A G E N D A - pat€¦ · Mrs M Ollerenshaw Non-Executive Director ... 023/2014 AUDIT COMMITTEE TERMS OF REFERENCE The revised terms of reference were approved. The Board confirmed

TRUST BOARD

DATE: THURSDAY 27 MARCH 2014 at 2pm

VENUE: ROOM 219, TRUST HEADQUARTERS NORTH MANCHESTER GENERAL HOSPITAL

A G E N D A ITEM Lead Time

1 APOLOGIES FOR ABSENCE

JJ Verbal 1400

2 DECLARATION OF INTERESTS

JJ Verbal

3 REAPPOINTMENT OF CHAIRMAN

JJ Verbal

4 APPOINTMENT OF CHIEF EXECUTIVE

JJ Verbal

5 MINUTE OF MEETING HELD ON 27 FEBRUARY 2014

JJ Attached

6

MATTERS ARISING

JJ

Verbal

PATIENT SAFETY

7 PATIENT STORY

MS Attached 1405

8 PATIENT SAFETY

RD / MS

Attached 1425

9 PATIENT EXPERIENCE REPORT – Complaints and PALS

GB Attached 1435

STRATEGY

10 LISTENING INTO ACTION

JS Attached 1445

PERFORMANCE, GOVERNANCE AND ASSURANCE

11

CORPORATE PERFORMANCE REPORT HM Attached 1450

FOR APPROVAL/NOTING

12

CIP APPROVAL BS Attached 1455

13 DATA QUALITY ASSURANCE FRAMEWORK

BS Attached

14 APPROVAL OF CHARITABLE FUNDS EXPENDITURE

BS Attached

MINUTES OF BOARD SUB COMMITTEES

15 CLINICAL GOVERNANCE and QUALITY COMMITTEE MINUTE 21 February 2014

JS Attached

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16 DATE AND TIME OF NEXT MEETING Thursday 24 April 2014 at 2pm at Fairfield General Hospital

JJ Verbal 1510

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U:execassts/meetings/trustboard/march2014/mins270214

THE PENNINE ACUTE HOSPITALS NHS TRUST

Trust Board Part 1

27 February 2014 at 2pm Education Centre, Rochdale Infirmary

PRESENT Mr J Jesky Chairman Dr R Davies Medical Director Mrs C Fairhurst Non-Executive Director Mrs C Guereca Non-Executive Director Mr M Holly Non-Executive Director (Items 020 – 029 only) Mrs C Mayer Non-Executive Director Mr H Mullen Director of Operations Mr R Pickering Director of Human Resources Mr J Saxby Chief Executive Mr B Steven Deputy Chief Executive / Director of Finance and IM&T Ms M Sunderland Chief Nurse Mr J Wilkes Director of Facilities IN ATTENDANCE Mr G Barclay Assistant Chief Executive (Board Secretary) Mr A Lynn Head of Communication BY INVITATION Ms B Armstrong Matron, Infectious Diseases (Item 025 only) Ms G Delaney HIV Specialist Nurse (Item 025 only) APOLOGIES Mrs S Dixon Non-Executive Director Mrs M Ollerenshaw Non-Executive Director 020/2014 DECLARATION OF INTERESTS There were no declarations of interest relating to items on the agenda. 021/2014 MINUTE OF THE TRUST BOARD MEETING HELD ON 30 JANUARY 2014 The minute of meeting of the Board held on 30 January 2014 was submitted, approved and signed by the Chairman. 022/2014 MATTERS ARISING

Learning Disabilities Lead Nurse Ms Sunderland reported that she was looking at opportunities for future funding of this post. 023/2014 AUDIT COMMITTEE TERMS OF REFERENCE The revised terms of reference were approved. The Board confirmed the appointment of Mrs Fairhurst to the Committee with effect from 1 January 2014.

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024/2014 MINUTE OF AUDIT COMMITTEE The minute of meeting of the Audit Committee dated 11 February 2014 was submitted and noted. Mr Holly said that the Committee had considered the merger of the Trust’s current internal audit providers, Audit North West, with Mersey Internal Audit Agency from 1 April 2014 with the new internal auditor being Mersey Internal Audit Agency from that date. In line with Standing Financial Instruction 11.1.3 the Director of Finance had approved the appointment. Mr Holly said that the Audit Committee had discussed the internal audit progress report, the annual accounts audit plan and counter fraud issues. He said that between the October 2013 and February 2014 meetings there had been a useful discussion on the Committee’s self assessment. It was noted that the Committee had agreed that the Trust should take a single segment approach to financial reporting. 025/2014 PATIENT STORY Ms Armstrong and Ms Delaney presented a patient story about how the HIV specialist service had supported a homeless patient. They also described how the homelessness policy had helped more patients move to suitable accommodation. Board members asked a number of questions about access to services, follow up care and arranging accommodation for out of area patients. 026/2014 PATIENT SAFETY REPORT Dr Davies spoke to the report and stated that the Trust’s mortality ratio continued to be one of the lowest in the North West. He said that Executive Patient Safety walkrounds continued. In response to a question from Mrs Mayer, Mr Wilkes and Mr Mullen gave some examples of the issues arising and actions taken as a result of Executive Patient Safety walkrounds. 027/2014 PATIENT EXPERIENCE REPORT – MRSA Ms Sunderland spoke to her papers which outlined the findings and actions associated with an increase in the number of MRSA bacteraemia reported during 2013/14. She said that there had been six bacteraemia reported against a zero tolerance target. Ms Sunderland outlined the issues arising in each case. She said that she did not believe there were systemic issues regarding infection control practice but for some of the individual cases there were some other elements of care that needed to be addressed. She said that a more formal compliance framework around all aspects of patient care was required and she would co-author with Dr Davies a letter to clinical staff regarding adherence to practice.

The report was noted. 028/2014 PATIENT EXPERIENCE REPORT – PRIVACY AND DIGNITY Ms Sunderland spoke to the report and drew attention to the results of local patient surveys and the friends and family test results. Ms Sunderland said that the friends and family test had now been extended to Maternity Services. Ms Sunderland commented on the introduction of the new nursing and midwifery compliance framework and the setting up of a Nursing and Midwifery Performance Committee which would be chaired by Mr Mullen. Nursing care indicators were being piloted at Fairfield General Hospital with the intention of these being rolled out across the Trust in April 2014. A compliance framework would be submitted to the Board in May 2014 with the statistical report provided in June 2014.

Action: MS The report was noted.

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029/2014 PATIENT EXPERIENCE REPORT – CLEANING Mr Wilkes spoke to the report and said that cleaning scores remained compliant against the relevant standards. However, a recent internal audit review had identified a small number of areas where further action was required and this had been raised with the cleaning contractor. In response to a question from Mr Holly, Ms Sunderland said that outstanding issues regarding nurse cleaning scores would form part of the new Nursing and Midwifery Compliance Framework.

The report was noted. 030/2014 ELIMINATING MIXED SEX ACCOMMODATION – DECLARATION OF

COMPLIANCE The Declaration was approved for publication.

031/2014 LISTENING INTO ACTION Mr Saxby spoke to the report and highlighted:

56 staff had attended taster sessions for the Trust Rock Choir

The first four consultant led LiA teams had started their projects. It was agreed that the full set of comments from the Bullying and Harassment Staff Conversations should be circulated to Board members.

Action: JS The report was noted.

032/2014 CORPORATE PERFORMANCE REPORT Mr Mullen spoke to the report and stated that the Trust remained below the upper threshold for CDT but as reported earlier in the meeting there had now been six MRSA cases. The Trust had achieved the 4 Hour Urgent Care standard for January, had narrowly missed the RTT standard and had achieved the cancer standards in December 2013. In response to a comment from the Chairman, Mr Mullen said that the year-end forecasts would be updated for the next report.

Action: HM The report was noted.

033/2014 FREEDOM OF INFORMATION ANNUAL REPORT Mr Barclay spoke to the report and highlighted the 30% increase in FOI requests from 2012 to a total of 455 requests in 2013. He commented on the source of requests and the type of information requested. He stated that exemptions had been used in a small number of cases. One direct referral had been made to the Information Commissioner in the year and the Information Commissioner had fully endorsed the approach taken by the Trust. Mr Barclay answered questions from Dr Davies and Mr Steven around risks, charging, sanctions and source of requests.

The report was noted. 034/2014 QUALITY ACCOUNTS 2013/14 BRIEFING PAPER Ms Sunderland spoke to her report which provided an outline of the contents of the Quality Account and information on the statement of directors’ responsibilities which would need to be signed as part of the Quality Account. Ms Sunderland said that the report confirmed that the items suggested at the previous meeting of the Board would be included in the Quality Account. She added that the consultation on the draft Quality Account would need to commence prior to the next Board meeting. It was agreed that this should be carried out and that the draft Quality Account could be submitted to the March Board meeting. Ms Sunderland said that following discussion at the Quality Strategy Group it had been agreed to reduce the number of quality priorities for 2014/15 to six, these being Nutrition, Mortality,

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Readmissions, Cancer Pathways, Referral to Treatment target and Discharge Arrangements.

The report was noted.

035/2014 MINUTES OF BOARD SUB COMMITTEES The minute of meeting of the Risk Management Committee dated 14 January 2014 was submitted and noted. The minute of meeting of the Clinical Governance and Quality Committee dated 17 January 2014 was submitted and noted. 036/2014 DATE AND TIME OF NEXT MEETING It was agreed that the next meeting of the Board be held on Thursday 27 March 2014 in Room 219, Trust Headquarters, North Manchester General Hospital at 2pm.

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Patient Stories Board Paper 02/14 1

Title of Report Patient Stories – March 2014

Executive Summary

The purpose of this report is to inform the Trust Board about patients’ experiences across the Trust.

Actions Requested:

For information and discussion.

Corporate Objectives supported by this paper: 2) Improving the patient experience

Risks: The publication of recent national reports into failings in NHS organisations has highlighted the importance of Trust Board’s understanding of the quality of the services that they provide.

Public and/or Patient Involvement: As described within the report. The purpose of this initiative is to make the Trust Board aware of individual patients’ experiences of the services provided by Pennine Acute Hospitals NHS Trust.

Resource Implications: N/A

Communication: In addition to presentation of patient stories at the Trust Board and Senior Management Group it will become a requirement from December 2013 to make Patient Stories available on the Trust internet site as part of NHS England’s Transparency Project.

Have all implications been considered? YES NO N/A

Assurance x

Information Governance Assurance x

Contract x

Equality and Diversity x

Financial / Efficiency x

HR x

Information Governance Assurance x

IM&T x

Local Delivery Plan / Trust Objectives x

National policy / legislation x

Sustainability x

Name Mandie Sunderland

Job Title Chief Nurse

Month and Year March 2014

Email [email protected]

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Patient Experience – Patient Stories

1. Introduction Stories can be used to communicate visions and needs in a powerful way; they offer a compelling and practical means of exploring issues and experiences from different perspectives, while promoting reflection and stimulating dialogue and debate. The Trust Board will be presented with a patient story at each meeting that will allow an in depth view of patients experiences within services across Pennine Acute Hospitals NHS Trust.

2. Strategic Context

This report directly contributes to 2013/14 Corporate Objective 2 (Improving the Patient Experience). The Trust’s vision and goals are underpinned by the corporate objectives that support patient experience. Identifying the achievement of objectives by identifying interactions with patients will give added assurance that these are being met.

3. Patient Stories

Patient Story – March 2014 The patient story will be told by Julie Archibald ward manager of the Clinical Assessment Unit (CAU) at Rochdale Infirmary (RI), she will articulate the story of how it felt for the ward team to receive a complaint from a family about the standard of nursing care on the unit and the impact that this has had on the team. A female patient aged 72 was admitted to the CAU at RI. The patient was admitted with reduced mobility and was suffering from dementia; the family were struggling to cope with her at home. On skin inspection it was noted that the patient had a moisture lesion to her sacral area .There were inconsistencies with the grading of the pressure ulcer on the Unit and untimely referral to Tissue Viability Nurse for advice. There was also a delay with Medical photography referral. . The moisture lesion became worse due to poor communication with Tissue Viability Team and care planning by the nursing team to prevent more damage and promote healing. The family raised a formal complaint and the senior nursing team met with the family. The concerns raised by the family were about care provided on the Unit, that showers were not offered daily and the lack of communication to the family.

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Lessons Learnt

All patients have a skin inspection within 6 hrs of admission or transfer to the unit as per Trust policy and care plans formulated as appropriate. All patients admitted with moisture lesion/pressure damage have immediate referral to TVN and medical photography. A new TVN link nurse has been identified for the unit and a robust programme of education has been put into place for all staff on the unit. All patients offered daily showers and this is documented on the patients individual hygiene care plan. All the issues raised by the family have been discussed with members of the ward team in order to improve patient care delivery and communication.

4. Conclusion The Board is asked to support the programme of activities and to note actions taken following review of this and previous care episodes. Mandie Sunderland Chief Nurse March 2014

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Title of Report Patient Safety Report

Executive Summary Update for Trust Board on progress with patient safety

Actions requested The Board is asked to note the contents of this report and progress. The Board is asked to approve the revised approach to Patient Safety Walkrounds.

Corporate Objectives supported by this paper: Objective 1 – Improving Patient Safety - Reduction in standardised mortality Objective 2 – Improving the Patient Experience

Risks: Board Risk Register: –

- Poor quality of care provided to patients as measured by HSMR if higher than expected mortality is not noticed and addressed at Trust site and speciality level.

Public and/or patient involvement: N/A

Resource implications: N/A

Communication: Through the Governance structures Dedicated section on Trust Internet site


Assurance

Information Governance Assurance

Contract

Equality and Diversity

Financial / Efficiency

HR

Information Governance Assurance

IM&T

Local Delivery Plan / Trust Objectives

National policy / legislation

Sustainability

Name Rob Davies Mandie Sunderland

Job Title Medical Director Chief Nurse

Date March 2014

Email [email protected] [email protected]

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HOSPITAL STANDARDISED MORTALITY RATIO (HSMR)

1. Introduction

1.1 This report covers the period from April to December 2013

2. Latest Results

2.1 The Trust’s HSMR for the year-to-date for April to December is 81.59 within

lower and upper confidence intervals of 77.68 and 85.64.

2.2 The graph below shows the trend for the period:

2.3 Regionally we are second highest performing Trust when compared to other

Acute Trusts. Salford NHS FT is currently at the top with a HSMR of 76.59.

2.4 There are currently no negative CUSUM alerts to report

The graph below shows how we are performing against our North West peers* and indicates that we remain below the North West average of 91.78 with an HSMR for April to December 2013 of 81.59. The position remains consistent with last month whilst the North West average has slightly decreased.

40

50

60

70

80

90

100

HSMR April to December 2013

HSMR

Target

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0

20

40

60

80

100

120

HSMR NW Acute Providers - April to December 2013

HSMR NW Average

*The peer performance includes any patients treated at Pennine who were also seen at other

providers for related care during their spell, known as the super spell. The number of super spells

during the period may vary and therefore the impact on the HSMR will differ slightly when comparing

Pennine only based reports as a result.

SHMI The graph below shows the quarterly SHMI trend for the last 3 years. SHMI for the period April 2012 to March 2013 is 107.36 which is statistically significantly high. The SHMI (in-hospital) element is within ‘expected’ range however and shows a score of 102.84. The latest data available for Quarter 1 of 2013/14 shows that SHMI has now reduced to 105.

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PATIENT SAFETY

1. Leadership for Harm Free Care

CQUIN Aim: A minimum of 10 walk rounds per Executive Team member (7

Executive Directors) (including Chief Executive) to have been undertaken during the

full year with a walk round being completed every month by a minimum of 3

Executives.

Rationale: All leaders should understand the importance of maintaining an effective

level of communication with patients and staff delivering the care.

Final indicator period: (on which payment is based) 1st April 2013 - 31st March

2014

Frequency of data collection: Monthly

N.B. Executive Directors are now undertaking walkround visits at Theatres at each

site and the number of completed theatres walkrounds is now included within the

figures.

