A meeting of the Dorset HealthCare NHS Foundation Trust Board of ...

A meeting of the Dorset HealthCare NHS Foundation Trust Board of Directors will be
held at 9.30am on Wednesday 27 May 2009 at Burraton House, Poundbury, Dorchester
in Conference Room 1
AGENDA PART I
N.B. The Executive Development Consultancy (EDC) will be attending the May
Board Meeting as observers as part of the EDC process. (Observers are Barrie
Sheppard and Debbie Rynda)
1. Apologies for absence 9.30-9.45
2. To confirm Part I Minutes of the Board Meeting held on
25 March 2009
3. Matters Arising and Action Plan
ITEMS FOR DISCUSSION
(enclosed
separately)
Appendix A
9.45-9.55
4. To discuss the Quality Report from the Director of Risk
Management – April 2009
5. To discuss the Performance Report from the Director of
Finance & Performance Management – April 2009
Appendix B 9.55-10.05
Appendix C 10.05-10.15
ITEMS FOR INFORMATION
6. Significant issues from Directors
7. Any Other Business
10.15-10.25
8. Date of Next Meeting
The next meeting will take place on Wednesday 24 June 2009 at 9.30 am in the
Conference Room, Trust Headquarters, 11 Shelley Road, Boscombe, Bournemouth.
To resolve that representatives of the press and other members of the public be excluded
from the remainder of this meeting having regard to the confidential nature of the
business to be transacted, publicity on which would be prejudicial to the public interest.

MONTHLY BOARD REPORT ON QUALITY
April 2009
Prepared by
Roy Plowman
Director of Risk Management
May 2009

INDEX
Section
Page Number
Introduction 1
Domain 1 – Safety 2 - 4
Domain 2 – Clinical and Cost Effectiveness 4 - 5
Domain 3 – Governance 5
Domain 4 – Patient Focus 6 – 7
Domain 5 – Accessible and Responsive Care 7
Domain 6 – Care Environment and Amenities 7
Domain 7 – Public Health 8
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MONTHLY BOARD REPORT ON QUALITY
April 2009
1 Introduction
1.1
1.2
1.3
The aim of this report is to give an overview of the work being undertaken by the Trust in
ensuring high quality and clinical excellence in our services for service users. It is divided
into the seven domains of the Department of Health’s Standards for Better Health. These
are monitored by the Healthcare Commission.
The report has been reviewed and agreed by the Trust Management Group (Risk
Management).
The Trust is continuing discussions around the format of the new Quality Account which
will, when agreed, replace this report.
2
Annual Health Check 2008/09
2.1
2.2
Following agreement by the Trust Board, the Trust submitted its Annual Health Check
declaration to the Care Quality Commission on 29th April 2009, ahead of the 1st May
deadline. The Trust was fully compliant with the Department of Health’s Core Standards
for Better Health. The Trust has also made this declaration publicly available on our
website in accordance with national requirements.
The Care Quality Commission is the independent regulator of health and social care in
England and they will publish the annual health check ratings in October 2009. Before this,
they will go through a process of cross-checking trusts’ declarations. It is possible that the
Trust maybe visited within the next few months as part of a risk-based or random checking
process. In previous years the Trust has been considered as low risk in terms of an
undeclared non-compliance with the Core Standards for Better Health and it is expected
that this will still be the case for the 2008/09 declaration.
3
Annual Health Check 2009/10
3.1
Trusts will be required to make another self declaration in October/November 2009. It is
understood that this will be based on the first six month’s of the year and will also consider
projected compliance for the final six months of the year. This will be the final declaration
against the Core Standards for Better Health as the process with be replaced by a
registration process with the Care Quality Commission, similar to the registration for Health
Care Associated Infection that the Trust has already gone through.
Further details will be made available to the Board as this information is made available by
the Care Quality Commission.
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DOMAIN 1 – SAFETY
INCIDENT REPORTING
The Trust has a system for recording, monitoring and learning from incidents. The latest incident
report that is available shows that in March 2009, 630 adverse incident forms were received
compared with 518 in February 2009. The following table also shows the number of incidents
reported over the last 12 months.
