CHAIRMAN S SUMMARY REPORT

CHAIRMAN S SUMMARY REPORT This summary sheet is for completion by the Chair of any committee/group to accompany the minutes required by a trust level committee. Name of Committee/Group: Trust Management Team Report From: Chief Executive/Chief Operating Officer Date: 22.06.12 Required by receiving X For Information committee/group: Decision Other Aims of Committee: Bullet point aims of the reporting committee (from Terms of Reference) Drivers: Are there any links with Care Quality Commission/Health & Safety/NHSLA/Trust Policy/Patient Experience etc. To oversee and co-ordinate the Trust operations on a Trustwide basis To direct and influence the Trust service strategies and other key service improvement strategies which impact on these, in accordance with the Trust overall vision, values and business strategy. The matters highlighted below are not driven directly by the CQC, Monitor, or any other outside body. They are driven variously by the imperatives to enhance patient experience, ensure patient safety, maximise operational efficiency and effectiveness, improve the quality of services, and safeguard the financial position of the Trust. Main Discussion/ Points: Bullet point the main areas of discussion held at the committee/group meeting which need to be highlighted Considered and approved the business case for a fourth procedure room and provision for a flexible Sigmoidoscopy Screening Programme Considered the PEAT Scores for 2012, which were consistently high for both hospital sites, and reflected the improvements undertaken at both sites and the hard work of staff. Approved in principle the business case for an IT application to enable 24 hour turnaround for day case discharge notifications to GPs. A second phase of e-discharge, to pick up all remaining services across RWHT requiring 24 hour turn around, will form the basis of a second business case in due course. Approved the business case for the further development of the specialist tissue viability service, intended to assist the Trust in its efforts to achieve no avoidable pressure ulcers by December 2012, to ensure the appropriate and safe use of pressure ulcer prevention equipment, and to meet the NICE guidelines 2005 for managing pressure ulcers. W:Gov office/ads/rwht Man Team 23.04.12 Page 1 of 2

Risks Identified: The Management Team has had regard to any risks identified in respect of these matters. Include Risk Grade (categorisation matrix/datix number) W:Gov office/ads/rwht Man Team 23.04.12 Page 2 of 2

s of the Meeting of the Trust Management Team Date: 22 nd June 2012 Venue: Time: Boardroom, Clinical Skills and Corporate Services Centre New Cross Hospital 1.30 p.m. Present: Ms. V. Hall (Chair) Chief Operating Officer Mr. G. Argent Divisional Manager, Estates and Facilities Mr. I. Badger Divisional Medical Director, Division 1 Dr. M. Cooper Director of Infection Prevention and Control Dr. J. Cotton Director of Research and Development Ms. M. Espley Director of Planning and Contracting Mr. M. Goodwin Head of Estates Development Ms. D. Hickman Head of Midwifery Dr. S. Kapadia Divisional Medical Director, Division 2 Dr. J. Odum Medical Director Mr. M. Ogden-Meade Interim Chief Operating Officer Dr. D. Rowlands Lead Cancer Clinician Mr. K. Stringer Chief Financial Officer Ms. Z. Young Head Nurse, Division 1 In Attendance: Mr. A. Sargent Trust Board Secretary Ms. M. Gay Deputy Chief Nurse Ms. C. Marshall Deputy Director of Human Resources Apologies: Ms. R. Baker Head Nurse, Division 2 Ms. C. Etches OBE Chief Nursing Officer Mr. L. Grant Deputy Chief Operating Officer, Division 1 Ms. D. Harnin Director of Human Resources Mr. D. Loughton CBE Chief Executive Mr. T. Powell Deputy Chief Operating Officer, Division 2 Dr. B.M. Singh Lead Director - IT Minute 12/172 DECLARATION OF INTERESTS There were no declarations of interest. 12/173 MINUTES OF THE MEETING HELD ON FRIDAY 25 th MAY 2012 IT WAS AGREED: that the Minutes of the Meeting of the Trust Management Team held on Friday 25 May, 2012, be approved as a correct record. 1

