Agenda and supporting papers - Plymouth Hospitals NHS Trust

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Item 15 SUMMARY REPORT Trust Board 5 July 2013 Subject Prepared by Approved by Presented by Safety and Quality Committee Chair’s Report Dr Mike D Williams, Safety & Quality Committee Chair Dr Mike D Williams, Safety & Quality Committee Chair Dr Mike D Williams, Safety & Quality Committee Chair Purpose This report highlights key issues considered at the Safety and Quality Meeting on the 17 June 2013 to provide assurance to the Trust Board that safety and quality governance arrangements are in place. Corporate Objectives Decision Approval Information Assurance Quality Care Inspired People Healthy Organisation Innovate & Collaborate • Executive Summary The main issues discussed at the meeting were: • • 1. Theatre Safety Following the CQC communication about Theatre safety, the committee received assurance from the Chief Executive and Director of Nursing that the Theatre Safety Improvement Plan had been subject to rigorous external review by the Trust Development Authority. Further actions are in hand to ensure the implementation of the plan, particularly around the scheduling of theatre lists. 2. Outpatient backlog The Committee considered a report detailing the work done to risk assess the outpatient backlog in ophthalmology. Further actions have now been requested to ensure that a similar risk assessment is undertaken for other specialties. It is apparent that there is insufficient capacity in a number of specialties to meet both the current demand and eliminate the backlog of patients. The risks associated with this situation need to be considered by the Trust Board in partnership with commissioners. 3. Maternity services The Committee received assurance from the Royal College of Obstetricians and Gynaecologists’ Report on patterns of maternity care in English hospitals. 4. Mortality data The Committee took assurance from the hospital standardised mortality ratio, which provides data about hospital mortality, that the current rate remains at around 20% less than it could be expected. Similarly, the Committee received assurances from the hospital mortality indicator, which provides data on deaths up to 30 days following hospitalisation, that the rate is around 7% less than could be expected. However, the Committee requested that consideration be given as to how to reduce further the mortality rate, especially for patients admitted over the weekend. 5. Serious incident W33081/W33105 – action plan report The Committee considered a range of issues resulting from this report. The general learning point was made about the necessity for the terms of reference for serious
Item 15 incident investigations to be clearly established and timeframes set to ensure issues are addressed more rapidly than had been in this case. 6. Health Records Action Plan The Committee received a detailed report about actions being undertaken to meet the required standards, which provided limited assurance. It is recognised that the complexity of some of the issues means that full implementation of the plan will require further work. The minutes of the meeting are attached at Annex 1. Quality Impact Assessment All issues discussed have potential to negatively impact on the quality of care provided. Financial Impact Assessment To be considered, where relevant. Regulatory Impact Assessment Relevant to all essential standards and outcomes. Key Recommendations The Trust Board is asked to: 1. Take assurance that suitable governance arrangements are in place for safety and quality issues addressed by the Committee. 2. Decide how to assess and except a degree of risk relating to the outpatient backlog with commissioners. Next Steps The Committee will continue to provide the Board with regular reports on its activities to provide assurance that we are providing safe, effective and personal care to our patients.
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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
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B1 Safe care Description Hospital S
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Response Rate Recommender Score B3
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B5 Other safety & quality metrics D
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C2 Non-Elective Activity Descriptio
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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 and 118: Item 12 3.6 The workforce is suppor
Page 119 and 120: Item 13 Key Recommendations The Tru
Page 121 and 122: Item 13 Telephone conversations.
Page 123 and 124: Item 13 19. The Medical Director ha
Page 125: Item 14 SUMMARY REPORT Trust Board
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 147 and 148: Item 18 SUMMARY REPORT Trust Board
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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