ENCLOSURE: J. Date of Trust Board 29 February Pressure Ulcer Clinical Improvement Programme. Purpose of Report
|
|
- Cornelius Bell
- 5 years ago
- Views:
Transcription
1 ENCLOSURE: J Date of Trust Board 29 February 2012 Title of Report Purpose of Report Abstract Pressure Ulcer Clinical Improvement Programme This paper provides a progress report on our work in support of the Midlands and East SHA ambition for 100% elimination of all grade 2, 3, and 4 Pressure Ulcers across all settings and NCH&C s planned approach. An emergent strategy has been created upon which the organisation will build as more details are released regarding this ambition and any associated tools we will be required to implement. A coordinated and cohesive approach has been developed in the form of a clinical improvement programme. This will ensure a robust accountability structure that will enable monitoring, accountability and governance for the delivery of the strategy. The fundamental aim of this programme will be to identify, communicate and implement the necessary clinical improvements necessary to ensure all avoidable pressure ulcers are eliminated. Our clinical staff and managers engagement in this clinical improvement programme is absolutely vital. As an organisation we must ensure they are supported and encouraged to implement the relevant tools and clinical interventions to meet this demanding ambition. Training and clinical competency will be the central focus required to improve pressure ulcer care, to achieve this at the necessary pace, it is essential that clinical staff are released to attend any necessary training and then supported to cascade this across their teams. Risks and benefits of proposed action 1. The significant risk associated with 100% elimination of grade 2, 3, 4 Pressure Ulcers, is within our Community nursing and Therapy teams. Many patients in their own home do not comply with the clinical guidance given or utilise the pressure relieving equipment provided, and a large proportion of pressure ulcers occur within care home settings. The clinical improvement task and finish group will work closely with the patient engagement task and finish group to develop enhanced ways and information to help patients and carers understand the risks and actions necessary to prevent a pressure ulcers. 2. Releasing clinical staff to undertake clinical training relating to Pressure Ulcer care and use of associated tools will also present a risk in relation to the impact on caseload activity. Every effort will be made by the clinical improvement programme team to ensure training can be delivered to staff as efficiently and effectively as possible e-learning and cascade methodologies will be applied where ever possible to minimise this risk. It is expected that under the SHA ambition training for Pressure Ulcer care will be mandated for all Trusts. 3. An increase in the number of reported Pressure Ulcers will occur over the first three months, once the Pressure Ulcer tools are launched alongside awareness training sessions. The Pressure Ulcer clinical Improvement steering group will monitor this change in reporting and implement any necessary actions to ensure the required decrease in avoidable Pressure Ulcers is achieved. A new baseline and trajectory will 1
2 be defined to replace our current QIPP KPI trajectory, once clarification has been provided from NHSN&W. Recommendation The board are requested to note the development of an emerging strategy to work towards the ambition to eliminate all avoidable pressure ulcers. Presented by Previous consideration by Board Committee or EDT Appendices Anna Morgan Director of Operations Quality and Risk Assurance Committee Appendix 1 Pressure Ulcer Grading definitions Appendix 2 Pressure Ulcer unavoidable NHS Midlands and East (SHA) Definition Appendix 3 NHS Norfolk QIPP KPI 30% reduction trajectory Appendix 4 Pressure Ulcer Clinical Improvement Programme Steering group and Task and Finish groups. In completing this report, I confirm the following matters have been considered: a) Implications for the NHS Constitution b) Implications for CQC registration c) Equalities Impact d) Environmental impact Any material considerations arising from the above are reported below. 2
3 1. Introduction Pressure Ulcer Progress Report 1.1 This paper provides a short summary of the NHS Midlands & East of England SHA Ambition for Pressure Ulcers which will be formally launched on the 28 th February 2012, along with a brief overview of NCH&C s progress to date and planned next steps for the Pressure ulcer clinical improvement programme. 2. Background 2.1 Pressure Ulcer prevention, management and eradication is currently a high profile issue for all Provider Services across the NHS. This is our top priority clinical improvement programme over the next year and beyond. It will need both clinical and managerial engagement at every level of the organisation to achieve the goals we aspire to. 2.2 Pressure ulcers are a significant burden to the NHS and have a detrimental effect on patients health and well-being. Original figures in 2009 based on 10.2% prevalence of pressure ulcers in hospital patients, estimated the following: 29,800 acquired in hospital, 20,700 acquired in the community with subsequent admission to hospital 2,838 cost of hospital care and 2,286 cost of follow-on community care per patient (total 5,124) These figures suggest a potential annual saving of 154 million The majority of cases are avoidable if patient solutions are put in place 2.3 Pressure ulcers are a recognisable proxy measure for the quality and safety of care patients receive. The QIPP Safe Care (Safety Express) programme which commenced across the SHA Cluster in January 2011 sought to reduce hospital acquired pressure ulcers by 80% and community-acquired pressure ulcers by 30% by December 2012 with the potential national annual savings of 154m. 2.4 The aim of NHS Midlands & East of England SHA Ambitions programme is to use the elimination of all avoidable Grade 2, 3 and 4 pressure ulcers as an outcome measure for nursing care which includes; hydration, nutrition, pressure area care, medication management and individualised care. Pressure ulcers are more likely to occur in patients who are malnourished, elderly, obese and also have underlying medical conditions, and therefore it is important that the fundamental aspects of high quality nursing care are in place. 2.5 Definition of a pressure ulcer 2.6 A pressure ulcer is a localised injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are associated with pressure ulcers; the significance of these is yet to be elucidated. Source: EPUAP and NPUAP (2009) 2.7 There are four categories of pressure ulcers from Grade 1 to 4 (see Appendix 1 for grading definitions). For the purposes of the Ambition, NHS Midlands and East SHA have agreed to concentrate on elimination of Grade 2, 3 and 4 avoidable pressure ulcers. Nationally the Department of Health have mandated that all NHS trusts across England will monitor reduction via the NHS Safety Thermometer data collection tool and triangulate this with Serious Incident Reporting. 2.8 An emergent strategy has been created by NCH&C to ambitiously strive for the elimination of all avoidable pressure ulcers. This strategy is in development due to the evolving requirements from the SHA and NHS Norfolk, in terms of the actual specification relating to
