Quality Improvement Plan Progress Report March 2017 Overview - - PowerPoint PPT Presentation

Quality Improvement Plan Progress Report

March 2017

Overview

NMUH Quality Improvement Plan Assurance Achievements Working with Community Partners

1 2 3 4

• 1. NMUH Quality Improvement Plan
• The CQC Report identified 28 “must do’s” and 49 “should

do’s”.

• We combined these with other CQC comments and our

pre existing plan, in to a single Improvement Plan.

• Each action has an assigned lead, with agreed timescales

for delivery and an assurance process.

Our Plan CQC Must and Should Do’s 77 Actions Local Improvement Plan 81 Actions CQC general feedback 123 Actions TOTAL 281 Actions

• 2. Assurance

CBU Quality and Improvement Meeting Monthly review at CBU level, of themes and outstanding actions. Executive Management Board Highlight progress Report

Monthly

Risk and Quality Committee Detailed report on achievements, and outstanding actions.

Bi- Monthly

Clinical Quality Review Group Highlight progress Report for Commissioner and NHS Improvement assurance. NMUH Trust Board Meeting Highlight progress Report

Quarterly

• 3. Sample achievements – as per

CQC recommendations

End of Life Care

The trust should provide a seven day face to face service as set

• ut within NICE guidance for EoLC.

Investment in additional staffing to enable a seven day palliative care service. The trust must produce and ratify an end of life care strategy This has now been completed, and was presented to the End of Life Care Strategy in February. The trust must send out bereavement surveys to the relatives

• f patients who have died within the hospital

Bereavement Surveys are now sent out to relatives.

Urgent and Emergency Services

Staffing remained fragile as it relied on a large amount of agency doctors to fill shifts. Increase in number of substantive middle grade and Consultant posts in ED. The trust must ensure learning from incidents is more robust and shared with all staff. Clinical Governance meetings fully embedded and a hotspots briefing template created to cascade information to staff. The trust should continue to make improvements to 15 minutes to triage time. More efficient ambulance triage to minimise delays. Nursing establishment increased to enable 24/7 ENP cover (to increase nurse led streaming service from April 17).

Maternity

The trust must carry out an audit of the stillbirth rate for the period January to December 2016 and develop an action plan to address themes. Audit completed and a draft action plan agreed. The Trust has also committed 17/18 funding to the national GROW progamme, which is expected to see a further reduction in the stillbirth rate. The trust should carry out a review of culture within maternity and use tools such as ‘walk in my shoes’. Trust have commissioned Shared Intelligence, (an independent third party) to undertake a programme of work to identify the underlying culture issues , and recommend how we can best move forward. Funding for five 'Whose shoes' sessions has been secured from a successful bid for national safety training

• funding. This work is already underway.

Insufficient staffing levels meant midwives did not always provide one to one care during labour. Midwifery staffing review, which has led to an increase in the number of midwives. 12 new midwives recruited.

Children and young people

Lack of specialist nursing staff to provide effective asthma and allergy clinics. Patients were waiting a long time for appointments. Approval for recruitment to two clinical nurse specialist posts – Asthma and Allergy. These posts will help reduce waiting times and compliance with national guidance. The trust should ensure that all children and young people up to their 19th birthday wherever they are cared for in the hospital should come under the governance of children’s services. The first Children's Board took place in January. The Board will look at processes for monitoring care provided to all patients aged under 19 and maintain an overview of the quality of services provided to children and young people up to their 19th birthday throughout the organisation.

Sample achievements – as per CQC recommendations

Other Areas of Progress

Well Led Safe Effective Caring Responsive

• Implementing a consistent approach to morbidity and mortality meetings
• Increased establishment to provide more cover to the Falls service
• Using a new system we are collecting patient dependency data to ensure best use of our nursing

resource

• Quality Improvement Groups now fully established to provide leadership and assurance
• £1M invested for 17/18 to improve quality of care
• New Maternity Leadership team in place
• More patients are being discharged home before lunchtime
• Sector wide, upper quartile performance for ambulance turnaround times
• Improved performance and compliance with the cancer 62 day standard, two months running (Nov

& Dec)

• Funding agreed for a Paediatric Allergy Clinical Nurse Specialist. This post will help reduce waiting

times, improve patient experience and implement the recommendations from the National Review

• f Asthma Deaths
• Bi weekly safe haven meeting for Critical Care staff
• Improvements in complaints response time – 85% within required timeframe
• To improve the care of patients with dementia the trust has launched the 'Forget-Me-Not' scheme.

• 4. Working with community partners

North Middlesex University Hospital NHS Trust is committed to strengthening its partnership working as part of its core business in order to help ensure that patient & community engagement is central to both current and future strategic priorities and developments.

• New Strategic Planning and Development lead post
• Developing a new local engagement framework with a variety of community and voluntary
• rganisations .
• Investigating a suitable consultative membership model for the Trust.
• Review was carried out of existing community recruitment links between November 2016 and

February 2017 and a subsequent paper detailing recommendations for future development submitted to the Trust’s Workforce Committee in February 2017.

• Aiming to extend and develop the Apprenticeship scheme from April - liaising with Haringey

Employment and Skills Board and South East Enfield Area Partnership and a range of local schools and sixth form colleges.

Any Questions