Action Plan - NHS Quality and its Improvement

NUH Action Plan of November 2013 after three 2013 Reports on
NHS Quality and its Improvement 1 & the CQC inspection
May 2014 Status Report
Stephen Fowlie, Medical Director
Jenny Leggott, Director of Nursing
These actions are the Trust’s comprehensive ongoing response to the three reports listed above. Those actions in bold are those considered by
the Board to be of the highest priority. When the Board has agreed an action is complete it is removed from the table and archived.
The Board will receive quarterly Status Reports
The action plan was developed by the NUH Board through an iterative review process. This included review of the plan with staff side. 2
In February 2014 the action plan was supplemented by actions identified from the CQC Report (after their inspection of November 2013). These
include two compliance actions (at the top of the table)
Sections:
1. CQC Compliance Actions
2. Priority Quality Actions
3. CQC Advisories
4. Quality Actions
5. CQC Observations (service / department specific)
1
1.‘The Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry’. (‘Francis Report II’), 2. ‘Review into the quality of care and treatment provided by 14 hospital trusts in England. NHS England, July
2013 (‘Keogh Review’) and 3 ‘A promise to learn – a commitment to act: Improving the safety of patients in England’. NHS England, August 2013 (‘Berwick Report’)
2
Staff side earlier provided the Trust with an extensive commentary on the Francis Report (II). This commentary informed this Action Plan.
Quality Action Plan : Status at 23 May 2014
Page 1 of 23
NUH ACTION PLAN AFTER THREE 2013 REPORTS ON NHS QUALITY AND ITS IMPROVEMENT
NOVEMBER 2013
Actions in bold are priority actions
Action
no. (as in ACTION
version 1)
Accountable
Executive(s) &
Officer
Progress Update
Date for
(substantive)
Completion
STATUS
CQC Compliance Actions
CQC
compliance
1/2
CQC
compliance
2/2
Ensure preventative
maintenance is carried out on
clinical equipment
Outcome: Expedition of
essential preventative
maintenance for clinical
equipment based on agreed
priorities and timescales
Ensure all staff receive
mandatory training
Outcome: Trust staff are up-todate with their mandatory
training
Quality Action Plan : Status at 23 May 2014
Chief Operating
Officer
[Head of Clinical
Engineering]
Director of
Workforce
[&Directorate
Management
Teams]
Improved stratification of preventative
maintenance priorities to ensure clinical
equipment is appropriately serviced in
accordance with manufacturers’ instructions
and NUH 31 March 2014
New processes to ensure maintenance
schedules achieved
April 2015
[Revised to Oct
14 in May 14]
On track
Recovery plan ongoing (notably by MT film)
April 2014
Off track will
be recovered
by the end of
June 14
Page 2 of 23
Priority Quality Actions
6
8
13
Strengthen policy, guidance
and training (incl Induction) to
ensure patient safety incidents
or concerns are reported by all
staff, and that reporters
receive timely feedback.
Performance-manage response
to incidents / concerns via
performance
management fora. Report to
the Board (at least annually)
compliance with the
agreed standards for response.
Make policy statements clear,
and ensure mechanisms to
communicate
expectations and monitor
compliance are equally clear
so that any breach of the rules
prompt consistent, described
and proportionate
consequences.
Quality Action Plan : Status at 23 May 2014
Director or
Nursing,
Medical Director
Draft Incident Reporting and Management
Policy and Serious Incident Policy and
Procedures on circulation/ consultation
currently.
March 2014
Completed
Chief Operating
Officer
Medical Director
Monthly Directorate Performance meetings
currently under review
April 2014
Off track
Not yet
embedded.
Completion
date reset to
Aug 14
Chief Executive
Trust Secretary
The latest trust (mandatory) template for
writing policies and procedures requires
authors to be clear and precise on the
relevant key policy requirements of the
subject in question.
With more than 300 such documents,
compliance is a matter for a combination of
line managers, topic trust-wide lead officers
and, if necessary, Human Resources under
formal employment processes.
Completed
template and
mechanisms
Ongoing
Page 3 of 23
15
20
Executive directors and clinical
directors should undertake
regular (at least quarterly)
visits to one or more clinical
service areas to assess
compliance with
“fundamental standards of
safety and quality”. Each such
visit should prompt a brief
report describing the degree of
confidence that the director
has achieved from what they
observed / heard / experienced.
