Issue - meetings

-        Tracey McErlain-Burns, Chief Nurse and Hilary Fawcett, Quality Governance Lead

Tracey McErlain-Burns, Chief Nurse, and Hilary Fawcett, Quality Governance Lead, gave the following powerpoint presentation:-

Quality Account

-     The focus of the Quality Account is on how we take assurance that the services we provide are safe, effective and enabling our patients, their families and carers to have a positive experience of care

Looking Back – our quality improvement for 2013/13

-          Priority 1 – Patient Safety – Intraoperative Fluid management (CQUIN) - Achieved

-          Priority 2 – Improving Data Quality - Improved

-          Priority 3 – Review of Death Certificates - Achieved

-          Priority 4 – Patient Experience – Dementia – Not achieved

Looking Forward – TRFT Quality Objectives 2014/15

-          1 – SAFE – Mortality – Deliver a 4 point reduction in HSMR

-          2 – SAFE – Harm free Care (HFC)

2.1  Minimum 96% HFC

2.2  Zero avoidable pressure ulcers grade 2-4

2.3  Zero avoidable falls with harm

-          3 – RELIABLE – Achieve all national waiting time targets

3.1  Cancer

       3.1.1 2 week waits

       3.1.2 31 days

       3.1.3 62 days

3.2  A&E

3.3  18 weeks

-          4 – CARING AND RELIABLE – Friends and Family (FFT)

4.1  Achieve an A&E net promoter score (NPS) of 75

4.2  Achieve an IP NPS of 83

4.3  Achieve a maternity NPS of 83

4.4  Achieve a 40% response rate for A&E, maternity and in-patients combined

CQC Inspection – all standards met

-          Consent to treatment

-          Care and welfare of people who use the service

-          Cleanliness and inflection control

-          Requirements relating to workers

-          Supporting workers

-          Assessing and monitoring the quality of service provision

Information Governance

-          Information Governance Management – 66% (satisfactory)

-          Confidentiality and Data Protection Assurance - 66% (satisfactory)

-          Information Security Assurance – 66% (satisfactory)

-          Clinical Information Assurance – 66% (satisfactory)

-          Secondary Use Assurance – 66% (satisfactory)

-          Corporate Information Assurance – 66% (satisfactory)

-          Overall 66% (satisfactory)

Discussion ensued on the presentation with the following issues raised/clarified:-

·           The mortality rates covered 3 principle measures:- Hospital Standardised Mortality Ratio (covered all deaths in hospital), SHMI (Summary Hospital Level Mortality Indicator) (covered all patients in the community if they died within 30 days of discharge from hospital) and RAMI (Risk Adjusted Mortality Index) (a different way of comparing hospital death rates within the service).  A further area to be implemented in 2014 was Chronic Obstructive Pulmonary Disease and Respiratory Disorders especially Acute Pneumonia  and the introduction of respiratory bundles

·           Infection Control – there had been 7 cases reported of Clostridium Difficile in September-October, 2013, with the precise cause not identified.   Since then cleaning, cleanliness standards, cleaning of wheelchairs, changing of curtains and all practices in relation to infection prevention had been looked at.  When the outbreak had occurred, the Trust had reverted to the very old fashioned process of isolation and converted a 14 bed into closed door isolation environment and prevented any further spread

·           A NEVER event involved factors  ...  view the full minutes text for item 7