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DRAFT CORE & DEVELOPMENTAL STANDARDS DECLARATION – 2007/8

This document outlines the compliance and developmental standards for better health, including the management process and monitoring. It also highlights challenges and actions needed to ensure compliance, as well as initiatives for multi-disciplinary working, dignity and respect, consent, patient confidentiality, patient involvement, access to services, and working in partnership.

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DRAFT CORE & DEVELOPMENTAL STANDARDS DECLARATION – 2007/8

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  1. DRAFT CORE & DEVELOPMENTAL STANDARDS DECLARATION – 2007/8 Item 4.3 GRAHAM RAMSAY MEDICAL DIRECTOR / PATIENT SAFETY DIRECTOR

  2. CONTEXT – STANDARDS FOR BETTER HEALTH (S4BH) • S4BH Published by DoH in July 2004 • Seven Domains • Two Types of Standards - Core & Development • 2007/8 - 42/44 Core Standards (end of year) Compliant

  3. Hygiene Code • Benchmarking against Hygiene Code (11 Duties) • Action plan • Significant reduction in C.Diff

  4. MANAGEMENT PROCESS & MONITORING • Overall Executive Lead – Medical Director • Domains Allocated to Executive Directors and Non-Executive Directors • Individual Standards Delegated to Operational Leads • S4BH Domain Action Plans Developed • Monthly Monitoring Meetings • Datix Utilised to Store Evidence

  5. COMPLIANCE 2007/8 • Core Standards : 2005/06 (30/44) 2006/07 (40/44) 2007/8 /43 3 Standards declared as ‘Not Met’ for full year 5 Standards achieving end of year compliance • Non-compliant for • C4c (decontamination), • C20b (mixed sex accommodation) and • C23 Public Health • Developmental Standards D1 - Good Developmental Progress D2a - Fair Progress

  6. CHALLENGES AHEAD TO ENSURE COMPLIANCE • C4c – Decontamination Need to drive forward work with our partners in the Confederation to provide regional decontamination services and ensure we meet compliance with all statutory regulations on locally led decontamination • C20b – Mixed sex accommodation Current focus must be on patient safety • C23 – Public Health Strategy in place, work programme to be take forward and monitored by Trust & PCT Public Health Forum • D1 - Detailed Review 7 Steps to Pt Safety • D2a - Ensure Full Compliance with Identified NSF’s and NICE Guidance

  7. Assurance for 2008/9 • Quarterly Board Reports for all Domains • Non-compliant action plans to be fed up to the Trust Board • Greater engagement with Non-executive Directors

  8. C6: Multi-disciplinary Working • MDT Coordinators for Cancer and Acute Medicine • Bed management and Discharge planning team • Lead Nurse and Clinician for Child Protection • Lead Nurse for Care of Vulnerable Adults

  9. C13a: Dignity and Respect • Bi-annual Trust Privacy & Dignity Audits • National Inpatient Surveys • Reports to the Trust Board

  10. C13b: Ensuring appropriate consent is obtained • Consent to Treatment Policy based on DoH Model • Policy for Production of Patient Information Policy/Database • Regularly review consent related incidents and complaints • Post Mortem Policy

  11. C13c: Ensuring Patient Confidentiality • Data Protection Policy / Audits / Training • Health Records Policy • Safe Haven Policy • Information Security Policy • Caldicott Guardian

  12. C17: Seeking views of patients and others • Patients Panel • Patient & Public Involvement Forum • iHUGS • Patient Involvement and Experience Strategy • Patient Feedback System

  13. C18: Access to Services • Equalities Framework • Interpreting and Translation Services • Choose & Book • Voluntary Transport Scheme

  14. C23: Working in Partnership • Partnership Matrix • Health & Social Care Partnerships (access to LSPs) • Crime & Disorder Partnership • Trust Public Health Forum

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