These reports should be made
available to the Board, and
archived.
Convene a task and finish
group to make
recommendations to the Board
for actions to better capture the
intelligence on safety and
quality from trainees.
Chief Executive
Planned monthly executive director visits in
place. Further work required on written
feedback of observations to board
March 2014
Completed
Twice yearly 15 Step Challenge- reports to
QUAC
Medical Director
Director of
Nursing
Trainee Doctor’s Patient Safety Board
established
Completed
Report came to Patient Safety Improvement
Group in January 2014 re trainees’ feedback
on safety.
Monthly meeting with the university to
discuss nursing and midwifery student
feedback.
21
Convene a task and finish
Medical Director
group to make
recommendations to the Board
for actions to better capture the
intelligence on safety and
quality from GPs and
commissioning organisations.
Quality Action Plan : Status at 23 May 2014
Paper being prepared to describe current
routes into NUH & processes to capture, gap
analysis, and proposed integrated approach
to reporting / learning.
March 2014
Off track
Delayed to
mid-2014;
on-going
discussion at
Contract
Clinical
Board
Page 4 of 23
23.1
27
31.1
cqc
Strengthen the narrative
perspective of information in
the Portfolio of Quality, by
refreshing how the Board (and
other committees) receives and
responds to patient stories.
Consider whether additional
physical inspection of our
clinical areas is required, and
whether current reports on the
physical condition of our
estate, and the Action Plans to
address shortcomings, are
sufficient. The Board should
receive a Report on NUH
readiness for this aspect of our
FT application. This should
make specific reference to the
condition of estate NUH
acquired when NUH took over
some community services in
2010/11.
Director of
Nursing
Currently, patient stories are presented
monthly to the Trust Board (reflecting a
concern or complaint). There are plans to
extend to PPI; social media stories and a
programme is in development.
March 2104
Completed
Director of
Estates &
Facilities
As part of the Market Testing works for EFM
the Trust is about to employ WT Partnership
(Surveying practice) to undertake a reinspection and reporting of data in relation to
Physical Condition (Facet 1) based on the
principles noted to the NHS Estate code
documents ‘Land and property appraisal
(2007)’ guidance and ‘A risk-based
methodology for establishing and managing
backlog (2004)’. The survey will be
completed, generally, to Level 2 (as Table 1
of the ‘Land and property appraisal’
guidance) at Block level.
NUH did not acquire any estate as part of the
transfer of community services in 2010/11.
The premises are managed and maintained
by Property Co (Prop Co.) [NUH services
occupy buildings as a tenant].
Twice yearly report to TB on AUKUH/ nurse
staffing.
Acuity will be reviewed twice daily in each
adult ward in March.
Nursing establishment and daily staffing
displayed in each ward of the trust.
Children’s Hospital is testing a staffing acuity
tool in March 2014 with a view to
implementation in July 2014.
Dec 2013
Off track
started
February
2014 (related
to decision by
EFM Market
Testing
Board).
Anticipated
completion
June 2014
March 2014
Completed
Build on the current use of
Director of
AUKUH ‘benchmarks’ and
Nursing
methodology to determine (and
make available to the Board
and to ward visitors) nurse
establishments for each ward
(or clinical area).
Quality Action Plan : Status at 23 May 2014
Page 5 of 23
31.2
33.3
Seek assurance from internal
or external audit that the
Quality Impact Assessment
methodology used by NUH for
all CIPs or proposed service
changes does effectively
consider the impact on
changes in staff numbers or
skill mix.
Improve the accessibility of the
information about how to
register a comment or
complaint.
Chief Executive
Internal Audit Review- FEP &
Transformation- PMO Governance
Arrangements- QIA process reviewedSignificant Assurance
Completed
To consider further inclusion within the
Internal Audit plan for 14/15
Director of
Nursing
Medical Director
Associate Dir
Comms
Include information about how to share
comments and make complaints in all core
Trust material for patients, including
- visitors’ code
- bedside folder
- patient/visitor leaflets
- LCD TV screens
- NUH website
- Social media
Posters describing how to make a complaint
on every inpatient and children’s ward
PALS development programme is underway,
and part of this will be to improve access to
PALS, in addition to raising the profile of
PALS within the Trust. Current training to
HCAs; ward sisters and deputy ward sisters
further promotes the process
Quality Action Plan : Status at 23 May 2014
February 2014
Completed
Completed
Aug 2013
Completed
Page 6 of 23
33.4
33.5
35.1
Review the threshold at which
locally-resolved complaints or
comments prompt
‘formal’ investigation and a
written response and
publication (or confidential
notification to regulator),
whether or not the informant
has indicated a desire to have
such investigation.
