Trust Board papers November 2012 - Barking Havering and ...

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Committee Review and monitoring of risks Incident Reporting (Patient Safety) Reporting to external agencies to support shared learning (NRLS) Information on complaints, claims and incidents is aggregated, analysed and disseminated Incidents graded according to severity Serious Incident investigations compliant with Incident and SI policy Safety Alerts implemented within Evidence of review and actions undertaken - recorded on Ulysses database quarterly reports Assurance that delivery and performance against the Trust’s objectives are being appropriately monitored. Incident reporting rate > NPSA average Evidence of timely reporting to NRLS Aggregated data reports are presented to Committees, Directorates and are published on the Trust Intranet including commentary on organisational learning All incidents are triaged and coded accurately, in line with severity as set out in the Incident and SI policy Audit of reports shows compliance with Incident and SI policy CAS alerts are implemented within time frames Quarterly Risk Management Team Performance Efficiency and Quality Committee Audit Committee Quality & Strategy Committee Relevant Directorates / Relevant Executive Monthly Trust Board Relevant Directorates On publication Quarterly On-going On-going Quarterly Clinical Risk Management Committee Clinical Risk management Committee Statutory Safety Committee Audit Committee Quality and Safety Committee Directorates Patient Safety Adviser Patient Safety Adviser Clinical Governance Director Clinical Risk Management Committee Relevant Directorates Relevant Directorates Relevant Directorates Relevant Directorates Relevant Directorates Audit Committee Quality and Safety Committee Clinical Risk Management Committee Clinical Risk Management Committee Clinical Risk management Committee Statutory Safety Committee Audit Committee Quality and Safety Committee Directorates Patient Safety Adviser Patient Safety Adviser Clinical Governance Director Clinical Risk Management Committee Barking, Havering & Redbridge University Hospitals NHS Trust Page 25 of 40 ????????????? ??/??/???? Version ?? Issued ????
timescale with supporting evidence provided Annual Health and Safety review Annual report detailing Health and Safety Issues within the Trust submitted to Statutory Safety Committee Annual Audit Committee Relevant Directorates Audit Committee Clinical Governance Review Annual report regarding Clinical Governance within the Trust submitted to Quality and Strategy Committee Annual Quality and Safety Committee Relevant Directorates Quality and Safety Committee Procedural documents are reviewed in line with review date Annual report to Clinical Governance Risk Committee Annual Relevant Committees Quality Systems Manager Quality Systems Manager Service Users Annual Patient Survey Annual Clinical Risk Management Committee Quality and Safety Committee Relevant Directorates Clinical Risk Management Committee Quality and Safety Committee Complaints compliant with national targets for responses Trust performance with acknowledgement within 2 days and 30 days targets Monthly Quarterly Trust Board Relevant Directorates Quality and Safety Committee Any deficiencies identified during monitoring will be recorded and reported to the Quality and Safety Committee. The nominated persons and, ultimately, the Quality and Safety Committee, will be responsible for ensuring that an action plan has been developed, is followed through, all required actions taken to remedy the deficiency/s identified and, where appropriate, information disseminated within the Trust to enable learning from the experience. 9. REFERENCES NHSLA Risk Management Strategy Checklist March 2012/13 The NHS Improvement Plan; 2006: Department of Health www.doh.org Making it Happen – a Guide for Risk Managers on How to Populate a Risk Register. Controls Assurance Support The How to Guide for Leadership for Safety. Patient Safety First Campaign. 2008.www.patientsafetyfirst.nhs.uk The Healthy NHS Board Principles for Good Governance. The Handbook to the NHS Constitution. Department of Health Quality governance in the NHS – a guide for provider boards – National Quality Board 2011 Compliance Framework - Monitor Barking, Havering & Redbridge University Hospitals NHS Trust Page 26 of 40 ????????????? ??/??/???? Version ?? Issued ????
