Agenda and supporting papers - Plymouth Hospitals NHS Trust

More documents

Recommendations

Info

Item 8 SUMMARY REPORT Trust Board 5 July 2013 Subject Prepared by Approved by Presented by Safety & Quality Report Deputy Director of Nursing, Patient Experience Manager, Patient Safety & Effectiveness Manager Director of Nursing and Medical Director Director of Nursing and Medical Director Purpose To provide a quarterly quality report on the work and activities of the Healthcare Governance Team and wider organisation. Corporate Objectives Decision Approval Information Assurance Quality Care Inspired People Healthy Organisation Innovate & Collaborate • Executive Summary This report provides a quarterly update to the Trust Board on Quality; it replaces the quarterly Healthcare Governance report. Healthcare governance activity is reported monthly to the Safety & Quality Committee. This report provides an overview for the quarter 1 April 2013 to 15 June 2013. The report includes an analysis of trends, hotspots, themes, issues and resulting improvement. • Patient Safety & Clinical Effectiveness highlights the following areas of notable performance: days since last never event; reduction in harm rate evidenced through global trigger tool and a significant reduction in inpatient falls over the past two months. In addition some areas have been highlighted as areas of concern as follows: an increase in the proportion of patients harmed measured using the safety thermometer. Personal experience report details progress against a number of areas including, PALS, complaints, local inpatient survey programme and the ‘friends and family test’ (FFT) The complaints response rate target of 80% has been achieved for 3 consecutive months, leading to agreement of a stretched target of 90% by October 2013. PALs figures continue to remain stable and have identified issues with access and waiting for our patients. Work to improve REI signage was as a result of information received through PALS. Plans to survey complainants to Plans to survey complainants once the complaints process is complete are now in place and will commence from July. 314 inpatients were surveyed during April and May, using the Meridian system delivered by our volunteers. FFT response rates continue to improve although the 15% target has not been achieved to date, further work to raise awareness with the public is underway with additional posters and banners emphasising the importance of feedback from our patients.
Item 8 Quality Impact Assessment Paper includes key patient safety, clinical effectiveness and patient experience data, providing assurance regarding high level clinical outcomes, management of adverse events, complaints, PALS, patient feedback and NICE guidance. Financial Impact Assessment Potential loss of income if Trust fails to meet CQC requirements and safety obligations. Regulatory Impact Assessment The Trust is required to demonstrate compliance with CQC requirements, potential litigation if incidents and complaints are not managed. Key Recommendations The Trust Board is asked to note the content of the report. Next Steps The Safety & Quality Committee will continue to receive monthly reports on healthcare governance activities. The Trust Board will continue to receive detailed quarterly reports, supplemented by summary reports monthly. 2
Page 1 and 2: Trust Board Friday 5 July 2013, 9.0
Page 3 and 4: Members of Plymouth Hospitals NHS T
Page 5 and 6: Item 3 observer. The Chairman requi
Page 7 and 8: Item 3 Board oversight of contribut
Page 9 and 10: Item 3 the Board next month. • Th
Page 11 and 12: Item 3 been involved and there was
Page 13 and 14: Item 3 continuing to build. Mr Babe
Page 15 and 16: Item 3 to Norovirus, Professor Lewi
Page 17 and 18: Item 3 • Careful communication of
Page 19 and 20: Item 3 • Approved the writing off
Page 21 and 22: Updated: prior to July Board Item 4
Page 23: Updated: prior to July Board Item 4
Page 27 and 28: Item 8 3.2 Quarterly Summary Hospit
Page 29 and 30: Item 8 4.4 Monthly Proportion of Pa
Page 31 and 32: Item 8 Inpatient falls are currentl
Page 33 and 34: Item 8 REI signage PALS were contac
Page 35 and 36: Item 8 Complaints received listed b
Page 37 and 38: Item 8 The graphs below illustrate
Page 39 and 40: Item 8 5.5 Friends and Family Test
Page 41 and 42: Item 8 1. Pressure Ulcers (EoC) 2.
Page 43 and 44: Item 8 Observations The essence of
Page 45 and 46: Item 8a SUMMARY REPORT Trust Board
Page 47 and 48: Annex 2 Item 8a Summary of Serious
Page 49 and 50: Item 9 Key Recommendations The Trus
Page 51 and 52: Item 9 Effective Care (Section B2 o
Page 53 and 54: Item 9 Description 31 days from 'de
Page 55 and 56: Item 9 4.6 Non Elective Activity is
Page 57 and 58: Item 9 Summary of performance excep
Page 59 and 60: Item 9 Ensure that all patients adm
Page 61 and 62: Item 9 Forecast Significant progres
Page 63 and 64: Item 9 Update on previous actions C
Page 65 and 66: 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 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 and 126:
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 147 and 148:
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
show all

Agenda and supporting papers - Plymouth Hospitals NHS Trust

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?