Incorporate the
recommendations of the
Patients Association peer
review into
complaints at the Mid
Staffordshire NHS Foundation
Trust into our complaints
processes.
Further emphasise in our
Values and Behaviours training
the duty of employees to be
honest, open, and truthful in all
their interactions with (1)
patients, (2) the public (see
35.2) and (3) their employer
(NUH) (see 35.3). Restate for all
employees that failure to
discharge these duties will
attract proportionate
consequences [& see earlier
Actions]. If this includes
additional criminal
consequences NUH will inform
employees.
Quality Action Plan : Status at 23 May 2014
Director of
Nursing
All complaints are formally investigated
currently, however a recent internal audit has
recommended a change in our process (we
are awaiting final report)
March 2014
Completed
Director of
Nursing
Action plan is in place with actions for
improvement taken from peer review and
also the Patients’ Association survey.
Is in the CQUIN programme for 2014/15
Mar 2015
On track –
ongoing
Chief Executive
Director of
Workforce
Medical Director
Director of
Nursing
An e-learning programme has been
developed and these requirements are
explicitly included in the new mandatory
training film. Both will be live from April 2014
April 2014
Completed
Page 7 of 23
35.2
35.3
38.2
38.3
Ensure that there is full and
timely disclosure (and support)
to the patient (or relatives)
where death or serious harm
has been (or may have been)
caused by an NUH action or
omission.
Ensure that registered
professional employees are
made aware of their duty to
report to the employer (here
NUH) as soon as is reasonably
practicable a belief or
suspicion that treatment or
care provided to a patient by or
on behalf of NUH has caused
death or serious injury to a
patient.
Strengthen the pre-eminence
of appropriate values,
attitudes and behaviours in
our recruitment processes (for
all staff).
Revise our Post Registration
Education and Practice (PREP)
guidance and processes
against the detail in Francis
recommendation 194, notably
the requirement for patient
feedback, and formal signingoff (a new step in the IPR
process).
Quality Action Plan : Status at 23 May 2014
Medical Director
Director of
Nursing
All harms which are investigated as serious
and high level incidents involve discussion
with patient (and / or relative) and their
questions are included within the
investigation ToR.
Timescales meet external SI requirements.
Ongoing
Medical Director
Director of
Nursing
See 35.1 above
April 2014
Extended to
include Duty
of Candour
and to
August 14
Director of
Workforce
Appointing Officer training under review to
strengthen behavioural-based interviewing.
Sep 2014
On track
Director of
Nursing
1)Revalidation consultation with Directorate
representation 3rd March 2014 responding to
NMC consultation,
2) Consultation with ward sisters 12 February
2014.
3) Establish a task group April/May for
planning options N&M NUH, based on NMC
decision
August 2014
On track
Page 8 of 23
39.3
Strengthen leadership
development for Band 5 and
student nurses.
Director of
Nursing
Consultation on band 5 development
priorities N&M Time out days.
April 2014
On track
Summary report time out days 13/14 to
NMSG
May 2014
On track
Task Group led by DNS planning band 5
Staff Nurse clinical leadership development
June 2014
On track
Launched invitation for applications to
University of Nottingham new Advantage
Award module (developed by Nursing
Development NUH nursing leadership
module). Students apply for the advantage
award in addition to their required modules.
February 2014
Completed
Successful student nurses commence May
2014
May 2014
Completed
Student Task Group bimonthly meetings.
Forum for student engagement and
development of leadership skills
Quality Action Plan : Status at 23 May 2014
Page 9 of 23
48
49
55
3
Test the extent to which
current NUH practices meet the
Francis requirement that
“Information about an older
patient’s condition, progress
and care and discharge plans
should be available and shared
with that patient and, where
appropriate, those close to
them, who must be included in
the therapeutic partnership to
which all patients, are entitled.”
