Standards for Better Health – update for Overview & Scrutiny

Committee

Jacqui Evans

Sarah Brierley

1 April 2008

Agenda Item No.

4.2

2

Introduction

Strengthening process Proposed declaration for core standards

2007-8 (overview) Focus on specific core standards

3

Strengthening Process

Revised process to:– Enhance ownership at Director level– Further develop audit trail of evidence

Monthly sign-off of compliance sheets by relevant Director

Monthly scrutiny by Board Assurance Committee

4

YEAR: 2007-8 COMMITTEE: CIRC DIRECTOR LEAD: XXX

DOMAIN: Safety CHAIRMAN: XXX STANDARD LEAD: YYY

STANDARD: C1a    

 

STANDARD ELEMENT EVIDENCE

Healthcare organisations protect patientsthrough systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from the analysis of incidents

1* Incidents are reported locally and to theNational Patient Safety Agency (NPSA)via the National Reporting and LearningSystem

 

  2* Reported incidents are analysed to seekto identify root causes, relevant trends and likelihood of repetition

 

  3* Demonstrable improvements in practice are made to prevent reoccurrence of incidents as a result of information arising from the analysis of local incidents and from the PSA’snational analysis of incidents

 

* Adequate levels of assurance can be provided by level 2 and above of the NHSLA’s Risk Management Standards for acute trusts.

 

END OF YEAR SIGN OFF

STATUS: Compliant full year Limited assurance* Not met*

 

* Please provide reasons  Date of reaching compliance (if relevant)

 SIGN OFF: ……………………………… DATE: ………………………………….

Compliance Sheet

5

Proposed declaration 2007-8

Compliant on most Insufficient assurance (awaiting report from

HCC)– C7e: Equality & human rights– C16: Patient information– C18: Access to service

6

Declaration of Specific Standards

06-07 HEALTH CARE COMMISSION STANDARDS

DIRECTOR

LEAD STANDARD LEAD(S)

G C6 - Health & Social care organisations co-operate to meet patients needs S Posey S Brierley

G C13a - Ensure that staff treat patients, relatives & carers with respect N Scanlon B Jenkins / N Pulford / C

O'Rourke / D Goodrum /

J Evans

G C13b - Ensure that appropriate consent is obtained J Quinn J Evans / Peter Rooth / D

Barber / F Smith / M

BondG C13c - Ensure that patient information is treated confidentially J Webster P Calvert / K Broughton

G C17 - Patient & carer views are intrinsic to designing, planning & delivering healthcare services S Posey N SmithG C18 - Equal access to all members of population is available J Webster D Govan / D Goodrum /

C O'RourkeG Public Health C22a - Co-operate with other NHS bodies, LA and other organisations S Posey N SmithG Public Health C22c - Make appropriate & effective contribution to local partnership agreements S Posey C Boseley

COMMITTEE REPORTING VIA

Position at

28th Feb 08

Anticipated

Position at

year end

Involvement CommitteeG G

Involvement Committee

G G

Clinical Standards and Effectiveness

Committee

G G

Health Records Committee

G G

Involvement Committee G G

Involvement Committee G G

Involvement Committee G G

A* (pending HCC report)

7

Core standard 6: cooperation (compliant)

Evidence of cooperation with internal and external partners:Children’s Assessment Unit & Bramble Suite Development Projects, Regular input into Local Strategic Partnerships (LSP’s) e.g. Member of Welhat Alliance, Contributor to North Herts Community Plan

Member of: Hertfordshire’s Children’s Trust Partnership Strategy & Planning sub-group, MSLC (Maternity services liaison committee), University of Hertfordshire’s Directors of Service and Education meetings, HCAI Whole System Review Group, East & North Hertfordshire Choose and Book Project Board

Age Concern have offices on Lister & QEII developing home care support for elderly patients

PCT host therapy services Member of the Stevenage Children’s Trust partnership

8

Core standard 13a: dignity & respect (compliant)

Range of policies inc ‘single sex accommodation’ Introduced mandatory Diversity training Liverpool care pathway Multi faith provision / dietary provision Audits / Surveys (Patient satisfaction, Essence of Care

benchmarks,Patient Experience trackers, PEAT, National In-Patient & Maternity Surveys, 2007)

Patient Experience report to Board / Involvement Committee HCC Visit (& follow up) re dignity PPI Forum visits to Strathmore Monthly Directorate CG reports Review of minority groups New – patient experience strategy

Action planningNegative feedback analysis

9

Core standard 13b: consent (compliant)

Use standard DH forms / compliant procedure specific forms

18 procedure specific forms ratified during 2007-8 Mandatory consent audit & presentations National Patient Survey (favourable results) Training (inc IMCA) – mandatory for jnr doctors Interpreter service Established processes for post mortems,

photography & research Monitoring of ‘breaches’ via incident / PALS reports

10

Core standard 13c: confidentiality (compliant)

Caldicott Guardian & protocols Internal Audit Report Dec 2007 Documentation Audit Monitoring via incident reports / PALS

11

Core standard 17: views of patients (compliant)

Involvement Committee established with diverse community representation

Regular Trust attendance at Patients Panel & BME Fresh Start meetings

Views of patients, carers and support groups actively sought during consultation preparatory work, during consultations, for service redesign and improvement work, recent consultations have included: Chemotherapy, DQHCH and PTS.

Consultation reports published and distributed, which include respondent details, comments and issues raised and Trust action plans for addressing issues raised.

12

Core standard 18: access (insufficient)

Ethnicity – interpreters / PAS/ complaints / NPS (limited)

Choose & Book service National Patient Survey Information (written) is limited Patient Involvement Strategy – focus on BME, hard

to reach groups Monitoring of incidents / PALS / complaints /

cancellations / waiting times

13

Core standard 22a: cooperation (compliant)

Cooperation with partners includes regular input into Local Strategic Partnerships (LSP’s) e.g. Member of Welhat Alliance, Contributor to North Herts Community Plan

Member of multi-agency groups including: Hertfordshire’s Children’s Trust Partnership Strategy & Planning sub-group, MSLC (Maternity services liaison committee), University of Hertfordshire’s Directors of Service and Education meetings

Age Concern have offices on Lister & QEII developing home care support for elderly patients

PCT host therapy services on Trust sites

Attendance at CDRP meetings for Welwyn/Hatfield, Stevenage, East and North Herts.

Involvement Committee work-plan includes work on the Patient experience and results of the patient survey

Collaboration on the recent DQHCH consultation Health Equality Impact Assessment

14

Core standard 22c: local partnerships (compliant)

Regular input into Local Strategic Partnerships (LSP’s) e.g. Member of Welhat Alliance, Contributor to North Herts Community Plan

Member of: Hertfordshire’s Children’s Trust Partnership Strategy & Planning sub-group, MSLC (Maternity services liaison committee), University of Hertfordshire’s Directors of Service and Education meetings, HCAI Whole System Review Group, East & North Hertfordshire Choose and Book Project Board

Attendance at CDRP meetings for Welwyn/Hatfield, Stevenage, East and North Herts.