12/174 MATTERS ARISING FROM THE MINUTES Seven Day Working and Review of Nursing and Midwifery (12/160) Ms. Espley reported that the Business Cases for Seven Day Working and the first phase of the Review of Nursing and Midwifery staffing in the Trust had been discussed by the Commissioners who had approved the principles involved, but had requested the Trust to provide further evidence of the proposed outcomes as a result of the investment, and a further meeting with the Commissioners was due to take place on the 19 July. 12/175 ACTION SUMMARY The following updates were received: 12/110: wording of Policies regarding Never Events: Ms. Gay indicated that work was continuing to review and, where necessary, revise the wording of Policies which had any bearing upon Never Events in the Trust. 12/112: Dr. Cooper indicated that money was already in the budget for the addition of the Toxin EIA test to the algorithm for C.difficile. The Chief Financial Officer and Chief Operating Officer undertook to look into this further. 12/113: extension of the wet age-related Macular Degeneration service: Ms. Espley confirmed that the written response from the Commissioner was not conclusive and they were requesting a peer review be undertaken ahead of any final decision on funding of the business case. This would be raised at the Contract Management meeting in the near future for further clarification. KS/MOM ME/KS IT WAS AGREED: that the Summary be noted. QUARTERLY REPORT 12/176 Research and Innovation Activity 2011/12 Dr. Cotton presented his Quarterly Report on Research and Innovation Activity 2011/12. He highlighted a number of matters contained within the report, including: Specialty areas which had, during the last year, managed to recruit large numbers of patients; Specialty areas which needed support to improve the rate of patient recruitment; Considerable improvements in obtaining timely management approval to trials; 2

Year on year growth in research funding, coupled with the need to continue to increase funding levels as well as activity; The constraints experienced because the Trust did not have a dedicated clinical research area; The successful development of a publication database which showed the amount which RWHT staff had published. Referring to the suggestion that the Trust should have dedicated clinical research facilities, Mr. Stringer enquired about funding sources for such a development. Dr. Cotton indicated that there was the possibility that help from industry might be available. IT WAS AGREED: that the Quarterly Report on Research and Development, be noted. DIVISIONAL MEDICAL DIRECTORS REPORTS Division 1 12/177 Governance Report Mr. Badger presented the monthly Governance Report for the Surgical Division and confirmed that the HAPU Grade 3 (reference 2012/12407) had been attributed to Ward D1. IT WAS AGREED: that the Governance Report for the Surgical Division, be noted. 12/178 Nursing, Midwifery and Quality Report Ms. Young drew out the highlights of the monthly Nursing, Midwifery and Quality Report for the Surgical Division. With regard to the recent period of increased incidence (PII) on Ward D2, Dr. Cooper reported that the specimen typing had confirmed that two different types had been identified and the episode did not fulfil the SHA criteria for PII, and there was no need for an external report. Ms. Hickman indicated that Maternity Service would seek NHSLA Level 2 accreditation this year, the formal assessment being expected towards the end of the financial year. Dr. Odum noted the trend reported in regard to facial sores. He asked whether this was a recent phenomenon. Ms. Young explained that tissue breaks caused by the plastic straps attached to oxygen masks had not previously been identified as constituting a HAPU, but staff were now being made aware of the need to report tissue breaks of this nature. Ms. Gay commented that greater clarification by the SHA on what should and should not be reported as pressure sores was leading to more careful attention to detail and reporting. She added that there had been a general improvement in the documentation around HAPUs. 3