Consider strengthening current
Policies, (eg Transfer of Care)
procedures (eg ‘Caring Round
the Clock’) and practices.
Review our Discharge Policy
and provide a detailed
response to Francis
recommendation 239 3.
Director of
Nursing
Medical Director
Continue to develop
information on each aspect of
the quality our services, to
disaggregate the data to the
most appropriate ‘provider unit
(eg ward or consultant), to
achieve as real-time data as is
practicable, and to make such
information as widely available
as is appropriate and
commensurate with the NHS
constitution.
Medical Director
Evaluation of the Phase 1 of ‘Caring Around
the Clock’ has been undertaken, and report
shared with QuAC.
Phase 2 to strengthening and embedding
implementation is being piloted and roll-out
programme developed. .
March 2014
Ongoing –
further work
required
April 2014, now
July 2014
Off track
(initial
completion
date Dec
2013)
March 2104
Off track
Considerable
progress, but
ongoing
‘Transfer of Care’ is subject of a pan-trust
‘Better for You’ project.
Chief Operating
Officer
Draft Discharge and Transfer Policy under
consultation (F Branch).
DGQ 18 March 2014 – out of hours
discharge section will require discussion and
approval re meeting Francis
recommendation.
Continuing work to standardise content and
presentation in quality reports.
Francis recommendation 239: “The care offered by a hospital should not end merely because the patient has surrendered a bed - it should never be acceptable for patients
to be discharged in the middle of the night, still less so any time without absolute assurance that a patient in need of care will receive it on arrival at the planned destination.”
Quality Action Plan : Status at 23 May 2014
Page 10 of 23
CQC Advisories
CQC advisory
2/10
Review the staffing requirements
for the paediatric wards and
departments.
Clinical Lead for
Children’s
Services
Appoint a children’s hospital site matron
Completed
Daily review of staffing requirements based
on ward patient numbers & dependency
Completed
Create Children’s Hospital Recruitment Team
to maximise successful recruitment &
retention
Ongoing
Approval of SIP to increase nurse staffing
establishment on NCH wards to RCN 2013
levels
CQC advisory
3/10
Ensure children are given
opportunities to give feedback on
their experiences of care
Clinical Lead for
Children’s
Services
Implement a nurse dependency tool for NCH
Pilot PANDA
Revise establishments
Revise NCH PPI plan for 2014 to include
feedback from Children & Young People as
well as Parents & Carers
April 2014
On track
Completed
Oct 2014
April 2014
On track
Completed
All ward areas using & displaying feedback
Appointment of dedicated Clinical Lead to
oversee all out-patient services at NUH
Oct 2014
April 14
On track
Completed
Implement change programme after service
review
To Oct 14
On track
Collect & report F&F and NPS information for
NCH wards
CQC advisory
4/10
Ensure there is management
oversight of the whole out-patient
service and processes to ensure
shared learning and consistent
practice
Quality Action Plan : Status at 23 May 2014
Chief Operating
Officer & Clinical
Director,
DCS
Page 11 of 23
CQC advisory
5/10
CQC advisory
7/10
CQC advisory
9/10
CQC advisory
10/10
Review the length of time patients
are waiting for out-patient
appointments and ensure people
are given information about how
long they will have to wait
Address the privacy and dignity
issues that patients may face
when the A&E Department has
reached capacity (and patients
have to be cared for in corridor
areas)
Review the facilities for visitors to
have access to a hot meal after
2pm, particularly for those visitors
who are further away from home
and need to stay for long periods
at the hospital to be with their
relative
Review the availability of
information so that it is accessible
for people who find it difficult to
read, and for those whose first
language is not English
As above
As above
Specialty
Management
Team
Interim action – Majors capacity increased by
three cubicles
As above
On track
Completed
Submit business case for expansion
Nov 2014
On track
Director of E&F
Signage to be installed to direct visitors to
facilities that provide hot meals/snacks until
the evening
QMC - B Floor, 7/7 8.00am-11.30pm
City - Coffee City 5, 7/7 8.00am-11.30pm
April 14
Completed
Associate
Director of
Comms & Head
of Equality &
Diversity
Improve visibility of NUH ‘accessibility
statement’ by producing a poster for main
public/clinic areas.
March 2014
Produce main (high volume) patient
information leaflets in the 3 most spoken
languages (Polish, Urdu and Punjabi) and
easy read versions.
