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

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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 Page 18 of 22
CQC Update Report 2012 autumn. RECORDS 81. Develop integrated patient administration and information systems to ensure that, where ever a patient is being treated within the trust, their full healthcare history can be accessed by all staff. A procurement process is underway to introduce an effective system to enable access to patient histories. Funding challenges have slowed introducing of a full electronic patient record. 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. Paul Richards RESPECT & INVOLVEMENT 27. Make sure that proactive and mandatory training and education regarding dignity, respect and tolerance is delivered to all staff. Dignity and respect benchmarking has been done; compliance reports on non‐attendance are being reviewed and a mandatory training programme is being developed. A leaflet for new staff about the Trust’s expectations of behaviour has been drafted and is due to be reviewed with the staff engagement group before roll out. The BHRUT Code is being reviewed and will be issued to all new starters with contract. Quality of Care audits of dignity and respect have been carried out in December and March so far and will continue in order to audit feedback from the real time patient survey. Bank managers to ensure that competence of all temporary clinical staff in this respect is monitored; if concerns are raised about temporary staff they should either not be booked again or only done so with documented supervision. Mandatory training development, reports on non‐attendance, leaflet re Behaviour and expectations; reviewed BHRUT Code; Survey Feedback, Update from Gill Perry re Bank competency framework monitoring. Gill Perry Claire O’Toole Alison Crombie MET BUSINESS AS USUAL Page 19 of 22
Page 1 and 2: TRUST BOARD MEETING Wednesday, 7 No
Page 3 and 4: 2 Following Mr White’s concerns r
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: CQC Update Report 2012 are now supe
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
Page 53 and 54: Information is a vital asset in ter
Page 55 and 56: starters as well as being mandatory
Page 57 and 58: The standards are split into the ar
Page 59 and 60: 10a Reapproval of IG training progr
Page 61 and 62: 343 Directorate Anaesthetic: Risk:
Page 63 and 64: Table of Contents TRUST PRINCIPAL O
Page 65 and 66: BHRUT STRATEGIC OBJECTIVES WITH EAC
Page 67 and 68: DIRECTORATES RISKS REVIEW 12 10 8 6
Page 69 and 70: RISKS DETAILS PRINCIPAL RISK What c
Page 71 and 72: PRINCIPAL RISK What could prevent t
Page 77 and 78: RISK DESCRIPTORS OBJECTIVE SAFE, HI
Page 79 and 80: BOARD ASSURANCE FRAMEWORK ELEMENTS
Page 81 and 82: EXECUTIVE SUMMARY TITLE: Risk Manag
Page 83 and 84: Contents Section Page 1 Introductio
Page 85 and 86: incorporate mitigation controls wit
Page 87 and 88: “Risk Register” “Risk Registe
Page 89 and 90: potential risks they may face in ac
Page 91 and 92: 4.1.1 Quality and Safety Committee
Page 93 and 94: • Financial risks: risks associat
Page 95 and 96:
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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Trust Board papers November 2012 - Barking Havering and ...

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