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

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1. Introduction The purpose of this report is to summarise the progress made in September 2012 against the maternity service improvement plan and the KPIs outlined in the maternity service specification as agreed with NELC. 2. Total Number of Births at BHRUT for September 2012 KGH Queens BHRUT (%) Elective CS 14 53 67 Emergency CS 26 113 139 Others 107 451 558 Total 147 617 764 9% 18% 73% * There were 17 births outside of the unit, registered as BBA and homebirths. Total birth rate for the Trust including outside deliveries is 781. 3. Monthly Activity (excluding elective LSCS) Monthly Hospital Delivery Activity 800 700 600 500 400 300 Queens Optimum QH KGH Optimum KGH 200 100 May Jun Jul Aug Sep Month Mat 2 October 2012 (2).doc Page 2 of 9 Compiled by C Frisby 12.07.2012 2
4. Capping The maternity service is no longer subject to capping births as BHRUT have moved towards business as usual. The service continues to use internal escalation and conforms to the pan London escalation policy. Discussions are underway with the commissioners to cap maternity bookings to ensure that births reduce to 8000 by 2013/14 5. Diverts Diverts occur when the number of labouring women accessing the service is greater than the service can deal with without compromising care. The Trust has moved to the pan London escalation policy since the lifting of restrictions in early June. In these instances, women are diverted to the nearest accepting unit unless their clinical presentation indicates that transfer to another provider would pose a greater risk. Since the lift of the cap, diverts are recorded based on a 24 hour clock (i.e. 0000 – 2400) and not between the hours of 18:00 - 18:00 as was the case previously. The divert policy was activated once across the Trust during the month of September. However, no women were actually diverted. On that occasion there were no other hospitals that could accept women from BHRUT which increased the risk at Queen’s Hospital. 6. Triage The standard is that 98% of women should be seen by a midwife within 30 minutes of arrival at triage. In September, 1014 women accessed the Triage service at Queen’s. Of these women 88% were seen within 30 minutes. The graph below depicts the monthly average percentage of patients seen within 30 minutes of their arrival in triage, indicated by a single figure for the month Triage Attendance - % seen ≤ 30 mins and No. of Women Attending % Seen ≤ 30 minutes 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% STANDARD 1200 STANDARD (98%) 87% 1163 86% 89% 1149 86% 88% 85% 1150 81% 1140 1146 78% 1110 1110 73% 1100 1085 1050 1014 1000 973 950 900 850 Jan Feb Mar Apr May Jun Jul Aug Sep % SEEN ≤ 30 MINS STANDARD No of women attending No of Women Attending (Actual) Mat 2 October 2012 (2).doc Page 3 of 9 Compiled by C Frisby 12.07.2012 3
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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
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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 and 140: would welcome feedback from the Tru
Page 141: Maternity Services Monthly Performa
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
Page 191 and 192: 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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