e

66 Appendix 1: Performance trends over Summary Green Red Service Performance measures Target achieved this month Target not achieved this month Equitable and timely access Velindre Cancer Centre Level 1 Metric VCC % of patients commencing radical radiotherapy within 28 days VCC % of patients commencing palliative radiotherapy within 14 days VCC % of patients commencing emergency radiotherapy within 2 days Apr May Jun Jul Aug Sept 98% 98% 98% 98% 97% 97% 97% 96% 99% 100% 100% 97% 98% 100% 100% 100% 94% 99% 100% 98% 98% 99% 98% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Oct Nov Dec Jan Feb Mar VCC 1-95% Linear Accelerar Uptime VCC 1-98% Patient Disruptive Uptime 94% 97% 99% 97% 97% 97% 97% 97% 99% 98% 95% 95% 97% 100% 100% 99% 99% 100% 99% 100% 100% 100% 96% 96% 66 P a g e

67 Metric VCC % of patients commencing emergency chemotherapy within 5 days VCC % of patients commencing nonemergency chemotherapy within 21 days VCC 118- All SACT referrals within turnaround Level 2 Metric VCC 130- CR Inpatients (within 1 working day) VCC 131- CT Inpatients (within 1 working day) VCC 132- MRI inpatients (within 1 working day) VCC 133- US inpatients (within 1 working day) VCC 134- CR Outpatients (within 7 days) Apr May Jun Jul Aug Sept 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% 99% 100% 99% 98% 100% 100% 99% 97% 99% 98% 97% 99% 99% 100% 99% 98% 100% 100% 99% 97% 99% 98% 97% Apr May Jun Jul Aug Sept 90% 87% 98% 98% 98% 98% 85% 90% 98% 97% 98% 99% 95% 100% 100% 100% 100% 95% 87% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 66% 100% 100% 75% 100% 100% 100% 100% 100% 100% 100% 100% 88% 100% 100% 90% 75% 100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Oct Oct Nov Nov Dec Dec Jan Jan Feb Feb Mar Mar 67 P a g e

68 Metric VCC 135- CT Outpatients (within 7 days) VCC 136- MRI Outpatients (within 7 days) VCC 137- US Outpatients (within 7 days) Apr May Jun Jul Aug Sept 100% 100% 100% 100% 100% 100% 100% 97% 98% 100% 98% 98% 100% 99% 100% 100% 100% 100% 100% 100% 100% 100% 96% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Oct Nov Dec Jan Feb Mar Welsh Blood Service Level 1 Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 292 (from Sept) new Bone Marrow Volunteers (BMV) registrations per month P a g e

69 Supporting our staff excel Velindre NHS Trust Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar COR % Sickness Absence rate (Trust Wide) COR % PADR (Trust Wide) COR % Sickness Absence rate (Corporate Services) COR % PADR (Corporate Services) 4.33% 4.28% 4.22% 4.18% 4.14% 4.11% 4.19% 4.18% 4.14% 4.15% 4.% 4.24% 59.7% 64.2% 66.2% 72.2% 75.1% 77.6% 77.6% 70.8% 71.8% 70.0% 68.9% 67.0% 4.11% 4.20% 4.27% 4.% 4.64% 4.90% 4.91% 4.86% 4.98% 4.89% 4.72% 4.62% 42.9% 62.8% 68.5% 72.9% 76.4% 77.4% 77.4% 74.3% 73.2% 71.6% 76.8% 85.7% 69 P a g e

70 Velindre Cancer Centre Metric COR % PADR Rate COR % Sickness absence rate Apr May Jun Jul Aug Sept 56.2% 59.4% 61.1% 71.3% 74.1% 75.7% 75.7% 66.6% 65.1% 62.2% 61.4% 59.4% 4.08% 4.05% 4.00% 3.91% 3.73% 3.59% 3.60% 3.56% 3.50% 3.53% 3.59% 3.70% Oct Nov Dec Jan Feb Mar Welsh Blood Service Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 85% PADR Rate 70.1% 73% 74.3% 73.5% 76.4% 77.4% 80.7% 76.3% 81.5% 81.2% 78.0% 73.4% 3.54% Sickness absence rate 4.82% 4.67% 4.58% 4.63% 4.67% 4.74% 4.94% 5.00% 4.94% 4.93% 4.94% 4.99% 70 P a g e

