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

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Over-arching IG action plan Action Plan for improvements to IG compliance Task Programme of work Task owner Current status Status date 1 Consistent attendance from all standard owners in IGSG and support for IG Toolkit compliance 2 Submission of monthly, quarterly and yearly reports to IGSG 3 Review latest version of IG toolkit to identify any changes to requirements 3a Advise all standard owners of requirements/function changes and need to start work on version 10 3b Remove out of date information on Version 10 of IG toolkit and upload current information where available 4 Development of standard owner action plans 4a Presentation of standard owner action plans at September IGSG 4b Further discussion concerning standard owner action plans 5 Submission of baseline return by 31/07/12 6 Updating of IG policies required out of date to IGSG for approval 7 Review of IG toolkit report from auditors 7a Formulate Trust response to audit report 7b Incorporation of auditor comments into standard owner action plans 8 Conclude distribution of IG local Guide 9 Update e-learning instructions for IG module and include on the Intranet 10 Promote annual training requirement via the Link, updating Learning & Development prospectus Standard owners Standard owners Completion due date In progress 02/10/2012 On going through the year In progress 02/10/2012 On going through the year SB Completed 01/06/2012 01/06/2012 SB Completed 01/06/2012 01/06/2012 Standard owners Standard owners Standard owners Standard owners In progress 02/10/2012 Imminent for remaining standard owners In progress 02/10/2012 Imminent for remaining standard owners Completed 02/10/2012 26/09/2012 To start 02/10/2012 22/10/2012 SB Completed 31/07/2012 31/07/2012 Standard On going 02/10/2012 31/12/2012 owners NM/SB/NMk Completed 22/08/2012 24/08/2012 NM/SB/NMk To start 22/08/2012 30/09/2012 Standard owners To start 02/10/2012 31/10/2012 SB Started 02/10/2012 on-going via training courses SB Completed 17/05/2012 17/05/2012 SB Completed 17/05/2012 17/05/2012 Barking, Havering & Redbridge University Hospitals NHS Trust Page 8 of 9 Information Governance Strategy Version 1.3 Issued August 2012
10a Reapproval of IG training programme with DOH 11 Sub group to review risk assessments/information flows from Parkhill project 11a Ensure current risk register captures all systems and appropriate risk owners 11b 11c Proposal from Auditors of IG work programme for 2012/13 for improving risk assessment and information flow standards Auditor IG work programme roll out 12 Submit IG Toolkit performance return by 31/10/12 deadline 13 Fax directory - work to identify all fax numbers, ensure confidentiality posters displayed, update fax directory on the intranet 14 Distribute Patient Information Leaflets 15 Review Data Quality processes - linked with Data Quality Group 16 Review Business Continuity Management plans SB To start 02/10/2012 Imminent Sub-group Completed 30/05/2012 30/05/2012 SB/Subgroup NMk/agreed with NM NMk in coordination with SB To start 02/10/2012 31/12/2012 Completed 31/07/2012 31/07/2012 Started 02/10/2012 30/10/2012 SB To start 02/10/2012 31/10/2012 SB/Telecoms To start 02/10/2012 31/12/2012 GE In progress 02/10/2012 on-going CB To start 02/10/2012 on-going DB/JH In progress 02/10/2012 31/12/2012 17 Development of survey monkey training evaluation forms SB In progress 02/10/2012 31/12/2012 17a Sending of evaluation forms SB To start 02/10/2012 31/01/2013 17b Evaluation of training evaluation forms SB To start 02/10/2012 28/02/2013 18 Review and update Information Governance Information on the Trust website SB Completed 22/08/2012 22/08/2012 18a Update FOI Publication Scheme, update on website SB To start 02/10/2012 28/02/2013 19 Arrange audit date for 2012/13 Toolkit return NM/SB To start 02/10/2012 31/12/2012 20 All evidence uploaded to IG toolkit Standard owners To start 02/10/2012 15/03/2013 20a Final review of evidence, marking all standards as complete SB To start 02/10/2012 25/03/2013 20b Sign off of final IG toolkit return NM To start 02/10/2012 28/03/2013 20c Submission of final IG toolkit return by 31/03/13 deadline SB To start 02/10/2012 29/03/2013 Barking, Havering & Redbridge University Hospitals NHS Trust Page 9 of 9 Information Governance Strategy Version 1.3 Issued August 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
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
Page 53 and 54: Information is a vital asset in ter
Page 55 and 56: starters as well as being mandatory
Page 57: The standards are split into the ar
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
Page 97 and 98: Trust’s risk matrix and will popu
Page 99 and 100: Risk Grading Staff Group Evidence R
Page 101 and 102: 4.8 RISK REGISTER The Risk Register
Page 103 and 104: 5.1 Consultation and Communication
Page 105 and 106: The Trust recognises the importance
Page 107 and 108: 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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