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

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Barking, Havering and Redbridge University Hospitals NHS Trust Source Responsibility On Target Target Of Concern Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Action Required Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Maternity Quality and Safety Committee attendance Number of guidelines over due for review SI's- declared with care service problems and contributory factors S.I panel meeting within 4 days No of S.I submitted within required time frame Improved patient satisfaction- 50% of women surveyed Complaints CNST JP Quorate Not Quorate Quorate Quorate Quorate Quorate Quorate Quorate CNST CH 5 10 0 25 19 16 10 12 CQUINN JP 0 3 5 5 3 6 2/5 6 / 11 0/2 CQUINN JP 95% 90% 50% 3 7 4/5 11 / 11 2/2 CQUINN JP 75% 60% 55% 0 7 2/5 5 / 13* 9/9 CQUINN WM 50% 40% 30% NA NA NA NA NA 70% TRUST SL 10 2 5 3 7 8 4 Activity Workforce Births Benchmarked to 8,700 KPI SL 710 730 766 667 802 782 823 804 781 Births in acute Queens LW setting KPI SL 540 560 580 516 605 591 641 636 617 Births taking place at KGH KPI SL 165 175 185 136 175 166 160 167 147 Midwife led unit (10%) of births KPI SL 70 75 80 NA NA NA NA NA NA Homebirths KPI SL 2% 1% 0.50% 1.00% 1% 1.50% 0.85% 1.30% 1.10% No of referrals received KPI SE 741 929(86) 1123(69) 985(66) 1136(59) 869(62) 943(84) No of referrals received by 10 weeks and 6 days KPI SE 720 769 621 590 726 521 No: of women booked before 12 weeks and 6 days KPI SE 90% 85-90%
Maternity Services Monthly Performance Report Trust Name Barking, Havering & Redbridge University Hospitals NHS Trust Reporting month This report covers the period: 1 st September to 30 th September 2012 Completed by Mr Dele Olorunshola Clinical Director of Obstetrics, Gynaecology and Sexual Health Wendy Matthews, Director of Midwifery Reviewed by Dorothy Hosein, Director of Transformation On behalf of Director of Nursing Neill Moloney Director of Planning & Performance Contact Details Barking, Havering & Redbridge University Hospitals NHS Trust 1st Floor Green Zone Maternity Services, Queens Hospital Rom Valley Way, Romford, RM7 0AG Tel: 01708 435 000 x 3894 A monthly report will be provided to; monitor the progress made against the maternity services improvement plan, provide assurance that the safety and quality of maternity services are improving within BHRUT. It will summarise the themes and actions that have arisen from the analysis of activity within the unit. Mat 2 October 2012 (2).doc Page 1 of 9 Compiled by C Frisby 12.07.2012 1
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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
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DIRECTORATES RISKS REVIEW 12 10 8 6
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RISKS DETAILS PRINCIPAL RISK What c
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PRINCIPAL RISK What could prevent t
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RISK DESCRIPTORS OBJECTIVE SAFE, HI
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BOARD ASSURANCE FRAMEWORK ELEMENTS
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EXECUTIVE SUMMARY TITLE: Risk Manag
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Contents Section Page 1 Introductio
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incorporate mitigation controls wit
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“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 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: would welcome feedback from the Tru
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
Page 169 and 170: SELF-CERTIFICATION RETURNS Organisa
Page 171 and 172: 12 AA - Quality Improvement Strateg
Page 173 and 174: TFA Progress BHR University Hospita
Page 175 and 176: 25 TFA - Final IBP /; LTFM Dec-12 H
Page 177 and 178: Effectiveness GOVERNANCE RISK RATIN
Page 179 and 180: Safety 4b MRSA Enter Are you below
Page 181 and 182: FINANCIAL RISK RATING BHR Universit
Page 183 and 184: CONTRACTUAL DATA BHR University Hos
Page 185 and 186: 4 Single Sex Accommodation Breaches
Page 187 and 188: TITLE: EXECUTIVE SUMMARY BOARD/GROU
Page 189 and 190: 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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Trust Board papers November 2012 - Barking Havering and ...

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