FT Keogh Plans Tameside Hospitals NHS Foundation Trust 15 January 2014 KEY Delivered On Track to deliver Some issues narrative disclosure Not on track to deliver
What are we doing? Tameside Hospitals NHS Foundation Trust - Our improvement plan & our progress Keogh review made 5 key recommendations in July 2013 which, if implemented, would improve the quality of our services by ensuring that we improve our communications and engage more effectively with patients, ensure that our patients are safely treated at all times, have all staff actively engaged with improving the quality of our services and ensuring that any concerns are raised promptly. Specifically, Keogh said that we need to: Undertake a review of our medical staffing to ensure appropriate supervision for our junior doctors. This ensures that patients receive the best possible outcomes whilst the junior doctors learn in a supportive environment. Improve how information & data about the quality of our services is assessed by the senior leadership. This is important to ensure that any problems are quickly identified and sustainable actions are implemented. Change how we listen to patients and ensure that we learn from their experience. This is important to ensure that we deliver a consistently excellent service all day, every day, across every part of the hospital. Ensure that the processes we have to manage emergency patients are effective and provide the best outcomes for our patients. This plan & progress document shows our plan for making these improvements and demonstrates how we re progressing against the plan. This document builds on the Key findings and action plan following risk summit document which we agreed immediately after the review was published http://www.nhs.uk/nhsengland/bruce-keoghreview/documents/outcomes/ Oversight and improvement arrangements have been put in place to support changes required While we take forward our plans to address the Keogh recommendations, the Trust is in special measures. More information about special measures can be found at http://www.monitor-nhsft.gov.uk/regulating-health-care-providers-commissioners/licensing-providers Who is responsible? Our actions to address the Keogh recommendations have been agreed by the Trust Board. Our interim Chief Executive, Karen James,is ultimately responsible for implementing actions in this document. Other key staff include Brendan Ryan, Interim Medical Director, Paul Williams Director of operations and John Goodenough, Director of Nursing Mike Shewan of Monitor is helping us to implement our actions by supporting our progress and challenging our approach to ensure we deliver the most effective service. Ultimately, our success in implementing the recommendations of the Keogh plan will be assessed by the Chief Inspector of Hospitals who will reinspect our Trust. If you have any questions about how we re doing, contact Trust Secretary, Tom Neve, on 0161 922 6000, or if you want to contact Monitor as an external expert, you can reach them on 020 7340 2453 or mailto:enquiries@monitor-nhsft.gov.uk How we will communicate progress to you We will provide a progress report every month whilst we are in special measures, which will be reviewed by the Board and published through our Trust website. We are constantly working with stakeholders to refining our action plan, so there will be slight amendments made to the report each month; to ensure it reflects progress. There will be regular updates on NHS Choices and subsequent longer term actions may be included as part of a continuous process. Signed by the Chair of the Trust (on behalf of the Board) T
Tameside Hospitals NHS Foundation Trust - Our improvement plan This table shows the actions we re taking to address the concerns about the quality of our services which were raised in the Keogh report. It also shows how we are progressing against our actions. Summary of Keogh Concerns Summary of Urgent Actions Required Agreed Timescale External Support/ Assurance Progress narrative Poor quality emergency care, patient monitoring and pathways. Conduct review of nurse staffing levels against patient acuity and dependency. Implementation of the Urgent Care recovery plan. Further develop ambulatory care pathways. Implement National Early Warning Score system. Weekly safety thermometer audits. Reinforce the critical care outreach policy to clinical staff. Appoint Head of Clinical Patient Flow. Improve ward-based pharmacy intervention & reconciliation. Jul-13 and 6 mthly Dec- 2013 Will be through Audit, Observation and External validation Completed 7/13 staffing levels realigned with implementation from 9/13 Monitored by Urgent Care Board Roll out plan for pathways in progress Work stream within safety programme In place since Sep-13 Reviewed, updated and widely circulated In post Additional Staff recruited Nov 13. Poor supervision and support to junior doctors overnight and at weekends. Enhance out-of-hours resident on-call cover. Provide additional middle-grade doctor cover. Establish weekly safety barometer with junior doctors. North West Deanery. Recruitment underway, interims in place. Recruitment underway, interims in place In place and reporting from July 13. Weak clinical leadership and engagement. Review out of hours clinical leadership. Appoint clinical governance leads for all divisions. Accelerate ward leadership programme. Develop clinical links within South Sector. Complete Oct-13 Jul-13 to Dec-13 Jul-13 to Jan-14 Complete Aug-13 Will be through Audit, Observation and External validation Medical rota increased Surgical middle grade cover on 24/7 basis. Clinical leadership being developed Recruitment in progress Commissioned and commence Nov 13 Ongoing communication & planning.
