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

CQC Update Report
2012
RADIOLOGY
31. Develop its planning and
bed management processes to
ensure all patients are cared for
in appropriate facilities.
Matrons and ward sisters are
monitoring this but the Trust has
not yet established how best to
measure success in this area. The
X‐Ray department has introduced
appropriate checklists for ensuring
patients are properly prepared.
The Department has developed Standard Operating Procedures
attached below which are evidence based and serve as the
baseline expectation for all staff. These have been ratified
internally, and are based on good practice examples.
These are well publicised throughout the department, and
subject to internal review.
• A Plan is in place to ensure publicity and accessibility at
ward level
• The impact of these documents is subject to audit in 6
months time.
Stephen
Griffiths
MET
BUSINESS
AS USUAL
RADIOLOGY
32. Put in place clear protocols
for the management of
interventional rradiology
patients with audit and
improvement cycles to ensure
standards are attained and
maintained.
Audit processes are in place and
are monitored at interventional
radiology meetings and at the
Divisional Board. SOPs are in place
and are being implemented for
each procedure in interventional
radiology.
CQC’s compliance activity supports
the Trust’s assessment of
significant progress in this area,
although more audit activity needs
to be delivered for this to be
considered fully met.
The Department has developed Standard Operating Procedures
attached below which are evidence based and serve as the
baseline expectation for all staff. These have been ratified
internally, and are based on good practice examples.
These are well publicised throughout the department, and
subject to internal review.
Stephen
Griffiths
MET
BUSINESS
AS USUAL
RECORDS
80. Improve its systems for
records management to ensure
that notes can be retrieved
effectively and expediently, and
reduce the risks associated with
multiple sets of temporary
notes and poor data handling.
The Trust’s Medical Records
Committee has been reestablished
with new Terms of
Reference; training levels for
healthcare professionals are
discussed at this Committee on a
regular basis. Weekend transport
for transfer of notes has been
reintroduced and a nursing
documentation booklet has been
piloted across several wards and
will be fully implemented by the
The development of the eHandover system will provide a
Trustwide joined up reference database for the use in patient
care.
A new PAS is being commissioned in 2013 for implementation
which will improve the availability of Patient records and reduce
the incidence of Temporary folders.
It is anticipated that patients will be migrated onto one hospital
number covered by barcode scanning options as part of the rollout
and implementation.
Ian Grant
Alex
Hammerton
PART MET
BUSINESS
AS USUAL
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