Month
03/2008
04/2008
05/2008
06/2008
07/2008
08/2008
09/2008
10/2008
11/2008
12/2008
01/2009
02/2009
03/2009
Total
forms
received
464 453 524 501 544 546 471 511 497 487 496 518 630
The figure for March is higher than previous months and there are many variables which can
affect this including:
• delays in forms being sent to the Risk Management Directorate
• training and awareness increasing reporting figures
• an increase in the incidents of patients found smoking within Trust premises.
The Trust is within the top quarter of reporting trusts to the National Patient Safety Agency and
in general, the higher the rate of reported incidents, the stronger the reporting culture is felt to
be within that organisation.
Each month there is an analysis of all incidents reported across the Trust by type of incident.
The four types of incidents with the highest numbers are patient to patient violence, patient to
staff violence, personal accidents (such as falls) and patients found smoking inside Trust sites.
To address the number of smoking related incidents following a risk assessment, a courtyard
has now been utilised for a safe and secure way to facilitate smoking breaks at St Ann’s
Hospital.
A large number of the incidents reported were very minor and resulted in no injury; however,
under Health and Safety legislation, all incidents/accidents to patients, staff or visitors must be
reported, no matter how minor.
Incidents are risk graded on a four point scale (very low, low, moderate and high). During March
624 (99%) incidents were graded as ‘very low or ‘low’.
The Serious Incident Panel is reviewing 3 high graded and 3 moderate graded incidents,
representing 1% of the incidents reported in the month.
Incidents Prevented
The National Patient Safety Agency encourages staff to report patient safety incidents that were
prevented (i.e., ‘near misses’) ‘no harm’ and low harm incidents as well as patient safety
incidents that caused moderate harm, severe harm or death. There were 4 prevented ‘very low’
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graded incidents: 3 security incidents and 1 absconding incident reported and 1 ‘low’ graded
incident: 1 absconding incident.
New Incident Reporting system
New software has now been purchased for incident reporting, claims, complaints and risk
registers. The Ulysses system started in April 2009 and initially the paper incident form will
continue to be used. It is hoped that by September 2009 the web based reporting side of the
system will be up and running. Both paper based and online reporting can continue at the
same time. It may not be possible to produce monthly incidents reports for May and June 2009
because of the need to have adequate data in the new system prior to setting up the reporting
formats.
Patient Safety Champions
During 2008, the Trust established Patient Safety Champions within each clinical team. The role
was developed in line with national recommendations, with the key purpose of providing a teambased
focus on the important issue of patient safety.
On the 8th April 2009, the Patient Safety Champion (PSC) leads met for their second Away
Day. At the previous away day, in October 2008, PSC leads had been asked to focus on a few
key patient safety areas of work within their teams. Prior to the day the Assistant Clinical Risk
Advisor had either met with or corresponded with the leads to get feedback on progress and to
provide support to them if necessary. As a result it was clearly established that there is a lot of
very good clinical practice of a high quality taking place and teams are focussed on
incorporating their identified issues into their areas of everyday practice. A few teams had
actually completed their work on their initial areas and were now concentrating on new issues.
Three leads were invited to present their projects at the Away Day and as a result one of the
areas has been asked to prepare a paper for publication. Outside of the presentations many
areas of good practice were also identified and all leads were encouraged to share their
examples.
All leads worked together to formulate an action plan and this included the need for area
specific support groups and to network with each other using an e-mail group and specific
Patient Safety computer network drive. It was also suggested that the NHS Mental Health Lead
for the National Patient Safety Agency (NPSA) be invited to the next Away Day. This was as
result of four PSC leads approaching the NPSA lead at a Patient Safety Conference in Oxford a
couple of weeks prior to the day and they established that she would be happy to attend, if
invited.