Tameside Hospitals NHS Foundation Trust - Our improvement plan This table shows the actions we re taking to address the concerns about the quality of our services which were raised in the Keogh report. It also shows how we are progressing against our actions. Summary of Keogh Concerns Summary of Urgent Actions Required Agreed Timescale External Support/ Assurance Progress narrative An organisational culture that accepts suboptimal care. Conduct review of nurse staffing levels against patient acuity and dependency. Improve safety reporting in the electronic rostering system. Review Trust behaviours to encourage transparency & develop an OD strategy to support this change. Development of over-arching quality strategy. Development of values-based recruitment process. Sep-13 and monthly Deloitte. completed 7/13 staffing levels realigned with implementation from 9/13 Implemented & being embedded Staff engaged in development process Draft is being consulted on, going to Jan 14 Board, for ratification Ongoing monthly programme. Poor Board reporting on quality and safety of services. Develop an Integrated Quality Board Report. External governance review to include focus on Board capacity, capability and effectiveness. Development of over-arching quality strategy. Advancing Quality Alliance Academy. Deloitte. Area Team & Clinical Commissioning Group. Reported to Board monthly since Aug 13 External review complete Nov-13 Draft is being consulted on, going to Jan 14 Board, for ratification Invest in quality reporting capacity. Develop patient safety ambassadors through the Advancing Quality Alliance Academy. Quality Dashboard monthly Aug 13 2 safety Ambassadors appointed Sep13. Poor transparency and engagement with stakeholders. Review structure and frequency of Council of Governor meetings. Develop governor development programme. Introduce a listening exercise, Tameside Listens, for patients, staff and the public. Aug-13 to Jan-14 Monitor. Complete Nov-13 Commenced in Jul-13 Tameside Listens commenced Aug13 Widen involvement of stakeholders in quality strategy. Engagement ongoing.
Tameside Hospitals NHS Foundation Trust - How we re checking that our improvement plan is working This table shows how and when we are checking that the actions we re taking are being delivered and how we are being held to account for these improvements in the quality of services Oversight and improvement action Timescale Action owner Progress Monitor requires the Trust to commission an independent review of governance. Address all issues identified by the CQC inspection in May 2013 and deliver all Keogh recommendations. Monitor has issued an additional licence condition allowing it to make leadership changes if improvements aren t made at the Trust within the agreed timescales. The Trust is planning to appoint a new Chief Executive and new Medical Director to support improvement in quality. Jul-13 Monitor Review complete Nov- 13 Action Plan in place Action plan in place Jul 13 Mar-14 Trust Interims provided by University Hospitals of South Manchester. Monthly accountability meeting with Monitor to track delivery of action plan. Aug -13 onwards Trust C.E/Monitor Monthly reports submitted by Trust Appointment of Oversight/Improvement Director (by Monitor) Complete Sept 2013 Monitor Mike Shewan Appointed Meetings of the Improvement Board on turnaround which will review evidence about how the trust action plan is improving our services in line with the Keogh recommendations. Sep-13 onwards Trust C.E Fortnightly meetings Improvement Board with Trust, CCG, Healthwatch & Monitor. Terms of Reference and Improvement Central Action Plan in place External quality governance review to look at how the trust is performing, provide assurance it is operating effectively and identify further opportunities for improvement. Complete Nov-13 Trust C.E Review completed Nov-13 Action Plan in place January 2014 Consideration of whether the trust is delivering its action plan and improvements in quality of services by a Quality Surveillance Group (QSG) composed of NHS England Area Team, Clinical Commissioning Groups, Monitor, Trust Development Authority, Care Quality Commission, Local Authority and Healthwatch. Sept 2013 to July 2014 Quality Surveillance Group Assurance provide d to CCG through CCG/ Trust Interface meeting and attendance at CCG Quality Group. Assurance to Monitor through monthly meeting Assurance also provided to LA & LAT through Health and Wellbeing Board and LAT visits Re-inspection TBA CQC Awaiting notification.