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

QUALITY
#REF!
Insert Performance in Month
Criteria
Unit Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
Septemb
er 12
Comments on Performance in Month
1 SHMI - latest data Ratio 95.6
2
Venous Thromboembolism (VTE)
Screening
% 92 92 90 90 91 91 94 94 93 94 94 95
To improve performance to ensure delivery of this
standard the following actions have been taken
A review of the pathway for patients who go straight to a
procedure without attending a pre‐admission clinic to
ensure that these patients are swabbed prior to admission.
This pathway will be implemented from October
3a Elective MRSA Screening % no data 71 61 67 81 78 78 78 74 78 79 84
A review of data capture to ensure that all swabs are
matched correctly to admissions – this will be completed in
September
Training of Admissions Team Leader on data accuracy,
which will improve data quality when patients are added to
waiting list and thereby improve coverage of data for MRSA
elective screening; this will be completed in September
To improve performance to ensure delivery of this
standard the following actions have been taken
3b Non Elective MRSA Screening % no data 76 72 71 70 69 69 74 83 77 75 79
• A change of process in emergency day unit (EMDU) to
screen patients who currently do not qualify for screening
has been implemented in September
• Using the ward board rounds to check if patents have
been screened. The Ward Sponsors will work with the
wards to ensure that screening takes place.
• Staff to be reminded to write legibly on test requests to
ensure that the Lab is able to identify which patient the
swabs have come from. This error will be addressed by the
roll out of order communications for Pathology in
December 2012,
• Review of the data to ensure patients who do not require
screening are excluded from the data this will be
completed in September