A national ‘Seven Steps to Patient Safety’ tool identifies that executives of trusts should visit
their wards/units to discuss the safety of patients and staff during for example, ‘Patient Safety
Walkabouts’. These were discussed at length during the day and it was agreed that leads would
discuss amongst themselves whether either unannounced or pre-planned visits would be
appropriate in all areas and feed this back to the Assistant Clinical Risk Advisor.
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SAFETY ALERT BROADCAST SYSTEM (SABS)
This is a national system introduced by the Department of Health to alert all NHS trusts and
other agencies on issues of safety regarding equipment and medicines. These are circulated to
appropriate staff within the Trust to identify the relevance of the alert and when necessary
appropriate action is taken in line with the requirements identified in the alert. 11 alerts were
issued in April 2009 as shown below:
• Abdominal aortic aneurysm grafts (Not applicable)
• Alcohol free surface disinfection wipes for medical devices (Circulated to staff)
• Healthcare Anaesthetic CareStations (Type not used in the Trust)
• Ambulatory insulin infusion pump (Not applicable)
• Applanation tonometer prism (Not applicable)
• Automatic external defibrillator (Type not used in the Trust)
• Disposable endoscopic polypectomy snares (Not applicable)
• Paediatric tracheostomy tubes (Not applicable)
• Reducing the risk of retained throat packs after surgery (Dental service compliant with alert)
• Bioprosthetic heart valves (Not applicable)
• Female urinary catheters causing trauma to adult males (Circulated to staff)
DOMAIN 2 – CLINICAL AND COST EFFECTIVENESS
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE) GUIDANCE
NICE regularly publish guidance which the Trust reviews on a monthly basis. In April 2009 the
following guidance was issued:
• Combined boney and soft tissue reconstruction for hip joint stabilisation in proximal focal
femoral deficiency (PFFD)
• Diarrhoea and vomiting in children under 5
• Endoscopic mastectomy and endoscopic wide local excision for breast cancer Ex-vivo
hepatic resection and reimplantation for liver cancer
• Glaucoma
• Venous thromboembolism - rivaroxaban
These were discussed at the Trust’s Clinical Governance meeting of the Trust Management
Group and it was agreed that none are relevant to the Trust.
NICE Baseline Assessments
As part of the process of implementation of NICE guidance, baseline reviews are carried
out by nominated leads. Details of the Trust’s compliance with each of NICE’s
recommendations are then presented to the Trust Management Group (TMG) and action
plans included, where necessary. The following NICE baseline reviews were presented to
the TMG in April, which show full compliance with all recommendations relevant to our
organisation.
• Promoting Children’s Social and Emotional Wellbeing in Primary Education – fully compliant
• Drug Misuse. Psychosocial Interventions – fully compliant
• Post Traumatic Stress Disorder – fully compliant
• Extraction of Wisdom Teeth – fully compliant
• Depression – fully compliant
• Use of Electroconvulsive Therapy (ECT) – fully compliant
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ANNUAL AUDIT PLAN 2009/10
The Trust Management Group approved the Trust’s 2009/10 audit plan in April. This includes
topics from all operational directorates and has a focus on the auditing of NICE guidance.
DOMAIN 3 – GOVERNANCE
APPROVED POLICIES
The following new/updated policies and procedures were approved by the Trust Management
Group in April.
• Policy on Food and Nutrition
• Policy on the Assessment and Management of Falls
• Policy on the Management of Blood and Body Fluid Spillages
• Policy on the Management of Extended Spectrum Beta-Lactamases
• Protocol and Standards for the Recording of Information and Advice Given by Staff on-call
• Policy for Deprivation of Liberty Safeguards
• Health and Safety Policy
• Guidelines for Curtains/Bedscreens
• Recruitment and Retention Premium Policy
NHS STAFF SURVEY
The results of the 2008 survey of NHS staff have been published and are available on the
Care Quality Commission website. This is the 6th annual survey of its type. The survey aims
to provide trusts with valuable information about the views and experiences of employees that
can help to improve the working lives of staff and the quality of care for patients. It also
provides an opportunity for trusts to compare their results with other similar trusts. The Trust’s
results showed little change from the previous survey. An action plan is being developed to
address the findings of the survey.