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Patient Safety Report –Ward Walk Rounds

Introduction: The Trust has been undertaking Executive Ward Walk Rounds since 2010, when they were introduced as part of the Patient Safety First Campaign. Ward Walk Rounds are a way of ensuring that executives are informed first hand, regarding the safety concerns of frontline staff. They are also a way of demonstrating visible commitment by listening to and supporting staff when issues of safety are raised. The aims of the walk round process are to:

Demonstrate top level commitment to patient safety

Increase the awareness of safety issues among all clinicians.

Make safety a priority for senior leaders by spending dedicated time promoting a safety culture.

Educate staff about patient safety concepts such as incident reporting.

Obtain and act on information gathered that identifies areas for improvement.

Build communication and relationship with frontline staff. In 2012-13, Greater Manchester commissioners included a new Commissioning for Quality and Innovation (CQUIN) payment target called “leadership for harm free care” which promotes patient safety. The CQUIN requires a minimum of 10 walk-rounds per Executive Director to have been undertaken during the year with a walk-round being completed every month by a minimum of three Executive Directors.

Strategic Context:

This report directly contributes to 2013/14 Corporate Objective 1 (Quality Improvement – Patient Safety)

Process:

A calendar of visits is agreed at the start of the year. Each Executive Director is allocated one visit per month. Visits are monitored against trajectory on a monthly basis. Scanned copies of completed walk round proformas are sent to relevant Divisional Directors. Data is submitted to the Clinical Audit Department to produce quarterly summary reports.

Analysis:

The analysis includes data returned to the Clinical Audit Department between the dates 1st November 2013 & 31st January 2014.

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Completed proformas received during the period (N=15):

Site / Division Medicine Surgery W&Cs Diagnostics Total

NMGH 1 1 - - 2

FGH 6 - - 2 8

RI - 1 1 - 2

ROH 1 2 - - 3

Total 8 4 1 2 15

1. Do all patients on your ward have an estimated date of discharge (EDD)?

Yes 8

No 1

N/A or unable to answer 6

2. Do all patients on your ward have a VTE Assessment?

Yes 12

No -


3. Do all patients on your ward have a Falls Risk Assessment (if appropriate)?

Yes 11

No -


4. Do all patients on your ward have a daily senior review (ST3 or above)?

Yes 10

No 1


5. Do you undertake “Intentional Rounding” on your ward?

Yes 8

No 1

N/A 6

In 1 case where “yes” was answered the review of evidence showed - “Not really evidenced” (D2, NMGH) In 1 case where the answer was “No”, the following comment was documented: “Might do if an individual patient was at risk” (Ward T3, TROH)

6. Are all ward staff aware of SBAR?

Yes 5

Unsure 1

No 5

N/A 4

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7. Is SBAR being implemented on your ward?

Yes 3

No 7

N/A 4 1 missing answer

8. When engaged in clinical care do all staff adhere to “bare below the elbow”?

Yes 15

No -

N/A -

9. Are all staff on your ward aware of the importance of accurate record keeping?

Yes 15

No -

N/A -

10. How would you rate the standard of record keeping on your ward?

Very good 10

Good 5

Average -

Poor -

11. How would you rate your ward’s compliance with recording of observations and

EWS?

Very good 12

Good 2

Poor -

N/A 1*

*Ante Natal day Unit

12. Are all medicines securely stored in line with Trust Policy?

Yes 15

No -

N/A -

13. How do you think the next patient might come to harm on your ward?

A number of individual comments were made with one recurring theme being the need to prevent falls.

14. What do you think that we can do to prevent this from happening?

A number of individual comments were made including improving rounding and patient observations and falls prevention work.

15. Would you be happy for a member of your family to be treated on this ward?

Yes 15

No -

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16. Any additional comments:

There were comments about

a busy ward environment but a positive atmosphere

patient transport arrangements need to be improved

the physical environment of the day surgery waiting area at North Manchester

Future Developments It is acknowledged that the process of undertaking Patient Safety Walkrounds has proved beneficial in ensuring a senior focus on safety issues within the Trust. However, the publication of recent reports such as The Francis Report (2013) and the Berwick Report (2013) have made clear the necessity for robust Board assurance. It is the view of the new Chief Nurse and Medical Director that there is now an opportunity to refresh the current approach and move forward with the development of a new framework which will encompass various activities to provide assurance. This framework will include:

Quarterly reviews of services utilising methodologies modelled on the Chief Inspector of Hospitals inspection regime. Senior leaders across the Trust (including Board members) will participate. These reviews encompass a variety of approaches including observation, talking to staff and patients and examination of relevant documentation.

“Back to the Floor” participation from Executive Directors and senior clinical and non-clinical managers.

Introduction of Nursing and Midwifery quality metrics (which are currently being piloted at Fairfield General Hospital) which will inform the quarterly inspection regime and visits from Non-Executive Directors.

Recommendation The Board is asked to approve the proposed approach. Mandie Sunderland Chief Nurse March 2014

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Title of Report

Quarterly Integrated PALS and Complaints Report For Quarter 3 (1 October 2013 – 31 December 2013)

Executive Summary

The report analyses both quantitative and qualitative data relating to complaints handling by the Trust for the period from 1 October 2013 – 31 December 2013 inclusive. It aims to highlight key themes and common causes for complaints. The period 1 October 2013 – 31 December 2013 has seen further emphasis on analysis of areas/departments reporting 2 or more complaints. Additional emphasis has also been placed on the timely response to complaints to achieve the 25 working day target. This followed evidence that suggested a timely response enhanced the likelihood of complainant satisfaction. Quarter 3 has seen a slight reduction in both the number of complaints received and PALS enquiries. The period 1 October 2013 – 31 December 2013 has also seen an improvement in both complaint response within the 25 working day target and the number of comebacks received. The focus of this quarter’s report is medical care.

Actions Requested:

The Clinical Governance Committee received this report on 21 March 2014 and was requested to take the following actions:

A review by Divisions for those areas/departments that have recorded two or more complaints for the last quarter.

Divisions must ensure all ‘Lessons Learned’ documents provided by the Complaints Department are completed and returned at the conclusion of the complaint and that staff in the clinical areas are kept informed.

The Bpard is asked to consider whether any further acftion is required and to note the report.

Corporate objectives supported by this paper:

Quality – Patient Safety

Quality – Patient Experience

Risks:

Failure to identify trends leading to repeat complaints;

Failure to meet corporate objective of improving patient experience;

Failure to meet CQC and NHSLA Risk Management.

Public and/or Patient Involvement: Patient involvement in individual complaints.

Resource Implications: None

Communication:

Inclusion in Trust annual report (published externally);

Copied to Trust and Divisional Clinical Governance Committees for review on

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behalf of the Board.

Discussion of patient experience/key themes at Ward/Directorate Manager meetings.


Assurance X

Contract X

Equality and Diversity X

Financial / Efficiency X

HR X

Information Governance Assurance X

IM&T X

Local Delivery Plan / Trust Objectives X

National policy / legislation X

Sustainability X

Name Gavin Barclay

Job Title Assistant Chief Executive

Date of completion March 2013

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Quarterly Integrated PALS/Complaints Report

1 October 2013 – 31 December 2013 (Quarter Three)

Introduction The purpose of this quarterly report is to provide an overview of activity for both the Patient Advice and Liaison Service (“PALS”) and the complaints department, which handles formal written complaints for patients, in the period from 1 October 2013 – 31 December 2013. The report analyses both quantitative and qualitative data relating to complaints handling by the Trust. It aims to highlight key themes and common causes for complaints and to initiate wider discussion about how to improve the quality of the Patient Experience. It also highlights what actions have been taken as a result of complaints. Strategic context This report contributes to the Trust’s corporate objectives – Quality – Patient Safety and Quality – Patient Experience. Background

The Trust Board takes a very keen interest in complaints. The Trust has a target of acknowledging every complaint within 3 working days of receipt. From April 2013 the Trust started to report complaint responses within 25 working days, as opposed to complaints responses within 25 working days or timescale agreed with the complainant. We believe that this internal target is easier to understand and brings consistency of approach in dealing with complaints promptly within the Trust. However, it is a more challenging target than that previously set. The Trust is committed to improving patient safety and the overall patient experience and considers that timely investigation and conclusion of complaints facilitates this. Having a system or process which allows complaint investigations and ultimately the provision of responses to be extended in the majority of cases does not serve these objectives. Weekly reports are sent to key divisional managers in order to monitor compliance against both targets. In some circumstances it will not always be possible to provide a response within 25 working days but where this is the case, the complainant should be updated and a new timescale will be agreed. The Trust also liaises closely with other NHS Trusts and NHS England as necessary (where a complaint involves more than one healthcare provider or where input is required in order to comprehensively respond to the complaint), to ensure that patients receive a full and detailed response, dealing with all elements of the complaint and within the 25 working day target where possible.

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As of 30 September 2013 John Culshaw became permanent Head of Complaints, PALS & Legal Services. One of his roles is to further examine the process of complaints handling, quality of responses and trends within the Trust. As an immediate benefit of the Service Level Agreement with Weightmans, the complaints team has been strengthened by the employment of two additional team members with complaints handling experience to enhance and compliment the department’s existing skill base and to boost resources. – One who commenced in October 2013 and another in January 2014.

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HEADLINE FIGURES FOR QUARTER THREE

Key Data for PALS and Complaints The information set out below represents the overall figures and key data for PALS enquiries/contacts and formal complaints received for Quarter Three. A more in depth analysis of the statistical data is set out later on in the report.

PALS key data

In Quarter three:

PALS received a total of 397 contacts/enquiries during the quarter.

This was a slight decrease from a total of 430 (7.7%) contacts/enquiries received during Quarter 2 (1 July 2013 – 30 September 2013) and a decrease of 65 (14.1%) contacts/enquiries compared with the same quarter in the previous year.

The top 5 reasons for contacting PALS (in descending order and excluding other) were as follows:

1. Communication – 92 contacts 2. Request for Information – 89 contacts 3. Cancellation of appointment – 31 contacts 4. Excellent Service – 25 contacts 5. Clinical Treatment – 22 contacts

Complaints Key data

In Quarter three:

The complaints department received 198 formal complaints during the quarter.

This was slight decrease from a total of 217 complaints received for Quarter 2 and a slight decrease compared with the same quarter in the previous year (when 212 complaints were received).

The complaints can be broken down into the relevant Divisions as follows:

1. Medicine & Community Service – 84 2. Surgery – 81 3. Women & Children – 21 4. Diagnostics & Clinical Support – 9 5. Corporate - 3

As the focus of this quarter’s report is medical care, out of those sites that received complaints specifically related to medical care, Fairfield received 8, North Manchester General Hospital received 26, Rochdale Infirmary received 2, Royal Oldham Hospital received 19, Manchester Community received 1 and Birch Hill received 1.

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The department grades complaints RED, AMBER or GREEN depending on the seriousness of the complaint. Of the 198 complaints received, 37 were initially classified as RED, 129 were classified as AMBER and 32 were classified as GREEN.

Of the 198 complaints received this quarter, 162 were concluded within the Trust target of 25 working days which equates to 81.82%. This was 75.9% in October, 87.7% in November and 81.9% in December 2013. The results show a significant increase against the 67.74% compliance rate achieved in the previous quarter and recorded the best performance since the introduction of the revised targets.

PALS - STATISTICAL ANALYSIS

Comparison of the number of PALS enquiries and complaints received over time.

Number of PALs enquires and complaints received

0

100

200

300

400

500

600

700

2011/12

Q3

2011/12

Q4

2012/13

Q1

2012/13

Q2

2012/13

Q3

2012/13

Q4

2013/14

Q1

2013/14

Q2

2013/14

Q3Quarter/Year

Nu

mb

er

rece

ive

d p

er

qu

arte

r

Complaints

PALs

The primary function of PALS is:

to advise and support patients to resolve any concerns they may have with NHS care/treatment;

to provide information on NHS services and non NHS services; to provide assistance to patients (for example problems with appointments); to listen to patients’ concerns, suggestions or queries; and to highlight to the Trust any issues, themes or trends in PALS queries.

As reported last quarter, the PALS enquiries have now stabilised. Quarter 3 has in fact recorded the lowest number of PALS contacts for two years and is below 400 for the first time.

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Specialities with 10 or more contacts/enquiries in quarter 2 were as follows:

Other Surgical Specialties – 70 (61 allocated to Out-Patient Surgery)

Booking & Scheduling – 45

Accident & Emergency – 43

Trauma & Orthopaedics – 21

PALS – 14

General Surgery - 12 The chart overleaf illustrates the number of PALS enquiries received in this quarter broken down by Specialty & Site (excluding requests for information, wait/cancelled appointment and positive comments i.e. compliments received):

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PALs enquires by specialty and hospital site 1

October to 31 December 2013 (excludes requests

for information, wait/cancelled appointments &

positive comments)

0 5 10 15 20 25 30 35 40

Other

Accident and Emergency (A&E)

(blank)

Other Surgical Specialties

Trauma and orthopaedics

General surgery

Other Diagnostic Services

Other Medical Specialties

Obstetrics

Cardiology

Gynaecology

General medicine

Radiology

Rehabilitation

Rheumatology

Other Specialities

Gastroenterology

Pain service

Not applicable

Vascular surgery

Thoracic / respiratory medicin

Breast surgery

Endocrinology

Paediatrics

Occupational therapy

Urology

Plastic surgery

Ophthalmology

ENT

1 Manchester Community

All Sites

Fairfield

N.M.G.H.

R.I.

R.O.H.

(blank)

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COMPLAINTS-STATISTICAL ANALYSIS The following sets out a more detailed analysis of the complaints data for Quarter 3. It includes a breakdown of complaints received by reference to division, wards/departments, sites and risk category. The aim is to identify areas where a disproportionate number of complaints are received so that the Trust can identify any reasons for this and take remedial action. Any departments that had two or more complaints within the quarter are identified so this can be investigated. This is to ensure that particular problem areas within the Trust are identified and improvement strategies implemented as necessary to prevent recurrence.

Number of Complaints Received by Ward and Site – Areas with Over Two Complaints Received Quarter 3 (1 October 2013 – 31 December 2013) The following wards/departments at Fairfield General Hospital received two or more complaints for this quarter:

Overall, complaints related to Fairfield have increased from 25 to 38 compared to the previous quarter. Accident and Emergency received the highest number of complaints at Fairfield General Hospital; the number has increased by 6 from the previous quarter. However Accident and Emergency is likely to receive the highest number of complaints due to the high number of attendances. The main reasons for complaints at Fairfield A&E were Inappropriate Discharge and Failure/Delay to Diagnose Fracture, both recording 3 complaints. Ward 7 has also seen an increase of 4 complaints compared to the previous quarter. The most notable reasons for complaints were: Inappropriate Discharge (x2), Lack/ Standard in Nursing Care (x2) and Failure to Treat Patient (x2)

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Other increases have been recorded for Out-Patients Surgery and Ward 6. Ward 9, Ward 14 and Ward 8 all appear in the report for Quarter three having been absent in the previous quarter. Out-Patients – Medicine and Ophthalmology do not appear on the list this for Quarter three having recorded two or more complaints for the previous two quarters. Ward 6 has reappeared this quarter having been absent last quarter. There has been an increase in areas that have reported two more complaints from 6 to 7.

The following wards/departments at North Manchester General Hospital received two or more complaints for this quarter:

Overall complaints received for NMGH have fallen from 59 to 38 this quarter compared to last. The most significant decrease was seen in Out-Patient Surgery whose number of complaints fell by 11. Other decreases were seen in DSU Theatre and significantly H3 (MEU) which recorded 8 complaints in the previous quarter however, does not appear on the list in Quarter 3. The following wards/departments appeared on the report last quarter however, this quarter they have received less than 2 complaints and do not appear:

J4 (N) Infectious Diseases

Koala Unit

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Post Natal Ward

Radiology General

H3 (MEU) The largest increase in complaints this quarter was seen in A&E which saw a rise of 4 complaints (main reason of complaint being Failure to Diagnose Condition). F5 (N) and I5 both saw an increase of 2 complaints received. E3 (N) remained static this quarter recording 2 complaints. The following ward/departments are present on the report this quarter having been absent last quarter:

Out-Patients Medicine – 3 complaints

F1 (Discharge Lounge) – 2 complaints

C6 (Urology) – 2 complaints

F6 (N) – 2 complaints

A&E (Children’s) – 2 complaints

Oral Surgery – 2 complaints

The overall number of wards/departments reporting 2 or more complaints has increased from 11 to 12. The following wards/departments at the Royal Oldham Hospital received two or more complaints for this quarter:

Similar to NMGH, Royal Oldham Hospital recorded a fall in overall complaints received from 63 to 53 compared to the previous quarter. The largest reduction was seen in A&E from 14 to 10 complaints received. Of the 15 areas/departments that recorded 2 more complaints in Quarter 2, 10 have seen a reduction or don’t appear on the list at all in Quarter 3.

