PHT Public Trust Board Papers March 2011.pdf - Plymouth Hospitals

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Item 7 The five priorities were developed following discussions with various groups within the Trust, including the Safety & Quality Committee, before agreement at the Trust Board. The Trust’s ‘governors in waiting’, recruited in preparation for our Foundation Trust application, were also consulted. Priority 1 – Reduce avoidable harm through improved levels of learning from incidents and complaints It is acknowledged nationwide that despite our best efforts patients suffer harm in hospital and many other patient narrowly avoid a similar experience, a ‘near miss’. Our first priority is aimed at reducing overall levels of harm and continuous improvement of services to ensure when things go wrong lessons are learnt and changes are made. How will we do it? We will collect information when things go wrong. Through reporting and analysis of adverse events using the root cause analysis tool, which allows us to identify the core issues and to learn lessons we will aim to preventing a reoccurrence. To support this approach root cause analysis training will be introduced for staff groups to identify true causes of harm. The Trust would encourage increased reporting of no harm or near miss incidents to enable to learning, a large proportion of near miss reflects a strong organisational reporting culture where potential problems are identified and action taken to prevent harm. The standard approach to reporting of adverse events, relies on voluntary, self reporting of incidents and is known to only identify 10 to 20% of adverse occurrences. In order to supplement this process the Trust has adopted the global trigger tool (GTT) to measure and identify events that cause harm to patients. It is a casenote review tool that enables the Trust to understand and measure adverse events and rates of harm, whereby a severity rating is assigned to each adverse event. A multi-disciplinary clinical team have been trained in how to conduct the GTT casenote review according to a pre-defined template. Members of this team meet fortnightly to ‘double review’ 20 sets of randomly selected noted each month. How will we measure it? GTT monthly data will be reviewed on a monthly basis alongside regular mortality data through the Clinical Governance Steering Group. Monitor Trust performance using Dr Foster data and incident reporting trends from the National Reporting and Learning System (NRLS). % reduction in the number of grade 3 pressure ulcers % reduction in the number of patient falls % reduction in surgical site infection % reduction of infections secondary to urinary catheters % reduction in the incidence of VTE % to be confirmed How will we report it? Regular monthly incident and complaints reports will be submitted to the Trust’s Safety & Quality Committee. Additional quarterly reports on progress against the global trigger tool will be submitted to the Clinical Governance Steering Group. Sarah Widnell / Jayne Glynn V7 21.03.11 4
Item 7 Priority 2 - Appropriate handover and escalation during patient management Identification of the deteriorating patient and ensuring appropriate escalation and response is an essential aspect of patient care. The Trust has developed an action plan to improve the care of deteriorating patients and reduce the number of cardiac arrests, which includes a colour banded observation chart for the early detection and appropriate escalation of unwell patients. How will we do it? The Trust has developed an action plan to improve the care of deteriorating patients and reduce the number of cardiac arrests, which includes a colour banded observation chart for the early detection and appropriate escalation of unwell patients. Patients that trigger on the observation chart will be added to the ward whiteboard and discussed at the daily safety briefing which have been introduced to ensure structured handover of key patient information including key principles Situation, Background, Assessment and Recommendation (SBAR). All cardiac arrests calls will be investigated to identify aspects of care which may have attributed to preventable deterioration. We will ensure that patient observations are carried out in a timely manner and that all deteriorating patients are appropriately escalated to ensure action is taken. How will we measure it? The percentage of patient who trigger on the Early Warning System and receive an appropriate response will be monitored monthly, alongside the number of rapid response calls made per month. These figures will provide assurance that when a patient deteriorates appropriate escalation has taken place. We will monitor the frequency and percentage of wards using daily safety briefings, to assess the communication methods used to handover patient information. The number of cardiac arrest calls will be monitored monthly to ascertain how many were avoidable. In addition the Trust subscribes to the Dr Foster mortality database, which predicts the Hospital Standardised Mortality Ratio (HSMR) which is an indicator of healthcare quality that measures whether the death