Nurses Day! - Birmingham Children's Hospital

l There are structured processes in place for
incident reporting and the investigation of
Serious Incidents Requiring Investigation
(SIRIs), complaints and litigation cases. Regular
audits are undertaken of these processes to
ensure they are appropriately followed and are
effective. The outcomes of these audits are
reported to the Clinical Risk and Quality
Assurance Committee.
l Incident reporting is openly encouraged across
the Trust through training, the use of online
incident reporting, and the communication of
positive outcomes as a result of reporting of
incidents, errors and near misses. Ward
inspections to check compliance with CQC
standards provide assurance that staff know how
to repor incidents.
l A non-executive director is invited to participate
in the Root Cause Analysis of every SIRI. This
helps ensure a good Board level understanding
of risk management processes in the
organisation.
l All papers presented to the Board of Directors
and Board committees contain an assessment of
key regulatory or statutory impacts, including
equality, diversity and human rights and
compliance with standards including NHS
Litigation Authority risk management standards
and CQC essential standards of quality and
safety.
l The Trust attends and submits a performance,
compliance and risk report to the Trust’s
Commissioner’s monthly Clinical Quality Review
Group.
l A representative of the Trust’s Commissioners is
invited to attend the Trust’s monthly Clinical Risk
and Quality Assurance Committee and is invited
to participate in the Root Cause Analysis of
SIRIs.
l All quality initiatives and Cost Improvement
Plans require a quality impact assessment,
which is scrutinised by the Chief Medical Officer
or Chief Nursing Officer before approval.
l Risk appetite is determined in relation to specific
matters reviewed by the Board through detailed
consideration of risk and benefit analysis.
Key Quality Governance Arrangements
The Trust has continued to refine its approach to
the analysis of incidents, potential incidents and
near misses, in order to identify and communicate
learning points and necessary actions. This
commitment to developing an environment of
honesty and openness, where mistakes and
untoward incidents are identified quickly and dealt
with in a positive and responsive way, has been
successful in engaging clinical staff. This approach
to learning is also informed by various sources
of information including surveys, patient and staff
feedback, service reviews, and clinical audits.
A regular Safety Dashboard is produced for
each Clinical Directorate, which incorporates an
overview of data such as incident reports, SIRIs,
complaints and Nursing Care Quality Indicators
(NCQI) performance per ward/department to
highlight potential issues or concerns about
safety or quality of services. The dashboard
allows an aggregated review and comparison of
these metrics against each individual ward and
department and incorporates a series of defined
‘triggers’ which, in combination, may indicate
problems with safety or quality in a specific area.
This allows the Directorate Management Teams
and Board committee responsible for safety to
focus attention where it may be required and acts
as an early warning system. From 2012, the Safety
Dashboard has also identified the departments
implementing a Cost Improvement Plan (CIP) so
an assessment can be made as to whether the
project is affecting quality and safety. Workforce
information is also included, as indications of low
staff engagement can act as an early warning
about a possible impact on our services.
In 2011/12 a Patient Safety Strategy was
developed which maps out the Trust’s journey
towards safer care. The Strategy is updated each
year and sets out a series of clearly defined,
measureable safety targets to achieving the Trust’s
aim to eliminate any less than perfect care. These
targets are produced through a process of risk
analysis, identifying areas for improvement through
data sources such as SIRIs, incident reporting,
complaints, litigation and patient experience
feedback, as well as national guidance and best
practice benchmarking. We believe that focussing
our efforts on a targeted list of specific projects will
have a significant impact on the amount of harm
which is suffered by our patients.
The Trust’s Values – which were agreed in
consultation with staff – have been embedded
during 2012/13 in our recruitment, induction
and appraisal processes. This ensures that all
new staff demonstrate our Values and that the
behaviours of all staff and the decisions that we
make are rooted in our values. Commitment to
these values – respect, trust, compassion, courage
and commitment - also encourages openness
and transparency, which supports robust quality
governance arrangements centred on learning.
The Trust commissioned an external review of
its governance structures in 2011/12 to ensure
they are fit for purpose and provide the Board
of Directors with sufficient, high quality, timely
information. As a result of this review, the
governance structure was redesigned to include 2
new Board Committees:
l Quality Committee, the aim of which is to
provide strategic direction and overview of all
issues related to the quality of care and service
provision, allowing integrated quality reporting to
the Board of Directors.
l Finance and Resources Committee, to review all
matters relating to resources, including finance,
investment, workforce and information
technology, and to provide strategic direction on
negotiating the risk environment.
This new structure was implemented in 2012/13
and its effectiveness was assessed at the end of
the year.
The Quality Report provides an overview of
the main indicators of quality across the Trust,
including high risks, incidents, mortality, patient
experience, safeguarding and infection control, as
well as progress against our Safety Strategy and
quality projects such as the Safety Thermometer
and our programme of Quality Walkabouts.
The report is considered every month by the
Board alongside our Resources Report, which,
in addition to giving details of the Trust’s financial
performance, examines the Trust’s activity
levels, including the way people are accessing
our services; and workforce indicators, such as
sickness levels, turnover, and mandatory training
and appraisal targets, to allow an assessment
of the impact of activity levels on our staff. The 2
reports together provide a broad perspective of
all the factors that make up the Trust’s system of
internal control.
In February 2013 our Internal Auditor completed
a review of the Trust’s Quality Governance
arrangements that ensure compliance with
Monitor’s Quality Governance Framework. This
review found that the Trust meets Monitor’s criteria,
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and provides ‘significant assurance’ that the Trust’s
arrangements are sound. A small number of areas
were identified which could be improved, and
we are implementing the recommendations of the
Internal Auditor so we can ensure that our quality
governance arrangements are the best they can be.
In 2012 both the Trust’s locations, at Parkview and
at Steelhouse Lane, received an unannounced
inspection from CQC. The review of the CAMH
Services at Parkview found full compliance with the
standards reviewed.
The review at Steelhouse Lane found a minor noncompliance
with standard 14: Supporting workers.
This finding related to a concern raised by some
Theatre staff about the way they were supported,
particularly in relation to the implementation of a
new way of working in Theatres.
In response we have changed the way we are
implementing the new process, and have engaged
closely with the Theatre staff to fully understand
their concerns and address them. In addition, we
have developed new ways of reporting potential
workforce issues to the Board and its committees
to identify as early as possible when our staff
may be feeling unhappy, unsupported, or under
pressure. We have also added further workforce
metrics to the Safety Dashboard to help us better
identify when a ward or department may be coming
under pressure, and where that could have an
impact on the quality of care.
The Trust is fully compliant with the registration
requirements of the Care Quality Commission.
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 into 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.
Control measures are in place to ensure that all
the Trusts obligations under equality, diversity and
human rights legislation are complied with.
The Trust has undertaken risk assessments and
Carbon Reduction Delivery Plans are in place
in accordance with emergency preparedness
and civil contingency requirements, as based
on UKCIP 2009 weather projects, to ensure
that this organisation’s obligations under the
Climate Change Act and the Adaptation Reporting
requirements are complied with.