4 Trusts, for achievement of this ambition. It is anticipated Trusts will receive greater clarity regarding the ambition by March 2012 along with a set of clinical tools to support the elimination of all grade 2,3,4 pressure Ulcers. 2.9 Achievement of this SHA ambition will be demonstrated by continuing to build on the progress made by the clinical improvement group under the existing QIPP KPI 30% reduction of all grade 3 and 4 for Pressure Ulcers. Clarification has been requested from NHS Norfolk regarding this QIPP KPI which currently runs until December The Pressure Ulcers Clinical Improvement Programme 3.1 A coordinated and cohesive approach has been developed in the form of a clinical improvement programme. This will ensure a robust accountability structure that will enable monitoring, accountability and governance for the delivery of the strategy. The fundamental aim of this programme will be to identify, communicate and implement the necessary clinical improvements necessary to ensure all avoidable pressure ulcers are eliminated. 3.2 This programme will ensure the most efficient use of clinical and managerial resources is possible to identify improvements in clinical interventions systems and process. To achieve effective co-production in this improvement programme it is essential to have good clinical and managerial engagement from both children s and adult business units across the Trust. This has been possible by identifying clinical leaders from recent workshops and through clinicians already participating in the QIPP KPI group, who will now be invited to engage in the various improvement programme task and finish groups. 3.3 As part of the clinical improvement programme a steering group has been formed to oversee the delivery of the strategy. This group have identified required streams of work and highlighted the expected deliverables from nominated task groups. The steering group will have executive leadership and strategic focus along with representation from Children s and Adults services plus the four task and finish group leads. 3.4 A baseline and trajectory for the reduction in grade 3 and 4 pressure ulcers has been developed, however this will be updated shortly to reflect the new SHA Ambition to include all grade 2, 3 and 4 avoidable Pressure Ulcers. (See appendix 3). Underpinning the Steering group are four specific task and finish groups. These task groups have responsibility to determine the specific measureable outcomes and associated activity to meet the required 100% elimination of all avoidable grade 2, 3, 4 pressure ulcers by December Again, this is in recognition that this strategy is dependent on the current work being undertaken by the SHA and PCT. They will provide regular feedback and reports to the steering group. The task and finish groups are as follows; (see appendix 4 for details of each group s role): Clinical Improvement and Outcomes Task & Finish Group (plus a subgroup for Equipment and another for clinical standards and protocols) Performance and Improvement Task & Finish Group Education, Competencies and Clinical Skills Training Task & Finish Group Partnership Working and Patient Engagement Task & Finish group 3.5 Integrated working across trust work streams and business units 3.6 To ensure the Preventing Pressure Ulcers (PPU) programme is fully aligned and synergised across existing corporate functions e.g. training, performance, business planning etc, a number of groups with corporate representation have been identified within the programme structure that will either influence the progress of the programme or require regular information and updates from the PPU steering group to deliver other key activities.
5 3.7 NHSN&W warmly received our proposed approach for pressure ulcer care and recognised the significant challenge the 100% elimination target presents to community services. Acknowledgement was also given to the progress achieved to date which will inform the clinical improvement programme delivery against the following areas: Membership of the SHA expert pressure ulcer group, and associated pressure ulcer networks QIPP Clinical engagement group / pressure ulcer action group Pressure ulcer policy (appendix 9) Documentation Waterlow assessment, Malnutrition universal screening tool (MUST) discharge, assessment tools E-learning tools for staff Initial review of SystmOne tools Pressure ulcer grading system Reporting processes review Review of RCA forms Identified themes from SUI / RCA 3.8 NHSN&W have also expressed a keenness to work with the Pressure Ulcer clinical improvement programme partnership and patient engagement task and finish group, to create a Norfolk wide approach building on this initiative. A scoping paper will presented by NCH&C in collaboration with NHSN&W via the Norfolk Directors of Nursing group by the Pressure Ulcer Programme lead. 4. Conclusion 4.1 Our clinical staff and managers engagement in this clinical improvement programme is absolutely vital. As an organisation we must ensure they are supported and encouraged to implement the relevant tools and clinical interventions to meet this demanding ambition. 4.2 Training and clinical competency will be the central focus required to improve pressure ulcer care, to achieve this at the necessary pace. It is essential that clinical staff are released to attend any necessary training and then supported to cascade this across their teams. The progress against targets will be monitored both internally through corporate performance structures and externally through safety thermometer and incident reporting. 5. Recommendations 5.1 The board are asked to acknowledge and champion this important clinical Improvement programme and to note the development of an emerging strategy to work towards the ambition to eliminate all avoidable pressure ulcers..
