Agenda and supporting papers - Plymouth Hospitals NHS Trust

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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
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Page 37 and 38: Item 8 The graphs below illustrate
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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
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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
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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
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C4 Referral To Treatment (RTT) Desc
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C6 Other access & activity metrics
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D2 Cost improvement programme (CIP)
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D4 Cash Management Description Revi
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E1 Staffing numbers Description Est
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E3 Sickness absence PERFORMANCE IND
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Risk Rating F2 Monitor's Financial
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Item 10 DETAILED REPORT Trust Board
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Item 10 4. Key Issues for the Board
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Item 11 SUMMARY REPORT Trust Board
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Item 11 DETAILED REPORT Trust Board
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Item 11 • Challenge in respect of
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Item 11 Over the past two years, me
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Item 11 Getting it Right Charter An
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Item 11 Outcome of review with exte
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Item 11 Learning Disabilities Natio
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Item 11 Peer Review 2.5 Peer Review
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Item 12 Next Steps 1. Conversation
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Item 12 2. Board Inclusion Developm
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Item 12 EDS Grades and E & D Object
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Item 12 Plymouth Hospitals Trust -
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Item 12 3.6 The workforce is suppor
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Item 13 Key Recommendations The Tru
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Item 13 Telephone conversations.
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Item 13 19. The Medical Director ha
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Item 15 incident investigations to
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Item 15, Annex 1 3. Review of Actio
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Item 15, Annex 1 • Top three issu
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Item 15, Annex 1 The Chair asked SS
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Item 16 COMMITTEE MINUTES Finance,
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Item 16 pay and staffing, highlight
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Item 16 • PACS contract - likely
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Item 17 Terms and Conditions of Emp
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Item 17, Annex 1 29/2013 Minutes an
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Item 17, Annex 1 31/2013 Francis Re
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Item 18 Next Steps The Audit Commit
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Item 18, Annex 1 Matters arising 4/
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Item 18, Annex 1 time to embed and
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Item 18, Annex 1 Payroll & Expenses
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Item 18, Annex 1 The Committee note
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Item 18, Annex 1 Going Concern Revi
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Item 18, Annex 1 if Internal Audit
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Agenda and supporting papers - Plymouth Hospitals NHS Trust

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