NATIONAL HEALTH SERVICE LITIGATION AUTHORITY (NHSLA) RISK MANAGEMENT
STANDARDS
The Trust successfully achieved Level 1 compliance with the NHSLA Risk Management
Standards for Mental Health and Learning Disability Trusts in September 2008. This
assessment is valid until the end June 2010 by which time the Trust will need to have agreed
whether it will be reassessed at the same level or request an assessment at Level 2 (a higher
level). In order to achieve Level 2 against the standards, the Trust will need to demonstrate
that not only has it the appropriate policies and procedures in place but also that it has
implemented them.
The NHSLA assessors can offer an informal visit prior to the assessment (at a mutually
convenient date) to provide advice on the suitability of the evidence collected.
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DOMAIN 4 – PATIENT FOCUS
COMPLIMENTS AND COMPLAINTS
The Trust welcomes feedback on its services from service users, their relatives and carers.
These may be in the form of compliments or complaints. The Trust monitors compliments and
complaints received in order to learn lessons. The latest report available is for February 2009.
The Trust received 32 compliments in February 2009, which compares to 52 received in the
same period in 2008.
In February 2009, there were 0 verbal complaints. 5 were received in the same period in
2008.
The number of written complaints received from 1st February 2009 to 30th April 2009 was 11
(6 for February, 5 for March and 0 for April). Please see the graph below.
5 (83%) of the February complaints were responded to in line with the national 25 day
deadline. The number of written complaints in February represents 0.035% of the total
number of patient treatments 16718 during the month.
See Appendix for the full compliments and complaints report.
Comparison of number of written complaints
14
12
10
8
6
4
2
0
12
12
7
6
5
0
February March April
2007/08
2008/09
Independent Reviews of Complaints
The February Quality Report provided details of 5 complaints that had been forwarded to the
Ombudsman There have been no additional complaints going through this process and no
further updates received about the 5 complaints.
PATIENT ADVICE AND LIAISON SERVICE (PALS)
The two tables below provide a summary of activity for the period 1 April to 30 April 2009 and a
comparison with the previous month. During April there were a total of 23 enquiries, of which 7
were specific to Dorset HealthCare NHS Foundation Trust and 16 were signposted to other
Trusts or organisations.
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Service
Number of enquiries
1 – 30 Apr 09
Number of enquiries
1 – 31 Mar 09
Non Trust and signposting 16 11
PALS enquiries relating to DHFT 7 16
Total number of enquiries 23 27
DHFT Service Areas
Adult mental health 4 6
Children 0 1
Learning disability 0 2
Older peoples mental health 1 3
Unknown/General enquiries 1 4
Addictions Service 1 0
Total 7 16
Nature of enquiry
Number of enquiries
1 – 30 Apr 09
Number of enquiries
1 – 31 Mar 09
Information/signposting 4 5
Communication 1
Treatment/care 1 4
Waiting lists/times/funding
Complaint
Attitude of staff 1
Building relationships
Security/Environment
Transport 1
Equipment
Concern/problem solving 1 4
Unknown
Compliment
Advice 1
Total 7 16
DOMAIN 5 – ACCESSIBLE AND RESPONSIVE CARE
WAITING TIMES
At the time of writing this report all Consultant led out-patient appointment waiting times, for
routine appointments, are within the nine weeks target.
DOMAIN 6 – CARE ENVIRONMENT AND AMENITIES
LOCAL SECURITY MANAGEMENT SPECIALIST (LSMS)
The annual report on the activities of the Trust’s LSMS, which went to the Trust Board in April,
has been sent to the Area Security Management Specialist at the NHS Security Management
Service.
The LSMS work plan for 2009/10 was approved by the Trust Management Group in April and
has also been sent to the Area Security Management Specialist for information.
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DOMAIN 7 – PUBLIC HEALTH
SWINE FLU
The Trust’s Director of Infection Prevention and Control is leading on the Trust’s preparations,
in conjunction with other local trusts, in the event of a swine flu pandemic in the region.
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