rate at a hospital is higher or lower than you would expect. % reduction in the number of cardiac arrest calls % increase in the number of rapid response calls Increase the % of patients who trigged on the EWS and receive an appropriate response Increase the frequency and percentage of wards using daily safety briefings % to be confirmed How will we report it? Regular monthly reports will be submitted to the Clinical Governance Steering Group and quarterly reports submitted to the Trust’s Safety & Quality Committee. Additional monthly reports on progress will be submitted to the SHA. Priority 3 - Ensure effective pathways of patient care across the health community, appropriate follow up, continuity of clinical care, reducing length of stay and reducing delayed discharges As a Health Community there is a requirement to make efficiencies throughout elective care, in order to improve both the patient experience and to reduce costs. Sarah Widnell / Jayne Glynn V7 21.03.11 5
Page 1 and 2: Trust Board Standing Items Friday 2
Page 3 and 4: Item 2 any long term harm. The Chai
Page 5 and 6: Item 2 Plymouth Hospitals NHS Trust
Page 7 and 8: Item 2 studies described in the rep
Page 9 and 10: Item 2 Performance against Monitor
Page 11 and 12: Item 2 30/11 Chairman’s report fr
Page 13 and 14: Item 5 SUMMARY REPORT Trust Board M
Page 15 and 16: A second “Continuing Medical Educ
Page 17 and 18: Item 6 DETAILED REPORT Trust Board
Page 19 and 20: Item 6 NHS Constitution Patient Ple
Page 21: Item 7 Plymouth Hospitals NHS Trust
Page 24 and 25: Item 7 1.2 Statement by Chief Execu
Page 28 and 29: Item 7 How will we do it? The Enhan
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Page 42 and 43: Item 7 Cancelled operations by the
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Page 50 and 51: Item 8 Dementia costs the UK econom
Page 52 and 53: Item 8 Standard 4: The hospital and
Page 54 and 55: Item 9 DETAILED REPORT Trust Board
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Page 58 and 59: Item 10 Safety 9. Infection Control
Page 60 and 61: Item 10 15. Going Further on Cancer
Page 62 and 63: Item 10 The Trust’s 12 month aver
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Page 68 and 69: Item 12 Key Recommendations 1. Cont
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Item 13 The Statement is not meant
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Information on staffing of the R&D
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Organisation study capabilities Typ
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Specialty Group Membership (Local a
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R&D SOP Ref Number SOP Title Versio
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Item 14 SUMMARY REPORT Trust Board
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Performance Databook February 2011
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SAFETY OBJECTIVE PERFORMANCE REPORT
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A&E BREACH REASONS 2010/11 Apr May
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AMBULANCE HANDOVER TIMES Maximum of
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DELAYED TRANSFERS OF CARE Current M
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# MRSA SCREENING Current Month: Feb
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7 Stroke Indicators Current Month:
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QUALITY OBJECTIVE PERFORMANCE REPOR
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Consultant Outpatients Waiting & Re
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Current Month : February 2011 Inpat
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11 Referral To Treatment (RTT) Time
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RAPID ACCESS CHEST PAIN SERVICE Cur
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DIAGNOSTIC NEUROPHYSIOLOGY WAITING
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# Inpatient & Day Case Waiting List
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# CANCELLED OPERATIONS - Number can
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9 Choose And Book Slot unavailabili
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CANCER TARGETS : 31 Day "Decision T
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GFOCW TARGETS : 62 Days from Screen
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GFOCW TARGETS : 2 Week Wait for Bre
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Reperfusion Waiting Times Current M
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PLYMOUTH HOSPITALS NHS TRUST Trust
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8 Access to GUM clinics - Offered t
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INFANT HEALTH & INEQUALITIES # SMOK
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PARTICIPATION IN HEART DISEASE AUDI
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WORKFORCE OBJECTIVE PERFORMANCE REP
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PHT Public Trust Board Papers March 2011.pdf - Plymouth Hospitals

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