6 Appendix 1 Grading Definitions
7 Appendix 2
8 Appendix 3 QIPP Target - to reduce Grade 3 and 4 PUs by 30% by Dec Q3 Q4 Q1 Q2 Q3 Oct 11 - Dec 11 Jan 12 - Mar 12 Apr 12 - Jun 12 Jul 12 - Sep 12 Oct 12 - Dec 12 Grade 3 & Actual Planned even reduction 30% reduction compared to same quarter last year
9 Appendix 4 The role of the Preventing Pressure Ulcer (PPU) Steering Group In view of the importance of this programme, this group will be chaired by the Chief Executive, together with the Deputy Director of Service Pathways, and the support of the Assistant Director of Service Development. The steering group will ensure that the Pressure Ulcer programme aligns and integrates with the SHA proposed targets, NHS Norfolk QIPP KPIs, Transforming Community Services, CQUIN and NCH&Cs Integrated Business Plan. They will ensure that this informs the organisation s workforce planning process. The group will monitor the performance and SIRI data, which will inform the direction of the strategy and ensure sustainability for the future. The steering group will receive regular updates from the associated task and finish groups ensuring the Pressure Ulcer risk register is maintained and actioned appropriately. Representation will also be sought from Learning disabilities and Children s directorates. The steering group will provide strategic direction and leadership to the associated groups and clinicians across the Trust as appropriate. The role of the Preventing Pressure Ulcer (PPU) Task & Finish Groups Four key task groups have been identified to provide wider expertise, engagement and involvement from key clinicians and individuals to facilitate the delivery of key operational tasks/objectives to support the overall goal & aim of the project. The membership of these task groups will vary depending on work streams but a representative group of clinicians and staff from both In-patient and community teams across the organisation is required. Each task group requires an identified lead. These leads will have expertise and knowledge of project aims and coordinate activity within each task group. They will also regularly attend; provide feedback and linkage to the steering group. The task groups identified are as follows: The role of the Clinical Improvement and Outcomes Task & Finish Group This group will develop protocols and standard operating procedures (SOPs) for specific clinical groups and develop a set of clinical competences and standards for NCH&C. This group will inform key performance indicators against clinical outcomes. They will present to the PU steering group with any concerns for agreement, and following approval at the PU Steering, all protocols and SOPs will be taken to the clinical polices steering group for ratification. Once this work is complete, the group will cease but reconvene when review of protocols standards and competencies is required and new conditions have been identified. *Supporting this task group will be two subgroups one for: Equipment and another for the development of clinical standards and protocols The role of the Performance and Improvement Task & Finish Group This group will identify what performance data is required which will meet the QIPP KPI and any other associated targets for 2011/12. The task group will review the results from the internal pressure ulcer audit and outcomes from SIRI reports and will use the baseline evidence to forecast the direction of roll out for Pressure Ulcers across Norfolk. Monthly performance reports will be presented to the steering group for information and review. A dashboard will also be used to demonstrate month on month progress against any agree trajectory for the agreed % reduction across inpatient and community team settings. The role of the Education, Competencies and Clinical Skills Training Task & Finish Group This task group will develop robust clinical competencies, training and education programmes for the organisation. The group will be responsible for the identification, design and
10 implementation of training packages, learning events. They will present to the PU steering group with any concerns for agreement before implementation. The role of the Partnership Working and Patient Engagement Task & Finish group This task group will develop/design patient information and to capture current patient and staff experiences of pressure ulcers, develop an engagement network for service users and carers. They will also work closely with the Clinical Protocols Task Group to share outcomes and testing of protocols with service users. report will be presented to the steering group on a monthly basis. The group will identify potential and known partners from acute hospitals and other patient settings where our clinical staff have involvement, and establish opportunities to improve clinical care and joint working to reduce and prevent pressure ulcers. Public and Patient Engagement group This group is already in existence within NCH&C s corporate structure and will play a fundamental role informing the Pressure Ulcer steering group and task and finish groups in the following areas: Identify key partnerships by working across provider organisations i.e. acute hospitals and residential homes Work with other providers to develop a system wide approach to Pressure Ulcer prevention and care for patients across Norfolk Involve patients and carers in the development/design of patient information and education process to prevent and manage effectively Pressure Ulcers particularly for patients in their own home i.e. establish a focus group Identify measurable targets that can demonstrate how we are Improving patient experience, delivering safe, seamless holistic care for patients with long term conditions and thus preventing avoidable Pressure Ulcers Workforce and Organisational Development A representative from the workforce/organisational development team will be an active member of the steering group. They will give guidance on the workforce /OD requirements for education and training. This will link with the strategy for leadership and development within NCH&C.
The Suffolk Marie Curie Delivering Choice Programme
The Suffolk Marie Curie Delivering Choice Programme Phase III A report on progress and achievements Date: April 2012 Author: Sandy Barron Project Lead Manager Design and Development - MCDCP 1 Table of
More informationBOARD MEETING. Document is for: (indicate with an x) Assurance x Information Decision. Executive Summary
Document Title: Presenter: Author: Contact details for further information: BOARD MEETING Review of Pressure Ulcer Prevalence across DCHS services March June 2012 Kath Henderson, Chief Nurse Michelle O
More informationTrust Board meeting: Wednesday 8 th May2013 TB
Trust Board meeting: Wednesday 8 th May2013 Title Pressure Ulcer Prevention Report Status History A paper for information N/A Board Lead(s) Mrs Elaine Strachan-Hall, Chief Nurse Key purpose Strategy Assurance
More informationPressure ulcers: revised definition and measurement. Summary and recommendations
Pressure ulcers: revised definition and measurement Summary and recommendations June 2018 We support providers to give patients safe, high quality, compassionate care within local health systems that are
More informationStaffordshire and Stoke on Trent Partnership NHS Trust. Operational Plan
Staffordshire and Stoke on Trent Partnership NHS Trust Operational Plan 2016-17 Contents Introducing Staffordshire and Stoke on Trent Partnership NHS Trust... 3 The vision of the health and care system...