IT WAS AGREED: that the Nursing, Midwifery and Quality Report for Division 1, be noted. Division 2 12/179 Governance Report Dr. Kapadia presented the monthly Governance Report for Division 2. IT WAS AGREED: that the Governance Report for the Medical Division, be noted. 12/180 Accident and Emergency Activity during May 2012 Dr. Kapadia presented a report which highlighted patterns of attendance, pressures in department, and demand variability in Accident and Emergency during May 2012, which was a very busy month including the busiest day on record. The majority of target metrics had been achieved despite bed availability issues. The report demonstrated the manner in which pressure varied depending on time of day and day of week, and the pattern of unplanned re-attendance rates and associated breaches. He indicated that psychiatric patients were likely to continue to be a disproportionate contributor to breaches and that this concern would be raised with the Black Country Partnership Mental Health Foundation Trust, along with the need for liaison with the relevant psychiatric teams. IT WAS AGREED: that the report on Accident and Emergency Activity during May 2012, be noted. 12/181 Business Case for a 4 th Procedure Room and Provision of a Flexible Sigmoidoscopy Screening Programme Dr. Kapadia submitted a Business Case for approval. He indicated that the work would be undertaken at the tariff rate and that the Commissioner had expressed support for this proposal. Mr. Goodwin referred to the capital programme provision of 700,000 related to this proposal, and noted that the Business Case appeared to exceed that amount by approximately 200,000. He indicated that the capital programme would be reviewed in an attempt to accommodate the extra estimated costs. Mr. Badger inquired whether the Business Case made allowance for increased demand on radiology, surgery and pathology arising from the additional screening. Dr. Kapadia confirmed that the Business Case took account of potential additional demand for services in pathology and surgery, but he did not anticipate any increase in demands upon radiology services. 4

Mr. Badger requested that further consideration be given to a possible need for short term increases in facilities in radiology and surgery to cope with the potential demand arising from the proposed screening programme. IT WAS AGREED: that the Business Case for a 4 th Procedure Room and provision of a Flexible Sigmoidoscopy Screening Programme, as outlined in the report, be approved. 12/182 Nursing and Quality Report Dr. Kapadia referred to the main points in the monthly Nursing and Quality Report for the Medical Division. It was noted that the one patient who had sustained serious harm as a result of a fall within the Division during May had previously fallen six times before the fall which resulted in her fracturing her hip, and Dr. Kapadia assured the meeting that many safeguards were already in place to prevent patient falls. IT WAS AGREED: that the Nursing and Quality Report for Division 2, be noted. REPORT OF THE CHIEF OPERATING OFFICER 12/183 Performance Report Mr. Odgen-Meade presented the monthly Operational Performance Report. He drew attention to the C.difficile cases reported in May and said that so far none had been reported in June. Dr. Cooper corrected the report, saying that there had been six (not seven) cases reported in May, and he had been unable to find any explanation for the sudden increase. Ms. Gay reported that there had been a sustained focus in respect of hand hygiene and all professional groups had been requested to improve performance. She added that hand hygiene would feature in the performance report to the Trust Board for the next few months until the position improved. Mr. Ogden-Meade also referred to the breach of the target for the sixty-two day wait for first treatment from consultant screening (all cancers). He pointed out that there were only six or seven patients per month and only one in breach was required to take the Trust over target. In this case, there had been a detailed analysis of the patient pathway and it appeared that the risk could potentially have been identified earlier in the process, and therefore a prospective alert system for patients on this particular pathway had now been introduced. Mr. Ogden-Meade referred also to the A & E performance during May. He said that so far during June there had been consistent under performance due to a number of causes, one of which was the increasing number of thirty day length of stay cases which had had an impact on the overall system. 5

