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
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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
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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
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Proposed declaration 2007-8
Compliant on most Insufficient assurance (awaiting report from
HCC)– C7e: Equality & human rights– C16: Patient information– C18: Access to service
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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)
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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
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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
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Core standard 13c: confidentiality (compliant)
Caldicott Guardian & protocols Internal Audit Report Dec 2007 Documentation Audit Monitoring via incident reports / PALS
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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.
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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
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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
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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.