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The following wards/departments saw a great improvement in complaints and do not appear on the graph this quarter:

Orthopaedic Clinic

T4

F1

Ophthalmology

T6

T5

Gynae Out-Patients Maternity General Areas (compromising of Mat 1 & Mat 2) recorded the largest increase in complaints from 3 to 9. There is no significant trend to report in this increase with the main reason being recorded as Failure to Diagnose Condition resulting in 2 complaints. T3 recorded an increase of 3 complaints and Out-Patients Surgery, an increase of 1. The following areas appear this quarter that were absent last:

G2 – 3 complaints

Post Natal Ward – 2 complaints

Surgical triage – 2 complaints

F7 – 2 complaints

Physiotherapy – 2 complaints Booking & Scheduling remained constant with 2 complaints in Quarter 3. T7, Orthopaedic Clinic and AMU all recorded reductions in complaints. For the second consecutive quarter there was a reduction in the number of wards/departments reporting two or more complaints. The following wards/departments at Rochdale Infirmary / Birch Hill Hospital received two or more complaints for this quarter:

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Rochdale Infirmary/Birch Hill have also seen a reduction in total number of complaints received from 12 to 6. The only area still present from the previous quarter in Out-Patients Surgery although the number of complaints received has fallen from 5 to 2. The Day Surgical Unit, Urgent Care Centre and Clinical Assessment Unit all appeared on the list last quarter but not this quarter. Endoscopy and Ophthalmology however, have recorded 2 or more complaints this quarter and now appear on the list. Departments recording 2 or more complaints each quarter for a 12 month period Following previous complaint reports, this report now contains data for those departments that have 2 or more complaints and those that consistently have 2 or more complaints over a 12 month period. This should allow divisions to identify those departments that present a continuing cause for concern. This then allows the divisions responsible to see if these complaints actually represent a pattern and take remedial action. The table below identifies areas that have reported 2 or more complaints in each quarter for the last 12 months.

In Quarter 2, 8 Departments/Wards were reported to have recorded to have reported 2 or more complaints for 4 consecutive quarters. This figure has now increased to 11 Deaprtments/Wards. Appearing on the report this quarter are DSU Theatre, Booking & Scheduling and AMU. Accident & Emergency have now seen an increase in the number of complaints for two consecutive quarters. The most prominent reason for complaints in Quarter 3 being Failure to Diagnose Condition (7) and Failure/Delay to Diagnose Fracture (5).

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Despite still appearing on the report, Out-Patients Surgery, Out-Patients Medicine, T7 and Ophthamology have all recorded a reduction in complaints. Divisions with wards/departments that recorded two or more complaints for a 12 month period as shown in the quarter 2 report were provided with a full breakdown of these complaints to enable the Divisions to undertake detailed analysis and take remedial action to address any emerging themes or trends. It is currently too soon to determine if such analysis and remedial action has resulted in a reduction in complaints. In preparation for the Chief Inspector of Hospitals Inspection, the Complaints Department has shared with the Governance Director the identity of all departments with more than 2 complaints in each quarter in 2013 so that the internal peer review can include these areas during the first wave of mock inspections. Complaints by Risk Category All new complaints received are risk assessed using the Complaints Grading matrix (initial risk rating). This risk assessment is a three-step process; the first step is to consider the potential consequences of a complaint; the second step is to assess the likelihood of recurrence, the third and final step is to grade the complaints Red (High risk), Amber (medium risk) and Green (low risk). For example a catastrophic event which is likely to happen again would be graded as a High Risk (Red) complaint. Based on the findings of the investigation, the complaint is once again risk rated. This may result in the risk rate being amended. The chart below illustrates the number of complaints received for this quarter by reference to risk rating.

Complaints received by initial risk rated category

0

20

40

60

80

100

120

140

160

180

2012/13 Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2013/14 Q1 2013/14 Q2 2013/14 Q3

Quarter

Nu

mb

er

of

com

pla

ints

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As with previous quarters, the majority of complaints received were risk rated as Amber. Before red complaints are sent to the Chief Executive for signature, they are reviewed by Divisional Directors, the Head of Complaints and finally the Head of Corporate Development. This ensures a high level of review and rigor is applied to the very serious complaints the Trust receives. A decision has been taken to treat all complaints relating to the Liverpool Care Pathway as ‘RED’ complaints. All new ‘RED’ complaints are copied to the Chief Nurse and Medical Director when received. Complaint Outcome by Division The charts below show the status of complaints received in this quarter broken down by division. Once a complaint has concluded (either following a local resolution meeting or once a formal written response has been sent) the outcome will be recorded. A complaint will be “upheld”, “upheld in part” or “not upheld” or may be marked as ‘withdrawn’. Those from this quarter not yet concluded or those to which we have not yet received consent will be categorised as “ongoing” or “blank”. The statistics illustrate that across the divisions the majority of complaints are “upheld in part” or “not upheld”. Those which are “ongoing” as at the end of the relevant quarter are likely to be complex, involving more than one division. Charts illustrating outcomes by division are set out below:

Outcome of Complaints – Medicine

0

10

20

30

40

50

Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2012/13 Q1 2013/14 Q2 2013/14 Q3 2013/14

Not Upheld

Ongoing

Upheld

Upheld In Part

Withdrawn

(blank)

Division Medicine & Community Services

Count of Case Number

Quarter

Outcome

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Outcome of Complaints – Surgery

0

5

10

15

20

25

30

35

Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2012/13 Q1 2013/14 Q2 2013/14 Q3 2013/14

Litigation

No Consent

Not Upheld

Ongoing

Upheld

Upheld In Part

Withdrawn

(blank)

Division Surgery


Quarter

Outcome

Outcome of Complaints – Women & Children’s

0

5

10

15

20

25

30

Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2012/13 Q1 2013/14 Q2 2013/14 Q3 2013/14

Litigation

Not Upheld

Ongoing

Upheld

Upheld In Part

(blank)

Division Women And Children


Quarter

Outcome

Outcome of complaints – Diagnostics

0

1

2

3

4

5

6

7

8

Q1

2012/13

Q2

2012/13

Q3

2012/13

Q4

2012/13

Q1

2013/14

Q2

2013/14

Q3

2013/14

Not Upheld

Ongoing

Upheld

Upheld In Part

Withdrawn

(blank)

Division Diagnostic / Clinical Support


Quarter

Outcome

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Overall the largest single outcome was “not upheld” (74) with “upheld in part” next (53). Only 23 complaints were considered completely “upheld”. These figures do not include those complaints received in the quarter which have not yet concluded.

COMEBACKS TO COMPLAINTS

In quarter three, 21 comebacks were received. No Division recorded an increase in comebacks compared to the previous quarter. Diagnostics & Clinical Support and Corporate recorded none for this quarter. The chart below illustrates the number of comebacks received in each quarter by division:

It is important to note however, that comeback figures are only correct at the date of reporting. It is highly possible that comebacks may be received for complaints lodged for this quarter at a much later date. This is highlighted by comebacks received for complaints lodged in Quarter 2. The figure reported in the previous Quarterly PALs and Complaints report was 26. To date, that figure has now increased to 31. The Trust has a target to ensure 70% of complaints are resolved at the first response to the complainants’ satisfaction. Based on this quarter’s current figure, we have a success rate of 89.4%. The recalculated figure for Quarter 2 is a success rate of 85.7%. There are several reasons for comebacks. Currently, the most common reason is that the complainant feels their questions or queries have not been fully answered. To address this, the Complaints Department will pilot providing Divisions with a template detailing key points and questions to be addressed and investigated in the response. The Complaints Department will also look to bring forward the date the response is reviewed prior to sending to the complainant. This will enable the department to challenge responses without breaching the 25 working day target. The Complaints department continues to contact complainants on receipt of complaints that are ambiguous and/or lacking in detail in order to respond effectively and in a timely manner.

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It was reported in the last quarter that 45% of comebacks received were initially responded to outside of the 25 working day target. Although the number of complaints responded to this quarter within the target timeframe has significantly increased and the number of comebacks has decreased, focus should indeed remain on timely responses. This should not be at the detriment of quality however. With the agreement of Divisions, we plan to introduce further quality assurance measures supported by complaint response training where necessary. Some complainants will comeback more than once. Generally, where this occurs, the Trust will have exhausted all options and the complainants’ best recourse will be to refer the matter to the Parliamentary Health Service Ombudsman (PHSO).

PARLIAMENTARY HEALTH SERVICE OMBUDSMAN (PHSO) Complainants dissatisfied with the Trust’s response have the right to ask the Parliamentary Health Service Ombudsman (PHSO) to consider their complaint. However, the complainant must be able to provide reasons for their continued dissatisfaction (in writing) to the PHSO.

The PHSO will consider the complaint file, medical records and any other relevant information as necessary. The PHSO may decide not to investigate further and no further action will be required from the Trust. Alternatively, recommendations might be made for the Trust to consider. The PHSO may decide to conduct a full investigation which might result in the Trust being required to make an apology, pay compensation and / or produce an action plan to describe what actions are planned to rectify the situation, prevent further occurrences, etc. The Trust received 7 letters from the PHSO this quarter.

Of the 7 letters received 3 were not upheld (i.e. the Ombudsman declined to investigate further) and 4 are ongoing. In addition, the Trust has been able to close 2 outstanding PHSO cases this quarter which have been investigated. Of these closed cases, neither were upheld. This is partly indicative of an effective initial complaint response. If the Trust responds to the complaint fully and where appropriate accepts responsibility and resolves to learn lessons, the PHSO will recognise this. When the PHSO issue their final report following their investigation of any of our cases, the Complaints Department will not close the PHSO case until assurance has been received that all the actions and recommendations have taken place. At this point the Complaints Department will relay such assurance to the complainant and the PHSO.

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QUALITATIVE DATA- PATIENT STORIES Each quarterly report presents qualitative information on one theme and associated sub-themes. The theme for this quarter is medical care. This forms the focus of the patient stories set out below. The patient stories represent a random sample of complaints of various risk grades concerning medical care and treatment which were received for this quarter. Theme – failures in Medical Care

i. Sub-theme: Failure to Diagnose Condition

COMPLAINT Hospital name – North Manchester General Hospital – Breast Clinic Patient Story The patient, who suffers from dementia, attended the breast clinic in November 2012 with a left side breast lump. The lump had been noticed by carers in the Nursing Home where she was a resident. She received a mammography and ultrasound scan but no biopsy was performed, nor arrangements for any follow up. The lump continued to grow and by September 2013 a 14cm Non Hodgkin’s Lymphoma was diagnosed. The family considered that the diagnosis was missed initially and that as a result, in combination with the failure to arrange any follow up, the patient’s life had been considerably shortened. OUTCOME:

An investigation was undertaken by the Assistant Directorate Manager for

Surgery. Comments were obtained from the Speciality Doctor in Breast

Surgery and Radiology team involved in the patient’s initial care.

It was confirmed to the family that normally a triple assessment with a needle

aspiration or biopsy would be undertaken on most breast lumps.

The Speciality Doctor confirmed that on this occasion this had not been done

as the lumps present appeared to be consistent with sebaceous cysts arising

from the skin and the level of suspicion following the clinical examination and

investigations did not warrant needle aspiration or biopsy.

Although lymphoma in the breast is uncommon, the patient was referred back

to hospital seven months later with a large lump in her left breast which on

clinical core biopsy unfortunately showed lymphoma.

ACTIONS TAKEN:

Staff involved were made aware of this case.

Thorough review and investigation undertaken.

The need for triple assessment was highlighted.

It was acknowledged that on this occasion the initial imaging features had not

been a true reflection of the disease process and an apology was made to the

family.

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ii. Sub-theme: Complications following Surgery/ procedure

COMPLAINT Hospital name – North Manchester General Hospital – Ward C4 Patient story Patient underwent keyhole surgery in the day surgery clinic to remove their gallbladder. The patient arrived at 7.30am and was asked to come back at midday which they did. They then waited until 4.30pm, nil by mouth, until being called in for surgery. When the patient woke up they experienced pains that felt like gallstones and received pain relief medication. The patient was discharged the next morning and continued to experience a few pains. The next day the patient began to experience a severe burning pain as well as being sick. Having had gallstones for four years they had never experienced pain like this and so called an ambulance. The pain continued to get worse during the patient’s admission to A&E and then during transfers to Wards C4 and F6. The patient was given morphine regularly which did not fully relieve the pain. The patient was not effectively reviewed by a Doctor until four days after being admitted with the severe pains. The patient was advised the problem was bile and was sent for drainage. However, the procedure could not be performed. The patient was sent back to the ward and then sent back to surgery a few hours later where a procedure was carried out inserting a camera into the patient and placing a clip on their liver. The patient continued to feel unwell and in pain after being discharged home and is unclear as to what the problem was, what was wrong with their liver and what procedure was carried out on their liver and why. OUTCOME:

An investigation was undertaken by the Assistant Directorate Manager for

Surgery and comments obtained from the Consultant Surgeon involved in the

patient’s care.

The patient had experienced a recognised complication of the laparoscopic

procedure, being a bile leak. This occurs in 1/100 operations and whilst not

apparent intraoperatively, becomes apparent in the days after surgery.

The patient had been re-admitted on a Saturday. Re-laparoscopy eventually

happened three days later. It was acknowledged that this could have been

done quicker and was recognised that the patient’s re-admission on a

weekend probably contributed to the delay.

The patient underwent re-operation to remove bile which involved applying a

clip to an exposed bile duct on the liver surface where the gallbladder had

been removed.

Consultant Surgeon explained the complications and need for further surgery

to the patient before they went for the re-operation and afterwards. Apologies

for the complication occurring were given on both occasions.

On discharge, arrangements were made for the patient to be reviewed in the

out-patients clinic and for a further procedure to remove the stent inserted.

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ACTIONS TAKEN:

Apologies were made again for the recognised complication occurring and for

the delay in the patient undergoing the re-operation.

Patient was reassured that the complication had been put right and there were

no long term implications.

The type of complication was discussed at the doctor’s weekly team meeting

and an action plan created from analysis of the complication by designing an

algorithm for patients presenting in the same manner as this one after this

surgery.

iii. Sub-theme: Complications Following Surgery/ Procedure

COMPLAINT Hospital name – Royal Oldham Hospital – Ward T7 Patient Story Patient broke their arm in 2006. Went on to develop a blood clot and received a skin graft, eventually undergoing surgery in 2007 at the Royal Oldham Hospital to have the arm fused. In August 2013, they started to feel pain and numbness in the left wrist and hand and noticed the wrist moving when it should not. An x-ray performed at Tameside Hospital revealed that the metal rod fusing the wrist had fractured at the centre by the wrist joint. The metal rod had a screw hole at the point it had fractured, but there was no screw in the hole. A few weeks later the patient received corrective surgery by the same surgeon who had performed the initial bone fusion and skin graft. The patient considered the metal rod had failed due to there being a hole in a vulnerable position in the rod which was unnecessary and did not have a screw in place. Patient was not given a clear response as to why it had happened and had been left untreated for 3 weeks before the corrective surgery took placed. OUTCOME:

A full investigation was undertaken by the Consultant Orthopaedic Surgeon in

which the full injury history dating back to 2006 was considered.

It was detailed that the patient had always been advised of the risk of non

union as a result of the fractures and necessary surgeries. Information was

provided to explain that one hole in the rod had been left without a screw

because this screw would have gone into the space of the wrist joint and

actually increased the risk of non union. There were three screws on either

side of the fusion area, which was considered acceptable both mechanically

and technically.

The Consultant Orthopaedic Surgeon advised that the reasons for the rod

failure were complex. Nothing in the x-rays post surgery had suggested that

the plate and screws inserted were the primary reason for the failure.