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TRUST BOARD MEETING Wednesday, 7 No
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2 Following Mr White’s concerns r
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4 forecast in terms of community be
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6 The Trust Board noted the Plan fo
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8 The Co-Chair of the Improving Pat
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TRUST BOARD MEETING Actions from Mi
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Agenda Item Action Deadline Date Da
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Question: Mr Skillman was pleased t
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CQC Trust-wide Action Plan Review a
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1.0 PURPOSE 1.1 Background This rep
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• Review the Senior Responsible O
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APPENDIX 1 ‐ CQC ACTION PLAN - EX
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RECORDS records management to ensur
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CQC Update Report 2012 Theme CQC Re
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CQC Update Report 2012 ASSESSING &
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CQC Update Report 2012 ASSESSING &
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CQC Update Report 2012 pathways thr
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CQC Update Report 2012 identified i
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CQC Update Report 2012 outlining th
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CQC Update Report 2012 improvements
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CQC Update Report 2012 aware of the
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CQC Update Report 2012 are now supe
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CQC Update Report 2012 autumn. RECO
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CQC Update Report 2012 of the pilot
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EXECUTIVE SUMMARY TITLE: Informatio
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INFORMATION GOVERNANCE STRATEGY 201
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Information is a vital asset in ter
Page 55 and 56: starters as well as being mandatory
Page 57 and 58: The standards are split into the ar
Page 59 and 60: 10a Reapproval of IG training progr
Page 61 and 62: 343 Directorate Anaesthetic: Risk:
Page 63 and 64: Table of Contents TRUST PRINCIPAL O
Page 65 and 66: BHRUT STRATEGIC OBJECTIVES WITH EAC
Page 67 and 68: DIRECTORATES RISKS REVIEW 12 10 8 6
Page 69 and 70: RISKS DETAILS PRINCIPAL RISK What c
Page 71 and 72: PRINCIPAL RISK What could prevent t
Page 77 and 78: RISK DESCRIPTORS OBJECTIVE SAFE, HI
Page 79 and 80: BOARD ASSURANCE FRAMEWORK ELEMENTS
Page 81 and 82: EXECUTIVE SUMMARY TITLE: Risk Manag
Page 83 and 84: Contents Section Page 1 Introductio
Page 85 and 86: incorporate mitigation controls wit
Page 87 and 88: “Risk Register” “Risk Registe
Page 89 and 90: potential risks they may face in ac
Page 91 and 92: 4.1.1 Quality and Safety Committee
Page 93 and 94: • Financial risks: risks associat
Page 95 and 96: Proactive risk assessment enables t
Page 97 and 98: Trust’s risk matrix and will popu
Page 99 and 100: Risk Grading Staff Group Evidence R
Page 101 and 102: 4.8 RISK REGISTER The Risk Register
Page 103 and 104: 5.1 Consultation and Communication
Page 105: The Trust recognises the importance
Page 109 and 110: Checklist for the Review and Approv
Page 111 and 112: Equality Impact Assessment Tool To
Page 113 and 114: Plan for Dissemination of Procedura
Page 115 and 116: Consequence score (severity levels)
Page 117 and 118: Frequency How often might it/does i
Page 119 and 120: Appendix 3 Framework for Risk Manag
Page 121 and 122: Risk Register inventory they are ex
Page 123 and 124: 2. DECISION REQUIRED: CATEGORY: The
Page 125 and 126: • A review of data capture to ens
Page 127 and 128: Pilot Wards Division Discharges Per
Page 129 and 130: Workforce Appraisals - the actions
Page 131 and 132: Delayed transfers of care (DTOC) -
Page 133 and 134: EXECUTIVE SUMMARY TITLE: Emergency
Page 135 and 136: • Training competencies are being
Page 137 and 138: Appendix A: Trajectory for all type
Page 139 and 140: would welcome feedback from the Tru
Page 141 and 142: Maternity Services Monthly Performa
Page 143 and 144: 4. Capping The maternity service is
Page 145 and 146: 7. Obstetric Assessment Unit (OAU)
Page 147 and 148: 10. Serious Incidents Reported Inci
Page 149 and 150: 12. Maternity Dashboard The dashboa
Page 151 and 152: It should also be noted that the ta
Page 153 and 154: Priority Action Lead Monitoring Too
Page 155 and 156: Priority Action Lead Monitoring Too
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Contents Section No: Description Pa
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3. Complaints Activity 3.1 Total Co
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3.5 Themes General care issues and
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Corporate Non Clinical Category Num
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order to resolve concerns. Particul
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The findings of the review were tha
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SELF-CERTIFICATION RETURNS Organisa
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12 AA - Quality Improvement Strateg
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TFA Progress BHR University Hospita
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25 TFA - Final IBP /; LTFM Dec-12 H
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Effectiveness GOVERNANCE RISK RATIN
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Safety 4b MRSA Enter Are you below
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FINANCIAL RISK RATING BHR Universit
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CONTRACTUAL DATA BHR University Hos
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4 Single Sex Accommodation Breaches
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TITLE: EXECUTIVE SUMMARY BOARD/GROU
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causes/ Not specified' will be remo
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Staff In Post Starters & Leavers FT
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TURNOVER Actual Versus Target Annua
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FTE Lost due to Sickness Absence by
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The data on the previous page has b
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Indicator Target Apr-12 May-12 Jun-
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Starters *¹ 7.00 3.60 5.00 7.43 6.
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EXECUTIVE SUMMARY TITLE: COST IMPRO
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Month 6 CIP Performance Workstream
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Governance The Cost Improvement Pro
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1 REPORT TO: REPORT FROM: Trust Boa
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3 Preparations for winter planning
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5 Preparing the Payment by Results
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7 People with dementia to receive m
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9 Clinical Patient Management and H
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102/2012 Apologies Apologies were r
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Action Members were advised that ac
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Action 115/2012 Any Other Business
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EXECUTIVE SUMMARY TITLE: Finance Re
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1. EXECUTIVE SUMMARY Monthly I&E Ru
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Trust I&E summary by Division/Direc
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Income by POD In Month Year to date
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Devolved income Annual Budget Forec
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4. BALANCE SHEET Balance Sheet Curr
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6. Business Unit Summaries Attached
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