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

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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