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

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3c 3d All Cancers: 31-day wait from diagnosis to first treatment Cancer: 2 week wait from referral to date first seen, comprising: all urgent referrals 93% for symptomatic breast patients (cancer not initially suspected) 93% 96% 0.5 yes yes yes yes yes yes Yes 0.5 yes yes yes yes yes yes Yes Quality 3e 3f 3g 3h A&E: From arrival to admission/transfer/discharge Care Programme Approach (CPA) patients, comprising: Minimising mental health delayed transfers of care Admissions to inpatients services had access to Crisis Resolution/Home Treatment teams Maximum waiting time of four hours Receiving follow-up contact within 7 days of discharge Having formal review within 12 months 95% 1.0 No No No No no no No 95% 1.0 N/a N/a N/a N/a n/a n/a Yes 95% ≤7.5% 1.0 yes yes Yes Yes yes yes Yes 95% 1.0 N/a N/a N/a n/a n/a n/a Yes Implement redesigned medical rotas – pilot on 7 day a week consultant cover commencing in November Bed Management review ensuring defined roles and responsibilities that support and focus on flow from ED to Assessment and then with focus on the delivery of bed availability from the inpatient areas to deliver seamless use of the bed capacity to meet demand and ensure timely patient flow. Ward reviews to commence 7 day working across the Trust including support services Reducing Length of Stay by working with partner organisations and families to reduce length of stay Improved communication with partner organisation to expedite discharges and forward planning to meet demand 3i Meeting commitment to serve new psychosis cases by early intervention teams 95% 0.5 N/a N/a N/a N/a n/a n/a Yes 3j Category A call – emergency response within 8 minutes 75% 1.0 N/a N/a N/a N/a n/a n/a Yes 3k Category A call – ambulance vehicle arrives within 19 minutes 95% 1.0 N/a N/a N/a N/a n/a n/a Yes There were 7 cases of infection reported during September, none of the patients acquiring the infection was as the result of cross contamination. 4a Clostridium Difficile Enter Are you below the ceiling for your contractual monthly trajectory ceiling 1.0 yes yes no no no no No Exception reporting occurred in all 7 cases against the standardised 17 criteria. 6 wards scored 100%, one ward (heather) scored less than 100% and has been required to produce an action plan to address the issues highlighted by the infection control exception report. No primary cause was identified for this case. The issues identified were practice related. The Infection Control Committee monitors the wards progress against their action plans
Safety 4b MRSA Enter Are you below the ceiling for your contractual monthly trajectory ceiling 1.0 yes yes no no No No No 2 cases Q1 , 2 cases in September. 6 YTD against ceiling 7 per year New Director of Infection Prevention and Control is now in post.There is a change of focus to Infection prevention and the current action plan is being reviewed to identify the high impact actions, one of which is ANTT. ANTT has been introduced across the Trust and to date 60% of Matrons and 72% of senior sisters have achieved Train the Trainer competencies. These staff will now roll out the training across the wards. New hand washing campaigns and training programmes introduced. Training for doctors has commenced for FY1/2s Consultants and is being planned for staff grades. A CQC Registration Non-Compliance with CQC Essential Standards resulting in a Major Impact on Patients 0 2.0 yes yes Yes No No No No B Non-Compliance with CQC Essential Standards resulting in Enforcement Action 0 4.0 yes yes Yes Yes Yes Yes Trust-wide action plan in place that captures all outstanding CQC requirements that has been comprehensively shared with the SHA and local Commissioners, is being implemented with Trust Board and is subjected to external monitoring. C NHS Litigation Authority – Failure to maintain, or certify a minimum published CNST level of 1.0 or have in place appropriate alternative arrangements 0 2.0 no no No No No No No RAG RATING : GREEN = Score of 1 or under TOTAL 5.5 5.5 8.5 8.5 7.5 3.5 8.5 AMBER/GREEN = Score between 1 and 1.9 AMBER / RED = Score between 2 and 3.9 RED = Score of 4 or above Overriding Rules - Nature and Duration of Override at SHA's Discretion Greater than six cases in the year to date, and either: i) Meeting the MRSA Objective Breaches the cumulative year-to-date trajectory for three successive quarters no no no No No no No Breaches its full year objective Greater than 12 cases in the year to date, and either: Breaches the cumulative year-to-date trajectory for three ii) Meeting the C-Diff Objective successive quarters Breaches its full year objective no no no no No No No Reports important or signficant outbreaks of C.difficile, as defined by the Health Protection Agency. Breaches: The admitted patients 18 weeks waiting time measure for a third successive quarter
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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
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4.1.1 Quality and Safety Committee
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• Financial risks: risks associat
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Proactive risk assessment enables t
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Trust’s risk matrix and will popu
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Risk Grading Staff Group Evidence R
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4.8 RISK REGISTER The Risk Register
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5.1 Consultation and Communication
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The Trust recognises the importance
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timescale with supporting evidence
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Checklist for the Review and Approv
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Equality Impact Assessment Tool To
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Plan for Dissemination of Procedura
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Consequence score (severity levels)
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Frequency How often might it/does i
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Appendix 3 Framework for Risk Manag
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Risk Register inventory they are ex
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2. DECISION REQUIRED: CATEGORY: The
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• 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
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: Effectiveness GOVERNANCE RISK RATIN
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
Page 193 and 194: TURNOVER Actual Versus Target Annua
Page 195 and 196: FTE Lost due to Sickness Absence by
Page 197 and 198: The data on the previous page has b
Page 199 and 200: Indicator Target Apr-12 May-12 Jun-
Page 201 and 202: Starters *¹ 7.00 3.60 5.00 7.43 6.
Page 203 and 204: EXECUTIVE SUMMARY TITLE: COST IMPRO
Page 205 and 206: Month 6 CIP Performance Workstream
Page 207 and 208: Governance The Cost Improvement Pro
Page 209 and 210: 1 REPORT TO: REPORT FROM: Trust Boa
Page 211 and 212: 3 Preparations for winter planning
Page 213 and 214: 5 Preparing the Payment by Results
Page 215 and 216: 7 People with dementia to receive m
Page 217 and 218: 9 Clinical Patient Management and H
Page 219 and 220: 102/2012 Apologies Apologies were r
Page 221 and 222: Action Members were advised that ac
Page 223 and 224: Action 115/2012 Any Other Business
Page 225 and 226: EXECUTIVE SUMMARY TITLE: Finance Re
Page 227 and 228: 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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