Agenda and supporting papers - Plymouth Hospitals NHS Trust

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Item 13 SUMMARY REPORT Trust Board 5 th July 2013 Subject Prepared by Approved by Presented by Information Governance Head of Clinical Systems Governance Director of Planning and Site Services (Senior Information Risk Owner) Director of Planning and Site Services (Senior Information Risk Owner) Purpose The Senior Information Risk Owner (SIRO) provides the Board with a quarterly update on Information Governance; highlighting key progress, risks, incidents and management action. The case note improvement project is being reported to the Safety and Quality Committee at each meeting. The evidence for Care Quality Commission Outcome 21 (Records) was presented to the May 13 Audit Committee. Decision Approval Information Assurance • • Corporate Objectives Quality Care Inspired People Healthy Organisation Innovate & Collaborate • Executive Summary Whilst Information Governance is part of everyone’s role within the Trust, work is being carried out by key teams to improve the overall Information Governance Framework. This is informed by the Information Governance Toolkit requirements, new incident reporting criteria, Care Quality Commission & NHS Litigation Authority (NHSLA) feedback and national Data Quality benchmarking on the Secondary Uses Service (SUS) dashboards. This report highlights the work carried out by the four steering groups reporting to the Records and Information Governance Forum. Quality Impact Assessment An effective Information Governance framework is essential to ensure that all members of staff manage information for the benefit of patients. Financial Impact Assessment • Information Governance Breaches can attract financial penalty from the Information Commissioner. • Effective corporate document management is essential for NHLSA Assessment and will affect premiums. • Whilst the primary reason for accurate information is for patient care, this information assists with running an efficient service. Regulatory Impact Assessment • The Information Commissioners Office regulates the use and access to personal and official data. The main laws being the Data Protection Act and the Freedom of Information Act. • The Care Quality Commission regulates: Records standards under Outcome 21. Transferring information to other providers under Outcome 6 • The Health & Social Care Information Centre oversee the Secondary Use Service (SUS). 1
Item 13 Key Recommendations The Trust Board is asked to note: 1. Work being overseen by the Records and Information Governance forum and the Records Strategy work being reported to the Safety and Quality Committee. 2. The Medical Director taking the role of Chief Clinical Information Officer. 3. The recruitment of a dedicated FOI Manager to address the FOI backlog. Next Steps 1. Follow up action for Outcome 21 issues raised by CARE QUALITY COMMISSION initial feedback. 2. The “Development and Management of Trust Wide Documents” Policy is being significantly changed and will be brought to a future Board meeting for ratification. 3. The IG team will submit V11 baseline IG Toolkit by 31 st July 13. 4. The IG team will produce figures for incidents recorded using new categories on Datix for next Board report. 5. The Caldicott Guardian to update the executive team on the implications of the recent IG report from Dame Fiona Caldicott known as Caldicott2. 2
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Trust Board Friday 5 July 2013, 9.0
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Members of Plymouth Hospitals NHS T
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Item 3 observer. The Chairman requi
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Item 3 Board oversight of contribut
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Item 3 the Board next month. • Th
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Item 3 been involved and there was
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Item 3 continuing to build. Mr Babe
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Item 3 to Norovirus, Professor Lewi
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Item 3 • Careful communication of
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Item 3 • Approved the writing off
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Updated: prior to July Board Item 4
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Updated: prior to July Board Item 4
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Item 8 Quality Impact Assessment Pa
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Item 8 3.2 Quarterly Summary Hospit
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Item 8 4.4 Monthly Proportion of Pa
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Item 8 Inpatient falls are currentl
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Item 8 REI signage PALS were contac
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Item 8 Complaints received listed b
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Item 8 The graphs below illustrate
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Item 8 5.5 Friends and Family Test
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Item 8 1. Pressure Ulcers (EoC) 2.
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Item 8 Observations The essence of
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Item 8a SUMMARY REPORT Trust Board
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Annex 2 Item 8a Summary of Serious
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Item 9 Key Recommendations The Trus
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Item 9 Effective Care (Section B2 o
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Item 9 Description 31 days from 'de
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Item 9 4.6 Non Elective Activity is
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Item 9 Summary of performance excep
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Item 9 Ensure that all patients adm
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Item 9 Forecast Significant progres
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Item 9 Update on previous actions C
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Contents EXECUTIVE SUMMARY D FINANC
Page 67 and 68: B1 Safe care Description Hospital S
Page 69 and 70: Response Rate Recommender Score B3
Page 71 and 72: B5 Other safety & quality metrics D
Page 73 and 74: C2 Non-Elective Activity Descriptio
Page 75 and 76: C4 Referral To Treatment (RTT) Desc
Page 77 and 78: C6 Other access & activity metrics
Page 79 and 80: D2 Cost improvement programme (CIP)
Page 81 and 82: D4 Cash Management Description Revi
Page 83 and 84: E1 Staffing numbers Description Est
Page 85 and 86: E3 Sickness absence PERFORMANCE IND
Page 87 and 88: Risk Rating F2 Monitor's Financial
Page 89 and 90: Item 10 DETAILED REPORT Trust Board
Page 91 and 92: Item 10 4. Key Issues for the Board
Page 93 and 94: Item 11 SUMMARY REPORT Trust Board
Page 95 and 96: Item 11 DETAILED REPORT Trust Board
Page 97 and 98: Item 11 • Challenge in respect of
Page 99 and 100: Item 11 Over the past two years, me
Page 101 and 102: Item 11 Getting it Right Charter An
Page 103 and 104: Item 11 Outcome of review with exte
Page 105 and 106: Item 11 Learning Disabilities Natio
Page 107 and 108: Item 11 Peer Review 2.5 Peer Review
Page 109 and 110: Item 12 Next Steps 1. Conversation
Page 111 and 112: Item 12 2. Board Inclusion Developm
Page 113 and 114: Item 12 EDS Grades and E & D Object
Page 115 and 116: Item 12 Plymouth Hospitals Trust -
Page 117: Item 12 3.6 The workforce is suppor
Page 121 and 122: Item 13 Telephone conversations.
Page 123 and 124: Item 13 19. The Medical Director ha
Page 127 and 128: Item 15 incident investigations to
Page 129 and 130: Item 15, Annex 1 3. Review of Actio
Page 131 and 132: Item 15, Annex 1 • Top three issu
Page 133 and 134: Item 15, Annex 1 The Chair asked SS
Page 135 and 136: Item 16 COMMITTEE MINUTES Finance,
Page 137 and 138: Item 16 pay and staffing, highlight
Page 139 and 140: Item 16 • PACS contract - likely
Page 141 and 142: Item 17 Terms and Conditions of Emp
Page 143 and 144: Item 17, Annex 1 29/2013 Minutes an
Page 145 and 146: Item 17, Annex 1 31/2013 Francis Re
Page 149 and 150: Item 18 Next Steps The Audit Commit
Page 151 and 152: Item 18, Annex 1 Matters arising 4/
Page 153 and 154: Item 18, Annex 1 time to embed and
Page 155 and 156: Item 18, Annex 1 Payroll & Expenses
Page 157 and 158: Item 18, Annex 1 The Committee note
Page 159 and 160: Item 18, Annex 1 Going Concern Revi
Page 161: Item 18, Annex 1 if Internal Audit
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Agenda and supporting papers - Plymouth Hospitals NHS Trust

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