Feb 2014
Quality Actions
Quality Action Plan : Status at 23 May 2014
Page 12 of 23
3
5
10
11
12
14
The Professional Heads and
Chief Executive will write jointly
to all staff setting out the way in
which NUH considers Francis
recommendations changes both
the employment contract and the
cultural compact for all NUH (and
NHS) staff.
Explore with the Colleges and
Deanery how we can jointly
promote this work and these
behaviours, including inclusion in
training and teaching curricula,
and identifying ‘school’ Board
leads for this domain
(communicating concerns).
Inaugurate a regular all-incident
review meeting under the
auspices of CRC.
Chief Executive
Director or
Nursing
Medical Director
Communication of NUH response and impact
on contract and compact is ongoing
Dec 2013
Incomplete &
ongoing
Director or
Nursing
Medical Director
Proactive Student nurses group who promote
ways to raise concern.
Dec 2013
Ongoing
The Annual Incident Report to the
Board will prioritise lessons from
incidents which are of particular
relevance for patient safety.
Review the description of
executive responsibilities and
ensure that each Board member
has an understanding of their
individual and collegiate
responsibilities in a system which
complies with “fundamental
standards of safety and quality”.
Review Disciplinary Policies and
procedures in light of Francis
proposal for strengthened
legal (criminal) liability.
Medical Director
Quality Action Plan : Status at 23 May 2014
Pastoral service provided by the University.
Included in induction for Student nurses prior
to their clinical placement in NUH.
Medical Director
Chairman,
Trust Secretary
Chief Executive
Director of
Workforce
Work has expanded into review of
March 2014
mechanisms to better capture and
disseminate learning from
incidents/complaint and claims in and via DG
March 2104
Off track
Anticipated
commence
July 2014
Completed
Review of executive directors’ job
descriptions, in conjunction with the Chair
and CEO and recommend (to the Board) any
necessary amendments accordingly.
March 2014
On track
March 2014
Board to
receive April
2014
Page 13 of 23
17
Explore how members and
Chief Executive
governors could help to assure
Trust Secretary
continual compliance with
“Fundamental standards of safety
and quality.”
Will be incorporated as standard item for
Council of Governors’ meetings. (Members
already involved in the 15 Step Challenge
Visits).
18
Develop NUH leadership
programmes to ensure
understanding of the duty to
observe, promote and manage to
improve ‘standards of safety and
quality.”
Work to inaugurate academy ongoing.
19
Director of
Nursing
Medical Director
Director of
Workforce
Examine custom and practice and Director of
new procedures to ensure that
Nursing
Medical Director
fundamental standards of safety
and quality are being met.
When shadow
Council of
Governors
meetings start ,
following
governor
elections (date
depends on FT
application
trajectory).
March 2014
Already
commenced
Complete
Nurse and Medical leads appointed to
leadership faculty.
Continuing Band 7 and 6 Leadership
Development Programmes
Quality & safety metrics displayed on all
wards.
Complete
Safety thermometer undertaken monthly.
[CQC visit did not raise nursing care
concerns after inspection Nov 2013]
22.1
22.2
Introduce an Integrated Portfolio
for Quality (IPQ) which includes
not only outcomes but
comprehensive safety-related
information (including that
capable of being derived from
incidents, complaints and
investigations).
Improve the intelligence derived
from analysis of the information
in the IPQ.
Quality Action Plan : Status at 23 May 2014
Medical Director
Integrated Report has been strengthened.
Jan 2014
Off track
March 2014
Ongoing
Proposal for ‘Surveillance Unit’ being
developed.
Chief Executive
Medial Director
As above
Page 14 of 23
22.3
Strengthen the processes of
organisational and individual
learning which arise from
Intelligence from each element of
the IPQ.
22.4
Improve communication of the
PQ, and align it with Annual Plan
and Quality Account.
22.5
Review how PQ data is collated
and triangulated, and how the
information sources are archived.
28.1
Review our proposed Foundation
Trust constitution and report to
the Board if it does not meet any
revised requirements after
Francis (notably re the role and
accountability of governors, and
the impact of the Data Protection
Act).