71 Estates Level 1 Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar COR 024a- Electricity (kwh) COR 024b- Gas (kwh) COR 025a- Electricity (CO2) COR 025b- Gas (CO2) COR 026- Water Usage (m3) 71 P a g e

72 Safe and reliable services Velindre Cancer Centre Level 1 Metric VCC 025- Death within 30 days of chemotherapy VCC 032a- 0 C.diff cases VCC 032b- 0 MRSA cases VCC 032c- 0 MSSA cases VCC Velindre hospital acquired pressure ulcers VCC unexpected inpatient deaths VCC % Compliance with CAUTI insertion care bundles VCC % Compliance with CAUTI maintenance care bundle VCC % compliance with CVC insertion care bundle Apr May Jun Jul Aug Sept Oct Metric under development % 100% 86% 88% 83% 100% 75% 100% 72% 100% 100% 69% 100% 100% 95% 100% 95% 100% 88% 100% 85% 93% 100% 88% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Nov Dec Jan Feb Mar 72 P a g e

73 Metric VCC % compliance with skin care bundle VCC 034a 90% patients have a documented thromboproxphylaxis risk assessment on admission VCC 034b 100% eligible patients prescribed thromboprophylaxis Apr May Jun Jul Aug Sept 67% 67% 93% 67% 100% 67% 100% 100% 100% 100% 83% 78% 69% 46% 55% 63% 27% 46% 48% 91% 96% 96% 96% 89% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Oct Nov Dec Jan Feb Mar Level 2 Metric VCC % hand hygiene compliance (averagenon inpatient areas) VCC % hand hygiene compliance (averageinpatient areas) VCC 036- Mortality Review of 100% of inpatient deaths Apr May Jun Jul Aug Sept 87% 93% 86% 90% 88% 92% 60% 75% 91% 86% 87% 71% 78% 79% 78% 86% 80% 95% 79% 80% 81% 82% 75% 72% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Oct Nov Dec Jan Feb Mar 73 P a g e

74 Level 3 Highlighted Measures Level 3 Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar VCC 146- Antibiotic Prescribing- 100% compliance with documenting duration/review date 60% 86% 41% 42% 76% 100% 100% 100% 100% 100% 100% 100% 74 P a g e

75 Welsh Blood Service Level 1 Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 100% Red cell supply meeting demand 100% of platelets supply meeting demand 98% of commercial product requests met 90% deceased donor typing / cross matching reported within 6 hours (quarterly metric) 100% delivery of Haemopoietic Stem Cell (HSC) internal targets stakeholders in full 111% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 141% 114% 102% 106% 121% 119% 108% 112% 124% 114% 120% 119% 99% 96% 100% 99% 91% 91% 98% 99% 95% 95% 99% 92% 100% 100% 100% 100% 135.6% 135.6% 155% 136% 155% 1.3% 136% 155% 1.3% 96.9% 96.9% 38.8% 75 P a g e

76 Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 100% facilitation / import of HSC products for patients in Cardiff and Vale UHB 75% 50% 100% 75% 125% 100% 50% 75% 71% 50% 100% 125% 90% Anti-D & -C Quantitation results provided cusmer hospitals within 5 working days (quarterly metric) 90% routine antenatal patient results provided cusmer hospitals within 3 working days 96% 99% 95% 91% 99% 99% 99% 98% (quarterly metric) 76 P a g e

77 Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 80% samples referred for red cell reference serology work up provided cusmer hospitals within 2 working days (quarterly metric) 81% 82% 82% 77% Metric Level 2 Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 60% red cells issued less than 14 days old 3% part bags collected 2% unsuccessful venepuncture 40% 28% 30% 31% 39% 53% 69% 61% 44% 46% 55% 31% 3% 3% 3% 3% 3% 3% 3% 3% 3% 3% 3% 4% 2% 2% 1.4% 1% 2% 2% 1% 2% 1% 2% 1% 1% 77 P a g e

