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

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1 BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST Minutes of the Part I Trust Board Meeting held on the 5 September 2012 in the Board Room, Trust Headquarters, Queen’s Hospital Present: Mr George Wood Interim Chairman Mrs Averil Dongworth Chief Executive Mr Stephen Burgess Director of Clinical Strategy & Deputy Medical Director Dr Maureen Dalziel Associate Non-Executive Director Mr William Langley Non-Executive Director Mr Keith Mahoney Non-Executive Director Mr Neill Moloney Director of Planning & Performance Prof Anthony Warrens Non-Executive Director Ms Judith Douglas Acting Director of Nursing Mr David Gilburt Interim Director of Finance Mrs Dorothy Hosein Director of Transformation Ms Caroline Wright Non-Executive Director Mr Michael White Non-Executive Director In Attendance: Mr Nick Hulme Project Director, Integration Ms Imogen Shillito Director of Communications Mrs Sue Williams Executive Assistant/Trust Board Secretary Ms Heather Wright Team Leader for Palliative Care Dr Andrew Gage Palliative Care Consultant Dr Derek Hicks Clinical Director, Emergency Care 2012/042 APOLOGIES FOR ABSENCE Mrs Cathy Geddes, Chief Operating Officer, Dr Mike Gill, Medical Director and Mrs Marie Gabriel, Chair of NELC. 2012/043 MINUTES OF THE PART I MEETING HELD ON 4 JULY 2012 The minutes of the Part I meeting held on the 4 July 2012 were noted as a true record and signed by the Interim Chairman. 2012/044 MATTERS ARISING 2012/011: Quality & Safety Committee continuing to review the Patient Stories paper and would make their recommendations to the Trust Board at a future meeting. 2012/045 BOARD ASSURANCE FRAMEWORK Mr Burgess presented the Board Assurance Framework (BAF) for the first quarter of 2012. He confirmed that following discussions at previous Trust Board meetings and at the Trust Executive Committee, there had been a progressive journey of improvement to the BAF and the comments at these meetings had been incorporated into the latest version. Mr Wood questioned when there would be a coordinated output from the Learning Lessons Group identified against Risk No 339. The Board was informed that this Group had been established by the previous Director of Nursing and responsibility for this area had now been moved to one of the Deputy Directors of Nursing, Gary Etheridge. Ms Douglas confirmed that one meeting had taken place to date and another was scheduled for mid-September. The Group were amalgamating information/intelligence from different sources in the organisation, including clinical and non-clinical, complaints, compliments, claims and safeguarding and would be preparing an action plan to go out to the Directorates and the Corporate areas for them to prioritise the main areas for resolution and to learn from the issues identified. It was agreed that the action plan would feed into the Quality & Safety Committee. Trust Board Minutes Part I – 5 September 2012
2 Following Mr White’s concerns raised around the ownership of risk management and the sequence of presenting papers to different Trust Committees, the Chief Executive confirmed that this was an area that would be picked up by the new appointment of a Director of Governance and Special Projects who would be starting with the Trust on the 10 September. The Board noted that the overall Board Assurance would report through the Trust Executive Committee and on to the Trust Board. The Clinical Governance Team was meeting with each Directorate and going through a rigorous training programme, in order to ensure that everyone understood the process. The Trust, through this new appointment, would be working towards Integrated Governance throughout the organisation. Dr Dalziel was concerned that the ‘Corporate Risks by Year’ chart did not provide a good comparison between 2011 and 2012 and she could not get a sense of whether the Trust had made improvements in going from quite a few risks, to less risks. The performance in 2011 looked to have doubled from the analysis in 2009 and 2010. It was agreed by the Board that when presenting this type of information, the report should include some narrative, in order to explain the trends. It was agreed that Mr Moloney, through the Performance/Information Department, would look at the quality control of information being presented to the Board to ensure it was meaningful for the members and complied with Information Governance. Dr Dalziel also felt that it was important to link these analyses to staffing and vacancy levels, as this information could not sit outside of this and needed to be linked to it in some way to ensure correlation of data. The Trust Board noted the changes to the Board Assurance Framework. Action: Neill Moloney 7.11.12 2012/046 QUALITY & PATIENT STANDARDS PERFORMANCE REPORT – JULY 2012 Mr Moloney informed the Board that there had been three MRSA bacteraemias reported during the month, bringing the Trust’s total up to five. Unfortunately since the report had been finalised, another case had been reported, bringing the total to six, against a yearly target of seven. It was felt that the target would be breached by the end of the year. He also reported that the complaints performance had returned to ‘green’ and the Trust had achieved 87% for its response times during the month of July. Another area to note was that length of stay had improved on non-elective, but worryingly DTOCs had not reduced; increased from 4.39% in June to 4.69% in July. Mr Mahoney raised the performance for MRSA Screening and the Trust’s position compared with other Trusts. The Board noted that this area had been discussed in detail with the Directorates, both for elective and non-elective and there had been a considerable amount of work ongoing since August to ensure an improvement in performance over the next two to three months. The Emergency Department