Patient Care Improvement Plan

Transcription

1 WYE VALLEY NHS TRUST Patient Care Improvement Plan Derek Smith Interim Chief Executive Officer January 2014

2 1. Introduction The Patient Care Improvement Plan is a comprehensive plan of action that is being delivered across Wye Valley NHS Trust s operational and corporate directorates. The plan has been formulated to address essential service improvements that ensure the Trust delivers high quality, safe care for all of the patients and carers who use its services. The plan is intended to coordinate and manage the delivery of actions that have been identified to mitigate the risks and issues recently highlighted following recent inspection visits and to sustain our approach to improving services we provide. The plan has been structured into four themes that are aligned to the framework of the key lines of enquiry used by the Rapid Responsive Review Team in October These are: 1. Governance & Leadership 2. Operational Effectiveness 3. Patient Experience 4. Workforce and Safety 1

3 2. Aims Theme 1.Governance & Leadership Expected end state a. Wye Valley Trust can clearly demonstrate the governance processes for assuring the quality of care. b. Leadership roles and responsibilities are clearly defined for our quality processes. c. We can all describe the quality governance process and how we would raise any concern we may have. d. An organisational development plan intended to reinforce the open and honest culture e. A single, prioritised action plan to focus on key improvement areas across the Trust. f. The required actions will be delivered within an agreed timeframe with Executive ownership and accountability. 2.Operational Effectiveness a. Effective governance arrangements for monitoring operational performance data at a senior level. b. The Board can evidence how it is using performance information to drive improvements in quality. c. Vital performance and quality requirements are consistently met. 3.Patient Experience 4.Workforce & Safety a. We can evidence how we engage with patients, their families and carers to seek views about their experience. b. We are aware of the key themes emerging from consulting patients on their experience and the actions taken to address them. c. The Board is aware of compliance and safety issues identified and actions taken to address them. d. The Board has adequate assurance that the organisation is delivering high quality safe care. a. We can clearly demonstrate that we are all engaged in developing our strategy. b. Staff are supported with adequate training and development c. We can demonstrate that we monitor and review patient safety indicators. d. Action is taken to improve patient safety whenever required. e. The workforce strategy and demonstrate effective workforce planning are clearly set out. f. The Board has adequate assurance that we have the necessary workforce deployed to deliver safe, effective care. 2

4 3. Governance Plan The framework for making change is designed to incorporate all relevant best practice for project management in a health care setting. This will ensure that the improvement tasks are: Owned by senior leaders with clear lines of accountability for delivery. Delivered in full within the required timescales. Monitored and reported regularly as a part of core business. As described previously, action is structured into 4 themes which will support efficient internal reporting and progress delivery. All actions are time bound and owned by Executive leads. The Programme is serviced by WVT s Programme Management Office (PMO) who have the responsibility for collating progress reports and supporting the monitoring process. Weekly reports are provided to the CEO and the Trust s Executive Directors. These reports are structured to provide information on progress against impending milestones. The RAG rating detailed below will be used to monitor progress with the actions through to completion. Key Evidence available to show outcome is met. Evidence is available to show mostly met or not sufficient evidence to demonstrate outcome is met. The action required is minimal. Evidence is available to show mostly met or not sufficient evidence to demonstrate outcome is met. The action required is moderate. Evidence available shows that this outcome is not being met or there is no evidence that the outcome is met. Action is required quickly. 3

5 The Patient Care Improvement Plan is a standing agenda item on the newly formed WVT Trust Executive Committee. This forum convenes fortnightly and is chaired by the CEO with the attendance of WVT s senior leaders - Executive Directors, Service Unit Directors, Clinical Directors and Service Unit Managers. 4. WVT Governance Structure WYE VALLEY NHS TRUST BOARD Patient Care Improvement Programme Governance & Leadership Governance Systems Ward To Board Care Bundles Operational Effectiveness TRUST EXECUTIVE COMMITTEE The Patient Care Improvement Programme does not replace existing management responsibilities or alter the assurance role of existing Board Committees Unscheduled care improvements Escalation areas Stroke Service review Obstetric Service review Patient Experience Complaints learning strategy Workforce & Safety Medical, Nursing & Midwifery reviews Learning & Training Infection Prevention & Control 4

6 CQC Actions (not related to RRR) Workforce & Safety Patient Experience Operational Effectiveness Governance & Leadership 5. Improving Patient Care and Organisational Performance Theme Total Recommendations Breakdown of compliance Outstanding Actions Target for completion Key Achievements 8 Completed Safety culture survey developed. Annual monitoring of governance and leadership 4 31/03/2014 arrangements /03/2014 Enhanced training programmes in relation to governance and leadership. 2 01/04/2014 Improved Executive and Non-Executive Director visibility throughout the organisation. 4 Completed Clinical Assessment Unit (CAU) now operational 7 days a week. 2 30/04/2014 Enhanced phlebotomy service /04/2014 Increased medical input to community hospitals. Mortality reduction plan implemented. 0 Completed 7 Completed Patient stories presented at the Trust Board. Improved complaints data provided from Ward to 4 31/05/2014 Board and vice versa /02/2014 Friends and Family data rolled out to Community Hospitals. 2 01/04/ Completed 11 30/06/ /02/ /03/ Completed 3 31/01/ /01/ Completed Standard Operating Procedures for Day Surgery Unit strengthened. Nursing and midwifery establishment review undertaken. Long term plan to improve the Day Surgery Unit layout developed. Provision of pressure area prevention materials reviewed and re-launched. Processes in relation to maximising privacy and dignity within Day Surgery Unit reviewed and update. 5