78 First class patient and donor experience Velindre Cancer Centre Level 1 Metric VCC 044- >80% patient overall experience rated 9 and above Apr May Jun Jul Aug Sept 94% 85% 81% 85% 80% 77% 72% 89% 86% 92% 90% 89% Oct Nov Dec Jan Feb Mar Level 2 Metric VCC 046- On the day waiting times in outpatients less than 20 minutes VCC % of palliative care patients have an POS-S or equivalent assessment within 24 hours of referral Apr May Jun Jul Aug Sept 45% 49% 59% 45% 52.3% 44.4% 50.2% 48.8% 54% 54% 53% 53% 100% 100% 80% 100% 100% No data provided Oct Nov Dec Jan Feb Mar 100% 100% 100% 100% 100% 100% 78 P a g e

79 Welsh Blood Service Level 1 Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 71% of blood donors scoring 5 or 6 out of 6 for satisfaction with overall service 100 % of concerns answered within 30 days 89% 88% 91% 90% 90% 88% 93% 94% 91% 92% 92% 92% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Level 2 Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Whole Blood: 1.25 units collected by WTE per hour Apheresis: 2.15 Average Adult Therapeutic Dose (ATD) per Donation P a g e

80 Spending every pound well Metric Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar <7% time expired platelets <0.5% volume of waste (red cells) <6% tal losses prior issue.7%.5%.3% 13.9%.2% 7.9% 5.1% 6.0% 10.3% 9.5% 11.0% 11.0% 0.1% 0.7% 1.5% 0.9% 0.8% 0.4% 0% 0.0% 0.1% 0.1% 0.1% 0.2% 6.1% 5.8% 5.5% 5.3% 5.6% 5.5% 5.3% 6.2% 5.3% 3.8% 5.8% 6.1% 80 P a g e

81 Service Improvement Workforce and Organisational Development Appendix 2: Progress against our three year plan Green Amber Red Closed Purple Grey Delivery again Plan objectives Actively managed processes proceeding as planned - no major risks or issues identified Problems have surfaced, considered manageable in the normal course Serious problems have surfaced make Senior Management Team aware Major issues remain unsolved- on hold until resolved - senior executive engaged Deliverable activity at feasibility/initiation stage At a Glance Summary Progress against 3 Year Plan Objectives Area Objective Level Status Forecast Status Risk WOD01 Leadership & Management Capability 2 WOD02 Quality & Continuous Improvement 2 WOD03 Diversity & Inclusiveness 2 WOD04 Staff Engagement & Well Being 2 WOD05 Collaborative & Partnership working 2 SI 01 Stimulate generation of the right ideas take forward 2 SI 02 Strengthening the arrangements for our international health links 2 81 P a g e

82 Research and Development Area Objective Level Status Forecast Status Risk SI 03 Enable the spread of learning 2 VCC059 Provide patients with timely access the latest anti-cancer treatments through participation in clinical trials 2 VCC 060 Actively promote the benefits of participating in research staff and patients 2 VCC 065- Develop department level strategies that are aligned the VCC R&D strategy 1 VCC 071- Continue develop the national leadership position of the RTTQA group 1 VCC 077- Increase recruitment in clinical trials activity in line with and beyond national targets where possible 1 VCC 078- Increase tissue collection for the Wales Cancer Bank 1 VCC080 - Develop Nurse and AHP research leads and research programs 2 VCC 081- Develop strategic collaborations and engagement 2 RD 001 Actively promote the benefits of participating in research of staff, donors and patients 2 RD 002 Re-design of R&D governance structure 1 RD 003 Operationalise the R&D Strategy 2 82 P a g e