More informationTRUST BOARD. Jo Furley, Interim Chief Nurse Dr Ben Lobo, Medical Director. Jo Hunter, Deputy Chief Nurse. Mary Heritage, Assistant Director of Quality
TRUST BOARD Document Title: Presenter: Quality Report Jo Hunter, Deputy Chief Nurse Authors: Contact details for further information: Jo Furley, Interim Chief Nurse Dr Ben Lobo, Medical Director Jo Hunter,
More informationTHE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST REDUCING HARM TISSUE VIABILITY PROGRESS REPORT
Agenda item A5(iv) THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST REDUCING HARM TISSUE VIABILITY PROGRESS REPORT EXECUTIVE SUMMARY The Tissue Viability Team assists wards and departments to reduce
More informationStop the Pressure: An update from NHS England
Stop the Pressure: An update from NHS England 4 th February 2015 Suzanne Banks Professional Advisor 4 th February 2015 Why is Patient Safety and Pressure Ulcer Prevention important? Don Berwick (2014)
More informationBoard of Director s Meeting
Board of Director s Meeting Meeting Date: 15 November 212 Agenda item: 6.1 Title: Purpose: Summary: Recommendation: Author: Presented by: QUALITY AND PATIENT SAFETY ASSURANCE COMMITTEE To provide an exception
More informationStop the Pressure Moving Forward. Susan Bowler Professional Advisor Stop the Pressure
Stop the Pressure Moving Forward Susan Bowler Professional Advisor Stop the Pressure Pressure ulcers : a costly and avoidable harm In the NHS in England from April 2014 to the end of March 2015 25,000
More informationWarrington Children and Young People s Mental Health and Wellbeing Local Transformation Plan
Warrington Children and Young People s Mental Health and Wellbeing Local Transformation Plan 2015-2020 1 Introduction 1.1 Welcome to the update on Warrington s Local Transformation Plan for Children and
More informationThe Royal Wolverhampton NHS Trust
The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 24 June 2013 Title: Executive Summary: Action Requested: Report of: Author: Contact Details: Resource Implications: Public or Private:
More informationNHS GRAMPIAN. Local Delivery Plan - Mental Health and Learning Disability Services
NHS GRAMPIAN Board Meeting 01.06.17 Open Session Item 8 Local Delivery Plan - Mental Health and Learning Disability Services 1. Actions Recommended The Board is asked to: Note the context regarding the
More informationDebbie Edwards Interim Deputy Director of Nursing Gail Naylor- Executive Director of Nursing & Midwifery. Safety & Quality Committee
Report to Trust Board of Directors Date of Meeting: 29 July 2014 Enclosure Number: 7 Title of Report: Author: Executive Lead: Responsible Sub- Committee (if appropriate): Executive Summary: Ward Accreditation
More informationTRUST BOARD 22 December Nursing, Quality & Patient Experience Directorate. TISSUE VIABILITY Update and Ambition
TRUST BOARD 22 December 26 Nursing, Quality & Patient Experience Directorate TISSUE VIABILITY Update and Ambition Executive Summary The aim of the Tissue Viability Service is to provide specialist assessment
More informationRBCH Actions to meet CQC Essential Standards
RBCH Actions to meet CQC Essential Standards REGULATION 17 How the regulation was not being met Patients, their relatives, and staff told us about incidents where people had not been treated with dignity
More informationJob Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement
Job Description Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement Grade 8b Tenure: Permanent Location of Post:
More informationQuality Accounts: Corroborative Statements from Commissioning Groups. Nottingham NHS Treatment Centre - Corroborative Statement
Quality Accounts: Corroborative Statements from Commissioning Groups Quality Accounts are annual reports to the public from providers of NHS healthcare about the quality of services they deliver. The primary
More informationPressure Ulcers The BHTA guide to prevention and cash releasing savings
Pressure Ulcers The BHTA guide to prevention and cash releasing savings Pressure Ulcers: The BHTA guide to prevention and cash releasing savings In the UK, around 400,000 individuals develop a new Pressure
More informationSupporting all NHS Trusts to achieve NHS Foundation Trust status by April 2014
TFA document Supporting all NHS Trusts to achieve NHS Foundation Trust status by April 2014 Tripartite Formal Agreement between: Hertfordshire Community NHS Trust NHS East of England Department of Health
More informationAppendix 1: Croydon Clinical Commissioning Group Risk Register and Board Assurance Framework - 9th April 2013
Appendix 1: Croydon Clinical Register and Board Assurance Framework - 9th April 2013 Principal to Delivery Key Assurance on we have in in our are 1. To achieve financial sustainability in three years (2013-2014
More informationService Transformation Report. Resource and Performance
SUMMARY REPORT Meeting Date: 31 May 2018 Agenda Item: 9.1 Enclosure Number: 9 Meeting: Trust Board (Part 1) Title: Author: Accountable Director: Other meetings presented to or previously agreed at: Service
More informationEliminating Avoidable Pressure Ulcers. Professor Gerard Stansby
Eliminating Avoidable Pressure Ulcers Professor Gerard Stansby gerard.stansby@nuth.nhs.uk Why is this important? Important patient safety issue Pressure ulcers can be prevented (?All) Pressure ulcers are
More informationCLINICAL AND CARE GOVERNANCE STRATEGY
CLINICAL AND CARE GOVERNANCE STRATEGY Clinical and Care Governance is the corporate responsibility for the quality of care Date: April 2016 2020 Next Formal Review: April 2020 Draft version: April 2016
More informationTHE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST NHS SAFETY THERMOMETER
Agenda item A5(vi) THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST NHS SAFETY THERMOMETER EXECUTIVE SUMMARY The NHS Safety Thermometer is a point of care survey, which is a local improvement tool
More informationQuality Framework Healthier, Happier, Longer
Quality Framework 2015-2016 Healthier, Happier, Longer Telford & Wrekin Clinical Commissioning Group (CCG) makes quality everyone s business. Our working processes are designed to ensure we all have the
More informationNHS DORSET CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING ADULT AND CHILDREN CONTINUING HEALTHCARE ANNUAL REPORT
9.6 NHS DORSET CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING ADULT AND CHILDREN CONTINUING HEALTHCARE ANNUAL REPORT Date of the meeting 18/07/2018 Author Sponsoring Board member Purpose of Report
More informationStrategy for Delivery of Clinical Quality and Patient Safety North Norfolk Clinical Commissioning Group.