was also looking at the Emergency Medicine Decision Unit (EMDU) to capture all the patients going through there as well, so this would contribute to the improvement in performance. Mr Moloney informed the Board that it had been made very clear at the Directorate Performance Review meetings recently that the performance against this target had to improve. The Interim Deputy Director of Nursing, Gary Etheridge had taken on responsibility for patient experience and he was currently taking a different approach to the implementation of the hand held devices, in order to encourage both patients and their relatives to complete the questionnaires. The Board agreed that this had to be part of the discharge process, so the Trust had some good quality data to refer to. The Interim Chairman raised his concerns regarding the drop in performance for appraisals (72.69%, a drop of 3.71% on last month’s position) and whether this meant that the Trust had a large number of staff in the organisation who did not have their objectives set for the next year. The Board agreed that it was very important for staff to have their objectives set, in order to performance manage people appropriately. It had been agreed at a previous Board meeting that Clinical Directors would ensure appraisals and objectives were aligned and cascaded down through their Directorates. The Chief Executive would take this up with the two Executive Directors currently covering the Chief Operating Officer’s responsibilities, namely Mrs Hosein and Mr Hulme, to ensure that the Associate Directors and other senior management had their objectives. The Chief Executive would provide the appropriate evidence for the Board. Trust Board Minutes Part I – 5 September 2012
Page 1: TRUST BOARD MEETING Wednesday, 7 No
Page 5 and 6: 4 forecast in terms of community be
Page 7 and 8: 6 The Trust Board noted the Plan fo
Page 9 and 10: 8 The Co-Chair of the Improving Pat
Page 11 and 12: TRUST BOARD MEETING Actions from Mi
Page 13 and 14: Agenda Item Action Deadline Date Da
Page 15 and 16: Question: Mr Skillman was pleased t
Page 17 and 18: CQC Trust-wide Action Plan Review a
Page 19 and 20: 1.0 PURPOSE 1.1 Background This rep
Page 21 and 22: • Review the Senior Responsible O
Page 23 and 24: APPENDIX 1 ‐ CQC ACTION PLAN - EX
Page 25 and 26: RECORDS records management to ensur
Page 27 and 28: CQC Update Report 2012 Theme CQC Re
Page 29 and 30: CQC Update Report 2012 ASSESSING &
Page 31 and 32: CQC Update Report 2012 ASSESSING &
Page 33 and 34: CQC Update Report 2012 pathways thr
Page 35 and 36: CQC Update Report 2012 identified i
Page 37 and 38: CQC Update Report 2012 outlining th
Page 39 and 40: CQC Update Report 2012 improvements
Page 41 and 42: CQC Update Report 2012 aware of the
Page 43 and 44: CQC Update Report 2012 are now supe
Page 45 and 46: CQC Update Report 2012 autumn. RECO
Page 47 and 48: CQC Update Report 2012 of the pilot
Page 49 and 50: EXECUTIVE SUMMARY TITLE: Informatio
Page 51 and 52: 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
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Pilot Wards Division Discharges Per
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Workforce Appraisals - the actions
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Delayed transfers of care (DTOC) -
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EXECUTIVE SUMMARY TITLE: Emergency
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• Training competencies are being
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Appendix A: Trajectory for all type
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would welcome feedback from the Tru
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Maternity Services Monthly Performa
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4. Capping The maternity service is
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7. Obstetric Assessment Unit (OAU)
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10. Serious Incidents Reported Inci
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12. Maternity Dashboard The dashboa
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It should also be noted that the ta
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Priority Action Lead Monitoring Too
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Priority Action Lead Monitoring Too
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Contents Section No: Description Pa
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3. Complaints Activity 3.1 Total Co
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3.5 Themes General care issues and
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Corporate Non Clinical Category Num
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order to resolve concerns. Particul
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The findings of the review were tha
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SELF-CERTIFICATION RETURNS Organisa
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12 AA - Quality Improvement Strateg
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TFA Progress BHR University Hospita
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25 TFA - Final IBP /; LTFM Dec-12 H
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Effectiveness GOVERNANCE RISK RATIN
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Safety 4b MRSA Enter Are you below
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FINANCIAL RISK RATING BHR Universit
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CONTRACTUAL DATA BHR University Hos
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4 Single Sex Accommodation Breaches
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TITLE: EXECUTIVE SUMMARY BOARD/GROU
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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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