More intensive monitoring of the thirty day patients had been introduced. Mr. Odgen-Meade also referred to the indicator for edischarge which had declined from almost 50% in April to 40% in May. He invited comments about the difficulties which were perceived to hinder achievement of this target. In response, Dr. Kapadia said that following the withdrawal of the discharge pads from D wards, some had achieved 100% of the target, but on the EAU the ward felt under pressure to move patients out, and therefore resorted to the faster process of the written forms. He had spoken to colleagues to stress the requirement to follow the edischarge procedures. Mr. Badger said that in his Division the experience had been that the IT did not support edischarge because it was too slow and additional computers were required. His staff saw their priority as treating patients and not spending long periods of time at a keyboard. Dr. Cotton indicated that the experience in Cardiology had been that it could take up to twenty minutes per patient to complete the edischarge procedure and, given other pressures, this was seen as unduly time consuming and needed to be made faster. He added that he believed that once the e-prescribing system was operational, edischarge would be greatly improved. However, at the moment there appeared to be a significant problem with multiple ward based IT systems sometimes hindering efficient patient care, rather than enhancing it and that this needed urgent attention. Mr. Ogden-Meade indicated that he understood that some new server capacity would soon come on stream within the Trust which would assist with some of the difficulties now mentioned. MOM/KS IT WAS AGREED: a) that the monthly Operational Performance Report, be noted; b) the Interim Chief Operating Officer and Chief Financial Officer establish a meeting with Divisional Medical Directors and other heads of service to discuss the experiences around edischarge, and identify methods of resolving any difficulties so as to enable the process to be followed and the edischarge target to be met. 12/184 Fire Safety Training Mr. Argent presented a report seeking endorsement to the requirements of the Department of Health Risk Management Advisor in relation to the delivery of Fire Safety Training in the Trust. Ms. Young indicated that the Trust should ensure that all staff who might be called upon to help evacuate patients receive appropriate training, and noted that the schedule of staff in Attachment 3 appeared not to be comprehensive. 6

Mr. Argent indicated that the approval of the principle was the main issue for this meeting and that the details would be worked out subsequently. IT WAS AGREED: that the approach to Fire Safety Training set out in the letter from the Risk Management Advisor to the Department of Health, be endorsed. 12/185 2012 PEAT Scores Mr. Argent presented the report on the PEAT Scores for 2012. The Estates Department were congratulated on the results now reported. It was noted that RWHT would be a pilot site for the new patient-led system which would replace PEAT. IT WAS AGREED: that the PEAT Scores for 2012, be noted. REPORT OF THE CHIEF FINANCIAL OFFICER 12/186 Financial Position of the Trust at the end of May 2012 (Month 2) Mr. Stringer reported that the overall position in May was an over performance on income of 855,000 and that patient activity levels were broadly at contracted values, being 89,000 in surplus. He reminded the meeting that the Trust did not recover the full cost of emergency admissions. He highlighted the worsening in-year expenditure position in both Division 1 and Division 2, which was mainly related to temporary staffing being higher than expected. In response to a question, Ms. Marshall confirmed that recruitment was under way for a Medical Locum Bank and she undertook to provide an update on this at the July meeting. DH Mr. Stringer went on to refer to the Cost Improvement Plans and said that the Change Programme Board had been focusing on the rate of implementation of schemes in Division 1. Turning to risks, Mr. Stringer commented on the contract penalties which had been negotiated with the Commissioner. IT WAS AGREED: that the Finance Report for May 2012 (Month 2), be noted. 12/187 Capital Programme 2012/13 Month 2 progress report Mr. Goodwin presented the Month 2 update on the Capital Programme 2012/13, and drew attention to the two risks identified. IT WAS AGREED: that the Month 2 progress report on the Capital Programme 2012/13, be noted. 7

12/188 edischarge Day Case Business Case Mr. Stringer drew out the salient points of a Business Case which was intended to provide an application to enable a twenty-four hour turnaround for day case discharge notifications to GPs. He highlighted that the Trust had a contractual obligation to send timely discharge information and that edischarge appeared to be an ideal vehicle to meet this requirement. Mr. Badger indicated that clinicians would potentially carry out less day cases if they were spending time attending to the administration of edischarge. He asked whether it would be possible for the current paper forms to be replicated in the edischarge process, and for the new system be designed to meet the needs of the users. Dr. Cotton indicated that the wards would support this development provided the appropriate infrastructure was in place prior to its rollout. Mr. Stringer acknowledged the concerns and requested that the Business Case be approved in principle, subject to further discussions with clinicians to ensure that the system could be rolled out without any undue difficulty. KS IT WAS AGREED: that the edischarge Business Case be approved in principle. REPORT OF THE DIRECTOR OF HUMAN RESOURCES 12/189 Health and Wellbeing Project Update Ms. Marshall introduced the update on the Health and Wellbeing Project and on the results of the sickness management pilot scheme in certain departments. She underlined that further work was taking place to provide better management information for both internal use for performance monitoring and performance reporting. She also indicated that the revised Sickness Absence Policy was due to be considered by the JNC. IT WAS AGREED: that the progress report on the Sickness Management Pilot Scheme, be noted. 12/190 Industrial on 21 June, 2012 verbal update Ms. Marshall reported orally that a relatively small number of inpatient and out-patient appointments had been rescheduled or postponed on the 21 June, and that the majority of doctors had worked as normal. IT WAS AGREED: that the oral report on the Industrial on 21 June 2012, be noted. 8