It was confirmed to the patient that they required the wrist plate to be replaced

as metal fatigue had occurred following the failure of the wrist to fuse.

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Review of the patient’s records demonstrated they had not been left without

treatment for three weeks, however, the complaint response indicates that the

investigation on this element of the complaint may have focused on the three

weeks from the patient’s initial appointment in 2006 and not the three weeks

prior to corrective surgery in 2013.

ACTION TAKEN:

Patient was given a detailed explanation as to the surgical care that had been

provided and the reasons for earlier surgery requiring revision which resulted

in part from the complexity of the injury.

Patient had an outpatient’s appointment with the surgeon after the complaint

was made and all concerns were discussed directly with the patient.

iv. Sub theme: Failure to diagnose condition

COMPLAINT Hospital name – Royal Oldham Hospital – Antenatal/ postnatal Patient story At 32 weeks pregnant patient went into early labour and was admitted to hospital and given medication to try to prevent the labour continuing. She was not monitored nor given a scan at or beyond 32 weeks during her admission. Her baby was then born with an open wound to her arm which staff did not treat. Patient was advised that before she could be discharged the staff would have to let her see her feed her baby or she would be reported to the authorities. Once discharged no follow up appointment was made by the hospital for the Community Nurse to visit. The baby went six weeks without having its arm treated, with the mother having to take the baby back into hospital. The baby had also been born with cerebral palsy which had been undiagnosed at birth. OUTCOME:

Full investigation carried out by Directorate Manager for Obstetrics and

Gynaecology.

Medical records showed that no clinical abnormalities had presented at 32

weeks to indicate a scan was required. Patient was advised that there was no

way of knowing if the event that caused the cerebral palsy had occurred after

32 weeks or before.

The patient had been monitored during her admission including a CTG on 3

occasions, foetal fibronectin test, steroid injection and nifedipine administered.

The baby was reviewed within an hour of birth and the following morning.

Assessment undertaken and plan put in place which had been discussed with

Consultant Neonatologist and specialists in orthopaedics and plastic surgery.

Baby was referred to the plastics team for an outpatients review.

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Community midwives visited three times after the birth and each time the

baby’s arm was recorded as being clean, dry and showing no signs of

infection. A later x-ray to the arm showed no abnormality or fracture.

The baby’s plastics review was brought forward.

ACTION TAKEN:

Apology made to the patient for distress caused.

Acknowledgment made that referral to the plastics team should have been an

urgent, not a routine referral.

Procedure reviewed so that if a similar incident re-occurred, consideration

would be given to involving a member of the tissue viability team in assessing

the wound and ensuring a consultant reviewed the patient prior to discharge.

v. Sub- theme: Failure to diagnose condition

COMPLAINT Hospital name – Royal Oldham Hospital – Maternity Patient Story Patient attended 36 week scan at their health centre advising the midwife they had not felt any movement of the baby. The midwife advised she had found the heartbeat near the groin and asked the patient if she was happy to agree that what she had found was the heartbeat. As she is not medically trained the patient found this inappropriate. At her next appointment at ROH antenatal clinic, the midwife could not find a heartbeat. A consultant was called and scan performed which confirmed the baby had died. The consultant advised the steps that would happen next. The patient returned the next day to take medication to induce labour; she had to be recalled into hospital as blood tests showed that her baby’s blood had gone into hers. When she went home she found that she had been sent home with the medical notes of a woman whose baby was alive and well. When she returned to give birth to the baby, her mother questioned the baby’s appearance and the midwife advised that ‘off the record’ the baby had probably died about two weeks ago, the time of the 36 week scan. Then finally on her actual due date, a midwife arrived unannounced at her house and dropped off photos of her stillborn daughter and then left, causing her further immense distress. OUTCOME:

Full investigation carried out by the Deputy Director of Women and Children’s

Division.

Meeting was held with the patient and her partner.

Comments of the meeting were fed back to staff, unfortunately two of the

midwives involved had left the Trust and another was on long term leave from

work.

Other staff involved were all spoken to and it was accepted that many

comments made to the patient had been inappropriate.

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Acknowledged that at the 36 week scan the patient could have been referred

for further monitoring, although this may not have affected the outcome.

It was recognised that the normal procedure is for a senior midwife to help and

offer counselling. A midwife would normally sit with a patient after a stillbirth

and explain things but this had not happened this time. A midwife would also

normally stay with the mother whilst they looked at the photos of the stillborn

baby.

ACTIONS TAKEN:

Apologies made for the inappropriate comments and lack of emotional support

provided.

Feedback to staff given that where a mother reports lack of foetal movement

pro-active action needs to be taken such as further monitoring.

Staff reminded that all documentation must be completed and followed up,

particularly regarding emotional support.

LEARNING FROM COMPLAINTS

Following the publication of the ‘Clwyd’ report in October 2013, the Trust has shared its action plan to address the Clwyd Report with the Trust Development Agency with a view to future implementation. The Complaints Department is currently analysing the 38 key recommendations in the report and will then commence a benchmarking exercise to determine the Trust’s current position against each recommendation. An action plan will then be developed for wider consideration highlighting suggested actions, if applicable to demonstrate implementation of the review. Following the presentation by Royal Liverpool & Broadgreen Hospitals NHS Trust, a key focus from their Chief Inspector of Hospitals visit was the expectation that complaints raised had effective action planning behind them and that staff knew where the process was up to for each issue relevant to their clinical area. It is therefore imperative that in preparation for our Chief Inspector of Hospitals Inspection, Divisions must ensure all ‘Lessons Learned’ documents provided by the Complaints Department are completed and returned at the conclusion of the complaint and that staff in the clinical areas are kept informed. Reporting monthly to Divisional Governance meetings details of complaints received, trends captured and potential lessons learned continues.

EQUALITY & DIVERSITY MONITORING An equality and diversity monitoring questionnaire (with a pre-paid envelope) is sent to all complainants with the acknowledgement letter to complete and return (completion of the questionnaire is voluntary). The table below shows the breakdown of the responses received by equality strand from people who made a complaint in quarter three (please note that the complaint may be made by someone on behalf of

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someone else who received care/treatment and may not be in respect of care/treatment received during this quarter). The reason for collecting this data is to monitor the services provided by the Trust which cover a large and diverse population and the results will hopefully help the Trust to identify any shortcomings or areas where improvements can be made. This also ensures that information relating to the complaints service is accessible to the population served by the Trust. The table below sets out the results for this quarter:

Age % Cases

0-19 9% 20-39 23% 40-59 18% 60-79 35% 80 + 14%

Unknown Age 1%

Gender

M 39% F 61% Religion/Belief

Other 1% Atheist 7% Christianity (All Denominations) 74% Islam 7% Judaism 2% Not Stated 6% Prefer Not To Say 3%

Sexual Orientation % Cases

Prefer not to say 4% Heterosexual 4% Lesbian, Gay or Bisexual 0% Not Answered

92%

Disability % Cases O Not Stated 84% A Prefer not to say 1% N No 9% Y Yes 6%

Ethnic group/Race

AA British - White 85% BB Irish - White 1% CC Any Other White 1% FF White & Asian - Mixed 0% JJ Pakistani - Asian Or Asian British 5% KK Bangladeshi - Asian Or Asian British 1% MM Black Caribbean - Black Or Black British 0% NN Black African - Black Or Black British 1%

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DD White & Black Caribbean 1% RR Chinese - Other Ethnic 0% SS Other Ethnic Category - Other Ethnic 1% ZZ Not Stated 4% LL Other Asian 1%

In previous years, two equality and diversity questions have been included on the satisfaction questionnaire sent to a random sample of complainant, specifically relating to ethnic group and disability (previously 15% of the total number of complaints received in a quarter). It was proposed that the satisfaction questionnaire results sent out in November for the preceding quarter would be reported on in this quarter’s report. However, the response rate to the questionnaire was of such a low number that analysis would not be meaningful. Accordingly, the Complaints Department is currently reviewing the content and layout of the questionnaire in order to encourage a greater response.

DEVELOPMENTS The service level agreement with Weightmans Solicitors to manage and deliver the complaints and PALS function, which commenced in Quarter 3, has already started to deliver results in terms of productivity and quality. The response rate compliance against the 90% of complaints responded to within the 25 working day target has seen an improvement in Quarter 3 to 81.82%. This compares favourably with the Quarter 1 compliance rate of 69.5% and the Quarter 2 compliance rate of 67.74%. Weightmans are providing expertise in terms of experience, resources and training. As an immediate benefit of the Service Level Agreement with Weightmans, the complaints team has been strengthened by the employment of two additional team members with complaints handling experience to enhance and compliment the department’s existing skill base and to boost resources. – One who commenced in October 2013 and another in January 2014. The Trust believes that this arrangement falls in line with the evidence suggested in the Francis Reports that patients might benefit from the complaints service provision being handled by an organisation external to the provider. It is vital to remain focused on timely and effective responses. A complaints training programme is nearing completion for both staff actively involved in complaints investigation in Divisions and the complaints department staff. As reported in the last quarter’s report, the Trust was in discussions with the CCGs to provide “real-time” complaints reporting. This report is now in place and all closed cases including complaint details, days to respond, risk rating and outcome details are now reported on a weekly basis to the CCGs. Gavin Barclay Assistant Chief Executive March 2014

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Title of Report Listening into Action

Executive Summary

This paper provides an update on the Listening into Action Programme.

Actions Requested:

The Board is asked to note the progress being made and to consider any further action that can be taken to support the programme.

Corporate objectives supported by this paper: Objective 4 - Workforce

Risks: Board level risk - Poor staff engagement / morale affecting patient care.

Public and/or Patient Involvement: Not relevant for this paper.

Resource Implications: Not relevant for this paper.

Communication: Through Trust communications channels and branded LiA publicity.


Assurance X

Contract X



HR X


IM&T X



Sustainability X

Name John Saxby

Job Title Chief Executive



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Listening into Action - Progress Report – March 2014 General Developments The LiA Trust Rock Choir started rehearsals on 20 March 201 and will be on track to perform at the Staff Awards. LiA Staff Conversations have been arranged to engage the junior doctors within the Trust. The first for FY1 doctors is to be held on 10 April 2014. The event for FY2 doctors is to be held on 29 April 2014. The Non-Executive Directors lead by Camilla Guereca has formed their own LiA Team and their Staff Conversation is planned for 13 May 2014. The team will be doing a blog as Trusts throughout the country are interested in the progress of this innovative team. LiA Navigation Day to be held in Birmingham with seven other Trusts to address the topics that were felt to be high on their collective agendas. Staff within the Trust will be attending and they have been allocated a topic as indicated in the table below.

Patient documentation JULIE OWEN

‘How could we streamline patient paperwork such as Basic Obs Chart, Fluid Balance Chart, Patient Record within and across Trusts to improve safety, free up time, and increase efficiency (Eg procurement of forms)?'

Frontline-led communication excellence TRACEY WELLS

‘Only 20% NHS staff thinks communication between management and staff is effective. How do we turn this on its head and what would make the biggest difference?’

Recruitment fit-for-purpose NICK HAYES

‘How do we: a) simplify and enrich the recruitment process, and b) optimise resource demand with supply to provide safer care in our hospitals?’ (might include identifying gaps faster, sourcing, approval process, securing staff, safe induction)'

Discharge planning and flow VANESSA KENNY

‘What would it look like if we had a system in place where every patient who should be discharged is discharged, same day?’ (might include exploring EDD, care package cancellation/suspension, ward rounds, addressing delays with TTOs, transport etc)'

Nurse-led, ward-based staffing model COLLETTE PARKER

‘If you were accountable and responsible for all care on your ward, what staffing model would you put in place?’ (roles, skills mix, numbers, support requirements, contingency)'

What a ward needs from leaders ANN POGSON

‘If you had all the support and guidance you needed on your ward, 24/7, what would that look like?’ (role of matron, doctors’ visibility, managers’ support)'

Junior doctor engagement: DR MUDIYIR GOPI

‘How do we ensure that we engage with tomorrow’s leaders today, build their confidence to deliver care, and learn from their ‘fresh pair of eyes’? (what junior docs need from their medical, clinical, managerial colleagues to lead a safe, quality service)'

Page 45 of 88

Reducing agency/bank staff costs: HOWARD CARTLEDGE

‘If we had no access to bank/agency staff, what would we do, and how do we build a less dependent model?’ (effective workforce planning, MDTs, sources of staff absences exploration: sickness, parallel vacations, training…)'

New Teams

Kath McGuiness Sister AMU at TROH. Car parking

Janet Birch Radiology, To improve the corporate image of Radiology

Glynis Jones Security Management. To start Hospital Watch on all 4 sites

Mr Mohammed Zahir Junior Doctor engagement Statistics

436

898

526 286

Staff Engagement at Conversations by Site August 2014 - February 2014

FGH

NMGH

ROH

RI

19

29 19

13

Conversations Per Site August 2012 - February 2014

FGH

NMGH

ROH

RI

Item

10

Page 46 of 88

Listening into Action Web Page Stats

2013 Aug Sept Oct Nov Dec

2014 Jan Feb

Introduction 183 545 660 220 406 343 242

Contact Details 8 27 40 10 26 19 24

Sponsor Group 4 32 45 5 15 22 25

Future Events 15 71 86 25 46 98 48

Past Events 7 28 59 6 23 46 56

Current Teams 23 75 143 16 46 69 59

Documents 17 51 83 14 37 49 40

Posters Adverts etc 15 53 76 13 32 47 44

Pass it on Event 9 37 88 6 16 61 41

Pulse checks 13 34 49 7 20 39 33

Monthly updates 26 77 151 22 53 66 54

What’s new 29 106 162 23 57 64 74

Have your say published here 17 61 100 20 36 51 31

Team Leader Piece 12 51 95 9 23 41 28

Competitions Events etc 16 120 113 27 62 51 24

Conversation notes 3 28 61

First ten teams 14 17 16

Previous teams 8 16 10

Get your notes on time video 0 11 19

The Ultrasound journey video 5 5 8

394 1368 1950 423 928 1143 937

John Saxby Chief Executive March 2014

25.2

20.1 21.7

16.5

Average Number of Staff Attending Each Conversations by

Site

ROH

FGH

NMGH

RI

Page 47 of 88

1

Title of Report The Corporate Performance Report

Executive Summary

The report provides information about the Trust’s performance against national and local indicators.

Actions requested

The Board is asked to review performance

Corporate Objectives supported by this paper: This paper supports corporate objectives – each KPI is mapped to the corporate objectives in the scorecard.

Risks: The Board Risk Register records 7 risks:

(1) Completing 90% of PDRs; (2) Delivery of 62 day cancer standards; (3) Delivery of 4 hour emergency care standard; (4) Break even; (5) Improvement in HSMR; (6) Delivery of RTT Standards; (7) HCAI

Public and/or patient involvement: The key performance indicators within this report are derived from the expectations of patients and the public.

Resource implications: Failure to achieve some national indicators could result in loss of income.

Communication: Through management structures


Assurance X

Contract X



HR X


IM&T X



Sustainability X

Name Hugh Mullen

Job Title Director of Operations

Date March 2014


Item

11

Page 48 of 88

2


The Corporate Performance Report Introduction

1. This report quantifies:

The Trust’s performance against national indicators used by regulatory agencies (identified in blue font throughout the report)

The Trust’s performance against a range of local indicators (identified in black font)

Strategic context

2. The scorecard included in this report identifies the corporate objective linked to each indicator.

Structure of the corporate performance report

3. The structure of the report is outlined below:-

Section 1 – Performance overview

A overview of underperforming key performance indicators

Section 2 – Performance scorecard

A summary of key performance indicators showing current status, historical trends, and forecasted future performance

Section 3 – The narrative to support the scorecard

A summary of issues and actions for underperforming KPIs for each section of the scorecard

Appendix 1 - Scorecard trends Appendix 2 - RAG rating thresholds applied to the KPIs

Page 49 of 88

3

Section 1 – Performance overview 4. Overall, the Trust’s performance is as follows for the most recently

available information:-

Reds include:- Hospital acquired infection, Stroke care standards, RTT standards achieved, Patient Experience question - Have you been informed of any dangers when you go home? Financial forecast outturn and performance against plan, Progress on delivery of CIP saving, Attendance rate, and PDR completion rate.

