BHRUT annual report 2009 - Barking Havering and Redbridge ...

Annual Report & Accounts 2009-2010
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outside agreed parameters triggers an exception
commentary and the application of root cause analysis
as required. A consistent and strong system of
monitoring complaints, incidents and safety alerts is in
place. The triaging of incidents and complaints
continues and all ‘red’ issues are circulated to the
executive and divisional teams for shared awareness
and action. The increased utilisation through staff
training of Dr Foster data and enhanced review of
mortality data allows for early identification of
potential problems which can be analysed and clinical
improvements made as needed. These processes help
support a ‘no surprises’ culture and the early
identification of trajectory change.
The Clinical Audit and NICE database maintains
progress against these key elements for clinical safety.
Internal Audit opinion provides adequate assurance
for these processes.
A “Visible Leadership” programme lead by the
Director of Nursing commenced in March and will
continue throughout the coming year. One day a
week all senior nursing staff spend dedicated time in
wards reviewing and assessing patient care against set
standards.
The Trust continues to participate in the ISO quality
framework, there are currently 8 areas accredited
through the British Standards Institute (BSI), with a
further 6 areas to achieve accreditation in 2010/11
and a further 3 in progress.
Full induction and statutory and mandatory training
programmes are in place for all staff.
The Clinical Governance Committee as a subcommittee
of the Trust Board has delegated
responsibility to interrogate and monitor the clinical
risk safety systems in place within the Trust to provide
assurance to the Board that clinical safety is
paramount and supported and there is early
identification of systemic weaknesses. The Price
Waterhouse Coopers report into deaths from
pneumonia, following identification of the Trust being
an outlier in Dr Foster data, made recommendation to
strengthen the Committee, which now meets monthly
with alternate meetings dedicated to patient safety
through surveillance of mortality data and SUI findings
to ensure continuous improvement in care is achieved.
Engagement with Patients and the Public has
continued to develop throughout the year. The
Improving Patient Experience Group (IPEG) set up in
2008 provides the Trust with feedback on a range of
patient related topics as well as participating in
surveys, sitting on the Clinical Governance Committee
and providing information on issues that impact on
how patients perceive and experience care and
treatment given by the Trust. The group is confident in
challenging Trust practices where necessary in a forum
that is open and honest.
To strengthen processes and capture patient
experience information an Associate Director of
Patient Involvement has been appointed to drive
forward new initiatives such as ‘real time surveys’ that
can provide large scale quality data to support
improvements in patient experience and to where
similar surveys of staff can identify areas where
additional support may be required.
Compliance with Equality, Diversity and Human
Rights, control measures are in place to ensure that
the organisation is working toward compliance with
all its obligations under equality, diversity and human
rights legislation. The Trust has worked closely with its
local health partners to fully implement the approved
Single Equality Scheme.
Compliance with the NHS Pension Scheme
regulations is in place. As an employer with staff
entitled to membership of the NHS Pension scheme,
control measures are in place to ensure all employer
obligations contained within the Scheme regulations
are complied with. This includes ensuring that
deductions from salary, employer’s contributions and
payments in to the Scheme are in accordance with the
Scheme rules, and that member Pension Scheme
records are accurately updated in accordance with the
timescales detailed in the Regulations.
Compliance with Climate Change Act 2008, in
response to the Act the Trust has factored climate
change adaptation into its strategic plans. The risks
climate change poses to the organisation will continue
to be assessed and actions taken to mitigate the
identified risks to ensure compliance with the
obligations identified under the Climate Change Act
and Adaptation Reporting Requirements.
Annual Accounts