Strategy for Delivery of Clinical Quality and Patient Safety North Norfolk Clinical Commissioning Group. 1. Introduction 1.1 The aim of this document is to set out the strategy for North Norfolk CCG (NNCCG)
More informationCOMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR:
MINDING THE GAP COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR: GOVERNANCE ASSURANCE AND PERFORMANCE. 1. INTRODUCTION AND CONTEXT Providing, delivering and developing the highest standards
More informationSpecialised Commissioning Oversight Group. Terms of Reference
Specialised Commissioning Oversight Group Terms of Reference Specialised commissioning oversight group terms of reference 1 1.1 Purpose NHS England is responsible for commissioning specialised services
More informationNHS Bradford Districts CCG Commissioning Intentions 2016/17
NHS Bradford Districts CCG Commissioning Intentions 2016/17 Introduction This document sets out the high level commissioning intentions of NHS Bradford Districts Clinical Commissioning Group (BDCCG) for
More informationPRESSURE ULCER THEMATIC ADVERSE EVENT REPORT - MARCH The aim of this report is to provide NHS Borders Board with a thematic review of:-
Appendix-15-35 Borders NHS Board PRESSURE ULCER THEMATIC ADVERSE EVENT REPORT - MARCH 15 Aim The aim of this report is to provide NHS Borders Board with a thematic review of:- Avoidable hospital developed
More informationOur Health & Care Strategy
MO Our Health & Care Strategy 2015-2020 Norfolk Community Health and Care NHS Trust Final September 2015 Version control Date Changes 1 19 th July 2015 Initial document 2 29 th July 2015 Following feedback
More information2017/ /19. Summary Operational Plan
2017/18 2018/19 Summary Operational Plan Introduction This is the summary Operational Plan for Central Manchester University Hospitals NHS Foundation Trust (CMFT) for 2017/18 2018/19. It sets out how we
More informationPATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE
PATIENT SAFETY AND QUALITY COMMITTEE TERMS OF REFERENCE Page 1 DOCUMENT CONTROL SHEET Name of Document: Patient Safety and Quality Committee Terms of Reference Version: 5 File Location / Document Name:
More informationSupporting all NHS Trusts to achieve NHS Foundation Trust status by April Ipswich Hospital NHS Trust NHS East of England Department of Health
TFA document Supporting all NHS Trusts to achieve NHS Foundation Trust status by April 2014 Tripartite Formal Agreement between: Ipswich Hospital NHS Trust NHS East of England Department of Health Introduction
More informationFOREWORD Introduction from the Chief Executive 2 BACKGROUND 3 OUR TRUST VALUES 4 OUR AIMS FOR QUALITY 5 HOW WE MEASURE QUALITY 16
Contents FOREWORD Introduction from the Chief Executive 2 BACKGROUND 3 OUR TRUST VALUES 4 OUR AIMS FOR QUALITY 5 - Our achievements so far - Our aims for quality 2017 2020 AIM 1: AIM 2: AIM 3: AIM 4: Reducing
More informationImproving Patient Outcomes Strategy
Improving Patient Outcomes Strategy 2015-2018 Hertford County I Lister I Mount Vernon Cancer Centre I QEII Improving Patient Outcomes Strategy 2015-2018 Page 1. Executive Summary 1 2. Introduction 2 3.