12/191 Inclement Weather Policy update (HR07) IT WAS AGREED: that the revised Inclement Weather Policy (HR07), be approved. 12/192 Dress Code Policy update (HR22) Ms. Marshall submitted the revised Dress Code Policy (HR22) for approval. Ms. Gay enquired about the wearing of false eyelashes and false nails vis a vis this policy, and Ms. Marshall undertook to investigate whether these were encompassed by the Policy and, if not, to revise it accordingly. CM/DH IT WAS AGREED: that the revised Dress Code Policy (HR22), be approved, subject to incorporating the points raised regarding false eyelashes and false nails. 12/193 Induction and Mandatory Training Policy update (OP41) Ms. Marshall presented for approval the updated Induction and Mandatory Training Policy (OP41). Mr. Badger requested that the Policy refer to hand hygiene and not hand washing. IT WAS AGREED: that the revised Induction and Mandatory Training Policy (OP41), as now submitted, be approved. REPORT OF THE CHIEF NURSING OFFICER 12/194 Red Incidents, Complaints and Operational Risks for Corporate Areas IT WAS AGREED: that the report on Red Incidents, Complaints and Operational Risks for Corporate Areas, be noted. 12/195 NHSLA General Standards update Ms. Gay introduced the monthly report on the NHSLA General Standards and the pre-assessment visit on the 11 June. Dr. Odum raised concerns about health records management, and mentioned the state of some files in the Trust. He recognised that there was a significant piece of work required to bring about the necessary improvements. Dr. Cotton reflected that in the past there had been disparate views among consultants about what was required on each file. Mr. Badger pointed out that each file must contain a significant amount of patient history; otherwise clinicians were at risk of missing important information and potentially putting patients at risk. Mr. Argent suggested that the emphasis should be on ensuring that the current cohort of patients with the Trust should have fit-for-purpose health records. IT WAS AGREED: that the report on the NHSLA Pre- Assessment Visit on the 11 June, be noted. 9

12/196 Development of the Specialist Tissue Viability Service Ms. Gay presented a Business Case for approval. She pointed out that the 76,961 recurring funding fitted with the priorities of the PCT for the next two years and therefore a bid had been made for non-recurring PCT re-ablement funds. Ms. Hall indicated that this development would be supported through CQUIN. In response to a question from Ms. Young, Ms. Gay said that the service proposed would enable a different kind of training and education to take place with a greater element of this being ward based and audits taking place via peer review processes. IT WAS AGREED: that the Business Case for the further Development of the Specialist Tissue Viability Service to meet the organisation s objectives for tissue viability, be approved. 12/197 Prevention and Control of MRSA, VRE and other Antibiotic Resistant Organisms Policy (IP03) IT WAS AGREED: that the revised Policy for the Prevention and Control of MRSA, VRE and other Antibiotic Resistant Organisms (IP03), be approved. 12/198 Linen Policy (IP05) IT WAS AGREED: approved. that the revised Linen Policy (IP05), be 12/199 Blood Culture Collection Policy (IP16) IT WAS AGREED: that the revised Blood Culture Collection Policy (IP16), be approved. 12/200 Norovirus Policy (IP18) IT WAS AGREED: that the revised Norovirus Policy (IP18), be approved. 12/201 Hand Hygiene Policy (IP01) Dr. Cooper reported that he had received guidance from the Department of Health on pseudomonas in water supplies, and suggested that this should be appended to this Policy. MG/MC IT WAS AGREED: that the revised Hand Hygiene Policy (IP01), be approved, subject to the appending of the Department of Health guidance on pseudomonas in water supplies. 10