83 Equitable and Timely Access Services Estates Organisational Learning Area Objective Level Status Forecast Status Risk OL 01 - Provide opportunities for patients, donors and carers provide feedback in order help staff build effective care partnerships OL 02 - Have in place fully functional reporting systems enable collection and analysis of patient, donor and carer feedback in order facilitate learning 2 2 OL 03 - Develop communication structures enable the spread of learning across the organisation 2 COR 022- Undertake a review of the Trust s Statury Compliance across divisions and hosted organisations. Achieve and maintain a Trust Statury Compliance Target of 90 %. COR 023 At least 50% of Trust properties and all Trust hospital sites certified ISO14001 by the end of the financial year. 1 1 Velindre Cancer Centre - At a Glance Summary - Progress against 3 Year Plan Objectives Strategic Theme Forecast Objective Level Status Risk Status VCC Consistently achieve waiting times recommendations for patients receiving Radiotherapy 1 Progress reported in Section 2 VCC 004- Develop a strategic plan for radiotherapy services including advanced radiotherapy 1 VCC 005- Increase radiotherapy access the appropriate rate for patients with cancer within our resident population 1 VCC 008- Repatriate all appropriate activity from England and increase the provision of SBRT and SRS 1 VCC 113 To work with Health Boards and WHSSC develop systems for the approval and funding of Emergency Access Medicines (EAMs) schemes 1 VCC0-019 Consistently meet waiting times targets for emergency and non-emergency chemotherapy patients 1 Progress reported in Section 2 VCC 020- Patients receive parental SACTs as close their homes as possible within environment which are appropriate for safe administration 1 VCC 083- Disaster Recovery Plans (DRP) in place support service in the event of an incident, ensuring a clear process in place in line with timely resolution 1 83 P a g e

84 First Class Patient Experience Safe and Reliable Services Strategic Theme Objective Level Status VCC 006 Increase provision of Intensity Modulated Radiotherapy (IMRT) 35% of radical plans 2 Forecast Status Risk VCC 007- Develop the use of Image Guided Radiotherapy (IGRT) techniques across tumour sites 2 VCC 022- Strengthen links with primary care: Review processes by which patients can receive care within local communities and utilise local resources 2 VCC Strengthen links with primary care: Review processes by which patients can be reviewed by oncology staff (VNHST) in primary care (or closer home) 2 VCC024 Maximise use of available information intelligence within medicine management systems support service development and clinical and financial audit 1 VCC 031- Review of Clinical nurse specialists and key workers ensure appropriate service provision 2 VCC 082- Support infrastructure in situ including sufficient capacity and resilience for the provision of continuous service 2 VCC 085- Explore technology underpin service in line with service improvements, and change in workflows/practices 2 VCC104 Implement the agreed recommendations from the internal pharmacy review, the Welsh Audit Office report and the MHRA inspection report in order improve the quality of the medicines management service. This is collectively termed the Medicines Management Action Plan VCC032 Reduce healthcare associated infections zero 1 Progress reported in Section 2 VCC033 Reduce Velindre acquired pressure ulcers zero 1 Progress reported in Section 2 VCC034 Ensure that all inpatients received documented thrombosis risk assessments on admissions 1 Progress reported in Section 2 VCC 040- Development of Acute oncology services across SE Wales 1 VCC 090- Implementation of Welsh Clinical Portal (which includes Medicines Transcriptions and Electronic Discharge Change Control 1 (MTedD)) with National Test Requesting and Results Reporting (TRRR) VCC 039- Improve oversight of medication related errors comply with NHS Wales standards 2 VCC 088- Implementation of National Image Sharing- Vendor Neutral Archive (VNA) Project support the care of cancer patients via cross organisation image sharing 2 VCC120 Strengthening business continuity and emergency planning resources, processes and plans VCC 012- Evaluate current waiting times targets for radical specific patient groups including lung and radical neurology patients 2 VCC 013- Implementation of Royal College or Radiologist guidance on management of interruptions for category 2 patients 2 VCC 028- Ensure that patients who take oral SACTs are able make fully informed decisions facilitate P a g e