28.2
NUH will amend its proposed FT
constitution to describe that
directors are required to
comply with a prescribed code of
conduct, and a finding that a
person is not a fit and
proper person on the ground of
serious misconduct or
incompetence is added to the list
of disqualifications.
Quality Action Plan : Status at 23 May 2014
Chief Executive
Medial Director
Director of
Nursing
Director of
Workforce
Medical Director
As above
March 2014
Ongoing
As above
March 2014
On track for
alignment
Chief Executive
Director of
Nursing
Medical Director
Trust Secretary
As above
Dec 2013
Off track
The existing draft NUH FT constitution was
legally compliant, but has been reviewed and
updated, in the light of this recommendation
and the revised Monitor Code of Governance
which is applicable to foundation trusts from
January 2014 (and which postdates and
reflects Francis).
April 2014
Completed
Trust Secretary
As 28.1
Dec 2013
Completed
Page 15 of 23
28.3
29.2
30
31.3
33.2
Review our training and
development programme of
directors in light of Francis new
(or restated) duties and
accountabilities of Boards and
directors.
Share Reports on serious
untoward incidents involving
death or serious injury to patient
or employee with the Health and
Safety Executive.
Re-examine and strengthen the
work to achieve the highest
NHSLA level as soon as
practicable.
Develop benchmarks for medical
staffing.
Chairman
Chief Executive
Trust Secretary
Board development sessions led by Director
of Workforce and Strategy.
Dec 2013
Completed
Medical Director
Intranet Page set up to house SI/HLI reports
(not yet populated)
April 2014
On track
Director of
Nursing
Medical Director
NHSLA will no longer update standards and
there will be no further assessments. In their
place will be a Safety and Learning Service.
April 2014
Completed
Medical Director
Director of
Workforce
March 2014
Off track
Constantly promote to the public
our desire to receive comments
and complaints.
Chief Operating
Officer
Associate Dir of
Comms
National work ongoing.
Reviewing Civil eyes benchmarking
Incorporated into medical workforce
effectiveness (& productivity) project
New dedicated ‘learning from complaints'
section on NUH public website
Quality Action Plan : Status at 23 May 2014
December 2013 Completed
Plans being developed to produce videos
April 2014
with patients/families and learning for website
On track
Actively promote and encourage use of
online feedback sources, including NHS
Choices and Patient Opinion across all NUH
communications channels
Completed
Page 16 of 23
33.6
Ensure independent investigation
of each complaint where the
complaint amounts to an
allegation of a serious untoward
incident, resolution requires an
expert clinical opinion, or
there are substantive concerns re
professional conduct or the
performance of senior
managers. The initiation and
outcome of each such
investigation will be included in
the Serious Incident Report
received by the Board. A
nominated non-executive should
oversee this process.
Deputy Chief
Executive
33.7
An anonymised summary of each
upheld complaint relating to
patient care (in terms agreed with
the complainant) and the trust’s
response will be published on our
website. If the complainant or
patient refuses permission to
publish the summary will be
shared confidentially with the
Commissioner and the Care
Quality Commission.
34.2
Develop mechanisms to gather
information from trainees and
students (medical and
nursing) about patient safety and
experience.
Quality Action Plan : Status at 23 May 2014
As for 33.4, in addition any such concerns
relating to allegations SI or professional
misconduct are escalated to the medical
director. There is a need to strengthen the
process whereby such complaints are
managed / discussed
March 2014
Completed
Weekly meeting have been established
between the Complaint Lead and the Deputy
Medical Director to review complaints and
review their severity scoring. This begin April
2014
April 2014
Completed
The risk scoring tool to be reviewed. National
scoping is underway. Pilot to be implemented
June 2014
On track
Trust Secretary
Director of
Nursing
The process has changed so complainants
are informed that an anonymised version of
their complaint will be published unless they
object.
Work is ongoing with the Communications
Team to develop a format in which stories
can be published. The plan is that by the end
of Q1 10% of complaints upheld will be
published as patient stories (if agreed by
complainant). Currently we publish 2 a month
as an interim measure.
Mar 2014
Off track
Target date
now Jun
2104
Medical Director,
Directors of
Postgraduate &
Undergraduate
Training
Nursing review of student incidents and
issues raised through monthly meeting with
university practice learning lead.
