Trust Board Febuary 2010 - Sandwell & West Birmingham Hospitals

MINUTES
however the structure would be presented at the next meeting of the Trust Board.
In terms of reporting, the Board was advised that it would be some time before the
information becomes robust enough to form meaningful and reliable information.
Until this time the twin track approach using manual information will be retained.
Mr Cash noted that it was expected to take two years to complete the first cohort
programme and remarked that in technology terms this was a considerable period
and asked whether the system can be adapted and maintained during this period.
He was advised that the two year timeframe had been built into the project plan for
the work and this was a realistic period to ensure that the information is as robust as
possible.
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Mr O’Donoghue presented an update on progress with implementing assurance on
mortality within the Trust. He explained that this work was part of the overall Quality
Management Framework and will ensure that every death in the Trust is reviewed in
a systematic manner.
The Board was advised that a mortality pilot had started in December 2009 and
since then the notes of every patient who dies in the Trust are reviewed by the
relevant clinical directors. The mechanism was noted to link into the risk
management processes already established. Further refinement of the system is
planned to ensure greater accuracy with regard to the most appropriate clinician
being sent the notes to review. Mr O’Donoghue advised that there were plans to
continue the pilot.
The Chair asked how serious the issue was regarding the mismatch of notes and
clinical directors. She was advised that the issue did not impact on the effective
processing of notes but was being addressed as a matter of priority. The instances
were reported to lie mainly with cases where the consultants involved are different
on admission to when the patient dies. Mr Adler added that this was reflective
particularly when a complex patient, with multiple co-morbidities is being treated.
The plans to introduce the electronic touch screen boards into wards, which link into
the Trust’s information systems, will assist with this matter.
Mr Cash asked what the Trust’s standardised mortality rate (SMR) was currently. He
was advised that it was 98.0, better than the national average of 100. This follows a
recent rebasing exercise.
Professor Alderson asked where the work of the mortality steering group would be
discussed. He was advised that a regular update would be presented to the
Governance Board and by exception this would also be discussed by the
Governance and Risk Management Committee. Once the system is embedded
further, a regular update will be presented to the Trust Board.
Mr Adler noted a discrepancy between the SMR figures in the corporate
performance monitoring report and the mortality update. He was advised that this
was due to the effect of the recent rebasing exercise.
11.3 Audit Commission – ‘Taking it on Trust’
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