More informationNHS Safety Thermometer CQUIN 2014/15. Frequently Asked Questions
NHS Safety Thermometer CQUIN 2014/15 Frequently Asked Questions This document is designed to support commissioners and providers in using the CQUIN, the CQUIN guidance and supporting resources. Page references
More informationDeveloping Plans for the Better Care Fund
Annex to the NHS England Planning Guidance Developing Plans for the Better Care Fund (formerly the Integration Transformation Fund) What is the Better Care Fund? 1. The Better Care Fund (previously referred
More informationBOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013
Borders NHS Board BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013 Aim The aim of this report is to provide the Board with an overview of progress in the areas of: Patient Safety Person Centred Health
More informationAyrshire and Arran NHS Board
Paper 6 Ayrshire and Arran NHS Board Monday 11 December 2017 SPSP Update: Acute Adult Programme Author: Laura Harvey, QI Lead for Acute Services, Person Centred & Customer Care Sponsoring Director: Liz
More informationNHS England (Wessex) Clinical Senate and Strategic Networks. Accountability and Governance Arrangements
NHS England (Wessex) Clinical Senate and Strategic Networks Accountability and Governance Arrangements Version 6.0 Document Location: This document is only valid on the day it was printed. Location/Path
More informationPATIENT AND SERVICE USER EXPERIENCE STRATEGY
PATIENT AND SERVICE USER EXPERIENCE STRATEGY APRIL 2017 TO MARCH 2020 Date 24 March 2017 Version Final Version Previously considered by The Patient Experience Group version 0.1 draft The Executive Management
More informationREQUIREMENT. Identify a minimum of 4 theme areas which are considered to have caused concern for patients during 2012/13
2012/13 SSOTP CQUIN INDICATOR TARGETS INDICATOR REQUIREMENT 1. Patient Experience Milestone 1 (15th working day of April 2012) Identify a minimum of 4 theme areas which are considered to have caused concern
More informationEnd of Life Care Commissioning Strategy. NHS North Lincolnshire - Adding Life to Years and Years to Life
End of Life Care Commissioning Strategy NHS North Lincolnshire - Adding Life to Years and Years to Life END OF LIFE CARE 1. Background NHS North Lincolnshire End of Life Care Commissioning Strategy The
More informationThe safety of every patient we care for is our number one priority
HUMBER NHS FOUNDATION TRUST INFECTION PREVENTION AND CONTROL STRATEGY 2015-2017 1. Introduction Healthcare associated infections (HCAI) continue to be a major cause of patient harm and although nationally
More informationFIVE TESTS FOR THE NHS LONG-TERM PLAN
Briefing 10 September 2018 FIVE TESTS FOR THE NHS LONG-TERM PLAN The new NHS long-term plan is a significant opportunity for the health service. It can set out a clear and achievable path for sustaining
More informationNHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011)
NHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011) INTRODUCTION This paper provides a monthly quality dashboard for NHS Lanarkshire. This is in line with
More informationCOVENTRY AND RUGBY CLINICAL COMMISSIONING GROUP
COVENTRY AND RUGBY CLINICAL COMMISSIONING GROUP Report To: Governing Body 11 September 2013 Report From: Title of Report: Purpose of the Report: Jacqueline Barnes, Executive Nurse The Nursing and Quality
More informationIQC/2013/48 Improvement and Quality Committee October 2013
Item 9.4 IQC/2013/48 Improvement and Quality Committee October 2013 Pressure Ulcer Prevalence Improvement Plan 1. SITUATION AND BACKGROUND This paper is to update the Improvement and Quality Committee
More informationLearning from Deaths Policy
Learning from Deaths Policy Version: 3 Approved by: Board of Directors Date Approved: October 2017 Lead Manager: Associate Medical Director for Patient Safety and Clinical Risk Responsible Director: Medical
More informationservice users greater clarity on what to expect from services
briefing November 2011 Issue 227 Payment by Results in mental health A challenging journey worth taking Key points Commissioners and providers support the introduction of Payment by Results for adult mental
More informationQuality Strategy and Improvement Plan
Quality Strategy and Improvement Plan 2015-2018 STRATEGY DOCUMENT DETAILS Status: FINAL Originating Date: October 2015 Date Ratified: Next Review Date: April 2018 Accountable Director: Strategy Authors:
More informationBusiness Plan April 2017 to March 2018
PLEASE DO NOT KEEP THE ORIGINAL OF THIS DOCUMENT OPEN AND LOCKED SAVE A COPY! Business Plan April 2017 to March 2018 1 Contents: Introduction Our plan in summary Part 1 Overview Our purpose, role and values
More informationLearning from Deaths Policy
Learning from Deaths Policy The Learning from Deaths Policy sets out the minimum acceptable standards of the national learning from deaths programme. Policy group General Document Detail Version 1 Approved
More informationRedesign of Front Door
Redesign of Front Door Transforming Acute and Urgent Care Strategic Background and Context Our Change and Improvement Programme What have we achieved and how? What did we learn? Ian Aitken, General Manager
More informationImplementation of Quality Framework Update
Joint Committee Meeting 26 January 2016 Title of the Committee Paper Framework Update Executive Lead: Director of Nursing & Quality Assurance Author: Director of Nursing & Quality Assurance Contact Details
More informationNovember NHS Rushcliffe CCG Assurance Framework
November 2015 NHS Rushcliffe CCG Assurance Framework ASSURANCE FRAMEWORK SUMMARY No. Lead & Sub Committee Date placed on Assurance Framework narrative Residual rating score L I rating in 19 March 2015
More informationAchieving Consensus in Pressure Ulcer Reporting
Achieving Consensus in Pressure Ulcer Reporting Tina Chambers Chair of Tissue Viability Society 2013-2015 Co-Chair TVS Pressure Ulcer Reporting Group Purpose of Document This document is for all organisations
More informationPRESSURE ULCER PREVENTION SIMPLIFIED
10 PRESSURE ULCER PREVENTION SIMPLIFIED This simplified leaflet is intended to give you information about pressure ulcer and aid your clinical practice PRESSURE ULCER PREVENTION SIMPLIFIED Pressure ulcer
More informationBOARD OF DIRECTORS PAPER COVER SHEET. Meeting Date: 1 st December 2010
BOARD OF DIRECTORS PAPER COVER SHEET Meeting Date: 1 st December 2010 Agenda Item: 9 Paper No: E Title: Management of Pressure Ulcers Purpose: For Information Summary: This paper provides a report on the
More informationGeneral Practice 5 Year Forward View Operational Plan Leicester, Leicestershire and Rutland (LLR) STP
Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group General Practice 5 Year Forward View Operational
More informationFIRST SAFEGUARDING REPORT FROM WORCESTERSHIRE CCGs APRIL-OCTOBER 2013
FIRST SAFEGUARDING REPORT FROM WORCESTERSHIRE CCGs APRIL-OCTOBER 2013 Author: On behalf of: Ellen Footman Designated Nurse for Safeguarding NHS Redditch and Bromsgrove CCG, NHS Wyre Forest CCG and NHS
More informationPressure Ulcers to Zero Collaborative Guide
Pressure Ulcers to Zero Collaborative Guide Table of Contents Page Number Purpose of the guide 2 Why get involved? 3 Pressure Ulcer Definition 5 What is the Pressure Ulcers to Zero Collaborative 6 Getting
More informationPsychiatric intensive care accreditation: The development of AIMS-PICU
Journal of Psychiatric Intensive Care Journal of Psychiatric Intensive Care Vol.6 No.2:117 122 doi:10.1017/s1742646410000063 Ó NAPICU 2010 Commentary Psychiatric intensive care accreditation: The development
More informationSolent. NHS Trust. Patient Experience Strategy Ensuring patients are at the forefront of all we do
Solent NHS Trust Patient Experience Strategy 2015-2018 Ensuring patients are at the forefront of all we do Executive Summary Your experience of our services matters to us. This strategy provides national
More informationBriefing. NHS Next Stage Review: workforce issues
Briefing NHS Next Stage Review: workforce issues Workforce issues, and particularly the importance of engaging and involving staff, are a central theme of the NHS Next Stage Review (NSR). It is the focus
More informationCalderdale and Huddersfield NHS Foundation Trust End of Life Care Strategy
Calderdale and Huddersfield NHS Foundation Trust End of Life Care Strategy 2016-2017 Contents Acknowledgements Subject Page Number 1. Introduction 4 2. Vision 5 3. National policy Context 5-6 4. Local
More informationQUALITY STRATEGY
NHS Nene and NHS Corby Clinical Commissioning Groups QUALITY STRATEGY 2017-2021 Approved: By the Joint Quality Committee on 11 April 2017 Ratified: By the NHS Corby Clinical Commissioning Group on 25 April
More informationNHS Trafford Clinical Commissioning Group Quality and Performance Strategy S T rafford Clinical Commissioning Group
De ce m be r 20 14 NHS Trafford Clinical Commissioning Group Quality and Performance Strategy N H 2015-2020 S T rafford Clinical Commissioning Group Version 2.0 Page 1 of 28 APRIL 2015 (RM) POLICY DOCUMENT
More informationAneurin Bevan University Health Board. Professional Revalidation
28 th January 20 Aneurin Bevan University Health Board Professional Revalidation Purpose of the Report: The purpose of this paper is to provide the Board with an update in relation to the Nursing Revalidation
More informationNorth School of Pharmacy and Medicines Optimisation Strategic Plan
North School of Pharmacy and Medicines Optimisation Strategic Plan 2018-2021 Published 9 February 2018 Professor Christopher Cutts Pharmacy Dean christopher.cutts@hee.nhs.uk HEE North School of Pharmacy
More information4. Risk (Threats or opportunities, link to a risk on the Risk Register, Board Assurance Framework etc) None.
Report to: Management Board Agenda item: 12 Date of Meeting: 22 July 2015 Title of Report: Annual Tissue Viability Report 2014/15 Status: To Note Board Sponsor: Helen Blanchard, Director of Nursing and
More informationWaiting Times Report Strategic. Thematic Goals
Strategic Improved Quality of Care Transformation - Prevention & Wellbeing Thematic Goals Waiting Times Report 2016-17 Transformation through Integration Improved Access to Services Improved Value This
More informationOpen and Honest Care in your Local Hospital
Open and Honest Care in your Local Hospital Report for: Royal Wolverhampton NHS Trust January 2016 The Open and Honest Care: Driving Improvement Programme aims to support organisations to become more transparent
More informationEquality and Health Inequalities Strategy
Equality and Health Inequalities Strategy 1 Schematic of the Equality and Health Inequality Strategy Improving Lives: People and Patients Listening and Learning Gaining Knowledge Making the System Work
More informationAgenda Item number: 8.1 Enclosure: 3. Discussion. Date reviewed. 22 nd September
Board meeting date: 27 th October 2011 Agenda Item number: 8.1 Enclosure: 3 Title Quality Report Accountable Director: Authors(name & title): Maggie Bayley, Director of Nursing and Quality Dr Alastair
More informationAppendix Five Decision Pathway Pressure Ulcers and safeguarding Adults (A3 format)
Appendix Five Decision Pathway Pressure Ulcers and safeguarding Adults (A3 format) Pressure ulcer is observed. Concern is raised that a person has significant skin damage. Category / Grade 3 and 4 or Multiple
More informationNorthumberland, Tyne and Wear NHS Foundation Trust. Board of Directors Meeting. Meeting Date: 25 October Executive Lead: Rajesh Nadkarni
Agenda item 9 ii) Northumberland, Tyne and Wear NHS Foundation Trust Board of Directors Meeting Meeting Date: 25 October 2017 Title and Author of Paper: Clinical Effectiveness (CE) Strategy update Simon
More informationKnowledge for healthcare: A briefing on the development framework
Developing people for health and healthcare Knowledge for healthcare: A briefing on the development framework for NHS library and knowledge services in England 2015-2020 Library and Knowledge Services
More informationWe value each other / We are empowered / We keep things simple / We are connected. Title: Patient Experience Strategy Progress Update April 2017
Report To: Board of Directors (Public) Paper Number: 2.3 Report For: Information Date: 27 April 2017 Report Author: Karen Reynolds Head of Governance and Quality Assurance Report of: Caroline Harris-Birtles
More informationYORKSHIRE AMBULANCE SERVICE NHS TRUST Quality Improvement Action Plan 23/05/1017 FINAL. Deputy/ Associate Director. Executive Director TRUST WIDE
YORKSHIRE AMBULANCE SERVICE NHS TRUST Quality Improvement Action Plan 23/05/1017 FINAL CQC findings TRUST WIDE 1.1 1.2 Ensure that at all times there are qualified experienced staff (including Staff communication
More informationAintree University Hospital NHS Foundation Trust Corporate Strategy
Aintree University Hospital NHS Foundation Trust Corporate Strategy 2015 2020 Aintree University Hospital NHS Foundation Trust 1 SECTION ONE: BACKGROUND AND CONTEXT 1 Introduction Aintree University Hospital
More informationQuality Strategy
Quality Strategy 2017-2020 Contents 05 Foreword 06 Introduction 06 Equality & Diversity 07 Context for this Strategy 08 Definition of Quality 10 Quality Objectives 10 Strategic Quality Objectives 16 Quality
More informationAppendix 1: South Lanarkshire H&SCP Improvement Plan 2017/18.
