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

Priority Action Lead Monitoring Tool Current Risk
Rating
Risk rating
previous
month
Antenatal
Access to maternity
services
Intrapartum
Ensure that Labour Ward
remains safe and
appropriate escalation
occurs
Women where the referral received by
10+6weeks to be booked by 12+6 weeks for
90% of maternities
90% of women to be triaged within 30
minutes of arrival
Number of bookings must not exceed cap
C:\Data\matthews w\
Bookings\New Templa
Escalation policy in place
NELC informed of diverts as per PAN London
divert policy
W
Matthews
Monthly reporting to Trust Board and
on maternity dashboard
92% 92%
A Archibald Monthly performance report 88% 89%
W
Matthews
Avril
Archibald
Weekly teleconference, weekly
submission of booking data
*Evidence of BHRUT escalation
implemented.
NELC informed of escalation in line
with agreed process.
Evidence of LSA database updated
with escalation details.
Awaiting cap
implementation
date
1 3
Ensuring woman receive
1:1 care by a midwife in
established labour
Staffing levels on Labour Ward to allow for
1:1 care in labour.
Clinical pathways facilitator to have an
overview of staffing levels across maternity in
hours, out of hours this is undertaken by
Labour Ward co-ordinator
Avril
Archibald
BHRUT to maintain a minimum
midwife ratio of 1:29.
Weekly audit of one to one care
Review of patient feedback.
Dashboard entry monthly
100% 100%
All women presenting to the
unit are assessed in a
timely way.
High risk women identified
*BHRUT to ensure that 90% of women seen
within 30mins of arrival to triage.
*Daily percentage of high risk women seen
within target time (98% within 1hour).
2
Monthly reporting. 88% 89%