Executive Summary
Overall Status: At Risk
Key Positives
- Maternity: Strong month for maternity services with 58 births and excellent outcomes across all indicators
- Infection Control: Excellent infection control performance
- ICT: ICT performing well across all metrics
Key Risks
- Human Resources: Staff fatigue risk from vacancy cover
- Human Resources: Leave liability growing
- Human Resources: Training compliance slipping
Items Requiring Board Attention
- Clinical Quality: Medication incident trend flagged to Clinical Governance Committee
- Human Resources: Nursing vacancy situation escalated to Executive Team
- Human Resources: Leave liability flagged to Finance Committee
Section Status Overview
| Section | Owner | Status | Key Issue |
|---|---|---|---|
| Maternity | Dr. Emma Chen | On Track | Midwife staffing remains tight for night shifts |
| Clinical Quality | Dr. James Wilson | Watch | Medication incident trend needs immediate attention |
| Infection Control | Dr. Priya Sharma | On Track | — |
| Clinical Dashboard | Operations | Watch | Occupancy impact from Ward C closure |
| Human Resources | HR Director | At Risk | Staff fatigue risk from vacancy cover |
| ICT | ICT Manager | On Track | EMR upgrade requires April downtime window |
| Buildings & Maintenance | Facilities Manager | Watch | HVAC surgical suite issue |
Maternity
Strong month for maternity services with 58 births and excellent outcomes across all indicators.
Key Metrics
Total Births
58
vs 52 prev
C-Section Rate
22%
vs 24% prev
Low Apgar Score (<7)
1
vs 2 prev
Readmissions within 28 days
0
vs 1 prev
Risks
- Midwife staffing remains tight for night shifts
Actions
- Recruitment for 2 additional midwives underway
Clinical Quality
Clinical quality generally stable but medication incidents elevated this month requiring focused attention.
Key Metrics
Patient Falls
4
vs 3 prev
Pressure Injuries
1
vs 2 prev
Medication Incidents
8
vs 5 prev
Formal Complaints
2
vs 3 prev
Risks
- Medication incident trend needs immediate attention
- Falls increase in Ward B
Actions
- RCA for medication incidents due 10 March
- Ward B falls prevention audit scheduled
- Staff refresher training on medication safety
Infection Control
Excellent infection control performance. Hand hygiene campaign showing positive results.
Key Metrics
Healthcare Acquired Infections
1
vs 2 prev
Hand Hygiene Compliance
94%
vs 91% prev
PPE Compliance
97%
vs 96% prev
Outbreak Days
0 days
vs 0 days prev
Actions
- Continue hand hygiene awareness program
Clinical Dashboard
Key clinical metrics stable. Occupancy temporarily lower due to Ward C maintenance.
Key Metrics
Bed Occupancy
78%
vs 85% prev
Average Length of Stay
4.8 days
vs 5.1 days prev
30-Day Readmission Rate
7.2%
vs 8.5% prev
Mortality Rate
1.2%
vs 1.4% prev
Risks
- Occupancy impact from Ward C closure
Actions
- Ward C returning to service 5 March
Human Resources
HR metrics are under significant pressure. Sick leave spike and critical vacancies are impacting operations.
Key Metrics
Staff Turnover
14%
vs 12% prev
Sick Leave Days
285 days
vs 220 days prev
Open Vacancies
12
vs 9 prev
Mandatory Training Compliance
88%
vs 92% prev
Leave Liability Hours
8,200 hrs
vs 7,800 hrs prev
Risks
- Staff fatigue risk from vacancy cover
- Leave liability growing
- Training compliance slipping
Actions
- Urgent recruitment campaign for nursing
- Wellbeing support program launch
- Leave reduction plan for Q2
ICT
ICT performing well across all metrics. EMR upgrade project progressing to plan.
Key Metrics
System Uptime
99.8%
vs 99.6% prev
Open Support Tickets
18
vs 25 prev
Security Incidents
0
vs 1 prev
Projects On Track
85%
vs 80% prev
Risks
- EMR upgrade requires April downtime window
Actions
- Finalise EMR upgrade communication plan
- Staff training sessions scheduled March
Buildings & Maintenance
Facilities under pressure from Ward C project and seasonal issues. All items being actively managed.
Key Metrics
Open Work Orders
28
vs 22 prev
Urgent Repairs Outstanding
3
vs 2 prev
Building Compliance
98%
vs 100% prev
Energy Usage vs Budget
105%
vs 98% prev
Risks
- HVAC surgical suite issue
- Fire door compliance gap
Actions
- HVAC repair contractor confirmed for 2 March
- Fire door inspection booked 3 March
- Ward C handover scheduled 5 March