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

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CIP Project Governance – Approval Flowchart New CIP scheme generated Work stream steering group Operational/ directorate Agree work stream Complete a Quality Impact Assessment Directorates add to their risk register Director/ divisional review meetings All schemes‐ Complete a Risk Assessment CD review of risk assessment Does the risk assessment contain any Moderate (M) or High (H) risks after mitigation? CIP delivery ( as per tracker) Clinical risk assessment Blue Green Amber Red 1 2 3 4 Low 1 1 2 3 4 Medium 2 2 4 6 8 High 3 3 6 9 12 PMO add to CIP risk register Service Transformation Office Complete a Project Mandate for schemes over £50,000 Transformation Board (Monthly) Ongoing monitoring of operational and clinical indictors via directorates dash boards Patient satisfaction, Length of stay HCAI’s, Hospital readmission rates, Staff satisfaction Clinical Quality Assurance Panel (Monthly) Quality and Safety Board (Bi‐monthly) Version 3- JM 19/10/12 Status to be tracked in both CIP and departmental risk register and the Q&S board 5
1 REPORT TO: REPORT FROM: Trust Board Chief Executive DATE: 11 October 2012 SUBJECT: FOR: CHAIRMAN & CHIEF EXECUTIVE’S REPORT Information ______________________________________________________________ 1. INTRODUCTION This report contains a summary of: • Actions taken under emergency powers • Executive decisions • National Issues/News • Local Issues/News 2. RECOMMENDATION The Board is asked to note this report. 3. ACTIONS TAKEN UNDER EMERGENCY POWERS No actions have been taken by the Chairman, or Chief Executive acting under emergency powers. 4. EXECUTIVE DECISIONS The Trust Executive Committee has been meeting on a monthly basis and have reviewed and inputted into several reports prior to their submission to the Trust Board, such as the Board Assurance Framework, Information Governance Strategy 2012/13, Complaints Annual Report 2011/12 and the Single Operating Model. . 1. Chairman & Chief Executive’s Report – November 2012
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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
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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
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
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: Governance The Cost Improvement Pro
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
Page 229 and 230: Trust I&E summary by Division/Direc
Page 231 and 232: Income by POD In Month Year to date
Page 233 and 234: Devolved income Annual Budget Forec
Page 237 and 238: 4. BALANCE SHEET Balance Sheet Curr
Page 239: 6. Business Unit Summaries Attached
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