Board of Directors Meeting - 29 March 2012 - Devon Partnership ...

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CQUIN 4Effectiveness 3Board of Directors Meeting, 29 March 2012Agenda Item 7Domain Indicator Target trigger April May June July Aug Sept Oct Nov Dec Jan Feb Mar% of people who report that the service has met their needs at alltimes85%% of clinical records which meet Trust standards (assessment,planning, review.)85% ≤75%% of clinical records with a formulation and diagnosis 85% ≤75%% of clinical records where the person has identified their desiredoutcomes85% ≤75%% of clinical records with a care plan for all identified needs 85% ≤75%NICE guidelines published in period -NICE guidelines reaching level 2 consideration -NICE guidelines bypassing level 2: sent to working group for actionplanning-NICE guidelines still under review -NICE guidelines triaged as appropriate for DPT -Already considered fully compliant -NICE guidelines received by cross directorate working group -% of urgent referrals seen in 5 working days: Q4: 90%% of routine referrals seen within 10 working days: Q4: 90%% of people admitted to an adult inpatient unit with a completedVTE risk assessment / number of admissions90% ≤90% / / / / / / / / / / / /% of OPMH services with full safety thermometer data 100% ≤100%% of people over 75 admitted to acute inpatient units who havebeen asked the dementia screening questionQ4:90%% of people over 75 admitted & screened units who have had adementia risk assessmentQ4:90%% of people over 75 admitted & assessed as high risk of dementiawho have been referred for specialist assessment.Q4:90%% OPMH CMHT staff with training in end of life care planning Q4:90%% of people with a medicines review in past 6 months Q4: TBCPBR: % open cases which have been care clustered Q4:95%PBR: % clustered cases within review timescales Q4:95%PBR: % clustered cases without data error Q4:95%3 Clinical record compliance data based on approximately 550 completed CRSM record audits per month4 CQUIN : quarterly reports will be provided as per schedule.Page 52 of 156
Appendix 2 PCA quality assuranceVerification Peer audits(observations of care) Other auditCheck functionTeam PCAsand actionplans Senior Manager /Modern Matron Review of PCA andaction plan forcompleteness andquality Minimum reviewperiodsExecutive monitoring: Weekly composite riskreview by executiveteamMonthly ClinicalDirectorategovernance andperformancemeetings Complianceposition Action planprogress Exceptions forresolution orescalation Completion andquality of checkfunction Executivechallenge andsupportQuarterly reviewof ClinicalDirectoratePerformance Complianceposition Action planprogress Completion ofcheck function Exceptions forresolution orescalationBoard of Directors Meeting, 29 March 2012Agenda Item 7Moderatedcompositedeclaration Quality andsafetycommittee Board Regulators CommissionersPage 53 of 156
Page 1 and 2: Devon Partnership NHS Trust Board o
Page 3 and 4: 3DEVON PARTNERSHIP NHS TRUSTBOARD O
Page 5 and 6: 4DEVON PARTNERSHIP NHS TRUSTBOARD O
Page 8 and 9: Board of Directors Meeting, 29 Marc
Page 18 and 19: Page 18 of 156
Page 26 and 27: Links to Strategic Aims:Safe x Reco
Page 28 and 29: 2.2.2 The key points for the Board
Page 30 and 31: Impact across many of these issues
Page 36 and 37: Action required, including Recommen
Page 38 and 39: 4 Quality improvementBoard of Direc
Page 40 and 41: 6. Compliance with Trust standards
Page 42 and 43: 7. The experience of using services
Page 46 and 47: 7.5.4 Acting on feedbackBoard of Di
Page 48 and 49: 9.2.4 Outbreaks and Incidents• Th
Page 50 and 51: Experience 2Appendix 1: Quality, sa
Page 54 and 55: Appendix 32012/13 CQUIN targetsBoar
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Page 64 and 65: PersonalisedXThis report references
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Board of Directors Performance Repo
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ASSURANCE FRAMEWORK AND CORPORATE R
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Board of Directors Meeting, 29 Marc
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KeyStandingcommitteeNED chairedStan
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Appendix D - Risk Escalation Matrix
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