Standards for Better Health – update for Overview & Scrutiny Committee

1. Agenda Item No. 4.2 Standards for Better Health – update for Overview & Scrutiny Committee Jacqui Evans Sarah Brierley 1 April 2008

2. Introduction • Strengthening process • Proposed declaration for core standards 2007-8 (overview) • Focus on specific core standards

3. Strengthening Process • Revised process to: • Enhance ownership at Director level • Further develop audit trail of evidence • Monthly sign-off of compliance sheets by relevant Director • Monthly scrutiny by Board Assurance Committee

4. YEAR: 2007-8 COMMITTEE: CIRC DIRECTOR LEAD: XXX DOMAIN: Safety CHAIRMAN: XXX STANDARD LEAD: YYY STANDARD: C1a STANDARD ELEMENT EVIDENCE Healthcare organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from the analysis of incidents 1* Incidents are reported locally and to the National Patient Safety Agency (NPSA) via the National Reporting and Learning System 2* Reported incidents are analysed to seek to identify root causes, relevant trends and likelihood of repetition 3* Demonstrable improvements in practice are made to prevent reoccurrence of incidents as a result of information arising from the analysis of local incidents and from the PSA’s national analysis of incidents * Adequate levels of assurance can be provided by level 2 and above of the NHSLA’s Risk Management Standards for acute trusts. END OF YEAR SIGN OFF STATUS:  Compliant full year  Limited assurance*  Not met* * Please provide reasons  Date of reaching compliance (if relevant) SIGN OFF: ……………………………… DATE: …………………………………. Compliance Sheet

5. Proposed declaration 2007-8 • Compliant on most • Insufficient assurance (awaiting report from HCC) • C7e: Equality & human rights • C16: Patient information • C18: Access to service

6. Declaration of Specific Standards

7. Core standard 6: cooperation (compliant) • Evidence of cooperation with internal and external partners:Children’s Assessment Unit & Bramble Suite Development Projects, Regular input into Local Strategic Partnerships (LSP’s) e.g. Member of Welhat Alliance, Contributor to North Herts Community Plan • Member of: Hertfordshire’s Children’s Trust Partnership Strategy & Planning sub-group, MSLC (Maternity services liaison committee), University of Hertfordshire’s Directors of Service and Education meetings, HCAI Whole System Review Group, East & North Hertfordshire Choose and Book Project Board • Age Concern have offices on Lister & QEII developing home care support for elderly patients • PCT host therapy services • Member of the Stevenage Children’s Trust partnership

8. Core standard 13a: dignity & respect (compliant) • Range of policies inc ‘single sex accommodation’ • Introduced mandatory Diversity training • Liverpool care pathway • Multi faith provision / dietary provision • Audits / Surveys (Patient satisfaction, Essence of Care benchmarks,Patient Experience trackers, PEAT, National In-Patient & Maternity Surveys, 2007) • Patient Experience report to Board / Involvement Committee • HCC Visit (& follow up) re dignity • PPI Forum visits to Strathmore • Monthly Directorate CG reports • Review of minority groups • New – patient experience strategy Action planning Negative feedback analysis

9. Core standard 13b: consent (compliant) • Use standard DH forms / compliant procedure specific forms • 18 procedure specific forms ratified during 2007-8 • Mandatory consent audit & presentations • National Patient Survey (favourable results) • Training (inc IMCA) – mandatory for jnr doctors • Interpreter service • Established processes for post mortems, photography & research • Monitoring of ‘breaches’ via incident / PALS reports

10. Core standard 13c: confidentiality (compliant) • Caldicott Guardian & protocols • Internal Audit Report Dec 2007 • Documentation Audit • Monitoring via incident reports / PALS

11. Core standard 17: views of patients (compliant) • Involvement Committee established with diverse community representation • Regular Trust attendance at Patients Panel & BME Fresh Start meetings • Views of patients, carers and support groups actively sought during consultation preparatory work, during consultations, for service redesign and improvement work, recent consultations have included: Chemotherapy, DQHCH and PTS. • Consultation reports published and distributed, which include respondent details, comments and issues raised and Trust action plans for addressing issues raised.

12. Core standard 18: access (insufficient) • Ethnicity – interpreters / PAS/ complaints / NPS (limited) • Choose & Book service • National Patient Survey • Information (written) is limited • Patient Involvement Strategy – focus on BME, hard to reach groups • Monitoring of incidents / PALS / complaints / cancellations / waiting times

13. Core standard 22a: cooperation(compliant) • Cooperation with partners includes regular input into Local Strategic Partnerships (LSP’s) e.g. Member of Welhat Alliance, Contributor to North Herts Community Plan • Member of multi-agency groups including: Hertfordshire’s Children’s Trust Partnership Strategy & Planning sub-group, MSLC (Maternity services liaison committee), University of Hertfordshire’s Directors of Service and Education meetings • Age Concern have offices on Lister & QEII developing home care support for elderly patients • PCT host therapy services on Trust sites • Attendance at CDRP meetings for Welwyn/Hatfield, Stevenage, East and North Herts. • Involvement Committee work-plan includes work on the Patient experience and results of the patient survey • Collaboration on the recent DQHCH consultation Health Equality Impact Assessment

14. Core standard 22c: local partnerships (compliant) • Regular input into Local Strategic Partnerships (LSP’s) e.g. Member of Welhat Alliance, Contributor to North Herts Community Plan • Member of: Hertfordshire’s Children’s Trust Partnership Strategy & Planning sub-group, MSLC (Maternity services liaison committee), University of Hertfordshire’s Directors of Service and Education meetings, HCAI Whole System Review Group, East & North Hertfordshire Choose and Book Project Board • Attendance at CDRP meetings for Welwyn/Hatfield, Stevenage, East and North Herts.