Ambers include:- Bank, agency and locum spend Section 2 – The corporate performance scorecard

RAG rating thresholds used in the scorecard 5. The Trust uses the following traffic light system

Table showing the three RAG rating thresholds:-

Performance Performance threshold names and descriptions

Green Achieved - The indicator has been met

Amber Underachieved - The indicator has been narrowly missed

Red Failed - The indicator has been missed by a significant margin

Black Unavailable - The indicator information is unavailable

6. Individual indicator thresholds are described in Appendix 2.

Item

11

Page 50 of 88

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Page 51 of 88

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Item

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Page 52 of 88

Section 3 – The narrative to support the scorecard

7. This section of the report is divided into sub-sections mirroring those used in the scorecard. Details are provided on underperforming indicators.

Clinical Quality, Effectiveness, and Safety 8. The following table summarises the underperforming indicators in this

section of the scorecard:-

Clinical Quality, Effectiveness, and Safety indicators not met Rating

Hospital acquired Infection - Achieving of MRSA & C-Diff reduction trajectories – Apr-13 to Feb-14 data

Red

Stroke Care - Number of stroke care standards achieved (best = 2) – Oct-13 to Dec-13

Red

Cancer - Number of national cancer standards being achieved (best possible = 10) – Jan-14

Red

Cancer standards indicator 9. This measure is made up from the following 10 sub-indicators:-

2 week cancer GP referral standard – (Achieved)

2 week breast symptomatic standard – (Failed)

31 day first definitive treatment standard – (Achieved)

31 day subsequent anti cancer drugs treatment – (Achieved)

31 day subsequent cancer surgery treatment – (Achieved)

62 day GP referred national standard – (Failed)

62 day GP referred local Network standard – (Failed)

62 day screening standard – (Failed)

62 day urgent upgrade local standard – (Achieved)

Cancer staging to be completed at MDT – (Achieved)

10. The 2 week breast symptomatic performance for Jan-14 was 86.3% against a target of 93%. Capacity constraints have given rise to the dip in performance. A review of clinic capacity has identified that sub-division of capacity between different patient groups has contributed to the imbalance between capacity and demand. Work is being undertaken to pool capacity by removing the sub-division and to also increase non-core capacity.

11. There are two 62 day GP referral standards for Greater Manchester providers, one is the national standard and the other is a local standard. The national standard allocates breaches of the standard for inter-provider pathways on a 50:50 basis. The local standard apportions inter-provider breaches on the basis of locally agreed timescales for passing patent care between providers. Performance for the national standard was 80.4% versus a target of 85%. Performance against the local target has not yet been published by the Network, but it is anticipated that it will be below the 85% target.

Page 53 of 88

12. 62 day performance has reduced as a result of an increase in the volume of complex clinical pathways. Additionally, patients choosing to defer treatment until after the holiday period is normally higher in January. The Deputy Medical Director and trust Cancer Clinical Lead is undertaking analysis of all breaches and working with cancer leads and management teams to take action to improve performance.

Hospital acquired infection indicator 13. This measure is made up from the following 2 sub-indicators:-

The number of hospital acquired C-Difficile cases against trajectory (achieved)

The number of hospital acquired MRSA cases against trajectory (failed)

14. The Trust reported 0 C-Difficile cases in February, achieving the

monthly trajectory of 9. The year to date performance trajectory of 68 was also achieved with 47 cases reported in the period April to January.

15. There was one MRSA case in February. Year to date there have been 6 MRSA cases. Work continues to ensure that the basics of care are priorities for all clinical staff along with the implementation of infection control policies and procedures.

Stroke Care - Number of stroke care standards achieved (best = 2) 16. This measure is made up from the following 2 sub-indicators:-

The proportion of stroke patients spending more than 90% of their hospital stay on a stroke unit – The target is 80% (achieved 95%)

The proportion of patients seen in a TIA clinic within 24 hours of referral (failed)

17. The TIA target is 60% of urgent TIA referrals to be seen in clinic with 24

hours of referral. Trust performance for Q3 was 55%. Capacity reduced in Q3 as a result of consultant S&A, and a vacant consultant post. Additionally, breaches occurred due to patient choice - in some instances the urgency of appointments had not been communicated by the referring clinician. Referral details have also been incomplete, making it difficult to contact some patients and agree appointments. The consultant S&A ended mid December, and a new consultant was appointed on 13th Jan-14. Work is ongoing across the health economy to improve the referrals process, communicating the urgency of referrals to patients, and ensuring that full and accurate patient information is provided. The TIA service is popular, with referrals 17% higher than last year. Year to date the Trust is achieving the standard and it is anticipated that the standard will be met for Q4. The indicators are available on a quarterly basis.

Item

11

Page 54 of 88

Patient Experience

18. The following table summarises the underperforming indicators in this section of the scorecard:-

Patient Experience indicators not met Rating

Number of national RTT standards achieved (best possible =4) Feb-14 Red

Have you been informed of any dangers when you go home? -Q3 Red

Number of RTT standards achieved indicator 19. The Trust failed 1 of the 4 national RTT standards:-

Admitted standard (failed)

Diagnostic waits within 6 weeks (achieved)

Non-Admitted standard (achieved)

Incomplete standard (achieved) 20. The Trust did not achieve the 90% Admitted standard for February –

Performance was 81.6%. Specialty level action plans to improve performance are being implemented for the main pressure specialties of T&O, ENT, Oral Surgery and General Surgery.

Have you been informed of any dangers when you go home?

21. The internal improvement target for this patient experience question has not been achieved.

22. A new Nursing and Midwifery Board (N&M Board) will start from April 2014. Supervisory ward sisters were appointed in January 2014, and performance metrics have been agreed in the format of "Ward at a Glance". These metrics form the basis of Divisional and Trust-level reporting. Board reports will reference the National Quality Board’s Safe Staffing ‘How To Guide’ for Nursing, Midwifery and care staff and triangulate near real-time information relating to Quality, Safety and Experience indicators including: Patient Safety (prevalence and incidence of falls; CAUTI, VTE and Pressure Ulcers); Staff sickness, Planned staffing against ratios; Actual staffing against ratios; Patient Experience – via Techno Huddle questionnaires and other experience measures; Staff Experience – via Techno Huddle questionnaires; Ward cleanliness; and Absence/vacancy information. Actions to improve areas of poor performance and patient satisfaction will be developed from the N&M Board.

Page 55 of 88

Resources Management

23. The following table summarises the underperforming indicators in this section of the scorecard (the Risk Rating is updated quarterly):-

Resources Management indicators not met Rating

Financial forecast outturn and performance against plan – Apr-13 to Feb-14 data

Red

Progress on delivery of QIPP savings – Apr-13 to Feb-14 data Red

24. The Trust deficit for February is £2.9m compared to a planned deficit of

£0.4m. The Trust is forecasting breakeven for the year. The Trust has identified CIPs with an annual value of £20.5m and identified a further non recurrent value of £8.6m towards the target of £31.9m.

Workforce

25. The following table summarises the underperforming indicators in this section of the scorecard:-

Workforce indicators not met Rating

Attendance rate - Feb-14 Red

PDR completion rate –Jan-13 to –Dec-13 data Red

Bank, agency and locum spend Apr-13 – Feb-14 Amber

Attendance rate indicator 26. In month sickness absence has fallen to 5.06%. Weekly reports are

being issued to Divisions showing manager compliance with data inputting and Return to work compliance. The Workforce Transformation committee has met with the Division of Surgery and the Women's and Childrens Division as part of its programme of seeking assurance from Divisions that they are dealing with the high sickness absence levels. The next two divisions to be invited are Medicine & Community services along with Elective Access

PDR completion rate indicator 27. The performance for quarter 3 was 72%. There has been a reduction in

headcount of 41 staff this month which has resulted in a further drop in the compliance with PDR’s. Completion of PDRs has been raised with the Divisional HR teams to support managers to undertake the PDR’s in their areas which are due. To achieve a 90% would require a further 1,300 PDR’s to be carried out in the next 3 weeks.

Bank, agency and locum spend indicator 28. The year to date performance was 8.13% against a target of 8%. The

increase in the monthly rate from January onwards was due to the implementation of the Winter Plan. Total expenditure on temporary staffing has fallen by £132,000. The contracted WTE has also fallen by 17 and the Paybill has fallen by £537,000.

Item

11

Page 56 of 88

Facilities

29. All of the indicators in the Facilities section were achieved. Summary

30. This report has quantified:

The Trust’s performance against national indicators used by regulatory bodies (identified in blue font throughout the report)

The Trust’s performance against a range of local indicators (identified in black font)

31. Where performance was below target, a summary of actions being

taken has been given. 32. The appendices of the report show:

The performance trends for every indicator

The performance scorecard RAG ratings thresholds and details of the sources of the thresholds

Recommendations 33. The Board is asked to review the Trust’s performance Hugh Mullen Director of Operations March 2014

Page 57 of 88

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een in

form

ed o

f any

dangers

when y

ou g

o

hom

e?

3. R

ES

OU

RC

ES

MA

NA

GE

ME

NT

Fin

ancia

l fore

cast outturn

& p

erf

orm

ance a

gain

st pla

n

Fin

ancia

l perf

orm

ance s

core

for

Tru

sts

Pro

gre

ss o

n d

eliv

ery

of C

IP s

avi

ngs

Ne

w m

ea

sure

sta

rte

d fro

m A

pr-

13

AP

PE

ND

IX 1

Item

11

Page 58 of 88

Ap

r-1

2M

ay-1

2J

un

-12

Ju

l-1

2A

ug

-12

Se

p-1

2O

ct-

12

No

v-1

2D

ec

-12

Ja

n-1

3Fe

b-1

3M

ar-

13

Ap

r-1

3M

ay-1

3J

un

-13

Ju

l-1

3A

ug

-13

Se

p-1

3O

ct-

13

No

v-1

3D

ec

-13

Ja

n-1

4Fe

b-1

4M

ar-

14

PE

RF

OR

MA

NC

E T

RE

ND

S (2012-1

3)

PE

RF

OR

MA

NC

E I

ND

ICA

TO

RQ

3Q

4Q

1Q

2

PE

RF

OR

MA

NC

E T

RE

ND

S (2013-1

4)

Q1

Q2

Q3

Q4

4. W

OR

KF

OR

CE

Attendance R

ate

Turn

ove

r R

ate

(ro

lling y

ear)

PD

R c

om

ple

tion R

ate

(Y

ear

To D

ate

)

Mandato

ry tra

inin

g 1

2 m

onth

rolli

ng c

om

plia

nce for

patie

nt handle

rs (

best =

3 s

tandard

s' t

raje

cto

ries m

et)

Bank,

Agency,

and L

ocum

spend

Bully

ing a

nd h

ara

ssm

ent cases

% o

f sta

ff r

ecru

ited w

ithin

sta

ndard

tim

es

5. F

AC

ILIT

IES

Tru

st te

lephone r

esponse tim

es -

ext

ern

al

Month

ly c

leanin

g s

core

s

Patie

nt satis

factio

n w

ith food

Esta

tes H

elp

desk

calls

attended w

ithin

allo

cate

d

timefr

am

e

Clin

ical w

aste

(ki

logra

ms p

er

patie

nt)

Energ

y consum

ptio

n p

er

heate

d v

olu

me -

GJ

/ 100m

3

Page 59 of 88

SC

OR

EC

AR

D R

AG

RA

TIN

G P

ER

FO

RM

AN

CE

TH

RE

SH

OL

DS

So

urc

e o

f T

hre

sh

old

s

PE

RF

OR

MA

NC

E T

HR

ES

HO

LD

S

On

targ

et (A

ch

ievin

g)

PE

RF

OR

MA

NC

E I

ND

ICA

TO

RW

ors

e th

an

targ

et (F

ailin

g)

Belo

w targ

et (U

nd

era

ch

ievin

g)

1. C

LIN

ICA

L Q

UA

LIT

Y, E

FF

EC

TIV

EN

ES

S, &

SA

FE

TY

Mort

alit

y In

dex

(All

Adm

issio

ns 2

011 C

HK

S M

odel)

>=

95%

of th

e 2

011-1

2 Q

3 o

utt

urn

>95%

of th

e 2

011-1

2 Q

3 o

utt

urn

and <

=100%

of outt

urn

>100%

of th

e 2

011-1

2 Q

3 o

utt

urn

Locally

agre

ed

NP

SA

'Neve

r' E

vents

0 in m

onth

n/a

>0 in m

onth

Locally

agre

ed

Hospita

l acquired In

fectio

n -

Achie

ving o

f M

RS

A &

C-D

iff r

eductio

n tra

jecto

ries (

Best =

2)

<=

cum

ula

tive

pro

file for

both

sta

ndard

s<

=cum

ula

tive

pro

file for

both

sta

ndard

s O

R c

urr

ent

month

>2

Std

devi

ations

>cum

ula

tive

pro

file for

either

sta

ndard

OR

curr

ent

month

>3

Std

Devi

ations

NH

S P

erform

ance F

ram

ew

ork

thre

shold

s u

sed for

traje

cto

ry &

local w

ithin

month

peak indic

ato

r added

4 h

our

em

erg

ency

access s

tandard

(P

rovi

der)

>=

95%

cum

ula

tive

quart

er

<95%

And <

=94%

cum

ula

tive

quart

er

<94%

cum

ula

tive

quart

er

NH

S P

erform

ance F

ram

ew

ork

thre

shold

s u

sed

Str

oke

Care

- N

um

ber

of str

oke

care

sta

ndard

s

achie

ved (

best =

2)

TIA

>=

60%

cum

ula

tive

YTD

And t

ime o

n s

troke u

nit >

=80%

TIA

<60%

and >

=50%

OR

Tim

e o

n s

troke u

nit <

80%

and

>=

60%

- B

oth

Cum

ula

tive

YTD

TIA

<50%

OR

Tim

e o

n s

troke u

nit <

60%

Contr

act

targ

et

used

Cancer

- N

um

ber

of natio

nal c

ancer

sta

ndard

s b

ein

g

achie

ved (

best possib

le =

10)

All

10 c

ancer

sta

ndard

s m

et

cum

ula

tive

quart

er

Any o

f th

e n

ational cancer

sta

ndard

s n

ot

met

during q

uart

er

Any n

ational cancer

sta

ndard

s faile

d for

the q

uart

er

NH

S P

erform

ance F

ram

ew

ork

thre

shold

s u

sed &

Contr

act

targ

ets

used

2. P

AT

IEN

T E

XP

ER

IEN

CE

Num

ber

of natio

nal R

TT

sta

ndard

s b

ein

g a

chie

ved

(best possib

le =

4)

All

of th

e 4

bott

om

lin

e s

tandard

s a

chie

ved

n/a

Any o

f th

e s

tandard

s faile

dN

HS

Perform

ance F

ram

ew

ork

thre

shold

s

Dela

yed tra

nsfe

rs o

f care

<=

3.5

% c

um

ula

tive

>3.5

% a

nd <

=5%

cum

ula

tive

>5%

cum

ula

tive

NH

S P

erform

ance F

ram

ew

ork

thre

shold

s

Mix

ed S

ex

Accom

modatio

n r

ate

per

1,0

00 F

CE

s=

0%

>0%

AN

D <

=0.5

%>

0.5

%N

HS

Perform

ance F

ram

ew

ork

thre

shold

s

Self-

cert

ificatio

n a

gain

st com

plia

nce w

ith r

equirem

ents

regard

ing a

ccess to h

ealth

care

for

people

with

a

learn

ing d

isabili

ty

Com

plia

nt

with s

tandard

sn/a

Not

com

plia

nt

with s

tandard

sN

ationally

specifi

ed

How

would

you r

ate

the o

vera

ll sta

ndard

of care

receiv

ed?

An im

pro

ved r

ating >

= 0

.5 p

er

quart

er

achie

ved a

bove

baselin

e o

f 81.0

An im

pro

ved r

ating >

=0.2

5 A

ND

<0.5

per

quart

er

above

baselin

e o

f 81.0

An im

pro

ved r

ating <

0.2

5 p

er

quart

er

above

baselin

e o

f 81.0

Locally

agre

ed

Have

you b

een in

form

ed o

f any

dangers

when y

ou g

o

hom

e?

