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

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6. Is the impact of the policy likely to be negative e.g. is their risk of: Illegal discrimination Reducing equality of opportunity for some groups? Harming relations between different people of different groups? 7. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 8. If so, what action could be taken to reduce adverse effects and promote or enhance positive effects? 9. Please describe the options available for incorporating equality monitoring into routine arrangements? Yes/No Comments If you have identified a potential discriminatory impact of this policy document, please refer the issue to the Workforce Equality Lead, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Workforce Equality Lead, HR Department, Queen’s Hospital on extension 3294. Barking, Havering & Redbridge University Hospitals NHS Trust Page 31 of 40 ????????????? ??/??/???? Version ?? Issued ????
Plan for Dissemination of Procedural Documents To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval or ratification. Title of document: Dissemination lead (name and contact details): Date finalised: Previous document already being used? Yes / No (Please delete as appropriate) Date due to be reviewed: If yes, in what format and where? Proposed action to retrieve out of date copies of the document: Have any training needs been identified and addressed (give details): To be disseminated to: How will it be disseminated, who will do it and when? Format (i.e. paper or electronic) Comments: Quality Systems Manager Originator to send after ratification at committee Electronic For numbering, logging and issue Web Manager Sent by Quality Systems Manager once numbered and logged Electronic For inclusion on Trust Intr@net and, where appropriate, archiving previous version. Originator Sent by Quality Systems Manager once issued Electronic For dissemination All staff Placed on Intr@net (fill in date once issued) Dissemination Record - to be used once document is approved, ratified and issued Disseminated to: (either directly or via meetings, etc.) Format (i.e. paper or electronic) Date disseminated: No. of copies sent: Contact details / comments: Please add as many extra lines as required to this document to ensure it reflects the dissemination plan for the Policy. Issued November 2010 Version 1 Barking, Havering & Redbridge University Hospitals NHS Trust Page 32 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
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starters as well as being mandatory
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The standards are split into the ar
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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 and 106: The Trust recognises the importance
Page 107 and 108: timescale with supporting evidence
Page 109 and 110: Checklist for the Review and Approv
Page 111: Equality Impact Assessment Tool To
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
Page 157 and 158: Contents Section No: Description Pa
Page 159 and 160: 3. Complaints Activity 3.1 Total Co
Page 161 and 162: 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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