Appendix 1: South Lanarkshire H&SCP Improvement Plan 2017/18. South Lanarkshire - Whole System Pathway Indicators identified capture key data across the whole H&SC system, primarily based around supporting
More informationQuality Improvement Strategy Safe care Effective care Excellent patient experience
Quality Improvement Strategy 2012-2015 Safe care Effective care Excellent patient experience Introduction High Quality Care for All (DoH, 2008) defined quality as having three dimensions: Ensuring that
More informationQuality and Safety Improvement Strategy
Quality and Safety Improvement Strategy 2016-2021 Page 1 of 20 1. Purpose of this Strategy Patient safety and quality of care are at the heart of the NHS agenda. Treating and caring for people in a safe
More informationNHS Electronic Referrals Service. Paper Switch Off an update Digital Health Webinar 4 May 2018
NHS Electronic Referrals Service Paper Switch Off an update Digital Health Webinar 4 May 2018 Aims of Session Introductions and refresh of Paper Switch Off Sharon Wilson Implementation manager NHS Digital
More informationAgreement between: Care Quality Commission and NHS Commissioning Board
Agreement between: Care Quality Commission and NHS Commissioning Board January 2013 1 Joint Statement This agreement sets out the strategic intent and commitment for the Care Quality Commission (CQC) and
More informationGE1 Clinical Utilisation Review
GE1 Clinical Utilisation Review Scheme Name QIPP Reference Eligible Providers GE1 Clinical Utilisation Review QIPP 16-17 S40-Commercial 17/18 QIPP reference to be added locally. This CQUIN is supported
More informationThe State Hospital Clinical Effectiveness Strategy & Delivery Plan January 2011 December 2013
The State Hospital Strategy & Delivery Plan January 2011 December 2013 NATIONAL STANDARDS NATIONAL GUIDELINES CLINICAL AUDIT CLINICAL EFFECTIVENESS INTEGRATED CARE PATHWAYS MANAGING CHANGE EDUCATION AND
More informationLearning from Patient Deaths: Update on Implementation and Reporting of Data: 5 th January 2018
Learning from Patient Deaths: Update on Implementation and Reporting of Data: 5 th January 218 Purpose The purpose of this paper is to update the Trust Board on progress with implementing the mandatory
More informationImprovement and assessment framework for children and young people s health services
Improvement and assessment framework for children and young people s health services To support challenged children and young people s health services achieve a good or outstanding CQC rating February
More informationWhittington Health Trust Board
Executive Offices Direct Line: 020 7288 3939/5959 www.whittington.nhs.uk The Whittington Hospital NHS Trust Magdala Avenue London N19 5NF Whittington Health Trust Board Title: 4 th March 2015 Sign up to
More informationEDS 2. Making sure that everyone counts Initial Self-Assessment
EDS 2 Making sure that everyone counts Initial Self-Assessment Equality Delivery System for the NHS EDS2 Summary Report Implementation of the Equality Delivery System EDS2 is a requirement on both NHS
More informationHard Truths Public Board 29th September, 2016
Hard Truths Public Board 29th September, 2016 Presented for: Presented by: Author Previous Committees Governance Professor Suzanne Hinchliffe CBE, Chief Nurse/Deputy Chief Executive Heather McClelland
More informationBoard Sponsor: Helen Blanchard, Director of Nursing and Midwifery Michaela Arrowsmith Lead Tissue Viability Nurse Specialist Appendices None
Report to: Public Board of Directors Agenda item: 6 Date of Meeting: 26 July 207 Title of Report: Annual Tissue Viability Report 206/7 Status: To Note Board Sponsor: Helen Blanchard, Director of Nursing
More informationQuality Strategy. The Quality department will progress all new, re-written and reviewed CBRs for final Trust approval. 4.0
Quality Strategy elibrary ID Reference No: This id will be applied to all new Trust-wide CBRs by the Quality Department and will be retained throughout its life span. GOV-STRAT-001-12 Newly developed Trust-wide
More informationJOB DESCRIPTION. Joint Commissioning Manager for Older People s Residential Care and Nursing Homes
JOB DESCRIPTION Job Title: Grade: Team: Accountable to: Joint Commissioning Manager for Older People s Residential Care and Nursing Homes HAY 14 / AfC 8b (indicative) Partnership Commissioning Team Head
More information