85 Providing Evidence Based Care and Research Strategic Theme Objective Level Status medication adherence VCC044 Increase positive patient experience levels through the collection of views and opinions from a wider sample of patients including outreach settings 1 VCC 045- Ensure that people living with and beyond cancer have a personalised assessment, information and care plan and are empowered manage their condition 2 VCC050 Establish an assessment unit at VCC 2 VCC 057- Increase the number of patients that die in their preferred place. Increase the number of patients who access their preferred place of care. 2 VCC % of palliative care patients have an POS-S (palliative care outcome scale) or equivalent assessment within 24 hours of referral 2 VCC111 Improve feedback mechanisms for patients 2 VCC 100- Maintain required standards for timeliness and completeness of clinical coding in line with targets set by the Welsh Government 1 VCC 014- Implement image guided brachytherapy for appropriate gynaecology cancer patients 2 VCC 029- Introduce and evaluate use of oncotype testing 2 Forecast Status Risk VCC 096 Improving the data quality within the electronic patient record Provision of accurate and up date information by the Medical Records Department 2 VCC 097- Development of an organizational informatics function inform service improvement plans, benchmarking, mandary returns, data extraction and validation 2 VCC 098- Implementation of the National Intelligent Integrated Audit Solution (NIIAS) 2 VCC 099- Implementation of Mobile Device Management Solution 2 VCC103 Increase capacity on the chemotherapy day case unit in order meet growing demand (approximately 250 additional patients per year) as a result of the introduction of Docetaxel chemotherapy for prostate cancer. 1 VCC109 Develop service provide Radium 223 patients with prostate cancer as per NICE appraisal 1 VCC114 To provide Cetuximab treatment patient population in line with AWMSG directive. 1 VCC115 To develop a business case for the provision of Zometa for breast patients 1 VCC1 To develop a business case for the provision of new lines of therapies (as per anticipated NICE publications) for patients with Melanoma Cancer 1 VCC118 Review structure and resources for Quality and Safety support provided by Cancer Services Management Offices 2 85 P a g e

86 First Class Donor Experien ce Safe and Reliable Services Equitable and Timely Access Services Welsh Blood Service- At a Glance Summary - Progress against 3 Year Plan Objectives Strategic Theme Objective Level Status Forecast Status Risk WBS001 Improve recruitment and retention of whole blood donors 1 WBS002 Recruit and retain new Bone Marrow Volunteers (BMV) donors, especially young donors 1 WBS004 Meet all Blood component demand in line with clinical need 1 WBS 005 Meet all Transplant Service requests 1 WBS 006 Meet all diagnostic service requests 1 WBS007 Maintain external regulary compliance: (MHRA/HTA/EFI/WMDA) 1 WBS Keep abreast of mandated changes testing and emerging clinical priorities including: (I) PAS and NAT HEV, and (ii) Pathogen Inactivation 1 WBS009 Existing Systems Maintenance & Support 1 WBS010 Retain wholesaling license 2 WBS IM&T Infrastructure Improvement Programme inc. disaster recovery 2 WBS Provision of technical support for Operational Project Delivery Programme (Software & Infrastructure) 2 WBS Develop and implement cross departmental and organisational processes for quality management inc. training records 2 WBS Continue improve satisfaction ratings from our donors 1 WBS Respond all concerns in a timely and effective way (links donor satisfaction) 1 86 P a g e

87 Spending Every Pound Well Supporting our staff excel Strategic Theme Objective Level Status Forecast Status Risk WBS 0 Continue improve donation experience 2 WBS 0 Keep abreast of advancements in technology for WTAIL 2 BS 021 To deliver new service models through an engaged and empowered workforce 2 BS 022 To ensure optimal flexible working patterns support new service models 2 BS 023 To develop a flexible laborary workforce using Modernising Scientific Careers 2 WBS 024 Reduce volume of production waste (namely Collections and Laboraries) 1 WBS025 Improve optimization of Estates Infrastructure 2 87 P a g e

88 Appendix 3: Equality Annual Moniring Report Data and Information Introduction We are pleased present Velindre NHS Trusts Equality Moniring report for April 20- March 20; this report provides the equality moniring data in line with our duties under the Equality Act Legal Context The Public Secr Equality Duty (PSED) requires that all public authorities covered under the specific duties in Wales should produce an annual equality report by 31 st March each year. The Trust published the report for for the March deadline 20. The information in this report therefore covers the following year bring it in line with the Trust Wide Annual report. The essential purpose of the specific duties under the Equality Act, in relation moniring, is help authorities have better due regard the need achieve the 3 aims of the general duty, which are ; eliminate unlawful discrimination, harassment, victimisation and any other conduct prohibited by the Act; advance equality of opportunity between people who share a protected characteristic and people who do not share it; and foster good relations between people who share a protected characteristic and people who do not share it. Therefore, as a specific duty itself, the role of annual reporting is support the Trust in meeting the general duty. It also has a role in setting out achievements and progress wards meeting the other specific duties. In particular, the annual report supports the Trust have a better due regard the duties by providing an opportunity ; Monir and review progress Monir and review the effectiveness and appropriateness of arrangements Review objectives and processes in light of new legislation and other new developments Engage with stakeholders around these issues, providing partners and the public with transparency. 88 P a g e