REPORT OF THE DIRECTOR OF PLANNING AND CONTRACTING 12/202 Any Qualified Provider Arrangements 2012/13 Ms. Espley presented an overview of the process for the implementation of Any Qualified Provider (AQP) and the response required from the Trust. Mr. Goodwin commented that there were certain implications arising from this initiative and he cited areas such as audiology where the accommodation did not currently meet the specification and would require significant investment to achieve compliance. Ms. Espley indicated that an action plan would be drawn up for improvements and agreed in consultation with the Commissioners. In response to a question from Ms. Marshall, Ms. Espley explained that community services were currently provided under a block contract and the services currently impacted by AQP were relatively discrete and constituted a small proportion of the services delivered by the Trust. The potential risk to the workforce was under review but it was thought that the greater risk would emerge when AQP was rolled out to the core community services provided. Ms. Marshall undertook to include this matter on the Workforce Return. IT WAS AGREED: that the update on Any Qualified Provider Arrangements 2012/13, be noted. 12/203 Change Programme Board Ms. Espley presented the monthly report of the Change Programme Board and confirmed that the recent meeting had focused on schemes which were slipping and had requested mitigation plans from Divisions to address schemes which were behind plan. IT WAS AGREED: that the monthly report of the Change Programme Board, be noted. REPORT OF THE MEDICAL DIRECTOR 12/204 Policy for the Management of Risks associated with Pathology and Radiology Clinical Diagnostic and Screening Tests (CP50) Dr. Odum reported that he had received a letter regarding Rule 43, which was a Coroner s rule for the implementation of certain requirements upon health organisations and individuals, and which highlighted the need for urgent test results to be telephoned through to clinicians in situations where conditions were life threatening and required to be acted upon urgently. 11

Ms. Young referred to recent Coroner training which she had attended where Rule 43 had been mentioned, and which had raised questions about how urgent results were recorded on the wards. Dr. Odum said that the detail needed to be worked through but he would expect such results normally to be transmitted direct to the clinician concerned. If they were telephoned to the ward then they should be recorded by the doctor on duty. Dr. Cooper indicated that the practice varied from ward to ward and that some urgent test results were noted on the Results Pad, others were clipped to the front of a file via any piece of paper available. He suggested that it would be best if a single template could be adopted for the entire Trust and this would be easier to audit. Ms. Gay said that this would be rolled out via the Best Practice wards. IT WAS AGREED: that the Policy for the Management of Risks associated with Pathology and Radiology Clinical Diagnostic and Screening Tests (CP50), be approved. REPORT OF THE CHIEF EXECUTIVE 12/205 Review of Terms of Reference of the Trust Management Team Ms. Hall noted that there were certain sub-groups which seldom or never reported back to the Trust Management Team, and requested that they do so during the year ahead. Mr Sargent said that a cycle of TMT business was being prepared which should assist in this regard. IT WAS AGREED: that the revised Terms of Reference of the Trust Management Team be approved, subject to the Change Management Board reporting on a monthly basis for the time being. 12/206 ANY OTHER BUSINESS It was noted that it was hoped that on Monday 28 June the Trust would have achieved 1,096 days free from an MRSA bacteraemia, which represented a three year period. 12/207 DATE, TIME AND VENUE OF NEXT MEETING It was noted that the next meeting of the Trust Management Team was due to be held on Friday 20 July, 2012 at 1.30 p.m. in the Boardroom of the Clinical Skills and Corporate Services Centre, New Cross Hospital. The meeting concluded at 3.45 p.m. ***** 12