Quality Improvement Plan Progress Report March 2017
Overview NMUH Quality Improvement Plan 1 Assurance 2 Achievements 3 Working with Community Partners 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 Monthly CBU Quality and Improvement Monthly review at CBU level, of themes and outstanding actions. Meeting Executive Management Highlight progress Report Bi- Monthly Board Risk and Quality Detailed report on achievements, and outstanding actions. Committee Clinical Quality Highlight progress Report for Commissioner and NHS Improvement Review Group assurance. Quarterly NMUH Trust Board Highlight progress Report Meeting
3. Sample achievements – as per CQC recommendations The trust should provide a seven day face to face service as set Investment in additional staffing to enable a seven day out within NICE guidance for EoLC. palliative care service. End of Life Care 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 Bereavement Surveys are now sent out to relatives. of patients who have died within the hospital Staffing remained fragile as it relied on a large amount of Increase in number of substantive middle grade and Consultant Urgent and agency doctors to fill shifts. posts in ED. Emergency The trust must ensure learning from incidents is more robust Clinical Governance meetings fully embedded and a hotspots Services and shared with all staff. briefing template created to cascade information to staff. The trust should continue to make improvements to 15 minutes More efficient ambulance triage to minimise delays. Nursing to triage time. establishment increased to enable 24/7 ENP cover (to increase nurse led streaming service from April 17).
Sample achievements – as per CQC recommendations The trust must carry out an audit of the stillbirth rate for the Audit completed and a draft action plan agreed. The Trust has period January to December 2016 and develop an action plan to also committed 17/18 funding to the national GROW address themes. progamme, which is expected to see a further reduction in the stillbirth rate. Maternity The trust should carry out a review of culture within maternity Trust have commissioned Shared Intelligence, (an independent and use tools such as ‘walk in my shoes’. 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 Midwifery staffing review, which has led to an increase in the provide one to one care during labour. number of midwives. 12 new midwives recruited. Lack of specialist nursing staff to provide effective asthma and Approval for recruitment to two clinical nurse specialist posts – Children allergy clinics. Patients were waiting a long time for Asthma and Allergy. These posts will help reduce waiting times appointments. and compliance with national guidance. and young The trust should ensure that all children and young people up The first Children's Board took place in January. The Board will people to their 19th birthday wherever they are cared for in the look at processes for monitoring care provided to all patients hospital should come under the governance of children’s aged under 19 and maintain an overview of the quality of services. services provided to children and young people up to their 19th birthday throughout the organisation.
Other Areas of Progress • Quality Improvement Groups now fully established to provide leadership and assurance • £1M invested for 17/18 to improve quality of care Well Led • New Maternity Leadership team in place • Implementing a consistent approach to morbidity and mortality meetings • Increased establishment to provide more cover to the Falls service Safe • Using a new system we are collecting patient dependency data to ensure best use of our nursing resource • 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 Effective of Asthma Deaths • Bi weekly safe haven meeting for Critical Care staff • Improvements in complaints response time – 85% within required timeframe Caring • To improve the care of patients with dementia the trust has launched the 'Forget-Me-Not' scheme. • More patients are being discharged home before lunchtime • Sector wide, upper quartile performance for ambulance turnaround times Responsive • Improved performance and compliance with the cancer 62 day standard , two months running (Nov & Dec)
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 organisations . 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
Recommend
More recommend
