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

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APPENDIX 2 REPORTING STRUCTURE FOR RISK TRUST BOARD PUBLIC Quality and Strategy Committee Audit Committee Clinical Risk Management Committee (CRC) Statutory Safety Committee Safeguarding Children Committee (SCC) Safeguarding Adults Committee (SAC) Evidence Based Practice Board (EBPC) Drugs and Therapeutic Committee (D&TC) Infection Control Committee (ICC) Clinical Audit Committee (CAC) Research & Development Committee (R&DC) Barking, Havering & Redbridge University Hospitals NHS Trust Page 37 of 40 ????????????? ??/??/???? Version ?? Issued ????
Appendix 3 Framework for Risk Management Self Assessment tool for Directorates/Departments Key Element Required Action Complaint Yes No N/A Leadership The Directorate/Department has a local clinical governance or risk management group which evaluates implementation of risk management systems and strategies and aggress service changes as necessary The Directorate group considers matters pertaining to risk management including incidents, complaints and claims There is an indentified lead for risk management who is part of the local clinical governance (or similar) group and whose remit includes sharing information and learning on incidents, complaints, claims and health and safety The Clinical Directorate team provide the medical director with an annual governance report outlining their progress against directorate and corporate objectives Culture Accountability The Clinical Director receives copies of all relevant guidance including NICE guidelines and Centralised Alerting Systems (CAS) alerts, national confidential enquiries and ensures that appropriate action is instigated All leaders behave in a way which is consistent with and demonstrates commitment to being open and fair The Directorate identify areas of required improvement through both corporate and local risk management systems and implement appropriately Incidents, near misses and risks are regularly reported using the Trust Risk Management reporting system Incidents and near misses are investigated and analysed and where specific areas of learning are identified or changes to practice required appropriate action is taken Major Incident Planning Incident investigation to the level appropriate for severity (as per policy) and final approval is undertaken within the agreed timescales The Directorate/Department managers are aware of the Trust Major Incident Plan The Directorate/Department managers are aware of their responsibilities in relation to the Major Incident Plan Business Continuity Management Strategy External Assessments Where relevant staff have received briefing/training on the Major Incident Plan and associated policies Directorate/Department Business Continuity plans are maintained The Directorate/Department teams participate in Business Continuity planning The Directorate/Department is aware of the objectives of the Trust Risk Management Policy and Strategy and has formulated a plane to enable these to be achieved locally The Directorate/Department has an action plan to meet local objectives related to risk management The Directorate/Department are aware of the safety and risk management standards as indentified by external agencies such as Care Quality Commission and NHS Litigation Authority Barking, Havering & Redbridge University Hospitals NHS Trust Page 38 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
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343 Directorate Anaesthetic: Risk:
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Table of Contents TRUST PRINCIPAL O
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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 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: Frequency How often might it/does i
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
Page 163 and 164: Corporate Non Clinical Category Num
Page 165 and 166: order to resolve concerns. Particul
Page 167 and 168: 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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