Agreed with LETB to pilot the draft tool they
are developing multi professional student
Quality Scorecard (April 2014) developing
and reporting through LEC
Dec 2013
Completed
for trainee
nurses
Incomplete
for trainee
doctors
Page 17 of 23
37.2
39.1
39.2
Review our Policies to ensure
Trust Secretary
that they are consonant with any
changes in the NHS
constitution, and consistent with
NHS principles and Francis
recommendations as they are
renewed (except those Policies
described earlier as requiring
earlier review).
Revise nursing establishments in Director of
wards (and other clinical areas) to Nursing
ensure that ward
nurse managers have the
capacity to supervise the clinical
practice of their nursing team.
The existing NUH policy on policies already
requires authors to consider, and document,
all relevant legislation and national guidance.
However, upon next review, the policy on
polices will include a more overt reference to
the considerations described in the
recommendation.
April 2014
Completed &
ongoing
Final paper to seek uplift in Band 5 and Band
3 roles to support supervisory status for
sisters/charge nurses submitted to be
considered via Investment Governance
process and awaiting outcome – on track for
April
Mar 2014
Anticipate
completion
Apr 2014
Review and increase A&C
support to release ward
managers back to the ‘floor’ to
supervise, role-model and
mentor (see 39.2)
Included in 39.1 above – Total of 43 WTE
posts requested
Mar 2014
Anticipate
completion
Apr 2014
Quality Action Plan : Status at 23 May 2014
Director of
Nursing
Page 18 of 23
39.4
Explore (1) how to incorporate
nursing-specific questions into
systematic patient feedback and
(2) the use of the ‘cultural
barometer’ (or similar
methodology) to assess the
attitudes and behaviours of
nurses.
Director of
Nursing
Pilot and use “cultural barometer” as part of
the diagnostic phase of supporting
individualised approach to CATC
Mar 2014
Ongoing –
(substantial
progress)
A multidisciplinary task and finish group has
created supplementary questions in addition
to the two mandatory Staff Friends and
Family Test. This will launch in NUH in May
2014. All staff will be asked the Staff FFT
questions plus our additional five questions at
least three times per year. The sources for
approved additional questions are - the
Cultural Barometer (2 questions), Productive
Ward (1 question), Shared Governance
Survey (1 question) plus the 2 National Staff
FFT questions plus an additional Staff FFT
about recommending the local team as a
team to work in. Free text is also included.
The tool will enable results to be viewed
through to ward / department level and by
staff group. Access to the tool will be on-line
or by completing a paper questionnaire. The
survey will be anonymous. It will include staff
and volunteers. Results will be published
internally (at ward / department level) and
externally for the Trust. The system is
currently being testing and pilot areas will
engage with the tool in April to ensure it is
ready for go live in May 2014.
Engagement surveys in progress (finish date
not clearly identified yet, maximise response
rate through the time-out days) to assess
readiness for shared governance
Quality Action Plan : Status at 23 May 2014
Page 19 of 23
40.
Re-invigorate the practice of
identifying a ‘Named Nurse’ for
each patient.
Director of
Nursing
41.
Continue to improve the transfer
of information within clinical
teams and at handover
between teams.
Consider changes to name
badges (to make them more
easily readable, including the
post of the member of staff).
Publish an NUH definition
(register) of senior board-level
healthcare leaders and
Managers.
Director of
Nursing
Medical Director
45
Develop a response to Francis
Recommendation 236 4.
Medical Director
Clinical Directors
46
Scope what would be needed to
provide areas “where more
mobile patients and their
visitors can meet in relative
privacy and comfort without
disturbing other patient (and the
implications for bed capacity).
Director of
Estates &
Facilities
43.2
44
4
Chief Operating
Officer
Director of
Workforce
Chief Executive
Trust Secretary
Revisit the PSAG modules (Use of behind
the bed boards) module productive ward and
look at the process of the named nurse
concept. (Kerry Bloodworth)
e EWS project will support this work via
handover module (1 year timeframe)
January 2014
Off track
Pilot commenced on ward C25 of yellow
name badges with black writing
To be presented at N&M strategy with results
March 2014
Off track
Incorporated in the NUH Corporate
Governance Framework Chapter 8,
Management Arrangements. Latest iteration
is version 13 (January 2014) and is
frequently reviewed
Register of specialty approaches (and
compliance) being compiled, college
guidance being considered with a view to
recommendation for policy autumn 2014
January 2014
Completed
March 2014
Off track
January 2014
Off track
Ongoing
Francis recommendation 236: “Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient’s case, so that patients
and their supporters are clear who is in overall charge of patient’s care.”