An im

pro

ved r

ating >

= 0

.5 p

er

quart

er

achie

ved a

bove

baselin

e o

f 81.0

An im

pro

ved r

ating >

=0.2

5 A

ND

<0.5

per

quart

er

above

baselin

e o

f 81.0

An im

pro

ved r

ating <

0.2

5 p

er

quart

er

above

baselin

e o

f 81.0

Locally

agre

ed

3. R

ES

OU

RC

ES

MA

NA

GE

ME

NT

Fin

ancia

l fore

cast outturn

& p

erf

orm

ance a

gain

st pla

nachie

ving o

r exceedin

g p

lan for

year

to d

ate

and p

lanned

outt

urn

not

achie

ving p

lan for

year

to d

ate

or

pla

nned o

utt

urn

by less

than 1

% o

f tu

rnove

r

not

achie

ving p

lan for

year

to d

ate

or

pla

nned o

utt

urn

by

more

than 1

% o

f tu

rnove

r

NH

S P

erform

ance F

ram

ew

ork

thre

shold

s u

sed

Fin

ancia

l perf

orm

ance s

core

for

Tru

sts

>=

32

1N

HS

Perform

ance F

ram

ew

ork

thre

shold

s u

sed

Pro

gre

ss o

n d

eliv

ery

of Q

IPP

savi

ngs

90%

of Q

IPP

targ

et

identifie

d a

s d

eliv

era

ble

and o

n t

arg

et

to

deliv

er

betw

een 6

0%

and 9

0%

of Q

IPP

targ

et

identifie

d a

s

deliv

era

ble

and o

n t

arg

et

to d

eliv

er

Less t

han 6

0%

of Q

IPP

targ

et

identifie

d a

s d

eliv

era

ble

and

on t

arg

et

to d

eliv

er

Local th

reshold

s

AP

PE

ND

IX 2

Item

11

Page 60 of 88

So

urc

e o

f T

hre

sh

old

s

PE

RF

OR

MA

NC

E T

HR

ES

HO

LD

S

On

targ

et (A

ch

ievin

g)

PE

RF

OR

MA

NC

E I

ND

ICA

TO

RW

ors

e th

an

targ

et (F

ailin

g)

Belo

w targ

et (U

nd

era

ch

ievin

g)

4. W

OR

KF

OR

CE

Attendance R

ate

>=

Month

ly p

lan

< M

onth

ly p

lan A

ND

>=

-0.5

% o

f pla

n<

-0.5

% o

f M

onth

pla

nLocally

agre

ed

Turn

ove

r R

ate

(ro

lling y

ear)

>=

7%

>7%

AN

D <

=6.0

%<

6.0

%Locally

agre

ed

PD

R c

om

ple

tion R

ate

90%

(ro

lling y

ear)

>=

-5%

of tr

aje

cto

ry<

-5%

of tr

aje

cto

ry A

ND

>=

-15%

of tr

aje

cto

ry<

-15%

of tr

aje

cto

ryLocally

agre

ed

Mandato

ry tra

inin

g c

om

plia

nce for

patie

nt handle

rs

(best=

3)

Mandato

ry t

rain

ing o

n t

raje

cto

ry for

all

3 t

ypes

<=

1 m

andato

ry t

rain

ing t

ypes r

ate

d a

s a

mber

2 o

r m

ore

mandato

ry t

rain

ing t

ypes r

ate

d a

s r

ed

Locally

agre

ed

Bank,

Agency,

and L

ocum

spend

<=

8%

cum

ula

tive

>8%

AN

D <

=10%

cum

ula

tive

>10%

cum

ula

tive

Locally

agre

ed

Bully

ing a

nd h

ara

ssm

ent cases r

educed b

y 10%

<=

last

year's

cum

ula

tive

actu

al

n/a

> last

year's

cum

ula

tive

actu

al

Locally

agre

ed

% o

f sta

ff r

ecru

ited w

ithin

sta

ndard

tim

es

>=

70%

com

plia

nce w

ith s

tandard

s<

70%

AN

D >

=50%

com

plia

nce w

ith s

tandard

s<

50%

com

plia

nce w

ith s

tandard

sLocally

agre

ed

5. F

AC

ILIT

IES

Tru

st te

lephone r

esponse tim

es -

ext

ern

al

>=

70%

within

20 s

econds c

um

ula

tive

>=

65%

and <

70%

within

20 s

ecs c

um

ula

tive

<65%

within

20 s

econds c

um

ula

tive

Locally

agre

ed

Month

ly c

leanin

g s

core

s>

=88.5

% c

um

ula

tive

<88.5

% A

ND

>=

80%

cum

ula

tive

<80%

cum

ula

tive

Locally

agre

ed

Patie

nt satis

factio

n w

ith food

>=

75%

score

d 3

fro

m 5

cum

ula

tive

<75%

AN

D >

=65%

score

d 3

fro

m 5

cum

ula

tive

<65%

score

d 3

fro

m 5

cum

ula

tive

Locally

agre

ed

Esta

tes H

elp

Desk

calls

attended w

ithin

allo

cate

d

timefr

am

e>

=80%

cum

ula

tive

<80%

and >

=70%

cum

ula

tive

<70%

cum

ula

tive

Locally

agre

ed

Clin

ical w

aste

(ki

logra

ms p

er

patie

nt)

<=

1.2

Kg /

Patient

cum

ula

tive

>1.2

Kg p

er

patient

AN

D <

=1.3

KG

per

patient

cum

ula

tive

>1.3

Kg /

Patient

cum

ula

tive

Locally

agre

ed

Energ

y consum

ptio

n p

er

heate

d v

olu

me (

2.5

%

reductio

n in

2011-1

2)

- G

J / 100m

3<

74.3

2>

74.3

2 A

ND

<=

75

>75

Locally

agre

ed

Page 61 of 88

Page 1 of 9

Title of Report The CIP plan for 2014/15 and 2015/16.

Executive Summary

This paper describes the board approved approach for the 2014/15 CIP process and seeks approval of 2014/15 CIP schemes identified to date.

Actions Requested:

The Board are asked to note the report and formally approve the 2014/15 and 2015/16 CIP programme. .

Corporate objectives supported by this paper: 5 Financial Sustainability

Risks: Failure to deliver savings and Financial Sustainability

Public and/or Patient Involvement: None

Resource Implications: Outlined through this paper

Communication: Through normal Trust channels


Assurance X

Contract X



HR X


IM&T X



Sustainability X

Name Brian Steven

Job Title Deputy Chief Executive and Director of Finance


Email [email protected] Ite

m 1

2

Page 62 of 88

Page 2 of 9

Agenda Item: 1 Introduction This paper describes at a high level, the 2013/14 CIP programme and process, in terms of what was financially achieved and how effective the governance process was. 2 Progress to date against the 2013/14 CIP programme At the end of month 11, the 2013/14 CIP programme is currently forecasting an actual achievement of £20.5m against a target of £29m. This gap of £8.5m is partly covered by non-recurrent measures in 2013/14. There is a net gap of £4.3m after the full year effect impact of the 2013/14 schemes, which is being carried forward to 2014/15.

3. Summary

The Trust is required by the TDA to submit a Trust Board approved, quality impact assessed (QIA) 2 year Cost Improvement Plan (CIP) by the 4th April 2014. The Trust has developed the 2 year plan in accordance with TDA guidance and this report summarises the content of and process which will be used to develop and deliver the plan.

Page 63 of 88

Page 3 of 9

Introduction

The 2014/15 and 2015/16 annual Plan submission to the TDA takes place on the 4th April with a requirement that all CIPs identified in the plan have been through a full QIA approval process. Full approval will be authorised at the 11th April Transformation Steering Group (TSG) meeting. Assurance exists in that the schemes within the plan have been approved at a high level review by the Medical Director’s Office and the Chief Nurse.

It should be noted that schemes continue to be identified and developed for approval at the monthly TSG meetings and priority is given for approval purposes, to those schemes with earlier delivery dates to ensure continued progress towards delivery of the CIP programme.

The TSG and the Transformation Board have meetings organised throughout 2014/15 which will be used to manage delivery of the CIP programme and address on a scheme by scheme basis, any issues which arise.

Development of the proposed 2014/15 and 2015/16 CIP governance process

The CIP Governance process has been developed and reviewed by the Executive Management Team and on a 1 to 1 basis with each individual executive.

The 2014/15 and 2015/16 CIP programme has been developed using the new process via an interim arrangement between the new and the old.

The 2014/15 and 2015/16 CIP governance process

To balance the necessity of ensuring that:

(a) 100% of all schemes are QIA approved,

(b) We recognise the need to do this quickly to maximise savings,

(c) That we need to involve the correct mix of both clinical and operational skilled personnel,

We have moved to a single process, described below, which combines a review of the operational delivery with a review of the quality impact for each scheme at the same time.

This process is designed to substantially streamline the current process and make it work more effectively with improved communications.

Item

12

Page 64 of 88

Page 4 of 9

Governance

The Transformation Board

The Transformation Board ensures that the CIP programme delivers high quality and safe services in conjunction with the five year Transformation plan.

The Transformation Board meets two weeks after the TSG on a monthly basis and is chaired by the Chief Executive who is also the Senior Responsible Officer SRO.

The restricted membership of the Transformation Board ensures that strategic operational issues escalated from the TSG are addressed. Members include: the Chief Executive (SRO and Chair), the Director of Operations, the Director of HR and OD, the Director of Finance, the Director of Transformation & Strategy, Executive Sponsors, The Chief Nurse, the Medical Director, the Director of Estates and Facilities, the Head of Strategy and business development, the Head of the PMO, the transformation Programme Manager, Executive Sponsors,

The Transformation Steering Group TSG

The TSG is established to ensure the operational delivery of the five year plan. The group develops, discusses, initiates and oversees all activities associated with the delivery of the Cost Improvement Programme (Transformation) and the associated five year plan.

It should be noted that the TSG approves the QIA for each scheme prior to commencement of the scheme.

The meeting is jointly chaired by the Director of Operations and the Chief Nurse. The meeting ensures that both Clinical and Operational issues are addressed, with the first meeting being held on the 11th April 2014 and monthly thereafter.

The TSG prioritises approval of schemes with earlier delivery dates during the initial meetings, whilst more complex or longer delivery timescale projects will be reviewed and approved at subsequent meetings, thus ensuring continued delivery on a consistent basis of the CIP programme. The TSG will regularly review existing and new schemes in addition to managing opportunities being developed.

The wider membership of the TSG ensures that all operational issues are capable of being addressed. Membership includes: The Director of Operations, the Chief Nurse, the Associate Medical Director, the Deputy Director of Finance, the Associate Director of Nursing, Divisional Directors, the Director of Turnaround, the Director of Estates, the Head of Governance, Clinical Leads, Project Leads, Non-Executive Directors and representatives from the CCG as required.

Page 65 of 88

Page 5 of 9

Trust Board

Quality

Committee (TBC)

Transformation Programme

Board

(Monthly Meeting)

Transformation

Programme Steering

Group

(Monthly Meeting)

Finance Committee

Divisional Director

Medicine &

Community

(weekly review)

Divisional Director

Diagnostics &

support services

(weekly review)

Divisional Director

Women & Children

(weekly review)

Divisional Director

Surgery

(weekly review)

Brian Steven

Business

development &

Innovation

(weekly review)

Roger Pickering

Workforce

(weekly review)

Brian Steven

Corporate

(weekly review)

Flow

Theatres

Outpatients

Elective Access

Workforce

Flow

Theatres

Outpatients

Elective Access

Workforce

Flow

Theatres

Outpatients

Elective Access

Workforce

Flow

Theatres

Outpatients

Elective Access

Workforce

Nursing Workforce

Mandie Sunderland

John Wilkes

Estates

Facilities &

Procurement

(weekly review)

Medical Workforce

Rob Davies

Hu

gh

Mu

llen

Jo

hn

Wilk

es

Medicines

Management

(weekly review)

Documentation

The documentation path in the 2014/15 and 2015/16 CIP programme is as follows:

1. An Idea is generated and developed into a Project Overview Document POD. The POD contains a high level description of the idea, the aims, objectives, milestones, impacts and financial information for the scheme. The POD is reviewed by the Transformation Steering Group where approval is given for the idea to be developed into a Project Initiation Document.

2. The Project Initiation Document PID is a detailed signed document which identifies all the stakeholders, quality impacts, risks, financials, benefits, issues, milestones and other information which can be monitored to assist in the delivery of the scheme.

3. Reporting Suite, the information from the PID generates a database of information which is interrogated for reporting purposes to assist the management of the CIP programme.

QIA

The Quality Impact Assessment QIA is embedded into the PID document so that the Transformation Steering Group members can have an overview of and approve the scheme whilst having an overview of the entire scheme impacts, whether they are financial, quality, risks etc.

The terms of reference for the TSG prevent approval of PODS and PIDS where the meeting Quorum of clinical presence is not met.

Item

12

Page 66 of 88

Page 6 of 9

Star Chamber approval of the 2014/15 and 2015/16 plan

The Commissioners (CCG) in exercising their obligation of ensuring that there is no risk of harm to the population review the trusts CIP QIA approved 2014/15 and 2015/16 CIP programme. The review process meeting is called a Star Chamber and will be held on the 14th April 2014.

Page 67 of 88

Page 7 of 9

The schemes approved at POD level for approval at the TSG are:

Division Title

Corporate Review senior nursing staffing structures

Corporate Safeguarding

Corporate Infection control

Corporate Governance and clinical audit

Corporate Patient information

Corporate Legal, complaints and PALS -outsourcing to Weightmans

Corporate Corporate admin (fundraising, FOI, committee admin) Merge with other regulatory, investigative administrative support?

Corporate Communications - rebanding saving in 2013/14

Corporate Interpreters - more use of telephone

Diagnostics Bed Management Review

Medicine

Ward reconfigurations

ROH - Move wards C1 and A2 into ward G1

NMGH - PIU Closure. J6 Cardiology beds move to FGH - J5 PIU moves to J6.

FGH - Move wards 18 and 21 into ward 14.

MedicineCardiology service Review - Cardiology ward reconfiguration NMGH/FGH - Wards 1 & 2 at FGH, CCU and ward J6 NMGH move to

ward 9.

Medicine Medical Agency Spend 2104-15 v2

Medicine ED Coding 2104-15 POD

Medicine Management Challenge 2104-15 POD

Medicine Pacemaker & Other Consumables 2104-15 POD

Medicine Pharmacy Drugs expenditure 2104-15 POD v2

Medicine Long Shift 2104-15 POD

SurgeryDevelopment of a Surgical Unit - FGH F28 Review of five 23 hour beds ward 14 at FGH (a) Review of remaining 10 elective beds at

FGH - inc in FGH STRATEGIC (a)

Surgery ROH D Block DSU Decommissioning F 34

Surgery Drugs savings F21/14

Surgery Community Dental SLA review F3

Surgery Private theatre development F4/5

Surgery Trauma and orthopaedic middle grade doctor review F27

Surgery Strategic Reconfiguration of breast surgery F21/48

Surgery Ophthalmology - merger of middle grade on call rota F25

Surgery Urology workforce plan and a review of middle grade doctors F0Surgery Endoscopy nursing review F47

Surgery Trauma and orthopaedic - Review of arthroplasty advanced practitioner role F46

Surgery Reconfiguration of pre-operative Assessment F44

Surgery Urology - Review of l ithotrypsy F48

Surgery Cell salvage - Theatres

Surgery Urology - increase market share

Surgery TWOC clinic - reduction

Surgery Orthopaedic pathway review

W&C Paediatric Nurse Led Discharge

W&C Post Menopausal Bleeding

W&C Private Fertil ity

W&C Oncology - End of l ife pathway for Gynae

W&C Enhanced Recovery Elective gynaecology

W&C Neonatal Social Care

W&C Nursing 1:28 midwifery:birth ratio and skil l mix review

W&C Gynaecology - One Stop Shop

W&C Paeds HDU

Workforce Sickness Absence

Workforce Agency Switch

Workforce Advance Nurse Practitioner (ANP)

Workforce Assistant Practitioner (AP)

Workforce Clinical Excellence Award

Workforce DRS Rostering

Workforce Centralised E-Rostering and Bank Management

Workforce HR Advisory Service

Workforce Intensity Payment

Workforce MUFTI

Workforce Payroll and Pensions Review

Workforce Chaplains Premia

Workforce Recruitment modernisation

Workforce Salary Sacrifice

Workforce Shift Standardisation

Workforce Financial Services Modernisation Item

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Page 8 of 9

Conclusion

In conclusion, the Board are asked to note the report and formally approve the 2014/15 and 2015/16 CIP programme, whilst recognising the work already done and still to be done.