89 Equality Data In the pie charts below you will find the breakdown of equality data in several areas; Staff in post by their protected characteristic All staff breakdown by grade o Each grade broken down by gender Working pattern broken down by gender Employment assignment broken down by gender Recruitment applications by their protected characteristics All staff breakdown upon leaving the Trust o Leavers by their protected characteristics The Trust made a decision use pie charts convey the equality data as tables created identifiable information, due small numbers. Therefore be able publish information and perform valid analysis the Trust has agreed use pie format display information. What the data does demonstrate is that for a number of the more sensitive equality areas, many staff have either decided that they would prefer not say or the data has not been captured at all. This is an area that has been identified for improvement and confidence in how the Trust will be using the data should over time, which will hopefully see the data gaps close. Please note that the Full Time Equivalent (FTE) data may differ that reported in the accounts as it is captured on a snapshot model. Age Band Age Band 1.01% 9.46% 4.07% 0.34% 0.31% 13.74% 5.34% 13.58% 13.66% 12.91% 13.94% 11.65% < Age Band Headcount % FTE < , P a g e

90 By Gender Gender Gender Headcount % FTE Female 2, Male 1, Grand Total 3, % 62% Female Male By Religious Beliefs 0.05% Religious Belief 0.23% 13.% 22.09% 7.29% 40.57% 14.23% 0.03% 1.52% 0.82% Atheism Buddhism Christianity Hinduism Islam Judaism Not Disclosed Other Sikhism Unspecified Religious Belief Headcount % FTE Atheism Buddhism Christianity 1, Hinduism Islam Judaism Not Disclosed Other Sikhism Unspecified Grand Total 3, By Sexual Orientation Sexual Orientation Sexual Orientation Headcount % FTE Bisexual % 0.72% 21.49% 68.25% 8.89% Bisexual Gay Heterosexual Lesbian Not Disclosed Unspecified Gay Heterosexual 2, Lesbian Not Disclosed Unspecified Grand Total 3, % 90 P a g e

91 By Employee Category Employee Category 73.43% 0.05% 26.52% Full Time Part Time Unspecified Employee Category Headcount % FTE Full Time 2, Part Time 1, Unspecified Grand Total 3, By Employee Category by Gender Female Male Female Male Unspecified Part Time Full Time Unspecified Part Time Full Time 91 P a g e

92 By Disability 3% Disability Disability Flag Headcount % FTE No 2, Not Declared Unspecified 1, % No Not Declared Yes Grand Total 3, Unspecified 5% 65% Yes 58% Disability 5% 14% 7% 7% Learning disability/difficulty Long-standing illness Mental Health Condition Other Physical Impairment Yes Disability Type FTE Headcount Headcount % Learning disability/difficulty Long-standing illness Mental Health Condition Other Physical Impairment Sensory Impairment Yes - Unspecified % 2% Sensory Impairment Yes - Unspecified 92 P a g e

93 By Ethnic Origin Ethnicity Ethnicity 4% 4% 5% 6% White 9% 7% 15% Mixed White Other Ethnic Minority 14% Asian Black Not Stated Chinese 81% Unspecified 55% Other Ethnic Group Headcount % FTE White 3, ,868 White Other Ethnic Minority Not Stated Unspecified Mixed Asian Black Chinese 0 15 Other P a g e

94 By Pay scale by Gender Band 1 Band 2 11% 54% 46% 89% Female Male Female Male Band 3 Band 4 30% 28% 70% 72% Female Male Female Male Band 5 Band 6 37% 63% 37% 63% Female Male Female Male Band 7 Band 8a 40% 60% 47% 53% Female Male Female Male 94 P a g e

95 Band 8b Band 8c 56% 44% 54% 46% Female Male Female Male Band 8d Band 9 29% 53% 47% 71% Female Male Female Male Medical and Dental Other 33% 67% 56% 44% Female Male Female Male 95 P a g e