Quality Action Plan : Status at 23 May 2014
Page 20 of 23
47
50
51
52
5
6
Consider with the authors and
recipients of discharge letters
how their quality can be
improved (incl whether a single
letter offers advantages over the
currently common
practice of a summary discharge
letter followed sometime later by
a more substantive
one).
Report staffing of, and
complaints, comments or
incidents about, the Discharge
Lounge as
for all other clinical areas.
Medical Director
[& Clinical
Directors]
Test the extent to which our
policies re EWS, ‘Caring Around
the Clock’ and ‘Accountability
Round the Clock’ meet the
requirements of Francis
recommendation 243 5.
Explore with patient groups how
they would wish to see Francis
recommendation 244 6
implemented, and its practicality.
Director of
Nursing
Director of
Nursing
Chief Operating
Officer
Director of
Nursing
Medical Director
Director of IT
March 2014
On track &
ongoing
Clinical Lead for Acute Medicine working with
Complaints Lead/ Datix Lead to disaggregate
information for these areas.
An analysis demonstrates only one complaint
in the last 12 months in relation to the
discharge lounge. This was about the length
of time a patient spent sitting in a chair
resulting in a blister on his leg and lack of
response to a request for a urine bottle.
Electronic recording of EWS measurement
will be piloted across 3 wards as part of
national Safer Wards Technology Fund
Dec 13
Off track –
anticipated
May 14
March 2014
Delayed to
when devices
available
(mid 2014)
Being incorporated into project to digitalise
health records (T Guyler & A Fearn).
March 2014
Off track
Francis recommendation 243: “The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being
immediately accessible to all staff electronically in a form enabling progress to be monitored and interpreted. If this cannot be done, there needs to be a system whereby
ward leaders and named nurses are responsible for ensuring that the observations are carried out and recorded.”
Francis recommendation 244: “Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter
comments. They should be enabled to have a copy of records in a form useable by them, if they wish to have one. If possible the summary care record should
be made accessible in this way.”
Quality Action Plan : Status at 23 May 2014
Page 21 of 23
56
58
Communicate to healthcare
professional employees their
professional duty to collaborate
in the provision of information on
the efficacy of treatment in
specialties, and where
appropriate amend contracts of
employment and appraisal
Policies.
Explore a step-wise approach,
with escalation of level of
seniority required to complete a
death certificate.
Medical Director
Director of
Workforce
Medical Director
[& Clinical
Directors]
March 2014
Complete
Significant communication to all consultants
re their greater involvement if certification
and coronial enquiries. Next phase is
removal of F1 ‘permissions’ to certification
(likely August 2104).
March 2014
Off track
(Anticipated
mid 2014)
CQC Observations (service / department specific)
FH obs 1
Senior management teams to
increase their accessibility,
visibility & communication with
frontline services
Clinical Director
Clinical Lead
FH
DMT to revise timetables to incorporate ward
visits and to hold service performance
meetings locally
Trust Board visit schedule reviewed
April 2014
On track
ED obs 2
Patient toilets in the reception
area, required refurbishment to
ensure they can be cleaned
effectively.
E&F
EF reviewing patient toilets and developing a
SiP for their refurbishment. Submit to EIRC
for consideration May 2014.
May 2104
On track
Quality Action Plan : Status at 23 May 2014
Page 22 of 23
ED obs 3
A sharps bin was found to be
over-filled, and clinical waste was
not stored securely at all times.
ED
In ambulatory cubicle’s tamper proof sharps
bins are now in use this ensures patients can
no longer access the sharps.
April 2014
Complete
OBC Nov 14
On track
The ED staff have been reminded through
the internal communication process to ensure
bins are disposed of as per trust policy when
the sharps reach the indicator line.
Acute
Med
obs 5
Clinic 1 staff told us they were
concerned about the number of
patients attending this unit, given
its capacity and the number of
staff who were available to
provide effective care.
Environment constraints.
Quality Action Plan : Status at 23 May 2014
Acute Med
Project established to develop option for ED
expansion (physical and staff capacity).
Page 23 of 23

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