The Trust Board are committed to ensuring that a robust QIA process is followed and that NO CIPS will be progressed which put patient safety or other quality of the service at risk and this philosophy is embedded throughout the Trust process.

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Page 9 of 9

Appendix 1 Opportunities Identified which are being worked up to close the unidentified gaps for 2014/15 and 2015/16.

Division Opportunities being developed

Corporate IT usage to reduce mail / post

Corporate IT helpdesk - options review

Corporate Electronic Patient Records

Corporate Management team review

Corporate Shuttle Bus to reduce inter site expenses

Corporate Payroll review

Corporate HR recruitment / advisory review

Corporate Financial services and procurement review

Corporate Staff bank review

Corporate Chaplaincy review

Corporate Review senior nursing staffing structures

Corporate Safeguarding review

Corporate Infection control review

Corporate Governance and clinical audit

Corporate Patient information review

Corporate Legal, complaints and PALS

Corporate Corporate admin (fundraising, FOI, committee admin)

Corporate Communications review

Corporate Work based learning

Corporate CPD review

Corporate Practice education

Corporate Libraries

Corporate L&OD

Corporate Training administration

Corporate Training & development

Corporate Interpreters

Corporate Management accounts, costing/income and contracting

Corporate Telephony review

Corporate Membership fees

Corporate HQ administration staff

Corporate Flexi time

Corporate On call

Corporate Shared services

Diagnostics Clinical Trials -recharge for relevant costs

Diagnostics Pain Nursing Income Opportunities

Diagnostics Additional Nurse led clinics

Diagnostics Pain Nursing Skil l Mix

Diagnostics Radiology Maintenance Contracts - outsource

Diagnostics Review of Immunology test referrals to CMFT

Diagnostics Pharmacy expenditure review to identify usage and trends

Diagnostics Pathology income opportunities

Diagnostics McKessons Workforce Innovation - Pharmacy

Diagnostics Nurse prescribing

Diagnostics Supportive drugs for chemotherapy

Diagnostics Tender for Paediatric TPN

Diagnostics Dinoprostone products

Diagnostics Steroid inhaler pilot

Diagnostics Patients Own Drugs

Diagnostics Waste reduction

Diagnostics Other supplier discounts

Estates Accommodation Income (space util isation

Estates Linen service review

Estates Rates rebates reviews

Estates Reconfigure Health Info Bureau opening times

Estates Occupational health secondment

Estates Training Functions review

Estates Retail premises review

Estates Nursery review

Estates EBME Contract

Estates Trustwide Estates rationalisation project

Estates Hotel Services contract and service review

Estates Power supply brokerage

Estates Review of Post Room

Estates Review of telecommunications / Operator service

Estates Review patients letters / other non clinical non electronic communications

Medicine Hospital at night

Medicine Develop GP practice to control A&E flow

Medicine

Review Local Authority services relating to patient discharges into the community. Also provide 24/7 care package to discharged patients. 24/7 day care packages transitional

support

Medicine Patient Discharge Lounge, volunteers pilot. Voluntary Agency to support discharges

Medicine More use of IT enablers, ie sharing data between GPs, Acute and Community

Medicine Tele Health - Mobile IMT working

Medicine Navigators: front end and back end, ANP get nurses through at NMGH

Medicine Therapists to follow stroke patients out

Medicine Virtual Ward, Virtual beds in patient homes, to reduce readmissions. Increased capacity by expansion of community MDT team. Step down into Community Beds

Medicine

Integrated Care Centre for Older people - Ambulatory care alternative to admission for older people. Create a nurse led elderley care (medically optimised patients) at Fairfield

General Hospital.

Medicine Medical rota review 3 sites, Junior and middle grade doctors in collaboration with nursing / midwifery strategy

Medicine Sickness and absence policy with review Junior Doctors to reduce agency costs and improve quality

Medicine Reinstate ENP / ANP service at FGH urgent care. ANP 24/7 or 16/7, urgent care discharge to Community

Reserves & TW Holiday Purchase

Reserves & TW Rota Flexibil ity, is Summer Winter demand management

Surgery Breast Surgery reconfiguration (B)

Surgery Breast Surgery SPN productivity review (b)

Surgery Endoscopy nursing review

Surgery Equipment hire / loan inc ortho loan kits

Surgery Review util isation of G2 ward at ROH

Surgery Review DSU activity at FGH - post endoscopy move (a)

Surgery Review of FGH short stay facil ities - STRATEGIC (a)

Surgery Review of short stay non elective beds at ROH - T4 - l inked to reconfig of Gen Surg

Surgery Endoscopy productivity review

Surgery Review of Band 6 and 7 theatre staffing

Surgery Review of NMGH staffing - economies of scale from all day l ists

Surgery Reduction in IP WLI costs through increased productivity in theatres ' €

Surgery Amalgamation of Breast one stop clinics (b)

Surgery MRSA Screening

Surgery Urology Middlegrade review

W&Cs Paediatric Summer / Winter beds

W&Cs Medical agency - DRS System

W&Cs Post Natal Bed blockages

W&Cs Sub-fertil ity NHS

W&Cs Paediatric review potential for short-stay beds

W&Cs Gynae ERP Roll out

Workforce On call /EDP review number of on call rotas Item

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1

Title of Report Data Quality Assurance Framework

Executive Summary

The purpose of this paper is to provide assurance to the Board that information governance is appropriately implemented and governed at the Trust. Data Quality is also a standing item in the Quality Accounts, following an audit a recommendation was made to present the Board with an annual report on Data Quality at the Trust.

Actions requested

The Board is asked to note the contents of the report and to be assured that there is an appropriate Data Quality Assurance Framework in place at the Trust.

Corporate Objectives supported by this paper: Data quality has not been established as a corporate objective however everybody has a responsibility to ensure that the quality of data in any format is complete and accurate, is presented and processed in a timely manner and in accordance with policy. Data quality therefore supports all the actions and activities of the Trust.

Risks: Where responsibilities for data quality have not been established and embedded into the Trust there is an increased risk that information produced may not be accurate. This could not only result in lack of confidence in corporate reporting but more importantly if information is not accurate this could lead to issues with quality of care and patient safety.

Public and/or patient involvement: N/A

Resource implications: N/A

Communication: None


Assurance Y

Contract Y

Equality and Diversity Y

Financial / Efficiency Y

HR Y

Information Governance Assurance Y

IM&T Y

Local Delivery Plan / Trust Objectives Y

National policy / legislation Y

Sustainability Y

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2

Name Brian Steven

Job Title Deputy Chief Executive / Director of Finance and IM&T

Date March 2014


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3

DATA QUALITY ASSURANCE FRAMEWORK 1 Introduction

The purpose of this paper is to give assurance to the Board around the data quality and in particular assurance regarding the Quality Accounts in line with our assurance framework. This report has been produced to outline what data quality processes are currently in place within the Trust and how assurance will be gained over the data items submitted to the Quality Accounts for 2014.

2 Executive Summary

Trusts are finding increasingly that the quality of the services they offer are viewed very much on the data entered in to their IT systems and submitted externally to the Department of Health and other agencies. Trusts are viewed to be either good, bad or indifferent based on the data harvested and submitted and therefore if as an organisation we do not have good quality data the Trust could attract a reputation based not on the quality of care provided but on the quality of data entered into its systems. The data gleaned is used for many purposes and by others such as the Department of Health, Care Quality Commission, Commissioners, Finance teams for income and planning, Dr Foster for monitoring mortality and benchmarking and therefore small differences in errors can paint a very different picture of the Trust and it is of great importance that the Trust endeavours to have high quality data.

3 Governance

There is a dedicated Data Quality Department at the Trust. The Department forms part of the IM&T Department and concentrates on the electronic systems in use at the Trust. The Data Quality Department work to an annual programme of audits agreed by the Information Quality Assurance Group (IQAG) and are undertaken by a dedicated Auditor. The Information Quality Assurance Group is the governing group for data quality at the Trust and is represented at a senior level with members from IM&T, Divisional representatives (clinical and non-clinical), Finance and Commissioning. The Group meets monthly and is chaired by the Director of IM&T. There is a structured approach to the work undertaken within the Data Quality Department and in addition there is a programme of audits, a cohort of which is focussed on key areas requiring improvement. Some of these have been established to fulfil the requirements of the Information Governance Toolkit, the Trust Annual Plan and others to satisfy publications

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such as the Quality Accounts. The results of these are presented monthly to the Information Quality Assurance Group.

There is an approved Data Quality Strategy and Data Quality Policy in place; these are reviewed as a minimum on an annual basis or sooner as required. The adherence to the policies are regularly reviewed as part of the assurance framework and the findings are presented and recorded via the Information Quality Assurance Group and are reported to the Audit Committee via the Risk Management Committee.

4 Validation and Operational Processes 4.1 Data Quality

The quality of the data in the Trust is affected by the number of legacy IT systems with limited integration which therefore impact on the frequency of duplicates and other data entry errors. However the IM&T strategy is to move away from legacy systems to fewer best of breed industry standard systems that will facilitate better data quality going forward. The Trust’s key systems range from the Patient Administration System (PAS) to clinical systems such as Symphony (A&E), PACS and the e-prescribing solution Medchart. 4.1.1 External Use of Trust Information The Trust submits key datasets from a number of these systems, PAS for inpatients, outpatients and referrals and Symphony for A&E activity to the Secondary Uses Service on a weekly basis. The Secondary Uses Service (SUS) is a single, comprehensive repository for healthcare data in England which enables a range of reporting and analyses to support the NHS in the delivery of healthcare services. This information is used nationally for many purposes including Department of Health analysis and reporting, extracts for Commissioners to support contract monitoring and Dr Foster Intelligence for benchmarking analysis. As the data submitted centrally to SUS is of high importance the Trust’s data quality audit programme is focussed on improving specific data items across the key datasets. Exception reports are in place to identify missing or incorrect data with daily reviews and updates to PAS undertaken by the Data Quality team. Key themes are fed back to relevant system users to raise awareness and prevent reoccurrence. 4.1.2 Data Quality Audit & Key Themes Part of the Data Quality Auditor role is to maintain and further develop the data quality validation framework. This includes regular reviews of information submissions to ensure agreed processes continue to be followed and also includes sample checks on the accuracy of the reports. The results of these audits are presented as a report and a suite of Key

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5

Performance Indicators to the Information Quality Assurance Group along with any areas and action plans for improvement. In addition to monitoring key data items in our systems there has been a specific focus on improving mortality through ensuring the underlying data is timely, complete and accurate. For example, the consultant attribution field was highlighted in an audit and targeted for improvement. Incorrect consultant attribution impacts on quality of care, mortality reporting, consultant appraisal and Dr Foster Intelligence benchmarking reports. Following in-depth audits and awareness sessions with ward staff, there has been a gradual improvement and reduced errors in the recording of consultant attribution. In addition, a further area identified for improvement was the recording of a patient’s diagnosis in either the first or second episode of the patient record. The recording of the diagnosis in the first two episodes of care has a major impact on the reporting of expected patient outcomes and depth of coding. Following a programme of improvement and engagement with awareness sessions for clinicians, there has been a significant increase in the recording of diagnosis in the first two episodes of care and as a consequence the Trust has demonstrated an increase in depth of coding. Review of data processes is undertaken as part of the audits which are then revised where appropriate and agreed actions are added to the validation action plan which forms part of the framework.

4.1.3 Ownership Over the last 12 months the Data Quality Manager and Data Quality Auditor have been working with the Divisions to transfer data quality tasks to appropriate operational staff. This is followed up with audit and reviews to ensure that this is being done correctly. This is a regular standing item on the Information Quality Assurance Group agenda where the findings of the audits and reviews are presented alongside action plans of what is required to improve the quality of the data entered into the Trust’s key systems at source.

4.2 Information

The Trust has a detailed and well established IM&T Strategy that is supported, regularly reviewed and routinely monitored by the Trust’s governance structure. This document outlines the future plans for consolidating existing key systems and an intent to replace legacy and limited departmental systems. An element of the strategy is to change the way information is provided to the organisation which in the future will be developed on a self-service model. Routine reports to support data quality improvement will be available directly to managers so that they can validate that the data entered by their

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staff is complete and accurate at a patient level shortly after the data has been entered into the systems. In order to deliver the strategy and provide information that is fit for purpose in real time, a project to redesign the Trust’s Data Warehouse commenced in early 2013 and is due to complete by 31st March 2014. The benefits to the organisation is that a number of data streams from key Trust systems will feed into the new Data Warehouse creating a robust data layer that will support improved reporting and analysis based on a ‘single version of the truth’. The new data layer is a data repository that houses key datasets including the following:

Admitted Patient Care

Outpatients

A&E

Theatres

Critical Care

Waiting Lists

Referrals

Referral To Treatment (RTT)

Radiology – Under development

Order Communications – Under development

Pharmacy – Under development This will support increased information provision and independent data validation. Each dataset will have a suite of validation reports that will be provided on a self-service basis for service managers and Information leads to access and audit data and results.

The Trust is intent on making ongoing improvements in the approach it adopts for ensuring that the information provided by the Trust is valid, complete and timely. Formal sign-off and approval processes are in place for the statutory/mandatory reporting requirements that are processed via the Information Department with Executive Director or Divisional Director approval required before they can be submitted or released. In many cases part of the approval process is the prior checking of the information which is undertaken by senior information staff before they are passed through for authorisation. In addition to the sign off and authorisation process, there is an annual review and audit of the Quality Accounts that is undertaken by the Corporate Information Manager.

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5 Quality Accounts Assurance Framework

In addition to monitoring data quality in line with the Trust’s assurance framework, particular attention is paid to the validation of our Quality Accounts as recommended by our auditors. The following key data items are to be included in the annual Quality Accounts for 2013/14:

o Summary Hospital-level Mortality Indicator (SHMI); o Clostridium Difficile (CDT); o PROMS; o Readmissions; o Friends and Family Test (Staff & Patients); o Patient Survey; and o VenousThromboembolism (VTE)

The background, detail and assurance methods for these items are scrutinised at the Quality Strategy Committee.

6 Conclusion

There are a number of processes in place to ensure the data items within external submissions and returns are as accurate as possible with verification at key stages. These are reviewed as guidance and services change or through audit recommendations. In order to address the issues relating to manual data capture across the organisation and the transcribing of this data into a variety of reports, new tools and technologies are currently being explored by the IM&T Department to enable capture at source with links directly into the Data Warehouse. This will support verification and sign off centrally. The Board is asked to note the contents of the report and to be assured that there is an appropriate Data Quality Assurance Framework in place at the Trust. The Board should be satisfied that it can sign off the statement of Directors responsibilities in relation to data quality. .

Brian Steven Deputy Chief Executive / Director of Finance and IM&T March 2014

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C:\Users\244991-Admin\AppData\Local\Temp\29142677-c7c5-44e4-98c0-4e8c370cb6e0.doc

Title of Report Approval of charitable funds expenditure

Executive Summary

Within Pennine Acute Hospitals Charitable Fund there are funds held and administered on behalf of Pennine Care. A request has been made, authorised by Judith Crosby Pennine Care’s Director of Finance, to spend £55,600 of their charitable monies on training. As the funding is held within Pennine Acute’s umbrella registration the authorisation of that request must comply with Pennine Acute’s governance arrangements.

Actions requested

The Board is asked to approve the charitable fund expenditure.

Corporate Objectives supported by this paper: None relevant for this paper.

Risks: None relevant for this paper.

Public and/or patient involvement: None relevant for this paper.

Resource implications: None relevant for this paper.

Communication: None relevant for this paper.


Assurance X

Contract X



HR X


IM&T X



Sustainability X

Name Brian Steven

Job Title Deputy Chief Executive and Director of Finance

Date March 2014


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Approval Request for £55,600 of Charitable Funds

Introduction 1. Within Pennine Acute Hospitals Charitable Fund there are funds held

and administered on behalf of Pennine Care. A request has been made, authorised by Judith Crosby Pennine Care’s Director of Finance, to spend £55,600 of their charitable monies on training. As the funding is held within Pennine Acute’s umbrella registration the authorisation of that request must comply with our governance arrangements.

Strategic context 2. Not applicable. Proposed Training Funded by Charitable Funds 3. A twelve month programme of self-management shared decision making training is planned to educate all integrated adult service staff within Heywood, Middleton and Rochdale, to support the Integrated Health & Social Care agenda and promote patient self-management in the community. Conclusion 4. In accordance with the SFIs the Board is requested to approve the expenditure of Pennine Care’s charitable monies as it exceeds £50,000. Recommendations 5. The Board is asked to approve this expenditure. Brian Steven Deputy Chief Executive and Director of Finance March 2014

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Title of Report Clinical Governance & Quality Committee Minutes – 21st February 2014

Executive Summary

The minutes from the Clinical Governance and Quality Committee in January 2014 reflect discussions on the following agenda items:

Mortality

Monitoring Scorecard

Monitoring Report

VTE

Friends and Family Test Action Plan

Cancer Action Plan Monthly Summary Report

MRSA Bloodstream Infection - Post Infection Review Toolkit

Quality Accounts 2013/14 Briefing Paper Divisional Governance Minutes

Actions Requested:

The Board is asked to note the content of the minutes

Corporate objectives supported by this paper: All Corporate Objectives are supported by the work of the CG&QC

Risks: Any risks identified at the meeting are referred to the relevant manager for possible inclusion on the relevant part of the risk register.

Public and/or Patient Involvement: Not relevant for this paper

Resource Implications: Not relevant for this paper

Communication: The CG&QC communicates its work through the Trust Board, Divisional Governance Committees and the Health and Safety structure.


Assurance √

Contract √

Equality and Diversity √

Financial / Efficiency √

HR √

Information Governance Assurance √

IM&T √

Local Delivery Plan / Trust Objectives √

National policy / legislation √

Sustainability √

Name Mr J Saxby

Job Title Chief Executive



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CG&QC/HC /Jen /February 2014 1

THE PENNINE ACUTE HOSPITALS NHS TRUST Clinical Governance & Quality Committee

21st February 2014 PRESENT: Mr J Saxby Chief Executive (Chair) Mrs A Jones Head of Nursing, Surgery Mrs A Jones Head of Nursing attending on behalf of Chief

Nurse, Mandie Sunderland Mr M Carmichael Deputy Divisional Director - Medicine Ms C Cullen Consultant, Orthopaedic Surgeon Dr R Davies Medical Director Ms P Jones Chief Pharmacist Mrs P Jones Chief Pharmacist attending on behalf of Chris

Sleight, Divisional Director for Diagnostic Division Mrs C Mayer Non Executive Director Mrs J Nolan Governance (Minutes) Mrs C Trinick Deputy Divisional Director for Women & Children /

Head of Midwifery Dr S Smith Head of Safeguard Dr C Rice Consultant in Obstetrics and Gynaecology Mr M Mullen Executive Director of Operations Mr R Pickering Executive Director of HR & OD IN ATTENDANCE: Mr D Solanki Business Manager, Governance Mrs N Rimmington Lead Cancer Manager APOLOGIES: Mrs D Ashton Divisional Director of Surgery Dr I Cartmill Consultant Microbiologist Dr P Cook Consultant, Palliative Care Mrs H Curtis Governance Director Mrs C Guereca Non Executive Director Ms J Moore Divisional Director, Women & Children Dr R Prudham Deputy Medical Director Mrs D Pullen Head of Corporate Development Mr C Sleight Divisional Director, Diagnostics & Cl Support Ms M Sunderland Chief Nurse (Chair) Mr S Taylor Divisional Director of Medicine & Community

Services DECLARATION OF INTERESTS None to note.

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020/14 MINUTE OF CLINICAL GOVERNANCE COMMITTEE HELD ON 17th January 2014 The minute of the CG&QC meeting dated 17th January 2014 was received and noted.

021/14 MATTERS ARISING FROM THE MINUTE 166/13 Red Incidents: Mrs Curtis reported that the review of incidents has now been completed and that a summary report will be submitted to the Committee and an Executive summary to the Trust Board. Ms Sunderland requested a copy of the report. Deferred to March meeting for update Action: HC 167/13 VTE: Agenda item. Work is still needed in Divisions to increase the pick up of non elective admitted patients. 154/13 PADAT – RECORDING OF PATIENT’S WEIGHT: Mrs Curtis advised that she has written formally to Dr Whiting, Chief Clinical Officer North Manchester CCG and is awaiting a reply regarding the recording of patient weight on referral letters. She will update the Committee when a response has been received. Updated deferred to the March meeting. Action: HC 010/13 ACCIDENT & INCIDENT REPORTING POLICY AND PROCEDURE: In relation to Duty of Candour Mrs Trinick raised the issue regarding how information is captured from the family especially if there has been a patient death and to look at how it could be done and how the processes can be formalised. To discuss at future meeting. 174/13 INDUCTION & MANDATORY TRAINING POLICY (for ratification): Mr Saxby reported that the Committee was in agreement that non-compliance of mandatory training and/or refusal by individual could result in a disciplinary. This is the joint responsibility of both member of staff and Line Manager. The policy to be amended and then ratified by the Committee the policy will be formally sanctioned. The Committee agreed this. Mr Pickering agreed to seek clarity regarding mandatory training alerts for staff, however it was noted this is the responsibility of all staff to ensure they are up to date on their mandatory training. Action: RP 127/13 LEGAL SERVICES ANNUAL REPORT: It was noted that Mr Steven, Deputy Chief Executive and Director of Finance, had undertaken work around the Trust’s

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clinical negligence claims and our NHSLA premium. The NHSLA’s premium would in future be calculated on the Trust’s claims history. This tended to suggest that an increase in premium payments was likely. More work needed be done within the Divisions to reduce incidents. 188/13 MONITORING REPORT: REGULATION 28: At a previous meeting Mr Sleight had suggested looking at benchmarking Trust staff numbers against available national guidance on adequate staffing levels for AHPs. He agreed to feedback to a subsequent meeting

Action: CS 216/13 PATIENT SAFETY & MORTALITY REDUCTION COMMITTEE: In relation to a reported incident about a patient with a fractured Neck of Femur, Mrs Curtis said that a High Level Review Panel will be set up to review this incident.The Root Cause Analysis (RCA) and action plan will BE fedback back to the Committee..

Action: HC 022/14 PAHT MONITORING SCORECARD The PAHT Monitoring Scorecard was presented to the Committee. Six MRSA bacteraemias reported to the Committee and discussed and noted was the open red incidents. In relation to the Staff Survey no further updates have been received. Mrs Jones stated a paper regarding the MRSA is being presented at the next Trust Board and a Root Cause Analysis (RCA) review is taking place. 023/14 MORTALITY The Mortality Report at 31st October was noted by the Committee. at the October 2013 position. The report provides an update on the progress with the mortality reduction project and offers a series of key indicators (KPIs) to assist with monitoring the progress of this work. Dr Davies reported on the ongoing work which is continuing relating to weekend mortality and the improvement which is continuing on week days. Discussion took place regarding death alerts. It was noted that this is being reviewed at the Patient Safety & Mortality Reduction Committee. Dr Davies stated the Trust does not have an individual consultant outlier. Mrs Jones observed that the report’s main focus is mortality and not morbidity. She would discuss this with Mrs Curtis. Mrs Jones agreed to cascade information to the Orthopaedic surgeons. Action: HC/RP

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024/14 VTE The VTE CQUIN for October 2012 to December 2013 was reported at 95.20% Continual monitoring is still required as compliance has slipped with more emphasis needed on maternity and non-elective admissions. Divisional Directors agreed to review the data and highlight any issues.. It was noted that a Task and Finish Group are currently looking at non-elective admissions and non-elective patients with a one day length of stay. Mrs Trinick reported that work is being undertaken within the Women & Children’s Division. Low reporting within Maternity could possibly be due to how women are assessed at booking. Mrs Trinick agreed to check the technicalities of admissions and to clarify the definition of VTE for Maternity. Mrs Jones reported that Mr Crumbleholme is currently undertaking work on looking at non-elective stay of patients of less than one day.

Action: CT 025/14 MONITORING REPORT The Monitoring Report was received and noted by the Committee. Regulation 28 (Rule 43) information was discussed and responses to the Coroner regarding the Regulation 28’s were attached for information purposes. Confirmation of the appropriate actions taken by the Trust in relation CQC Maternity Outlier Alert for Puerperal Sepsis was noted by the Committee. This has now been closed by the CQC and is to be monitored via the Committee with an update to be presented at the April meeting. Action: CT 026/14 PATIENT EXPERIENCE INCLUDING CQUINs : FRIENDS AND FAMILY TEST ACTION PLAN The Friends and Family Test Action Plan was circulated to the Committee for information purposes and was noted. Mrs Jones reported on the work Mrs Parker, Acting Lead Nurse for Patient Experience, has been undertaking to improve compliance across the Trust. This is being reported to Nurse Managers and Matrons on a weekly basis.The information is also distributed to all wards for information and so that patients can be informed. Mr Mullen suggested inviting Mrs Parker to the next Committee to present an overview of work being undertaken by site, A&E and at ward level. In relation to the comment boxes available across the Trust for the Friends and Family Test Cards it was noted that these are not always identifiable. Mrs Trinick reported that from a maternity perspective they have received a great response and exceeded their target however

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there is a possible weak link within the Community service and this information is to be fed back to Mrs Parker. Action: CP 027/14 CLINICAL EFFECTIVENESS INCLUDING CQUINS: CANCER ACTION PLAN MONTHLY SUMMARY REPORT Mrs Rimmington presented the Cancer Action Plan. The report highlights the developments and progression within Cancer Services focussing on patient experience and user involvement and included a cancer performance summary. In relation to the National Cancer Patient Experience Survey the Trust was in the highest 20% for patients feeling they had confidence and trust in ward nurses and also information provision on cancer research.For most results the Trust was in mid range, however, it was in the lowest 20% with regards to information around diagnostic tests, surgery and in two discharge components; namely, taking part in cancer research and provision of information regarding the side effects of medication. The Trust needs to focus on these areas and will be monitored by the MDT Business Meetings and the Cancer Peer Review Process. The Committee discussed in detail what hospital survival data are available and in what form the data are available. Mrs Rimmington agreed to feed back to the PACC for clarity and request further information. Mr Saxby asked for further information regarding the Trust’s position in relation to a Lymphodema Service and asked for an update at the next meeting.

Action: JK POLICIES, STRATEGIES AND REPORTS 028/14 MRSA BLOODSTREAM INFECTION – POST INFECTION REVIEW TOOLKIT Mrs Jones presented The MRSA Bloodstream Infection - Post Infection Review Toolkit to the Committee and the contents were noted. It was reported that copies of the patient care alert have been circulated to all wards and department as part of the Root Cause Analysis (RCA) action plan. There was a discussion about patient diagnosis and how action plans were to be implemented. Mrs Rice suggested colour code alerts should m be used within patient’s records for Doctors to use. Mrs Jones agreed to feed this back to the IPCC. Action: AJ 029/14 IMPROVED MONITORING OF WHO SURGICAL SAFETY The Improved Monitoring of WHO Surgical Safety paper was circulated to the Committee and its contents were noted.

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Mr Mullen suggested that Ms Brown who has done a significant piece of work with Mrs Statom should be invited to the next Committee meeting to report on the work undertaken. It was noted that there is a discrepancy in the reported figures and Mr Saxby suggested this issue to be raised at the Patient Safety & Mortality Committee to seek clarification. Action: HM 030/14 QUALITY ACCOUNTS 2013/2014 BRIEFING PAPER Mr Solanki presented an overview of the Quality Accounts 2013/14 briefing paper in the absence of Mrs Curtis. The paper provided an update on the procedure for completion and sought views of the Committee on the priorities for inclusion within the Quality Accounts. Consultation has taken place and feedback is awaited from the CCGs. Any relevant additional comments received are to be factored into the report by the 27th February 2014 deadline. The Committee highlighted the need for the inclusion of the WHO safety check issues as the Trust should be addressing significant issues raised in the recent Never Event . Work is ongoing to ensure the deadline for the completion of the Quality Accounts Paper is met. . Any comments should be submitted directly to Mrs Curtis. FOR SCRUTINY AND FOLLOW UP 031/14 PENNINE ACUTE DRUGS & THERAPEUTIC COMMITTEE (PADAT) The minute of the Pennine Acute Drugs & Therapeutic Committee (PADAT) meeting held on 3rd January 2014 was received and noted. No significant issues raised. 032/14 PATIENT SAFETY & MORTALITY REDUCTION COMMITTEE The minute of the Patient Safety & Mortality Reduction Committee meeting held on the 31st January 2014 was received and noted. Mrs Cullen reported on work being undertaken to look at mortality cases focusing on four areas of improvement. The aim was to increase the number of cases reviewed and to monitor this through the Patient Safety & Mortality Reduction Committee. . Action: CC

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033/14 CRITICAL CARE STEERING GROUP MINUTES No minutes submitted 034/14 CLINICAL AUDIT & EFFECTIVENESS COMMITTEE MINUTES The minute of the Clinical Audit & Effectiveness Committee meeting held on the 11December 2013 was received and noted. No significant issues raised. 035/14 ORGAN DONATION COMMITTEE MINUTES The minute of the Organ Donation Committee meeting dated 23rd January 2014 was received and noted. It was noted the Committee is evolving as the meeting takes place. Highlighted was the proposal to be mindful of cultural issues. Mr Saxby suggested contact be made with Collette Parker, Acting Lead Nurse for Patient Experience for as there had been work carried out earlier to increase the number of organ donors from within minority communities. 036/14 INFECTION PREVENTION CONTROL COMMITTEE MINUTES The minute of the Infection Prevention Control Committee meeting dated 6th September 2013 was received and noted. No significant issues raised. 037/14 RESEARCH & DEVELOPMENT COMMITTEE MINUTES The minute of the Research & Development Committee meeting dated 12th September 2013 was received and noted. Dr Davies agreed to liaise with Mr Woby regarding the frequency of meetings taking place. Action: RD 038/14 EQUALITY & DIVERSITY COMMITTEE MINUTES The minute of the Equality & Diversity Committee meeting dated 6th September 2013 was received and noted. No significant issues raised. 039/14 EDUCATION GOVERNANCE COMMITTEE MINUTES No meeting has taken place since July 2013 therefore no minutes submitted.

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040/14 DIVISION OF DIAGNOSTICS AND CLINICAL SUPPORT GOVERNANCE MINUTES The minute of the Division of Diagnostic and Clinical Support Governance Divisional Governance Committee meeting dated 6th January 2014 was received and noted. The M&M template was completed and presented. Mrs Jones reported that in relation to the assurance of staffing activity levels from groups other than medical and nursing there is no national guidance, therefore local benchmarking will be undertaken. Concern was raised about the lack of consultant attendance at the Diagnostic and Clinical Support Governance Committee.Mr Mullen agreed to discuss this matter with Mr Sleight.

Action: HM/CS 041/14 DIVISION OF SURGERY GOVERNANCE MINUTES The minute of the Division of Surgery Clinical Governance & Quality Committee meeting dated 8th January 2013 was received and noted together with a completed M&M template. 042/14 DIVISION OF MEDICINE & COMMUNITY SERVICES GOVERNANCE MINUTES The minute of the Division of Medicine Clinical Governance & Quality Committee meeting dated 16th January 2014 was received and noted. A Completed M&M template was received and noted. 043/14 DIVISION OF WOMEN & CHILDREN GOVERNANCE MINUTES The minute of the Women & Children’s Governance Committee meeting dated 8th January 2014 was received and noted. M&M template was completed. No issues raised. 044/14 ANY OTHER BUSINESS None to note. 045/14 DATE, TIME AND PLACE OF NEXT MEETING The next meeting of the Clinical Governance & Quality Committee will be held on Friday, 21st March 2014 in the Monsall Room, North Manchester General Hospital at 12.30 pm

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